title: Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean.
abstract: OBJECTIVE
  in the context of a rising caesarean section (CS) rate in Japan, the objectives of this study were; to investigate the national situation for women's birth options after primary CS; to explore characteristics of institutions accepting planned vaginal birth after caesarean (VBAC); to identify the timing and type of information given to women about their birth options by health professionals.
  
  
  METHODS
  a national census study using a self-administered postal survey of nursing managers within obstetric departments in Japanese hospitals and clinics was conducted. Data were analyzed to explore characteristics of institutions accepting or not accepting VBAC and information given to women about planned VBAC and planned repeat CS.
  
  
  METHODS
  institutions included hospitals and clinics providing childbirth services throughout Japan.
  
  
  METHODS
  nursing managers from hospitals (n=303) and clinics (n=196) completed surveys about their institutional policies and practices around birth after CS.
  
  
  RESULTS
  only 154 (30.9%) of 499 institutions examined, accepted planned vaginal birth as an option for birth after CS. The success rate of VBAC was 77.0% in these institutions. Availability of transport services for institutional transfer and existence of a Maternal Fetal Intensive Care Unit (MFICU) were significantly associated with acceptance of VBAC (OR=5.39, p<0.001; OR=2.96, p=0.04). Information about options for birth method was mostly provided in the form of consent documents, and doctors were the sole provider of information about method of childbirth in 55.7% of institutions. Nursing managers described challenges in caring for women who strongly desire VBAC when women did not have access to information or if institutional policies conflicted with women's wishes. They recommended evidence-based information for women regarding birth choices after CS and recognised the necessity of emotional support for women faced with decision dilemmas.
  
  
  CONCLUSIONS
  institutional policies and practices for birth after CS vary widely in Japan, with evidence of limited opportunities for women to make informed choices about planned VBAC. It was difficult for nurse managers to support women to choose VBAC when institutional policy conflicted with this choice and when women did not have consistent or balanced information.
  
  
  CONCLUSIONS
  strategies are needed to support women as well as pregnancy care providers to support women to consider VBAC as a possible birth option after CS and to expand the use of shared decision making in pregnancy care settings in Japan.
authors.affiliation: Department of Midwifery, Graduate School of Nursing Fukuoka Prefectural University, 4395 Ita, Tagawa City, 825-8585, Japan. Electronic address: torigoe@fukuoka-pu.ac.jp.
authors.forename: Ikuyo
authors.initials: I
authors.lastname: Torigoe
authors.affiliation: Guilford, CT, USA. Electronic address: bashorten@hotmail.com.
authors.forename: Brett
authors.initials: B
authors.lastname: Shorten
authors.affiliation: Department of Midwifery, Graduate School of Nursing Fukuoka Prefectural University, 4395 Ita, Tagawa City, 825-8585, Japan. Electronic address: yoshida@fukuoka-pu.ac.jp.
authors.forename: Shizuka
authors.initials: S
authors.lastname: Yoshida
authors.affiliation: Yale University School of Nursing, 400 West Campus Drive, Orange, CT 06477, USA. Electronic address: allison.shorten@yale.edu.
authors.forename: Allison
authors.initials: A
authors.lastname: Shorten
mesh_terms: D002585:Cesarean Section / Q000523:psychology / Q000592:standards*; D017604:Cesarean Section, Repeat / Q000523:psychology / Q000706:statistics & numerical data; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007564:Japan; D009774:Obstetrics / Q000379:methods; D036801:Parturition / Q000523:psychology; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000523:psychology; D011795:Surveys and Questionnaires; D016064:Vaginal Birth after Cesarean / Q000523:psychology* / Q000706:statistics & numerical data
keywords: Decision aids; Informed choice; Repeat caesarean section; Shared decision making; Trial of labour after caesarean (TOLAC); Vaginal birth after caesarean (VBAC)