Barriers to labor after cesarean: A survey of United States midwives

Barriers and facilitators of choosing a vaginal birth after cesarean: A mixed-methods systematic review

BACKGROUND

Vaginal birth after cesarean is an effective way of reducing cesarean section rates and preventing a variety of short- and long-term complications associated with cesarean deliveries. Additionally, vaginal birth after cesarean can enhance breastfeeding rates, expedite postpartum recovery, and minimize hospitalization duration for women. Despite these benefits, the prevalence of vaginal birth after cesarean remains low in many countries, and only limited reviews have investigated the factors contributing to the low vaginal birth after cesarean rates.

OBJECTIVES

This review aims to explore the barriers and facilitators influencing decision-making during the process of vaginal birth after cesarean.

DESIGN

A mixed-methods systematic review.

METHODS

Ten electronic databases were systematically and comprehensively searched for qualitative, quantitative, and mixed-methods studies. Two reviewers critically appraised the eligible studies independently using the Joanna Briggs Institute Critical Appraisal Tool. We converted quantitative findings to narrative form and employed a convergent synthesis design to synthesize the data thematically.

RESULTS

This review included 55 studies published between 2002 and 2024. These studies originated from 19 countries and comprised 21 quantitative studies, 31 qualitative studies, and three mixed-methods studies. The methodological quality of the included studies was assessed as moderate to high. We divided the barriers and facilitators influencing vaginal birth after cesarean decision-making into four categories and nine subcategories: individual factors of pregnant women (sociodemographic characteristics, physiological factors, cognition, and psychological factors); interpersonal relationships (emotional support and communication); healthcare system factors (healthcare professionals' acceptance and commitment to action as well as healthcare facilities); and social factors (culture and ethnicity, along with law and policy).

CONCLUSIONS

This study broadens the understanding of the various factors that influence vaginal birth after cesarean decisions and may provide valuable insights for future modifications in vaginal birth after cesarean practices to enhance its availability for women. We conclude that successful implementation of vaginal birth after cesarean requires the concerted efforts of all stakeholders. Hospitals should improve the quality of care, enhance the capacity of the healthcare system to support vaginal birth after cesarean, and respect the preferences of pregnant women by providing support and encouraging their active participation in decision-making.

REGISTRATION

This systematic review was registered in PROSPERO on June 24, 2022 (CRD42022339434).

An exploration of barriers to access to trial of labor and vaginal birth after cesarean in the United States: a scoping review

INTRODUCTION

Increasing the number of vaginal birth after cesarean (VBAC) deliveries is one strategy to reduce the cesarean rate in the United States. Despite evidence of its safety, access to trial of labor after cesarean (TOLAC) and VBAC are limited by many clinical and non-clinical factors. We used a scoping review methodology to identify barriers to access of TOLAC and VBAC in the United States and extract potential leverage points from the literature.

CONTENT

We searched PubMed, Embase, Cochrane, and CINAHL for peer-reviewed, English-language studies published after 1990, focusing on access to TOLAC and/or VBAC in the United States. Themes and potential leverage points were mapped onto the Minority Health and Health Disparities Research Framework. The search yielded 21 peer-reviewed papers.

SUMMARY

Barriers varied across levels of influence and included factors related to restrictive clinical guidelines, provider reluctance, geographic disparities, and midwifery scopes of practice. While barriers varied in levels of influence, the majority were related to systemic and interpersonal factors.

OUTLOOK

Barriers to TOLAC and VBAC exist at many levels and are both clinical and non-clinical in nature. The existing body of literature can benefit from more research examining the impact of recent revisions to clinical guidelines related to VBAC as well as additional qualitative studies to more deeply understand the complexity of provider reluctance.

How to Foster Effective Midwife-Obstetrician Collaboration on Labor and Birth Units: Qualitative Analysis of Experiences of Clinicians in the United States

INTRODUCTION

Effective collaboration between midwives and obstetricians on labor and birth units in hospitals has been shown to improve birth outcomes and quality of care. Guidelines for collaborative care in the United States exist; however, studies describing the actual lived experiences of midwives and obstetricians in collaborative practice are lacking. The goal of this study was to explore the experiences and perspectives of midwives and obstetricians working in collaborative practices on labor and birth units across the United States and to identify strategies that foster effective collaboration between them.

METHODS

We performed qualitative analyses of open-ended comments obtained in an instrument validation survey assessing collaboration between midwives and obstetricians on labor and birth in the United States. Certified nurse-midwives, certified midwives, attending general obstetricians, maternal-fetal medicine attending physicians, and fellows across the United States were included in this study, herein called midwives and obstetricians. The final sample in the original validation survey included 232 midwives and 471 obstetricians (n = 703). Of these, 79 midwives and 132 obstetricians (n = 211) provided narrative comments on their perspectives and experiences with collaborative practice on labor and birth units in the United States. The narrative comments were analyzed using inductive techniques derived from grounded theory.

RESULTS

Four themes around how to foster effective collaboration were identified: (1) developing trust and respect, (2) promoting effective communication, (3) individual variability and need for clear guidelines, and (4) balancing autonomy. The midwives and obstetricians shared lived experiences that they perceived affected their work satisfaction and clinical outcomes in collaborative practices.

DISCUSSION

These findings hold potential to inform clinicians and health care leaders on ways to foster effective collaboration between midwives and obstetricians on labor and birth units. This in turn can improve quality of care for birthing persons, perinatal outcomes and clinician job satisfaction.