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02-08-2011 | Gynaecology | Article

Non-clinical factors significantly affect vaginal birth after previous cesarean


Free abstract

MedWire News: Non-clinical factors can significantly increase the rate of vaginal births among women who have previously undergone a cesarean section, shows a review of 20 years of data.

Factors including the implementation of national guidelines on a local level and dissemination of individualized information to women prenatally can significantly increase the rate of vaginal birth after cesarean section (VBAC), report the researchers.

"Cesarean rates have increased around the world in the past two decades and much of this increase is due to women who have had previous cesareans," said lead author Christine Catling-Paull (University of Technology Sydney, New South Wales, Australia).

Catling-Paull and colleagues explain in the Journal of Advanced Nursing that the reasons why women undergo repeat cesareans are unclear, but could include fear of rupture in subsequent labor and birth, fear from healthcare providers who only offer repeat cesareans, and convenience for women and clinicians.

The team conducted a systematic review of studies published up to 2008 that evaluated non-clinical interventions designed to either increase the number of women choosing VBAC or increase the VBAC success rate.

Twelve papers analyzed information and/or guidelines for providers. Of these, 3 studies (two US, one Canadian) showed that national guidelines increased the VBAC rate, from 22.0-31.0% in one study, from 12.6-18.5% in another, and from 6.0-16.0% in the third study.

A further Canadian study showed a "remarkable" increase in VBAC uptake rates, from 7-79% when a "small community hospital" changed its guidelines in line with national ones.

Three studies that looked exclusively at local guidelines also showed an increase in VBAC rates after their implementation, from 45-86% in one study, 53-70% in another, and from 32% to 84% - a statistically significant increase.

Catling-Paull and co-investigators report mixed findings with regard to healthcare insurance status and women attempting VBAC. For example, one study from 2008 reported no significant difference in uptake or success of VBAC among women with and without private insurance.

However, a 1999 study showed that privately insured women were less likely to attempt VBAC (5% vs 64%) and had low VBAC success rates. Similar findings, including one significant result, were observed in studies published in 1990 and 1996.

Four studies investigated the impact of provision of information to women. One showed that a verbal-based prenatal information program increased VBAC rates compared with a document-based program, although the difference was nonsignificant.

Two studies that compared decision-aids (computer-based and a booklet) given to women prenatally, with usual care, revealed that while VBAC uptake rates tended to be nonsignificantly higher, women who received the intervention reported largely reduced decisional conflict.

"Reducing women's decisional conflict and involving women more fully in decision-making is an important aspect of obstetric and midwifery care," write Catling-Paull et al.

They conclude that: "Nonclinical factors can have a significant impact on vaginal birth after cesarean section uptake and success."

On the basis of their findings, the team recommends the implementation of evidence-based local guidelines and decisional aids "to address the need for clear and consistent… information-sharing with women."

By Sarah Guy