Vaginal birth after cesarean section: provider perspectives and maternal decision making.

Although evidence suggests vaginal birth after cesarean section (VBAC) leads to fewer complications in subsequent pregnancies, lower risk of maternal morbidity, and fewer cesarean sections overall, VBAC rates in Florida are at 5.5%, notably lower than the U.S. average of 8.0%. This exploratory study examines the factors contributing to these low VBAC rates through a qualitative investigation using grounded theory. Semi-structured interviews with women and maternity care providers were conducted to explore attitudes, motivations, and experiences regarding VBAC. Findings reveal a distinction between providers' and women's attitudes toward and experiences with VBAC and identify factors involved in decision-making. Three themes emerged: (1) patient-provider interactions; (2) perceptions of risks; and (3) rejection/adoption of biomedical authority. Women weighed the risks and benefits of VBAC through their perceptions and experiences of physical and emotional consequences, whereas providers relied on their experiences with medical practice, legal outcomes, policy, and evidence-based medicine. This exploratory research identifies a critical need for further attention to the disconnects between providers’ and women’s perspectives on and experiences with VBAC to address the tensions between biomedical and alternative forms of birth knowledge better and develop comprehensive VBAC guidelines that integrate the needs and concerns of women and providers. Florida Public Health Review, 2015; 12, 41-48. BACKGROUND Vaginal birth after cesarean section (VBAC) is a contested issue in the United States (U.S.). Although evidence suggests that VBAC leads to fewer complications in subsequent pregnancies and a lower risk of maternal morbidity compared to repeat cesarean sections (RCS), one-third of hospitals in the U.S. no longer offer VBAC (Cheng et al., 2011). In 2006, the national VBAC rate was 8.5% (Cheng et al., 2011) and was even lower in Florida, at 5.5% (MacDorman, Declercq, & Menacker, 2011). As demonstrated by the Healthy People 2020 goal to decrease the RCS rate from 90.8% to 81.7% in the U.S., there is growing concern about low rates of VBAC (U.S. Department of Health and Human Services, 2011). The concern with the rise in cesarean section is twofold. First, women appear to be undergoing unnecessary surgery, facing the potential complications of major surgery and its expenses. Second, high rates of cesarean section call into question women’s autonomy in decision-making in regards to labor and delivery. Thus, this exploratory research sought to understand why VBAC rates in Florida are so low if evidence based research supports VBAC as a legitimate birth option for many women. The objectives of this investigation were to: (1) explore maternal care providers’ (MCP) attitudes toward VBAC; (2) identify potential motivations behind these attitudes; and (3) document women’s experiences with VBAC in Tampa, Florida. The most commonly reported risk associated with VBAC is uterine rupture, which occurs at the site of the previous cesarean scar on the uterine wall (Guise et al., 2010). Although the risk is less than 1% (Shanks & Cahill, 2011) the possibility of maternal and infant mortality has resulted in this being a focal point when discussing VBAC. Since the 1970s, the incidence of cesarean section has increased steadily and is associated with a high risk of uterine rupture during attempted VBAC (American College of Obstetricians and Gynecologists, 2010). Consequently, the commonly heard phrase coined in 1916, “once a cesarean, always a cesarean,” continues to influence popular beliefs regarding VBAC risks (Cragin, 1916; Flamm, 2001).