title: Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a qualitative study from countries with high VBAC rates.
abstract: BACKGROUND
  The most common reason for caesarean section (CS) is repeat CS following previous CS. Vaginal birth after caesarean section (VBAC) rates vary widely in different healthcare settings and countries. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Interview studies with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of 'OptiBIRTH', an ongoing research project. The study reported here is based on interviews in high VBAC countries. The aim of the study was to investigate the views of clinicians working in countries with high VBAC rates on factors of importance for improving VBAC rates.
  
  
  METHODS
  Individual (face-to-face or telephone) interviews and focus group interviews with clinicians (in different maternity care settings) in three countries with high VBAC rates were conducted during 2012-2013. In total, 44 clinicians participated: 26 midwives and 18 obstetricians. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country.
  
  
  RESULTS
  The findings are presented in four main categories with subcategories. First, a common approach is needed, including: feeling confident with VBAC, considering VBAC as the first alternative, communicating well, working in a team, working in accordance with a model and making agreements with the woman. Second, obstetricians need to make the final decision on the mode of delivery while involving women in counselling towards VBAC. Third, a woman who has a previous CS has a similar need for support as other labouring women, but with some extra precautions and additional recommendations for her care. Finally, clinicians should help strengthen women's trust in VBAC, including building their trust in giving birth vaginally, recognising that giving birth naturally is an empowering experience for women, alleviating fear and offering extra visits to discuss the previous CS, and joining with the woman in a dialogue while leaving the decision about the mode of birth open.
  
  
  CONCLUSIONS
  This study shows that, according to midwives and obstetricians from countries with high VBAC rates, the important factors for improving the VBAC rate are related to the structure of the maternity care system in the country, to the cooperation between midwives and obstetricians, and to the care offered during pregnancy and birth. More research on clinicians' perspectives is needed from countries with low, as well as high, VBAC rates.
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: Department of Midwifery Science, Zuyd University, PO Box 1256, 6201 BG, Maastricht, The Netherlands. e.vanlimbeek@av-m.nl.
authors: Evelien
authors: E
authors: van Limbeek
authors: University of Eastern Finland, Faculty of Health Sciences, Kuopio University Hospital, PO Box 1627, 70211, Kuopio, Finland. katri.vehvilainenjulkunen@uef.fi.
authors: Katri
authors: K
authors: Vehvilainen-Julkunen
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
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D017604:Cesarean Section, Repeat / Q000706:statistics & numerical data; D003657:Decision Making; D005260:Female; D005387:Finland; D017144:Focus Groups; D005858:Germany; D006801:Humans; D015994:Incidence; D007407:Interviews as Topic; D007494:Ireland; D007558:Italy; D000068097:Maternal Health; D009426:Netherlands; D009774:Obstetrics / Q000379:methods*; D061214:Patient Safety; D010817:Physician-Patient Relations; D011247:Pregnancy; D011256:Pregnancy Outcome; D036301:Qualitative Research; D013548:Sweden; D016064:Vaginal Birth after Cesarean / Q000379:methods / Q000706:statistics & numerical data*