Improving the organisation of maternal health service delivery, and optimising childbirth, by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care. (OptiBIRTH)
The European Perinatal Health Report (2008) notes “widespread concern” over rising CS rates, which vary from 15% in the Netherlands to 38% in Italy. Much of the rise is due to routine CS following previous CS, despite calls for increased vaginal birth after caesarean (VBAC), which results in less mortality and morbidity and is the preferred option for the majority of women. VBAC rates in Ireland, Germany, and Italy are significantly lower (29-36%) than those in the Netherlands, Sweden, and Finland (45-55%), a difference equating to 160,000 unnecessary CSs per annum in Europe, at an extra direct annual cost of €156m.
To improve maternal health service delivery, and optimise childbirth, by increasing vaginal birth after caesarean section (VBAC) through enhanced patient-centred maternity care across Europe.
The OptiBIRTH trial investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units in three European countries with relatively low VBAC rates (Germany, Ireland and Italy). The intervention was based on focus group interviews with 115 professionals and women in three countries with high VBAC rates (Sweden, Finland and the Netherlands), and three counties with low VBAC rates (Germany, Ireland and Italy). The intervention consisted of the provision of evidence-based education of women and clinicians, access to optional online resources, introduction of communities of practice (women and clinicians sharing knowledge), appointment of site midwife and obstetric opinion leaders, audit and peer review of CS rates in each site, and joint decision-making by women and clinicians. The control sites continued with usual care.
The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. A synthesis of the qualitative studies shows how the culture differs between the high and low VBAC rate countries; from being an obvious first alternative to an issue dependent on many factors; from something included in the ordinary care to something special; and from obstetrician making the final decision to a choice by the woman. A theme, preparing for a new birth by early follow-up and leaving the last birth behind, reflects coherence between the cultures.
Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances. In order to improve VBAC rates both maternity care settings and individual professionals need to reflect on their VBAC culture, and make changes to develop a ‘pro-VBAC culture’.
Vaginal birth after caesarean section, women-centred care, normal birth, randomised trial
Name: Prof Cecily Begley
Institution address: Trinity College Dublin, Ireland and Sahlgrenska Academy, University of Gothenburg, Sweden
Scientific WG-leader for intervention development: Ingela Lundgren, professor, University of Gothenburg.
The project team developed from an ESF-funded workshop “Promoting Normality in Childbirth” and a COST Action (IS0907: Creating a Dynamic EU Framework for Optimal Maternity Care), and includes 11 partners from 8 countries representing service users, midwifery, obstetrics, epidemiology, sociology, bioethics, health economics and industry (SME).
List of participants:
1 Trinity College Dublin, Dublin (TCD), Ireland
2 University of Gothenburg (UGOT), Sweden
3 Zuyd University (ZU), The Netherlands
4 University of Eastern Finland, Finland
5 University of Ulster (UU), UK
6 Entando (EN), Italy
7 Queen’s University of Belfast (QUB), UK
8 Medizinische Hochschule Hannover (MHH), Germany
9 National University of Ireland, Galway (NUIG), Ireland
10 Universita Degli Studi Di Genova (UNIGE), Italy
11 Vrije Universiteit Brussel (VUB), Belgium
Lundgren, I., Smith V., Nilsson, C., Vehvilainen Julkunen, K., Nicoletti, J., Devane, D., Bernloehr, A., van Limbeek, E., Lalor, J., Begley, C. (2015). Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review. BMC Pregnancy and Childbirth. 15:16
Nilsson, C., Smith, V., Lundgren, I., Vehvilainen Julkunen, K., Nicoletti, J., Devane, D., Bernloehr, A., van Limbeek, E., Lalor, J., Begley, C. (2015). Women-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review. Midwifery, 31(7), 657-663.
Lundgren, I., van Limbeek, E., Vehvilainen-Julkunen, K., Nilsson, C. (2015). Clinicians views of factors of importance for improving the rate of VBAC- A qualitative study from countries with high VBAC-rates. BMC Pregnancy and Childbirth. 15:196.
Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., Lundgren, I. (2015). Vaginal birth after Cesarean: Views of women from countries with high VBAC rates. Qualitative Health Research, 27(3), 325-340.
Lundgren, l, Carrol, M., Healy, P., Begley, C., Gross, M., Grylka-Baeschlin, S., Nicoletti, J., Morano, S., Nilsson, C., Lalor, J. (2016). Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy and Childbirth. 16:350.
Sinclair, M., Stockdale, J., Holman, MR., Brown, MJ., Morano, S., Gross, MM. & Lundgren, I. (2017). A systematic literature review of computer-based behavioural change interventions to inform the design of an online VBAC intervention for the OptiBIRTH European randomized trial. Evidense Based Midwifery. 15(1); 5-13.
Nilsson, C., Lalor, J., Begley, C., Carrol, M,, Gross, MM., Grylka-Baeschlin, S., Lundgren, I., Mattere, A., Morano, S., Nicoletti, J., Healy, P. (2017). Vaginal Birth After Caesarean: Views of women from countries with low VBAC rates. Women and Birth.
Morano, S., Migliorini, L., Rania, N., Piano, L., Tassara, T., Nicoletti, J., Lundgren, I. (2017). Emotions in labour: a qualitative study on Italian obstetricians´point of view. Journal of Reproductive and Infant Psychology
Lundgren. I., Morano, S., Nilsson,,C., Sinclair,, M., Begley,, C. (2020). Cultural perspectives on vaginal birth after previous Caesarean section in countries with high and low rates – a hermeneutic study. Women and Birth. Jul;33(4):e339-e347.
Clarke, M., Devane, D., Gross, MM., Morano, S., Lundgren, I., Sinclair, M., Putman, K., Beech, B., Vehviläinen-Julkunen, K., Nieuwenhuijze, M., Wiseman, H., Smith, V., Daly, D., Savage, G., Newell, J., Simpkin, A., Grylka-Baeschlin, S., Healy, P., Nicoletti, J., Lalor, J., Carroll, M., van Limbeek, E., Nilsson, C., Stockdale, J., Fobelets, M., Cecily Begley, C. (2020). OptiBIRTH: a Cluster Randomised Trial of a Complex Intervention to Increase Vaginal Birth After Caesarean Section (ISRCTN10612254). BMC Pregnancy and Childbirth. 20:143.
Portz, S., Stoll, K., Lundgren, I., Gross, MM. (2021) Midwives and obstetricians’ attitudes towards VBAC: Development and validation of the HCAV. Sexual and Reproductive Healthcare. 27: 100589.