Planning a VBAC in Australia

Planning a VBAC in Australia

Guest Blog by: Hazel Keedle

With the current caesarean rate of 37% for first time mothers in Australia there are on average over 46 thousand women a year having their first birth via caesarean section. Once a woman has a caesarean, she has a choice between planning a repeat elective caesarean or planning a vaginal birth after caesarean (VBAC) for her next birth. In Australia in 2018, the great majority (85%) of women with a previous caesarean had a repeat caesarean, 11% had a VBAC and 3.5% of women had an instrumental vaginal birth (AIHW, 2020) .

Research shows having a VBAC can be a safe and empowering experience for many women so why are the Australian VBAC rates so low? In this blog post I will explore the factors that research found increased VBAC rates and discuss their relevance here in Australia.

Factors that increase VBAC rates

There are some known factors associated with VBAC rates. Women who have had a previous vaginal birth prior to their caesarean, or women who have had a previous VBAC, have higher VBAC rates (Algert et al., 2008; Mercer et al., 2008) . As a midwife this makes sense to me. Women who have already birthed a baby through their vagina know they can do it and this gives a sense of confidence and understanding of their body’s abilities. This is very different when women haven’t yet birthed vaginally, in that instance the woman can have feelings of doubt and lack confidence in their birthing ability.

Another factor that increases VBAC rates is whether labour starts spontaneously (on its’ own). The alternative to this is having labour started with an intervention (induced). Women who were induced had lower VBAC rates (Wu et al., 2019) but having an induction can be a useful option in situations where an induction is required.

There has also been research that identifies women over the age of 40 and women with a BMI over 40 have lower VBAC rates (Wu et al., 2019; Yao et al., 2019) , this doesn’t mean that women with these factors can’t plan a VBAC but maybe need to look at other influential factors that may increase VBAC rates.

The maternity model of care women choose or are allocated to can have an impact on VBAC experience. Models of care can provide continuity of care (CoC) from a known provider, or from a small team of providers, in a shared care or primary carer format or provide a fragmented model where women see different providers at appointments (Sandall et al., 2016) . There is limited research on the impact of model of care for women planning a VBAC. A small study found women planning a VBAC with midwifery continuity of care had 20% higher rates of VBAC compared to women who had standard maternity care (Zhang & Liu, 2016) .

In my PhD study I explored women’s experiences of planning a VBAC in Australia. I found that women go on a journey from pain (their previous caesarean) to power (their VBAC) and along the journey there were positive peaks and negative troughs (Keedle et al., 2018) . In the qualitative phase of the study I found there were 4 important factors that influenced how women felt after their birthing experience following planning a VBAC. These are ‘having control’, ‘having confidence’, ‘having a relationship’ and ‘having active labour’. Feeling in control and confident during pregnancy, labour and birth, having a relationship with a health care provider based on support and equality and being active in labour resulted in women feeling positive and resolved after their birthing experience, regardless of having a VBAC or a repeat caesarean during labour (Keedle et al., 2019) . In the final phase of my PhD I undertook an Australian VBAC survey. The results found that women who had continuity of care with a midwife were more likely to feel in control, have more confidence, have a supportive and respectful relationship with their midwife and be more likely to be upright and active during labour and birth (Keedle et al., 2020) .

Women deserve to feel respected and in control of their choices, wishes and outcomes when they are planning a VBAC and research has shown that women who have continuity of care with a midwife can increase these feelings in women.

References:

AIHW. (2020). Australia’s mothers and babies 2018—in brief (Perinatal statistics series no. 36, Issue

Algert, C. S., Morris, J. M., Simpson, J. M., Ford, J. B., & Roberts, C. L. (2008, Nov). Labor before a primary cesarean delivery: reduced risk of uterine rupture in a subsequent trial of labor for vaginal birth after cesarean [Research Support, Non-U.S. Gov't]. Obstetrics and gynecology, 112(5), 1061-1066. https://doi.org/10.1097/AOG.0b013e31818b42e3

Keedle, Schmied, V., Burns, E., & Dahlen, H. (2018). The journey from pain to power: A meta- ethnography on women’s experiences of vaginal birth after caesarean. Women and Birth, 31(1), 69-79.

Keedle, H., Peters, L., Schmied, V., Burns, E., Keedle, W., & Dahlen, H. G. (2020, 2020/06/30). Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy Childbirth, 20(1), 381. https://doi.org/10.1186/s12884-020-03075-8

Keedle, H., Schmied, V., Burns, E., & Dahlen, H. G. (2019, Apr 29). A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory. BMC Pregnancy Childbirth, 19(1), 142. https://doi.org/10.1186/s12884-019-2297-4

Mercer, B. M., Gilbert, S., Landon, M. B., Spong, C. Y., Leveno, K. J., Rouse, D. J., Varner, M. W., Moawad, A. H., Simhan, H. N., Harper, M., Wapner, R. J., Sorokin, Y., Miodovnik, M., Carpenter, M., Peaceman, A., O'Sullivan, M. J., Sibai, B. M., Langer, O., Thorp, J. M., & Ramin, S. M. (2008, Feb). Labor outcomes with increasing number of prior vaginal births after cesarean delivery [Multicenter Study Research Support, N.I.H., Extramural]. Obstetrics and gynecology, 111(2 Pt 1), 285-291. https://doi.org/10.1097/AOG.0b013e31816102b9

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife‐led continuity models versus other models of care for childbearing women. Cochrane database of systematic reviews(4). https://doi.org/10.1002/14651858.CD004667.pub5

About Hazel Keedle

Hazel Keedle is a Lecturer and PhD candidate in the School of Nursing and Midwifery at Western Sydney University. Hazel is passionate about improving support for women during pregnancy, birth and the early transition to mothering. Hazel has more than two decades of experience as a clinician in nursing and midwifery, educator and researcher. Her research focuses on midwifery practice/education and women’s experience of maternity care.