Women’s Perceptions of Barriers and Facilitators to Vaginal Birth After Cesarean in the United States: An Integrative Review

Abstract

Introduction:

The purpose of this integrative review was to synthesize the literature on women’s perceived barriers and facilitators to achieving a vaginal birth after cesarean (VBAC).

Methods:

A search of Scopus and PubMed databases and relevant citations from 2000 to 2018 was conducted with 16 resources meeting inclusion criteria. PRISMA guidelines were followed.

Results:

Factors identified by women with a history of cesarean that act as facilitators or barriers to achieving a vaginal birth after cesarean included: (1) individual factors (knowledge, body and psychological), (2) social factors (culture and social support), and (3) system factors (provider, health system, and financial). Some factors related to barriers and facilitators reflected opposing aspects of the same phenomenon on a continuum.

Discussion:

Enhancing facilitators identified by women, while addressing perceived barriers may increase access to labor after cesarean for women in the United States. Increasing access to labor after cesarean may subsequently improve women’s experiences of care and decrease the US cesarean rate, positively affecting individual health outcomes and overall health of childbearing women in the United States.

PRECIS

Women’s perceptions on accessing labor after prior cesarean in the United States are complex, reflecting individual, social, and system factors.

INTRODUCTION

One out of 3 women who give birth in the United States each year will have a cesarean.¹ When compared to vaginal birth, cesarean birth is associated with an increased risk of morbidity for both the woman and the newborn. These risks include a higher likelihood of maternal mortality and long-term maternal surgical sequalae including surgical adhesions, chronic pelvic pain, abnormal placentation, and infertility.^2,3 These risks increase with each subsequent surgery.^4,5 Benefits of vaginal birth for a woman include shorter recovery time and hospital length of stay,⁵ and higher rates of breastfeeding initiation and success.⁶ A vaginal birth conveys benefits for the infant as well, including lower rates of respiratory distress,⁷ a transfer of beneficial bacteria from maternal vaginal flora,⁸ and the experience of birth’s hormonal cascade in preparation for life outside the womb.^9,10

Each year, almost 600,000 women in the United States who have experienced cesarean birth will give birth to a subsequent child.¹¹ A majority of these women are medically eligible to labor after cesarean,¹² with the anticipated outcome of a vaginal birth after cesarean (VBAC). Professional organizations representing midwives and obstetricians, and the National Institutes of Health recommend labor after cesarean and VBAC for women who are medically eligible.^12–14 Approximately 74% of women who labor after cesarean will have a successful VBAC.¹² Despite professional recommendations and a high likelihood of VBAC success, only 13.3% of women with a history of cesarean will have a subsequent VBAC.¹⁵

The reasons for low VBAC rates are complex. One potential reason is that labor after cesarean resulting in unintended cesarean birth is associated with the highest risk of maternal and newborn adverse outcomes.^14,16 For women with a history of cesarean, a VBAC is the safest mode for a subsequent birth, followed by a planned repeat cesarean birth.^14,16 Although the safety of labor after cesarean has been well established, availability of labor after cesarean continues to be limited.^17–19 In the most recent 2013 Listening to Mothers survey, 46% of women interested in VBAC were unable to choose to labor after cesarean and the most common reasons given were a medical reason unrelated to their prior cesarean (45%), unwillingness of their caregiver (24%), or unwillingness of the hospital (15%).²⁰ These surveys indicate a need to more fully understand what facilitates or limits a woman’s ability to access, choose, and collaboratively plan to labor after cesarean with her health care provider in the United States.^4,21

Following input from a large team of experts in the field and an extensive systematic review of the research,² the 2010 National Institutes of Health (NIH) Consensus Development Conference on VBAC identified 10 critical gaps in the evidence for decision making about birth after cesarean.^{12(pp30−32)} The panel concluded that a variety of medical and nonmedical factors (i.e. geography, workforce training and availability, health insurance, institutional policy) affect access to labor after cesarean, but noted that these factors have not been well studied.¹² The panel also cited other influential factors on women’s preferences (such as sociodemographic status, social norms, values, and beliefs) as also important but not well understood.¹²

In order to further understand the experiences of US women who have sought to attempt a VBAC and to address the knowledge gaps identified by the NIH Consensus Development Conference, the purpose of this integrative review was to synthesize the existing literature to identify women’s perceived barriers and facilitators to accessing the potential to labor after cesarean in the United States.

METHODS

An integrative review of the literature was conducted using Whittemore and Knafl’s methodology.²² Integrative reviews are the broadest type of research review method, allowing for the inclusion of diverse literature sources to more comprehensively understand complex health care situations.²² Steps in the process include a systematic literature search, determination of manuscript eligibility, evaluation of quality, and data extraction. Using data displays, data analysis, comparison, conclusion drawing and verification was completed.²³ PRISMA Guidelines were followed (Figure 1).²⁴

Figure 1:

Search Strategy: PRISMA 2009 Flow Diagram

Adapted from: Moher D, et al.²⁴

The sources in this literature review used a variety of terms (i.e., VBAC, planned VBAC, TOLAC) when referring to women who had the ultimate goal of a VBAC. A common term in the literature is “trial of labor after cesarean” (TOLAC) as described in the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin #205 on VBAC.¹⁴ The Royal College of Obstetricians and Gynecologists (RCOG) uses the terms “birth after caesarean” and “planned VBAC”²⁵ and the American College of Nurse-Midwives uses the term “labor after cesarean”.¹³ For simplicity, we have chosen to use the emerging term “labor after cesarean” rather than TOLAC in our writing.

Search Strategy

A literature search was completed in September 2019 using the databases of Scopus and PubMed with consultation from a medical librarian. The following search terms were combined with VBAC and TOLAC using the “AND” search language: barrier (i.e. “VBAC AND barrier”), facilitator, facilitate, access, experience, perception, success, support. Additionally, a search for “VBAC” in the ProQuest database was completed to identify unpublished dissertations. Because the number of published research studies describing women’s experiences of VBAC in the United States is small, nontraditional resources such as dissertations and gray literature describing women’s experiences of VBAC were included since they contained a significant amount of rich data on the topic. Article reference lists, and the “similar articles” and “cited by” tools on PubMed and Scopus were hand searched to ensure thorough data discovery.

Inclusion criteria included research conducted with women in the United States and articles reporting on the experience from the woman’s perspective. To capture the experiences of women who are most medically-eligible to labor after cesarean, exclusion criteria included out-of-hospital birth location, multiple gestation, and women with more than one prior cesarean birth. Sources from 2000–2018 were included based on historical VBAC trends in the United States. The US VBAC rate dropped from approximately 28.2% to 10.3% between 2000–2005.²⁶ Therefore, the current state of access to labor after cesarean is quite different from the prevalence of labor after cesarean in the mid to late 1990s. Consequently, publications from the 1980s and 1990s were excluded.

The quality of the peer-reviewed qualitative studies and the qualitative dissertations was evaluated using the National Institute for Health and Care Excellence (NICE) quality appraisal checklists for qualitative studies.²⁷ The resources included in this review scored the highest possible score (“++”), indicating the studies have been designed to minimize bias.²⁷ The quality of the peer-reviewed quantitative studies was evaluated using the Critical Appraisal Skills Programme (CASP) Cohort Study Checklist.²⁸ The CASP checklists do not give a score, but the included quantitative studies fulfilled the entire checklist, indicating sufficient quality. Non-research resources were evaluated for authenticity and informational value as described by Whittemore and Knafl.²²

Data from the included resources were extracted using a template matrix that included the following headings: year of publication, sample number and characteristics, study design type, purpose, methods of data collection and analysis, and any text describing barriers and facilitators as perceived by women. Descriptive phrases for barriers and facilitators were identified and the data were coded with these descriptors.²² Patterns and types of barriers and facilitators were then identified from the coded data. Verification that all of the data were coded and assigned an appropriate label of type of barrier or facilitator was then completed by carefully reviewing the matrix. Data coding and analytic decisions were verified and agreed upon by all three authors.

RESULTS

The data sources used in the final data collection and analysis included, 6 qualitative studies,^29–34 3 quantitative studies,^20,35,36 2 literature reviews,^21,26 2 dissertations describing qualitative studies,^37,38 1 patient education article,³⁹ 1 investigative reporting book,⁴⁰ and 1 law journal article.⁴¹ (Table 1)

Table 1:

Summary Table of Data Sources (in chronological order)

1st Author, Year	Purpose	Study Design/Type; Method; Sample/ N	Results
Fransisco 201830	To explore the cesarean and VBAC experiences of black women	Qualitative Narrative analysis of birth stories posted online 39 birth stories posted by women identified as Black	Prior experiences of cesarean continued to impact black women’s lives as they decided whether to have another child. They often chose VBAC to regain their agency. Gaining knowledge allowed black women to make informed choices about their subsequent birth, leading to healing and becoming empowered.
Konheim-Kalkstein 201531	Capture why women initially post messages on internet discussion boards	Qualitative and quantitative Content analysis of posts Chi squared analysis 300 posts on VBAC on U.S. based website discussion board	Women contemplating a VBAC sought more information on health care providers, more information about labor and delivery, and actively sought birth narratives from other women.
Hill-Karbowski 201437	Gain insight into the comparative experience of VBAC and cesarean	Qualitative study using birth stories from interviews as data (Dissertation) Feminist perspective Purposive sample of 13 women; southeastern area of Wisconsin; Demographics collected but not specified	Four themes identified: perspectives on cesarean, informed decision making, perspectives on VBAC, and cesarean resolution.
Keegan 201438	To determine what influences a woman’ decision-making to have a VBAC	Qualitative study of diverse sample of women about how they make their choice to VBAC or schedule a repeat cesarean (Dissertation) Grounded theory method; prospective: first interview while pregnant and planning VBAC 16 women in New York City; 12 white, 4 black; 15 privately insured	Identified influencing factors in choosing VBAC: previous birthing experiences; internalized cultural ideals about birthing and parenting; the patient-provider relationship.
Konheim-Kalkstein 201435	Examine differences among women who were deciding about mode of birth after cesarean	Quantitative: one-way ANOVA and Gabriel’s pair-wise comparison test Online survey (agree vs disagree with certain statements) 166 pregnant women and 117 intending to become pregnant; all with previous cesarean; contacted once before their subsequent birth; no demographic characteristics listed	Women planning to have a VBAC perceived a cesarean as the riskier option, while women choosing repeat cesarean perceived a VBAC as the riskier option. Women who planned to have a VBAC were less satisfied overall with their first birth. Women who are planning a VBAC have a higher internal locus of control for labor and delivery and a lower ‘powerful others’ locus of control than woman planning a repeat cesarean. Women who plan to have a VBAC may be more influenced by online sources and less influenced by healthcare providers, relative to women who plan a repeat cesarean.
Pratt 201441	Part I: To discuss the history of VBAC, emergence of VBAC bans, medical research and relevant legal framework; Part II: voluntary policies and laws that restrict VBAC access; Part III: impact of restrictions on women	Law journal review	Policies prohibiting VBAC are generating a public health crisis. A high cesarean rate combined with a lack of available VBAC options burdens the healthcare system, puts women at unnecessary risk, and limits patient choice. Improving profits nor protection from liability are not adequate justifications to reduce women’s rights in pregnancy.
Dahlen 201329	Examine how women use blogs as a source of data on VBAC	Qualitative study of internet blog sites and posts Thematic analysis of content of blog postings 311 blog posts mentioning VBAC in one year; Authors presumed that most are US women based on the source blogs’ website	Themes identified: surviving the damage; inadequate bodies; choice and control; fearing and trusting birth; negotiating the system; and minimizing or overestimating risk.
Declercq 201320	Understand the experiences and views of childbearing women in the United States and capture longitudinal trends	Survey of 2400 women across the U.S. who gave birth mid-2011 to mid-2012; weighted to be representative of the target population.	14% of women with a history of cesarean had a VBAC. 48% of women with a history of cesarean were interested in a VBAC; of those 46% were denied the option for medical reasons unrelated to the prior cesarean (45%), unwillingness of the provider (24%) or hospital (15%). Among women with a history of cesarean, 97% had a discussion with their provider about a repeat cesarean and 60% indicated there had been discussion about why they should have a VBAC. When their provider expressed an opinion, 88% of the time it was in favor of repeat cesarean.
Fineberg 201221	Reviewed the current literature and summarizes opinions of community obstetricians and midwives.	Literature review and clinician perspective; drew on authors’ experience in a community hospital with a previously high VBAC rate and a subsequent ban.	Used descriptive data to document the scope of the problem and identify barriers: liability concerns, provider biases, and institutional restrictions.
Soliday 201233	Identify conceptualizations of maternal autonomy in accounts of VBAC	Qualitative analysis of 3 case presentations gleaned from interviews for a larger study of maternity practices Interviewed women in late pregnancy and early postpartum 18 women who had a VBAC, selected from a group of 75 study participants in a larger study	Used 3 representative maternal accounts obtained prior to and after birth after cesarean to describe how current scientific knowledge and obstetric practices factor into restricted maternal autonomy.
Korst 201126	Identify nonclinical barriers to VBAC	Literature review	Identified 5 categories of factors that appear to influence rates of TOLAC / VBAC: opinion leaders and professional guidelines, hospital facilities and cesarean availability, reimbursement for providing TOLAC, medical liability, and patient-level factors.
Namey 201034	Deconstruct the meaning of the word “control” used by childbearing women; focus was not specifically on VBAC	Qualitative analysis of interviews/ birth narratives 101 parous women in the US; purposive sampling for variety of experiences & diversity; Southeastern US metro area	Analyzed meanings of control within the context of birth narratives, which corresponded to 5 domains: self-determination, respect, personal security, attachment, and knowledge.
Romano 201039	Examine role of online social networks in informing women about VBAC, produce decision aids and enabling stakeholder collaboration to remove barriers in VBAC access	Patient education journal article	Social media and the online community can help to empower and equip women to contribute to research, policy making, care quality improvement, and advocacy.
Block 200740	A narrative investigation seeking to present the complete picture of US maternity care.	Investigative reporting book	US women face multiple challenges in accessing providers or hospitals that will offer VBAC, including submitting to unwanted cesareans due to lack of other options. These challenges can result in determination to VBAC by waiting until crowning to go to the hospital or giving birth at home (sometimes attended and sometimes not), Emphasized emotional toll on women.
Declercq 200736	Identify areas to improve conditions of birth, including the experiences of women with a history of prior cesarean	Quantitative survey Phone and internet surveys; statistical analysis of results; Adjusted to be representative of national sample 1573 women who had singleton births in US hospitals in 2005	11% of women with a previous cesarean had a VBAC; 45% of women with a previous cesarean were interested in the option of a VBAC, of those 57% were denied that option. The reasons given were unwillingness of their caregiver (45%) or the hospital (23%), followed by a medical reason unrelated to the prior cesarean (20%).
Ridley32 2002	To discover what influences women to VBAC	Descriptive qualitative phenomenology 5 white women who had a VBAC 2–4 months prior to the study; recruited from rural Southeastern US	Major influences that affect a woman’s decision to choose VBAC are: the woman’s sense of control in the decision-making process; provider encouragement for VBAC; and delivery type outcome advantages, incorporating physical and emotional factors.

Abbreviations: VBAC, vaginal birth after cesarean; ANOVA, analysis of variance; TOLAC, trial of labor after cesarean

The resources varied widely with regard to sample size, demographic characteristics, location, sampling method, and type of data collected and presented. Samples included 2 nationally representative surveys of 1500–2400 postpartum women,^{24, 26} a purposive sample of 13 women in southeastern Wisconsin,³⁷ a racially diverse sample of 16 well-educated, mainly privately insured women in New York City,³⁸ analyses of 300 anonymous internet blog posts,²⁹ and 310 posts on internet discussion boards about VBAC.³¹

Woman-Perceived Barriers and Facilitators to Accessing VBAC

Factors that act as barriers and facilitators to accessing labor after cesarean reported by women in the literature are presented in Figure 2. Barriers and facilitators were identified and categorized into three types: (1) individual factors (knowledge, body, and psychological), (2) social factors (culture and social support) (3) system factors (provider, health system, and financial). It is important to note that most factors related to barriers and facilitators were similar, reflecting opposing aspects of the same phenomenon. Exemplary quotes are presented in Table 2.

Figure 2:

Continuum of Factors Affecting US Women’s Access to Labor After Cesarean

Table 2:

Woman-Experienced Factors Related to Accessing VBAC in the United States and Exemplary Quotes

Specific Factor	Exemplary Quote
Lack of knowledge20,26,33,37,41	“Women anticipating birth in a hospital prohibiting VBAC are often unaware of their right to refuse the surgery, or they do not know how to assert those rights.”41(pp117−118); author
Body: Body as inadequate29,33	“Her reasoning is that because I’ve laboured before and dilated fully to 10 cm and was still unable to get my baby out that chances are my pelvis is either misshapen or too small.”29(p170) a; research participant
Psychological: Fear and concern about risk29,33,38	“… most agree that the safest place for me is to VBAC in a hospital with a supportive staff. I am scared over these risks, no matter how small, and frightened of these doctors who would judge me harshly …”29(p171); research participant
Psychological: Concern about loss of control29,38	“As much as I want to be in control, I’m not in control of that experience.”38(p90); research participant
Knowledge30,32–34,37,39	“I was armed with all that information when I went in to talk to the doctor”32(p668); research participant
Body: Belief in birth/ trust in body20,29,30,32,34,38	“I’m doing this, I know what my body’s doing, it can do this.”34(p774); research participant
Body: Expected easier recovery33,38	“I always thought that there were so many advantages to doing the VBAC, and the biggest one in my mind was really the quicker recovery time.”38(p87); research participant
Body: Prior vaginal birth38	“Both definitively stated that they had a superior experience with their [previous] vaginal birth: ‘I had a great birth experience with him. It was really good.’”38(p69); author and research participant
Psychological: VBAC as healing29,30,38	“… I was in disbelief. My body had done this all on its own, my body wasn’t a failure … I used to cry whenever I talked about the birth of my oldest children. I felt empty and like something was stolen from me. But now I feel like I have healed…”30(p86); research participant
Psychological: Sense of control30,32,37,38	“I had a lot more control over [the decision whether to attempt VBAC or have a repeat cesarean].…I had a lot more input … a lot of it is control.”32(p668); research participant
Psychological: Self-advocacy30,33,37	“Unlike with my first pregnancy, I was educated about the different interventions and medications and was able to advocate for myself. I was confident and bold enough to say no when the doctors on call attempted to rush and intimidate me into breaking my water too early. I was bold enough to fire one doctor who was clearly not in support of my VBAC and was cocky and even rude …”30(p85); research participant
Psychological: Determination30,32,34,37	“So you’re in this stigma that you can’t do it and obviously I wanted to prove everybody wrong that I can do it”37(p199); research participant
Support of other women29,30,37,39	“In preparing for the birth of my second child and talking to many other women who were doing the same”29(p170); research participant
Family support33,37	“We looked up research together, and we were trying to make the decision mutually but he kept saying this is your body…whatever you want to do it is your body…I’ll support you.”37(p194); research participant
Cultural factors38	“I guess it’s [decision to plan VBAC] partly probably our generation is, like, big on the natural birth thing and breastfeeding. And as my friends have, like, started to have kids and the conversation about birth has happened, more and more people talk about midwives and trying to do it naturally.”38(p67); research participant
Unsupportive provider20,26,29–31,33,35–37,40,41	“I was always told by my doctors that because I had my first c-section that I would have to keep having them, even though my first c-section was the result of an induction gone wrong. There was no medical reason that I couldn’t have a vaginal birth, so when I discovered other women were having vaginal births after c-sections I was angry. I felt lied to … manipulated.”30(p82); research participant
Health system barrier: VBAC bans20,21,26,29,33,36,38–41	“Pregnant with her fourth child, [JZ] planned to give birth at her local hospital, as she had done with her first three children. However, just a few months short of her due date, her doctor informed her that due to a recent change in the hospital’s policies, she would have to schedule a cesarean. During her second pregnancy, [JZ] had a placental abruption and an emergency cesarean. Although she had a successful vaginal birth with her third pregnancy, the hospital is one of hundreds of hospitals that prohibit vaginal birth after cesarean (VBAC), and their new policy would require her to have a medically unnecessary cesarean that she did not want.”41(p105); author
Health system barrier: Distance20,21,26,31,36,41	“I am having an impossible time finding a hospital that does VBACs in my state that isn’t over 2 hours away!”31(p279); research participant
Financial: Insurance38,40	“Insurance would only cover delivery at [X] Hospital and she called every obstetrician with privileges there. Just one told her she would allow a vaginal birth, but she added that [she] was too far along to transfer care.”40(p142); author
Financial: Lack of resources21,41	“Many other women have chosen repeat [cesarean] at our facility due to lack of resources rather than preferences. Half of our obstetric patients are [publicly] insured. They frequently do not have reliable transportation, family support, or education that would enable them to seek delivery in another city and hospital.21(p1001); author
VBAC supportive provider29,32,35,37,38	“Sally is the fourth provider I’ve seen during this pregnancy and I just started with her at 28 weeks! It took me that long to find a provider AND a hospital that would be supportive in this endeavor [VBAC]!!”29(p171); research participant
VBAC supportive policies and procedures29,37	“You could tell they [the birth unit nurses] were all rooting for me to have this baby vaginally…they all knew that I wanted to have the vaginal birth.”37(p200); research participant

^a“Labour” is used instead of “labor” throughout the Dahlen et al study,²⁹ likely because it was published in a UK-based journal. However, they noted that most of the blog posts were from US women.

Individual Factors

Individual factors that acted as barriers to accessing labor after cesarean included: lack of knowledge, body factors and psychological factors. Lack of knowledge about their medical eligibility^33,37,42 or option to labor after cesarean⁴¹ acted as a barrier to planning their subsequent birth for many women.

Women’s perceptions of their previous labor or cesarean birth that led them to believe their body was broken or inadequate for childbirth were categorized as body factors.⁴³ These factors also included the perception that they could not give birth vaginally³³ or that labor would be too painful.²⁹ These factors also acted as barriers to some women considering labor after cesarean.

Psychological factors that acted as barriers included fear, concern about loss of control, and concern about risk.^29,33,38 In one source, vaginal birth was described as unknown and therefore frightening for women who were considering this option.²⁹ Women were also concerned about loss of control during vaginal birth.³⁸ Concern about risk of harm to mother or baby during an attempted VBAC was also mentioned by women as a barrier.⁴³

The same individual factors identified as barriers to labor after cesarean also could also be perceived by women as facilitators. Knowledge of physiologic birth and options for birth after cesarean was one of the most commonly described facilitators to accessing a labor after cesarean.^{30,32–34,37,39} Women described knowledge as empowering. “The biggest thing for me was the success rate … 80% of the women who tried it were able to do it.”^32(p669) Women reported that they gained knowledge from a variety of sources including providers, other women, books, the internet, and medical journals.

Multiple facilitators related to women’s perceptions of their bodies included having a belief in birth or trusting one’s body to birth,^{29,30,32,34,38} expecting an easier recovery following vaginal birth when compared to cesarean birth,^33,38 and having a prior experience with vaginal birth.⁴² Some women viewed vaginal birth as beneficial, natural, and healthy and they reported confidence or trust in their bodies to birth vaginally.^32,38

Women with a history of cesarean birth are generally caring for children during a subsequent pregnancy. Childcare and family obligations were identified as influences on their choice of birth method. Some women perceived that VBAC contributed to an easier recovery and an increased ability to meet childcare and family obligations.^33,38 One woman stated, “I was so worried about how life was going to go with a toddler and a newborn, while I was recovering from a major surgery.”^38(p87) Having a positive experience in a previous vaginal birth or having familiarity with vaginal birth also alleviated the fear of the unknown and gave women confidence that they could achieve a VBAC.^38,43

The psychological factors that acted as facilitators for labor after cesarean included self-advocacy and determination, having a sense of control over their birth experience during labor, and the perception of achieving a VBAC as healing.^29,30,38 Many women shared stories of how they acted as their own advocates in the prenatal decision-making process and during labor and birth.^30,33,37 Some women reported a determination that they were going to achieve a VBAC, regardless of the opposition or challenges faced, stating “I’m doing this.”³⁴ and similar sentiments.^30,32,34,37 Feeling in control of their labor and birth was often perceived as lost during previous cesarean surgeries.³⁸ Some woman felt that by planning labor after cesarean, they were able to regain this control over their medical decision making, their lives, and their bodies.^32,38 Some women perceived their VBACs to be a healing experience. Keegan (2014) described the achievement of VBAC as healing emotional damage from previous cesarean birth.³⁸

Social Factors

The social support provided by family members^33,37 and other women,^29,30,37,39 as well as belonging to a culture that supports and values vaginal birth,³⁸ were perceived by women to be facilitators to accessing labor after cesarean. Having a partner or other family members who were supportive of decisions to plan a labor after cesarean acted as a facilitator for many women. Women reported that the support of other women was extremely helpful in planning for a labor after cesarean. This support was found online^31,37,39 and in person through support groups and doulas present at the birth.^30,38,43 Belonging to a culture that places a higher value on vaginal birth than on medicalization and intervention³⁸ was perceived as helping women have confidence to plan a VBAC.

Health System Factors

System factors perceived as barriers by women interested in labor after cesarean included unsupportive providers, unsupportive health system practices and policies, and financial factors. Providers who were perceived as unsupportive used negative language²⁹ or declined to give women the option to labor after cesarean.⁴⁰ Perceptions of an unsupportive system included descriptions of an official VBAC ban or a de facto ban, where VBAC was not technically disallowed but there were no providers offering to attend women who desired to labor after a prior cesarean.^{21,26,29,33,36,38–41} Another perception of an unsupportive system were hospitals that threatened negative action against women who refused to consent to a repeat cesarean, such as calling child protective services⁴¹ or obtaining a court order to operate on the woman without her consent.^39,40 Distance was also a system barrier.^{21,26,31,36,41} Many women lived too far from a hospital that offered VBAC to make it a feasible option for birth. In 2 studies, women stated that the closest hospital that allowed VBAC was more than 2 hours away.^31,36

Financial factors included women’s medical insurance coverage and availability or lack of resources, which often impacted her ability to plan a labor after cesarean. Insurance coverage for a specific type of provider or hospital was a barrier reported by some women.^38,40 For example, one woman’s insurance limited her to give birth in a specific hospital, at which she could not find a provider willing to take her as a patient or to plan a labor after cesarean.⁴⁰ In another study, a group of women who desired midwifery care for their prenatal care and labor were unable to obtain it due to lack of insurance reimbursement for midwives.³⁸ Some women reported a lack of financial resources to access an out of network provider, a VBAC supportive hospital,^21,41,42 or a lack of reliable transportation to travel to a more distant VBAC supportive hospital.^21,41

System factors that women described as facilitators to accessing a labor after cesarean included having a VBAC supportive provider and giving birth within a VBAC supportive healthcare system; these are the inverse of the systemic barriers to accessing VBAC. Many women recognized the importance of a provider who was supportive of VBAC in order to give them access to different birth options.^{29,30,32,35,37,38} Some women reported switching providers or having multiple providers in one pregnancy, to facilitate their access to labor after cesarean.²⁹ A supportive system also included VBAC supportive hospital policies, and a VBAC supportive culture on the labor and delivery unit.^29,37 One woman described the nurses’ support for her during her labor after cesarean as helpful in achieving a VBAC.³⁷

DISCUSSION

The purpose of this integrative review was to identify barriers and facilitators to planning a labor after cesarean as perceived by women who were eligible for labor after cesarean in recent studies conducted in the United States. Women’s perceptions were complex, reflecting individual, social, and system factors. Individual factors included knowledge, body, and psychological concerns. Social factors reflected the various influences from the interpersonal realms of culture and social support. System factors included the woman’s relationship with her provider, health system policies and practices, and financial factors.

Many factors affecting a woman’s experience accessing labor after cesarean could be conceptualized as being on a continuum, acting as either a barrier or facilitator (Figure 2). For example, many facilitators were the direct inverse of a barrier including the continuums described by the following terms: (a) knowledge or lack thereof, (b) experience with vaginal delivery and fear of an unknown vaginal delivery, (c) a woman’s sense of control and concern about loss of control, (d) a woman’s trust in her body or perceptions of her body as inadequate, and (e) support versus nonsupport of provider, system, family, and culture. Although some of these factors are relatively immutable, some may have the potential to be modified through clinical interventions, practice change, education, or policy change.

Results of previous research on decision making for birth after cesarean, providers’ perceptions about barriers and facilitators to accessing VBAC, and women’s experiences of VBAC internationally include similar factors to those identified in this review. Specifically, providers in the United States and women using international health systems also identified knowledge,^44–47 social support,^{44–46,48–50} the quality of the relationship with their provider,^{44,46,50–52} and skill in navigating the health system as integral factors in their experience accessing a labor after cesarean.

Women in many high resource countries have identified access to unbiased knowledge as a key facilitator in their planning and obtaining a VBAC.^44–47 Increased knowledge about the risks and benefits associated with VBAC versus repeat cesarean was found to be positively associated with the decision to labor after cesarean.⁵³ However, Bernstein et al reported that at the time of admission for birth, many women continued to demonstrate a lack of knowledge about risks and benefits of repeat cesarean versus VBAC.⁵⁴ These knowledge deficits about birth options after previous caesarean may constrain women’s choices to seek access to VBAC.⁵⁵ Knowledge of risks and benefits of birth options might also help to address women’s fear and concern about their body being inadequate for birth.

In international studies of women’s experiences, social support identified by women with a history of cesarean included peers and family, support groups, and the internet.^{44–46,48–50,56} Social factors, such as the support of her choice by her partner, family, friends, and provider, appeared to play a stronger role in women’s decision making about mode of birth after cesarean than their perceptions of risk or health concerns.⁴⁸ As identified in this review, a woman’s partner also has considerable influence on the decision about mode of birth,^49,50 as does a woman’s perception of support for her choice by her family, friends, and provider.^44–46 Similar to results of this review, previous research supports that women view their provider as a very valuable source of information about pregnancy and birth⁵¹ and women perceive a supportive clinician as a key facilitator for a successful VBAC.^44,46 A positive relationship with a provider is of critical importance⁵⁰ as it has been found that providers’ preference significantly affects a woman’s choice of mode of birth after cesarean.^52,54

Implications for Practice, Policy, and Research

Consistent, balanced, and evidence-based health education about risks and benefits of labor after cesarean is important for women to make informed decisions collaboratively with their healthcare provider. Ideally, this communication occurs as part of shared decision making wherein women and providers take time to work together to understand the woman’s knowledge, values, and beliefs in order to better tailor care and education to their needs.⁴⁷ While time in prenatal appointments can be limited, efforts could be made to provide unbiased information about options for birth after cesarean at multiple appointments during the course of prenatal care, to allow women to process information.¹⁴ Reviewing the specific reasons why labor after cesarean is or is not medically recommended may help to dispel a woman’s ideas about her body being broken or inadequate for birth. There are mixed findings on postpartum debriefing about the birth experience⁵⁶ and there are no studies that have evaluated the effect of postpartum debriefing after an unplanned cesarean on future birth choices. However, a conversation between a woman and her provider after an unplanned cesarean may be helpful to answer questions about what occurred during an unplanned cesarean birth and to open a dialogue about options for future births. This is also an important area for future inquiry.

Although there were similarities between barriers and facilitators; individual factors were more frequently described as facilitators and system factors were more often described by women as barriers to VBAC. Strong evidence about the safety of labor after cesarean for women who are medically eligible¹⁴ may be used to advocate for a repeal of VBAC bans in hospital systems in order to decrease the number of hospitals that do not permit VBAC.⁴¹ Increasing training and education about VBAC for providers could increase provider confidence to support labor after cesarean.⁵⁷ Medicolegal reform⁵⁸ through changes to patients’ health insurance and providers’ malpractice insurance may create a climate that is more conducive to providers and hospitals offering VBAC.^57,59,60 Further research on long term health outcomes for both women and children born via VBAC versus cesarean can help guide clinical decision making. The support of other women who have experienced pregnancy and birth after cesarean was identified as a strong facilitator, thus future research could explore the role of peer-support networks and birth support persons or doulas in facilitating women’s access to VBAC.

There are several limitations of this integrative review. Because of the small number of studies of women’s experiences of labor after cesarean in the United States, some of the resources used in this review were not peer-reviewed, published, research studies. The 2 dissertations, evaluated as the highest score for quality using the NICE criteria,²⁷ contained the largest amount of data relevant to the study purpose. Another limitation is that Dahlen et al²⁹ stated that the authors assumed that a majority of their discussion board data originated in the United States. Additionally, a number of the resources used in this analysis,^{32,34,36,39,40} were conducted or written before the publication of the 2010 NIH Consensus on VBAC¹² and the 2010 ACOG practice bulletin.⁶¹ Thus, the experiences of the women in these resources cannot be assumed to be reflective of current practice in 2019 or the effect of these guidelines on access to care. Further research is needed on women’s contemporary experiences of pregnancy and birth after cesarean as VBAC rates remain low and relatively unchanged.

CONCLUSION

The findings of this integrative review indicate that women residing in the United States have experienced individual, social, and system factors that act as barriers and facilitators to planning a labor after cesarean. These findings may be used to inform future research on VBAC, advocate for practice change, develop interventions, and for changes in policy. Practice and policy change may be developed to build upon women, provider and system facilitators, while simultaneously addressing perceived barriers to VBAC to increase access to VBAC for women in the United States. Increasing access to VBAC for women who are eligible may improve their experiences of care and decrease the US cesarean rate, thus improving health outcomes.

Quick Points:

1. VBAC rates in the United States are low but the reasons for this are not well understood.

2. Women’s perceptions about their ability to attempt a VBAC in the United States included individual, social, and system factors. These factors fall on a continuum for each woman, acting as either a barrier or facilitator.

3. Individual factors, including knowledge, self-determination, and a sense of control, account for the majority of facilitators to women planning labor after cesarean. Factors related to the health system: relationship with maternity provider, unsupportive health system practices and policies, and financial factors represent a majority of the barriers to women planning labor after cesarean in the United States.

4. Improving women’s knowledge and personal control can be augmented through practice and policy changes to decrease barriers and improve their potential to attempt a VBAC. Increasing women’s access to labor after cesarean in the United States may decrease cesarean rates thereby improving individual health outcomes and overall US public health.

Biographic sketches:

Bridget Basile Ibrahim, MA, MSN, FNP-BC is a PhD Candidate at Yale University.

Holly Powell Kennedy, PhD, CNM, FACNM, FAAN is the Helen Varney Professor of Midwifery at Yale University.

Robin Whittemore, PhD, APRN, FAAN is a Professor of Nursing at Yale University.