title: Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review.
abstract: BACKGROUND
  The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC.
  
  
  METHODS
  The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, 'Effective Public Health Practice Project'. The primary outcome measure was VBAC rates.
  
  
  RESULTS
  238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates.
  
  
  CONCLUSIONS
  This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.
authors: Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Box 457, , SE-405 30, Gothenburg, Sweden. ingela.lundgren@gu.se.
authors: Ingela
authors: I
authors: Lundgren
authors: School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland. smithv1@tcd.ie.
authors: Valerie
authors: V
authors: Smith
authors: Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Box 457, , SE-405 30, Gothenburg, Sweden. christina.nilsson@gu.se.
authors: Christina
authors: C
authors: Nilsson
authors: University of Eastern Finland, Faculty of Health Sciences, POB 1627, Kuopio University Hospital, 70211, Kuopio, Finland. katri.vehvilainenjulkunen@uef.fi.
authors: Katri
authors: K
authors: Vehvilainen-Julkunen
authors: Universita Degli Studi di Genova, Via Balbi 5, 16126, Genoa, Italy. jnicoletti@libero.it.
authors: Jane
authors: J
authors: Nicoletti
authors: School of Nursing and Midwifery, NUI Galway/West North West Hospital Group, University Road, Galway, Ireland. declan.devane@nuigalway.ie.
authors: Declan
authors: D
authors: Devane
authors: Department of Obstetrics, Gynaecology and Reproductive Medicine, Midwifery Research and Education Unit, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany. bernloehr.annette@mh-hannover.de.
authors: Annette
authors: A
authors: Bernloehr
authors: Department of Midwifery Science, Zuyd University, POB 1256, 6201 BG, Maastricht, The Netherlands. e.vanlimbeek@av-m.nl.
authors: Evelien
authors: E
authors: van Limbeek
authors: School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland. LALORJ1@tcd.ie.
authors: Joan
authors: J
authors: Lalor
authors: School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland. cbegley@tcd.ie.
authors: Cecily
authors: C
authors: Begley
mesh_terms: D000328:Adult; D017604:Cesarean Section, Repeat / Q000193:education / Q000523:psychology; D003657:Decision Making; D005260:Female; D006801:Humans; D008880:Midwifery / Q000379:methods; D009774:Obstetrics / Q000379:methods; D010353:Patient Education as Topic; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D016064:Vaginal Birth after Cesarean / Q000193:education / Q000523:psychology
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