title: Do Women Have a Choice? Care Providers' and Decision Makers' Perspectives on Barriers to Access of Health Services for Birth after a Previous Cesarean.
abstract: Repeat cesarean delivery is the single largest contributor to the escalating cesarean rate worldwide. Approximately 80 percent of women with a past cesarean are candidates for vaginal birth after a cesarean (VBAC), but in Canada less than one-third plan VBAC. Emerging evidence suggests that these trends may be due in part to nonclinical factors, including care provider practice patterns and delays in access to surgical and anesthesia services. This study sought to explore maternity care providers' and decision makers' attitudes toward and experiences with providing and planning services for women with a previous cesarean.
  
  
  
  In-depth, semi-structured interviews were conducted with family physicians, midwives, obstetricians, nurses, anesthetists, and health service decision makers recruited from three rural and two urban Canadian communities. Constructivist grounded theory informed iterative data collection and analysis.
  
  
  
  Analysis of interviews (n = 35) revealed that the factors influencing decisions resulted from interactions between the clinical, organizational, and policy levels of the health care system. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from competing access to surgical resources.
  
  
  
  To facilitate women's increased access to planned VBAC, it is necessary to address the barriers perceived by care providers and decision makers. Strategies to mitigate concerns include initiating decision support immediately after the primary cesarean, addressing the social risks that influence women's preferences, and managing perceptions of patient and litigation risks through shared decision making.
authors.affiliation: Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.|The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA.
authors.forename: Sarah
authors.identifier: 0000-0002-3884-6592
authors.initials: S
authors.lastname: Munro
authors.affiliation: Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.|Centre for Rural Health Research and Applied Policy Research Unit, Vancouver, BC, Canada.
authors.forename: Jude
authors.initials: J
authors.lastname: Kornelsen
authors.affiliation: School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.
authors.forename: Kitty
authors.initials: K
authors.lastname: Corbett
authors.affiliation: School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Wilcox
authors.affiliation: University of British Columbia School of Population and Public Health, Vancouver, BC, Canada.|Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada.|Centre for Clinical Epidemiology and Evaluation, Vancouver, BC, Canada.
authors.forename: Nick
authors.initials: N
authors.lastname: Bansback
authors.affiliation: School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.|BC Children's Hospital Research Institute, Vancouver, BC, Canada.
authors.forename: Patricia
authors.initials: P
authors.lastname: Janssen
mesh_terms: D001291:Attitude of Health Personnel; D002170:Canada; D017604:Cesarean Section, Repeat; D002755:Choice Behavior; D000066491:Clinical Decision-Making; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D057240:Patient Preference; D061214:Patient Safety; D011247:Pregnancy; D016064:Vaginal Birth after Cesarean
keywords: behavior; decision making; vaginal birth after cesarean