For decades, women who have had a single prior cesarean section have had to have a planned repeat cesarean section due to factors that affect the availability and management of a trial of labor needed for a Vaginal Birth After Cesarean (VBAC) delivery. These factors impact a mothers’ autonomy to choose how she wants to deliver. Further studies are needed demonstrating that promoting education to mothers about making an informed decisions can help increase the uptake of a trial of labor after a cesarean and restore a mothers’ autonomy.” Once a cesarean, always a cesarean,” first stated by Dr. Edwin Cragin in 1916 (Bernstein, Matalon-Grazi & Rosenn, 2012, p. 204). Since then, obstetricians have thought and practiced this belief. Questions were raised about this belief as early as the 1960’s, but it was not until after the National Institutes of Health (NIH) consensus conference in 1980 that vaginal birth after cesarean rates began to significantly increase to 28. 3 percent in 1996 (Bernstein et al., 2012). However, shortly after that, obstetricians began to raise questions about the safety of a VBAC. Specifically, they were concerned about professional liability in response to an increase in reports of uterine rupture (Bernstein et al., 2012). In 1998, the American College of Obstetricians and Gynecologists (ACOG) released new guidelines for VBAC deliveries in hopes to increase safety and decrease liability issues but by 2004, the rate of VBAC deliveries had fallen to 9. 2 percent (Bernstein et al., 2012).
In a systematic review study by Catling-Paull et al. (2011), the non-clinical interventions that could increase the uptake of and/or success rates of VBAC deliveries were examined (Catling-Paull, Johnston, Ryan, Foureur, & Homer, 2011). All of the examined factors were seen to have an impact on the uptake of VBAC deliveries except for private health insurance which had inconsistent evidence (Catling-Paull et al., 2011). The aim of the study was to identify the most effective interventions that would increase the rate and success (Catling-Paull et al., 2011). It was found that local ownership of the desire to reduce cesarean section rates or increase VBAC delivery rates may be the most effective non-clinical intervention in improving the uptake of VBAC deliveries (Catling-Paull et al., 2011). This study examined the effective ways of providing information to women about VBAC and repeat cesarean deliveries. They looked at the use of prenatal education and support programs that promoted VBAC deliveries, individualized discussions (verbal-based), document-based information (pamphlets), and computer-based decision aids (Catling-Paull et al., 2011). A few of these studies reported that VBAC delivery rates were higher in teaching hospitals that had an emphasis on evidence-based practices (Catling-Paull et al., 2011). This study concluded that giving women information about their options for mode of delivery is likely to be beneficial in increasing VBAC delivery rates. This was due to the evidenced-based information about their options that was provided to them which aided in reducing their decisional conflict (Catling-Paull et al., 2011). A qualitative analysis study by David et al. (2010), found that women required access to non-biased information in order to make an informed decision about choosing a VBAC delivery (David, Fenwick, Bayes & Martin, 2010). This study analyzed 170 telephone calls made by women to the Next Birth After Caesarean (NBAC) antenatal clinic over a period of 16 months (David et al., 2010). The calls were separated into six distinct categories depending on the type of information women were seeking. The study concluded that a telephone service provided by midwives can be an effective strategy in meeting women’s informational needs and addressing decisional conflict in women seeking a VBAC delivery (David et al., 2010). Overall, this study found that providing women with the needed information that they desired on an individual basis gave them the ability to make informed decisions on whether to choose a VBAC delivery (David et al., 2010). David et al. (2010) explained that providing a service with accurate, up-to-date, and evidence-based information of the risks and benefits of a VBAC delivery can help reduce a mother’s decision conflict (David et al., 2010). Catling-Paull et al. (2011), concluded that reducing decisional conflict and providing evidence-based information can help mothers’ make more informed decisions which may lead to an increase in the uptake of VBAC deliveries (Catling-Paull et al., 2011). A study done by Bernstein et al. (2012), demonstrated that candidates for a VBAC delivery knew very little about the risks and benefits associated with a VBAC delivery and that the preference of their providers affected their choice on whether to choose a VBAC delivery versus a repeat cesarean section (Bernstein et al., 2012). This was a prospective study where women who were candidates for a VBAC delivery filled out a questionnaire prior to their scheduled repeat cesarean or upon admission for a VBAC delivery (Bernstein et al., 2012). A majority of the women in this study demonstrated a lack of knowledge on the risks and benefits of both VBAC and repeat cesarean deliveries (Bernstein et al., 2012). Also, this study demonstrated that the women were more likely to choose the method of delivery that their provider preferred (Bernstein et al., 2012). This study demonstrates that women are not informed on the risks and benefits of a VBAC delivery and therefore are not able to make an informed decision about their mode of delivery. This in turn affects the rate of VBAC deliveries. In a study by Frost et al. (2009), the views of women on decision making and on decisional aids was explored and found that women value structured information relevant to their individual needs to help them reduce their decisional conflict and make an informed decision regarding their mode of delivery (Frost, Shaw, Montgomery & Murphy, 2009). This was a qualitative study that interviewed women about the use and impact of decision aids and the outcome on their mode of delivery (Frost et al., 2009). The study found that decision aids played a significant role in helping women decide on mode of delivery by increasing their knowledge while not increasing their anxiety (Frost et al., 2009). The authors concluded that in addition to other empirical evidence, individualized decision aids are acceptable and are valuable as an aid to patients’ decision making which may increase the overall uptake of VBAC deliveries (Frost et al., 2009). A review of literature on risk communication, provider and patient preference, and obstetrical decision making involving VBAC deliveries was done by Kaimal and Kuppermann (2010). The decision making process regarding mode of delivery is complex and requires great consideration (Kaimal & Kuppermann, 2010). The authors state that providing mothers with clear information regarding risks and benefits is a necessary part of providing evidence-based, patient-centered care and they offer recommendations on how to incorporate a mothers’ preference in the decision-making process (Kaimal & Kuppermann, 2010). The authors examined different tools to enhance decision-making and their overall effects on the mother’s decision of mode of delivery (Kaimal & Kuppermann, 2010). They found that several studies done on decisional aids were associated with higher rates of VBAC deliveries (Kaimal & Kuppermann, 2010).
Incorporation of Evidence into Current Practice Settings
Even though the number of providers and facilities that will allow a VBAC delivery has declined, there are still many women who want this option (Bernstein et al., 2012). This decline in providers and facilities that will allow a VBAC delivery forces many women to reluctantly choose a repeat cesarean (Bernstein et al., 2012). This choice is often not much of a choice, since the full range of options is not always on the table. Research-based evidence has confirmed the safety of VBAC deliveries yet there is still an astonishing amount of hospitals and providers that still will not provide this service (Kaimal & Kuppermann, 2010). In March 2010, the NIH released another consensus statement, expressing their concern about the informed consent process for a VBAC delivery (Catling-Paull et al., 2011). The NIH panel urged clinicians to use evidence-based information in a way that will enable women to participate in a shared decision-making process (Catling-Paull et al., 2011). Evidence based studies have shown that increasing a women’s knowledge about birth choices has increased the uptake of VBAC deliveries (Catling-Paull et al., 2011). The informed consent process has three components: an understanding of the risks and benefits, competence, and voluntariness (Guido, 2010). It is assumed that most women having a child are competent to sign an informed consent. If the mother was given evidence-based information regarding the risks and benefits of a VBAC delivery versus a repeat cesarean and had a good understand of the information, would she even be able to choose a VBAC delivery? If there are no providers or facilities which allow a VBAC delivery, then how is the informed consent process still voluntary? The autonomy of these mothers’ is undercut by a lack of access to a VBAC delivery (Cunningham, Bangdiwala, Brown, Dean, Frederiksen, Rowland-Hogue, King, Spencer-Lukacz, McCullough, Nicholson, Petit, Probstfield, Viguera, Wong, Zimmet, 2010). These mothers are not able to choose the mode of delivery they want due to hospitals and providers not offering this service. Hospitals and providers need to overcome the barriers and allow for greater access to VBAC deliveries (Cunningham et al., 2010). Allowing for greater access will help to restore a mother’s autonomy in the decision making process regarding mode of delivery (Cunningham et al., 2010). Bernstein et al. (2012) stated that the patient’s in their study showed an overall lack of knowledge regarding the potential risks and benefits of VBAC and repeat cesarean deliveries (Bernstein et al., 2012). This study also stated that women tended to choose the mode of delivery which was favored by their physician if they were given an option at all (Bernstein et al., 2012). The women in this study did not have the proper information to make an informed decision. Some women were not even given the option to choose their mode of delivery (Bernstein et al., 2012). This study showed that provider bias plays a role in the patient’s opinion and influences the patient’s voluntary choice of mode of delivery (Bernstein et al., 2012). If there was not a lack of access for VBAC deliveries, women would still need evidenced-based information in order to make an informed decision. At this time, women are given little or no choice by their physician as to mode of delivery and therefore, they are only given the risks and benefits of the chosen mode of delivery and not both (Bernstein et al., 2012). Information needs to be provided to mothers for both modes of delivery so that they can make an informed decision. The use of decision aids can enhance patient-physician encounters by providing the patient with a systematic approach to their decision making process (Frost et al., 2009). Decision aids have been shown to reduce a patient’s decisional conflict in several recent studies (Bernstein et al. 2012; David et al. 2010; Frost et al. 2009). David et al. (2010) showed that providing accurate, up-to-date, and evidence-based information of the risks and benefits of a VBAC delivery can reduce a mother’s decision conflict (David et al., 2010). Catling-Paull et al. (2011), concluded that reducing a mother’s decisional conflict by providing evidence-based information can help mothers’ make more informed decisions leading to an increase in the uptake of VBAC deliveries (Catling-Paull et al., 2011). When a mother has accurate and up-to-date information regarding the risks and benefits of both modes of delivery, her decisional conflict is reduced allowing her to make a decision with less anxiety and more ease (Kaimal & Kuppermann, 2010). Kaimal & Kuppermann (2010) stated that the use of decision aids in a study of 700 women reduced decisional conflict, reduced anxiety, and increased knowledge of VBAC deliveries which lead to an increased rate of VBAC deliveries (Kaimal & Kuppermann, 2010). The studies reviewed in this paper show that mothers are lacking the needed evidenced-based information in order to make an informed decision about their mode of delivery. The use of decisional aids can help to provide mothers with the needed information in order for them to make an informed decision. Honestly, in order for the rates of VBAC deliveries to truly increase, the barriers to access need to be removed so that more women have an option to choose a VBAC delivery. Therefore, until the lack of access to VBAC deliveries is resolved, the uptake of VBAC deliveries may not increase significantly (Cunningham et al., 2010). Also, physician bias needs to be improved. Physicians should have a more open mind about the options that are available and their proven safety. Many physicians get set in there ways of always performing repeat cesarean sections. Women are influenced by their physician’s opinion and feel that going against them would be too stressful (Frost et al., 2009). Women want to be involved in the decision making process with their physician but with physician bias, these women felt they would be taking on all the responsibility and the potential consequences if they chose a different delivery method other than a planned repeat cesarean (Kaimal & Kuppermann, 2010).
Women who have had a single prior cesarean section face many obstacles when choosing their mode of delivery. There are many factors that affect the availability of a VBAC delivery making it difficult for mothers to have access to a facility and/or provider who will provide this service. Not having adequate access to facilities providing VBAC deliveries impacts a mother’s autonomy to choose how she wants to deliver. Promoting education to mothers about making an informed decision can help increase the uptake of a VBAC delivery and help to restore a mothers’ autonomy through the use of decisional aid and proper informed consent processes. Women making decisions about mode of delivery after a previous caesarean section can benefit from access to decisional aids by reducing their decisional conflict and anxiety and by increasing their knowledge about the potential risks and benefits. These factors can ultimately increase the uptake of VBAC deliveries. Helping women to learn about the safety, success rates, and potential risks and benefits of VBAC deliveries can help women make a more informed decision. Women with a prior cesarean section need to be offered information on both modes of delivery available to them despite the lack of access. Women have a right to choose and a right to know the potential risks and benefits of both modes of delivery so that they can make an informed decision. The physician and the patient need to work together in the informed decision process and physician bias needs to be removed. Overall, improving the informed consent process through decreasing bias and increase patient education can help to increase the uptake of VBAC deliveries.