Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England: secondary analysis of the Birthplace national prospective cohort study

Challenging norms: Making non-normative choices in childbearing. Results of a meta ethnographic review of the literature

OBJECTIVE

Women have the right to make choices during pregnancy and birth that sit outside clinical guidelines, medical recommendations, or normative expectations. Declining recommended place or mode of birth, routine intervention or screening can be considered 'non-normative' within western cultural and social expectations around pregnancy and childbirth. The aim of this review is to establish what is known about the experiences, views, and perceptions of women who make non-normative choices during pregnancy and childbirth to uncover new understandings, conceptualisations, and theories within existing literature.

METHODS

Using the meta-ethnographic method, and following its seven canonical stages, a systematic search of databases was performed, informed by eMERGe guidelines.

FINDINGS

Thirty-three studies met the inclusion criteria. Reciprocal translation resulted in three third order constructs - 'influences and motivators', 'barriers and conflict and 'knowledge as empowerment'. Refutational translation resulted in one third order construct - 'the middle ground', which informed the line of argument synthesis and theoretical insights.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings of this review suggest that whilst existing literature from a range of high-income countries with similar healthcare systems to the UK have begun to explore non-normative decision-making for discrete episodes of care and choices, knowledge based, theoretical and population gaps exist in relation to understanding the experiences of, and wider social processes involved in, making non-normative choices across the UK maternity care continuum.

Perinatal outcomes of planned home birth after cesarean and planned hospital vaginal birth after cesarean at term gestation in British Columbia, Canada: A retrospective population-based cohort study

BACKGROUND

The aim of this retrospective population-based cohort study was to determine whether the mode of delivery and maternal and neonatal outcomes differ between planned home VBAC (HBAC) and planned hospital VBAC.

METHODS

All midwifery clients with at least one prior cesarean birth delivered between April 2000 and March 2017 (N = 4741; n = 4180 planned hospital VBAC, n = 561 planned HBAC) were included. Multivariate binomial logistic regression analyses were conducted to calculate the odds ratios adjusted for the potential covariates. The primary outcome was the mode of delivery, and the secondary outcomes were uterine rupture/dehiscence, postpartum hemorrhage, nonintact perineum, episiotomy, obstetric trauma, Apgar score <7 at 5 minutes, neonatal resuscitation requiring positive pressure ventilation, neonatal intensive care unit admission, and a composite outcome of severe neonatal mortality and morbidity and maternal mortality and morbidity.

RESULTS

Planned HBAC was associated with a significant 39% decrease in the odds of having a cesarean birth (aOR 0.61, 95% CI 0.47-0.79) adjusting for the prepregnancy and pregnancy characteristics. Severe adverse outcomes were relatively rare in both settings; thus, our study did not have sufficient power to detect the true differences associated with the place of birth.

CONCLUSIONS

Home births for those eligible for VBACs and attended by registered midwives within an integrated health system were associated with higher vaginal birth rates compared with planned hospital VBACs. Severe adverse outcomes were relatively rare in both settings.

Vaginal birth after Cesarean experience in Romania: A retrospective case-series study and online survey

The high Romanian Cesarean delivery rates have led to an increase in a women's desire to achieve vaginal birth after Cesarean delivery (VBAC), but certain impediments make this process difficult. We retrospectively evaluated the VBAC cases in a tertiary maternity hospital from Romania, and assessed the Romanian women's opinion about VBAC using a questionnaire that was distributed to three specific Facebook groups. We evaluated 63 patients who achieved VBAC between January 2014 and August 2020. In addition, an online survey with 41 open and closed questions assessed the participants' opinion regarding VBAC in Romania. The results are summarized and discussed. The results revealed that VBAC rates were under 1%. The main observed complications that followed VBAC were postpartum hemorrhage (15.8%), and uterine atony (7.93%), while the most frequent types of lesions encountered after VBAC were cervical tear (12.6%), followed by labial fissure (9.5%) and vaginal tear (7.9%). The patient's confidence in the health care system is low, and many women decide to try TOLAC at home. In conclusion, VBAC is an important topic in the context of high Romanian Cesarean rates, and the decision factors must provide consistent strategies that promote this mode of delivery.

The experiences of privately practising midwives in Australia who have been reported to the Australian Health Practitioner Regulation Agency: A qualitative study

BACKGROUND

In Australia the majority of homebirths are attended by privately practising midwives (PPMs). In recent years PPMs have been increasingly reported to the Australian Health Practitioner Regulation Agency (AHPRA) mostly by other health professionals.

PURPOSE

to explore the experiences of PPMs in Australia who have been reported to the AHPRA.

METHODS

A qualitative interpretive approach, employing in-depth interviews with eight PPMs was undertaken and analysed using thematic analysis. A feminist theoretical framework was used to underpin the research.

RESULTS

The majority of reports made to AHPRA occurred when midwives supported women who chose care considered outside the recommended Australian College of Midwives (ACM) Consultation and Referral Guidelines. During data analysis an overarching theme emerged, "Caught between women and the system", which described the participants' feelings of working as a PPM in Australia. There were six themes and several sub-themes: The suppression of midwifery, A flawed system, Lack of support, Devastation on so many levels, Making changes in the aftermath and Walking a tight rope forever. The findings from this study reveal that midwives who are under investigation suffer from emotional and psychological distress. Understanding the effects of the process of investigation is important to improve the quality of professional and personal support available to PPMs who are reported to AHPRA and to streamline processes.

CONCLUSION

It is becoming increasingly difficult for PPMs to support the wishes and needs of individual women and also meet the requirements of the regulators, as well as the increasingly risk averse health service.

Obstetric practices in planned home births assisted in Brazil

OBJECTIVE

To describe obstetric practices in planned home births, assisted by qualified professionals in Brazil.

METHOD

This is a descriptive study, with data collected in an online bank maintained by 49 professionals from December 2014 to November 2015, in which the target population was women and newborns assisted in home births. Data were analyzed through descriptive statistics.

RESULTS

A total of 667 women and 665 newborns were included. Most of the women gave birth at home (84.4%), in a nonlithotomic position (99.1%); none underwent episiotomy; 32.3% had intact perineum; and 37.8% had first-degree lacerations, some underwent amniotomy (5.4%), oxytocin administration (0.4%), and Kristeller's maneuver (0.2%); 80.8% of the women with a previous cesarean section had home birth. The rate of transfer of parturients was 15.6%, of puerperal women was 1.9%, and of neonates 1.6%. The rate of cesarean section in the parturients that started labor at home was 9.0%.

CONCLUSION

The obstetric practices taken are consistent with the scientific evidence; however, unnecessary interventions are still performed. The rates of cesarean sections and maternal and neonatal transfers are low. Home can be a place of birth option for women seeking a physiological delivery.

Planned private homebirth in Victoria 2000-2015: a retrospective cohort study of Victorian perinatal data

BACKGROUND

The outcomes for planned homebirth in Victoria are unknown. We aimed to compare the rates of outcomes for high risk and low risk women who planned to birth at home compared to those who planned to birth in hospital.

METHODS

We undertook a population based cohort study of all births in Victoria, Australia 2000-2015. Women were defined as being of low or high risk of adverse pregnancy outcomes according to the eligibility criteria for homebirth and either planning to birth at home or in a hospital setting at the at the onset of labour. Rates of perinatal and maternal mortality and morbidity as well as obstetric interventions were compared.

RESULTS

Three thousand nine hundred forty-five women planned to give birth at home with a privately practising midwife and 829,286 women planned to give birth in a hospital setting. Regardless of risk status, planned homebirth was associated with significantly lower rates of all obstetric interventions and higher rates of spontaneous vaginal birth (p ≤ 0.0001 for all). For low risk women the rates of perinatal mortality were similar (1.6 per 1000 v's 1.7 per 1000; p = 0.90) and overall composite perinatal (3.6% v's 13.4%; p ≤ 0.001) and maternal morbidities (10.7% v's 17.3%; p ≤ 0.001) were significantly lower for those planning a homebirth. Planned homebirth among high risk women was associated with significantly higher rates of perinatal mortality (9.3 per 1000 v's 3.5 per 1000; p = 0.009) but an overall significant decrease in composite perinatal (7.8% v's 16.9%; p ≤ 0.001) and maternal morbidities (16.7% v's 24.6%; p ≤ 0.001).

CONCLUSION

Regardless of risk status, planned homebirth was associated with significantly lower rates of obstetric interventions and combined overall maternal and perinatal morbidities. For low risk women, planned homebirth was also associated with similar risks of perinatal mortality, however for women with recognized risk factors, planned homebirth was associated with significantly higher rates of perinatal mortality.

Parâmetros utilizados na avaliação de bem-estar do bebê no nascimento

Objectivo: identificar parâmetros que se utilizan para evaluar el bienestar del recién nacido.Síntesis del contenido: revisión integrativa de la literatura, realizada en las bases PubMed y Biblioteca Virtual de Salud (bvs), que utilizó los descriptores “apgar score”, “neonatal outcomes”, “fetal vitality” y “health services evaluation”. El recorte temporal fue de enero del 2011 a diciembre del 2016. Se importaron los resúmenes para el software Endnote Web®, para la remoción de duplicados y los remanentes exportados para el software Covidence®, lo que permitió la selección de la muestra final por dos investigadoras, de forma independiente. La muestra final incluyó 17 estudios. Los parámetros más utilizados fueron admisión del neonato en Unidad de Cuidados Intensivos en las primeras 24 a 48 horas de vida y el índice de Apgar, pero hubo variaciones en la mensuración de esos parámetros entre los estudios. Otros parámetros fueron: peso al nacer, temperatura corporal, natimortalidad y mortalidad neonatal. El Apgar, a pesar de utilizado mundialmente, posibilita subjetividad en la evaluación de algunas variables; este puede evaluar la respuesta del bebé a las maniobras empleadas en el atendimiento en sala de parto, pero no debe ser un parámetro decisorio para instituir o no maniobras de reanimación.Conclusión: algunos parámetros fueron comunes entre los estudios, sin embargo pueden agregarse otros parâmetros al abordar patologías específicas. Se considera importante entrenar enfermeiros en la medición del Apgar, pues son professionales responsables por el cuidado de la madre y el bebé 24 horas del día y, en muchos servicios, por la primera atención del recién nacido.

The journey from pain to power: A meta-ethnography on women's experiences of vaginal birth after caesarean

BACKGROUND

Vaginal birth after caesarean can be a safe and satisfying option for many women who have had a previous caesarean, yet rates of vaginal birth after caesarean remain low in the majority of countries. Exploring women's experiences of vaginal birth after caesarean can improve health practitioners' understanding of the factors that facilitate or hinder women in the journey to have a vaginal birth after caesarean.

METHODS

This paper reports on a meta-ethnographic review of 20 research papers exploring women's experience of vaginal birth after caesarean in a variety of birth locations. Meta-ethnography utilises a seven-stage process to synthesise qualitative research.

RESULTS

The overarching theme was 'the journey from pain to power'. The theme 'the hurt me' describes the previous caesarean experience and resulting feelings. Women experience a journey of 'peaks and troughs' moving from their previous caesarean to their vaginal birth after caesarean. Achieving a vaginal birth after caesarean was seen in the theme 'the powerful me,' and the resultant benefits are described in the theme 'the ongoing journey'.

CONCLUSION

Women undergo a journey from their previous caesarean with different positive and negative experiences as they move towards their goal of achieving a vaginal birth after caesarean. This 'journey from pain to power' is strongly influenced by both negative and positive support provided by health care practitioners. Positive support from a health care professional is more common in confident practitioners and continuity of care with a midwife.

Vaginal birth after cesarean: neonatal outcomes and United States birth setting

BACKGROUND

Women who seek vaginal birth after cesarean delivery may find limited in-hospital options. Increasing numbers of women in the United States are delivering by vaginal birth after cesarean delivery out-of-hospital. Little is known about neonatal outcomes among those who deliver by vaginal birth after cesarean delivery in- vs out-of-hospital.

OBJECTIVE

The purpose of this study was to compare neonatal outcomes between women who deliver via vaginal birth after cesarean delivery in-hospital vs out-of-hospital (home and freestanding birth center).

STUDY DESIGN

We conducted a retrospective cohort study using 2007-2010 linked United States birth and death records to compare singleton, term, vertex, nonanomolous, and liveborn neonates who delivered by vaginal birth after cesarean delivery in- or out-of-hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth-setting risk differences. Analyses were stratified by parity and history of vaginal birth. Sensitivity analyses that involved 3 transfer status scenarios were conducted.

RESULTS

Of women in the United States with a history of cesarean delivery (n=1,138,813), only a small proportion delivered by vaginal birth after cesarean delivery with the subsequent pregnancy (n=109,970; 9.65%). The proportion of home vaginal birth after cesarean delivery births increased from 1.78-2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out-of-hospital setting (neonatal seizures, 23 [0.02%] vs 6 [0.19%; P<.001]; Apgar score <7, 2859 [2.68%] vs 139 [4.42%; P<.001; Apgar score <4, 431 [0.4%] vs 23 [0.73; P=.01]). A similar, but nonsignificant, pattern of increased risk was observed for neonatal death and ventilator support among those neonates who were born in the out-of-hospital setting. Multivariate regression estimated that neonates who were born in an out-of-hospital setting had higher odds of poor outcomes (neonatal seizures [adjusted odds ratio, 8.53; 95% confidence interval, 2.87-25.4); Apgar score <7 [adjusted odds ratio, 1.62; 95% confidence interval, 1.35-1.96]; Apgar score <4 [adjusted odds ratio, 1.77; 95% confidence interval, 1.12-2.79]). Although the odds of neonatal death (adjusted odds ratio, 2.1; 95% confidence interval, 0.73-6.05; P=.18) and ventilator support (adjusted odds ratio, 1.36; 95% confidence interval, 0.75-2.46) appeared to be increased in out-of-hospital settings, findings did not reach statistical significance. Women birthing their second child by vaginal birth after cesarean delivery in out-of-hospital settings had higher odds of neonatal morbidity and death compared with women of higher parity. Women who had not birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery had higher odds of neonatal morbidity and mortality compared with women who had birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery. Sensitivity analyses generated distributions of plausible alternative estimates by outcome.

CONCLUSION

Fewer than 1 in 10 women in the United States with a previous cesarean delivery delivered by vaginal birth after cesarean delivery in any setting, and increasing proportions of these women delivered in an out-of-hospital setting. Adverse outcomes were more frequent for neonates who were born in an out-of-hospital setting, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availability of in-hospital vaginal birth after cesarean delivery and suggests that there may be benefit associated with increasing options that support physiologic birth and may prevent primary cesarean delivery safely. Results may inform evidence-based recommendations for birthplace among women who seek vaginal birth after cesarean delivery.

Serious adverse neonatal outcomes such as 5-minute Apgar score of zero and seizures or severe neurologic dysfunction are increased in planned home births after cesarean delivery

The United States is with 37,451 home births in 2014 the country with the largest absolute number of home births among all developed countries. The purpose of this study was to examine the occurrence and risks of a 5-minute Apgar score of zero and neonatal seizures or serious neurologic dysfunction in women with a history of prior cesarean delivery for planned home vaginal birth after cesarean (VBAC), compared to hospital VBAC and hospital birth cesarean deliveries for term normal weight infants in the United States from 2007-2014. We report in this study outcomes of women who had one or more prior cesarean deliveries and included women who had a successful vaginal birth after a trial of labor after cesarean (TOLAC) at home and in the hospital, and a repeat cesarean delivery in the hospital. We excluded preterm births (<37 weeks) and infants weighing under 2500 g. Hospital VBACS were the reference. Women with a planned home birth VBAC had an approximately 10-fold and higher increase in adverse neonatal outcomes when compared to hospital VBACS and hospital repeat cesarean deliveries, a significantly higher incidence and risk of a 5-minute Apgar score of 0 of 1 in 890 (11.24/10,000, relative risk 9.04, 95% confidence interval 4-20.39, p<.0001) and an incidence of neonatal seizures or severe neurologic dysfunction of 1 in 814 (Incidence: 12.27/10,000, relative risk 11.19, 95% confidence interval 5.13-24.29, p<.0001). Because of the significantly increased neonatal risks, obstetric providers should therefore not offer or perform planned home TOLACs and for those desiring a VBAC should strongly recommend a planned TOLAC in the appropriate hospital setting. We emphasize that this stance should be accompanied by effective efforts to make TOLAC available in the appropriate hospital setting.

Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVE

To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC.

DESIGN

Prospective cohort study.

SETTING

OUs and planned home births in England.

POPULATION

1436 women planning VBAC in the Birthplace cohort, including 209 planning home VBAC.

METHODS

We used Poisson regression to calculate relative risks adjusted for maternal characteristics.

MAIN OUTCOME MEASURES

MAIN OUTCOMES

(i) vaginal birth and (ii) transfer from planned home birth to OU during labour or immediately after birth.

SECONDARY OUTCOMES

(i) composite of maternal blood transfusion or admission to higher level care, (ii) stillbirth or Apgar score <7 at 5 minutes, (iii) neonatal unit admission.

RESULTS

Planned VBAC at home was associated with a statistically significant increase in the chances of having a vaginal birth compared with planned VBAC in an OU (adjusted relative risk 1.15, 95% confidence interval 1.06-1.24). The risk of an adverse maternal outcome was around 2-3% in both settings, with a similar risk of an adverse neonatal outcome. Transfer rates were high (37%) and varied markedly by parity (para 1, 56.7% versus para 2+, 24.6%).

CONCLUSION

Women in the cohort who planned VBAC at home had an increased chance of a vaginal birth compared with those planning VBAC in an OU, but transfer rates were high, particularly for women with only one previous birth, and the risk of an adverse maternal or perinatal outcome was around 2-3%. No change in guidance can be recommended.

TWEETABLE ABSTRACT

Higher vaginal birth rates in planned VBAC at home versus in OU but 2-3% adverse outcomes and high transfer rate.