Groping Through the Fog

A Metasynthesis of Women's Experiences on VBAC (Vaginal Birth After Caesarean Section)

Ingela Lundgren; Cecily Begley; Mechthild M Gross; Terese Bondas

BMC Pregnancy Childbirth. 2012;12(85)

Conclusion

Due to the rising CS-rate increasing numbers of women and health professionals have to decide mode of delivery in the subsequent birth. Vaginal birth is recommended as best practice for the majority of women, associated with lower maternal mortality than repeat CS, and less overall morbidity for mothers and babies. However, there are few studies about women's experiences of VBAC. This metasynthesis based on eight studies from an Anglo-American context, where informed choice is an option, raise the question of why women's experiences are not studied in other countries and maternity care settings. The study gives an understanding of how difficult VBAC is from women's perspectives. The women are groping through the fog and must have a strong sense of their own responsibility for giving birth vaginally since VBAC is mainly described by health professionals in relation to the risks involved. Women are well informed about these risks, but positive aspects of VBAC are mainly described by the women themselves. Giving birth vaginally is described as empowering, as best for the baby and as important in a life-perspective for them as women. In order to promote VBAC, more studies from different countries and maternity care settings are needed. Maternity care professionals must give women evidence-based information not only on risks but also on positive aspects of VBAC.

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Abbreviations
VBAC: Vaginal birth after Caesarean section; CS: Caesarean section.

Authors' contributions
IL, CB and MG participated in design of the study. All authors participated in data analysis, and drafted the manuscript. TB carried out a critical revision in relation to the method. All authors read and approved the final version.

Table 1. Articles included in the metasynthesis and quality assessment
Reference	Aim	Method	Data collection Setting	Quality assessment
Author		Theoretical
Discipline		perspective
2. Emmet, Shaw, Montgomery, Murphy, Nursing	To explore women's experiences of decision-making about mode of delivery after previous CS	Qualitative study	21 women with a previous CS	M:36
		Framework approach	12 planned a VBAC, 9 planned a CS
			The participants home
			Two city hospitals England and Scotland
13. McGrath, Phillips, Vaughan	To explore the decision-process from the mothers' perspective with regard to subsequent birth choice for women who had previously been delivered by CS	Descriptive phenomenology	4 women who had a VBAC	M:34
Nursing		Van Manen	Locations of the participants' choice 6–8 weeks post partum
Nursing		Van Manen	Australia
18. Phillips, McGrath, Vaughan	The reasons motivating women to try for a VBAC from the perspective of women	Descriptive phenomenology	4 women who had a VBAC	M:35
Nursing		Van Manen	Locations of the participants' choice 6–8 weeks post partum
Nursing		Van Manen	Australia
19. Fenwick, Gamble Hauck Midwifery	Explore and describe the childbirth expectations knowledge, beliefs and attitudes of women who have experienced a CS and would prefer a VBAC in subsequent pregnancy	Thematic analysis	35 women recruited from 157 respondents; 24 who attempted a vaginal birth and 11 who would choose this in a subsequent pregnancy	M:36
19. Fenwick, Gamble Hauck Midwifery			Australia	M:36
20. Meddings, Phipps	The lived experience of women who elected to attempt a vaginal birth following a previous CS	Phenomenological method	8 women recruited via community	M:31
Haith-Cooper, Haigh Nursing			Pregnancy 34 weeks and 6 weeks after birth
			Participants' own home UK

29. McGrath, Phillips	The focus is on women who valued a vaginal birth who delivered by CS	Descriptive phenomenology	8 women who valued a vaginal delivery but who delivered by CS	M:34
Vaughan			Locations of the participants' choice
Nursing			6–8 weeks post partum
Nursing			Australia
30. Goodhall, McVittie,	Explore mother's perceptions of the influence of health professionals (GP, midwives, and consultants) on decisions as to mode of delivery of second children, following a previous CS.	Interpretative phenomenology	10 pregnant women (medium gestation of 32 weeks) recruited via Edinburgh	M:32
Magil
Psychology			National Childbirth Trust and personal contacts
			Interviewee's home
			UK
31. Ridley, Davis	Discover what influences women in the decision to deliver via VBAC	Descriptive qualitative method	4 women delivered via VBAC	M:35
Bright, Sinclair			2–4 months post partum
Nursing			Postpartum unit in a hospital
			US

M = Moderate quality.

Table 2. Quality assessment
Domain 1: Research team and reflexivity
1.	Statement of which author/s conducted the interview or focus group*
2.	List of the researchers' credentials, e.g., PhD, MD*
3.	Statement of their occupation at the time of the study*
4.	Indication of the gender of the researcher(s)*
5.	Statement of relevant experience or training that researcher(s) had*
6.	Statement of any relationship established between participants and researchers prior to study start*
7.	Statement of participant knowledge of the interviewer*
8.	Evidence of self-awareness/insight in the characteristics reported about the interviewer/facilitator: e.g., assumptions, bias, reasons for or interest in the research topic*
Domain 2: Scope and purpose*
9.	Link between research and existing knowledge demonstrated*
10.	A clear aim for the study was stated*
Domain 3: study design
11.	A clear methodological orientation was stated to underpin the study e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis*
12.	Ethical committee approval granted*
13.	Documentation of how autonomy, consent, confidentiality etc. were managed*
14.	Description of how participants were selected: e.g. purposive, convenience, consecutive, snowball*
15.	Description of method of approach e.g. face-to-face, telephone, mail/email*
16.	Sample size: number of participants in the study declared*
17.	Number of people who refused to participate or dropped out given, with reasons*
18.	Description of setting of data collection e.g. home, clinic, workplace*
19.	Declaration of presence of non-participants, if applicable*
20.	Description of important characteristics of the sample e.g., demographic data, date data collected*
21.	Description of interview guide given e.g., questions, prompts, guides, and any pilot testing*
22.	Number of repeat interviews given, if applicable*
23.	Statements of audio/visual recording or not*
24.	Statements of whether or not fields notes were used*
25.	Duration of interviews or focus group given*
26.	Evidence provided that the data reached saturation or discussion/rationale if they did not*
27.	Statements of whether or not transcripts were returned to participants for comment and/or correction*
Domain 4: analysis and findings
28.	Number of data coders given/evidence of more than one researcher involved*
29.	Description provided of the coding tree/discussion of how coding system evolved*
30.	Statement of whether themes were identified in advance or derived from the data*
31.	Statement of manual analysis, or the software that was used to manage the data*
32.	Statement of whether or not participants provided feedback on the findings*
33.	Statements of whether or not deviant data were sought, if applicable*
34.	Statement of whether or not researchers "dwelt with the data", interrogating if for alternative explanations of phenomena*
35.	Sufficient discussion of research processes such that others can follow 'decision trail'*
36.	Identified participant quotations (e.g. by participant number) presented to illustrate the themes/findings*
37.	Consistency seen between the data presented in the findings*
38.	Major themes clearly presented in the findings*
39.	Description given of diverse cases or minor themes*
40.	The results are presented with an essence (phenomenology), main interpretation (hermeneutics), theory/main concepts (grounded theory), main theme (content analysis)*
41.	Evidence of systematic location and inclusion of literature and theory to contextualize findings*
Domain 5: Relevance and transferability
42.	Clearly resonates with other knowledge and experience*
43.	Provides new insights and increases understanding*
44.	Limitations/weaknesses clearly outlined*
45.	Further directions for investigation outlined*

*Yes, no or not applicable

Table 3. Themes and sub-themes
Sub-themes	Themes	Articles
In relation to the women themselves	Own strong responsibility for giving birth vaginally	13,18,19,29,30
In relation to information		2,13,18,19,29,30
In relation to health-professionals		13,18,19
To have to confront serious risks mediated by health-professionals	Vaginal birth after CS is a risky project	2,13,18,19,29,30,31
Lack of information about the benefits of vaginal birth		2,13,30
Not supported if you want a VBAC		2,13,19,30
Good for the baby and the mother- baby relationship	Vaginal birth has several positive aspects mainly described by women	2,18,19,20,29,30,31
A meaningful experience of importance for them as women		18,19,20,29,30,31
An easier birth in relation to recovery afterwards		2,19,20,31
Some health professionals are pro VBAC		2,13,20,29,31
Not being informed enough	To be involved in decision about mode of delivery is hard and important	2,13,19,20,31
Conflicting information		2,18,19,20,29,30,31
Important to have a choice		2,19,20,29,31
Uncertainty in relation to choice		2,19,20,29,31
Information/support from others not the hospital		2,13,18,19,29,31
Support from professionals		2,13,29,30,31
Experiences from the last birth influence the choice		2,19,29,30,31