“I had to fight for my VBAC”: A mixed methods exploration of women’s experiences of pregnancy and vaginal birth after cesarean in the United States

Abstract

BACKGROUND:

Vaginal birth after cesarean (VBAC) is safe, cost-effective, and beneficial. Despite professional recommendations supporting VBAC and high success rates, VBAC rates in the United States (US) have remained below 15% since 2002. Very little has been written about access to VBAC in the US from the perspectives of birthing people. We describe findings from a mixed methods study examining experiences in seeking a VBAC in the US.

METHODS:

Individuals with a history of cesarean and recent subsequent birth were recruited through social media groups. Using an online questionnaire, we collected sociodemographic and birth history information, qualitative accounts of participants’ experiences, and scores on the Mothers on Respect Index, the Mothers Autonomy in Decision Making Scale, and the Generalized Self-Efficacy Scale.

RESULTS:

Participants (N=1711) representing all 50 states completed the questionnaire; 1151 provided qualitative data. Participants who planned a VBAC reported significantly greater decision-making autonomy and respectful treatment in their maternity care compared with those who did not. The qualitative theme: “I had to fight for my VBAC” describes participants’ accounts of navigating obstacles to VBAC, including finding a supportive provider and travelling long distances to locate a clinician and/or hospital willing to provide care. Participants cited support from providers, doulas, and peers as critical to their ability to acquire the requisite knowledge and power to effectively self-advocate.

DISCUSSION:

Findings highlight the difficulties individuals face accessing VBAC within the context of a complex health system and help to explain why rates of attempted VBAC remain low.

Introduction

Vaginal birth after cesarean (VBAC) is generally a safe^1–4 and cost-effective^5,6 option for birth. Vaginal birth conveys long and short term benefits to women^7–9 and their children.^7,10–13 Evidence of emotional benefits from VBAC includes improved bonding,¹⁴ higher birth satisfaction,¹⁵ maternal empowerment and emotional well-being.¹⁶ Cesarean birth, in addition to the risks of major surgery,^17–20 also carries a higher incidence of abnormal placentation and complications in future pregnancies, with elevated risk for morbidity and mortality.^21–23 These risks increase with each subsequent surgery.²⁴

Annually, over 600,000 US people with a prior cesarean birth have a subsequent birth.²⁵ Despite professional recommendations for VBAC for most^1,3,4 and an average success rate of 74% when attempted,⁴ only 13% of US individuals had a VBAC in 2018,²⁶ a rate that has remained below 15% since 2002.²⁷ Reasons for this are poorly understood. Very few studies describe the experiences of people who desire a VBAC, despite a decade of nationally-representative surveys reporting that nearly half of US women interested in planning a VBAC were denied the opportunity.^28–30 One recent review of literature indicated that people often have to go to extraordinary lengths in order to attempt a VBAC.³¹ The purpose of this study was to investigate how US women who desired a VBAC navigated a subsequent pregnancy and childbirth. We investigated their experiences and their perceptions of respectful care, self-efficacy, and autonomy in decision making.

Methods

We used a convergent parallel mixed methods design where quantitative and qualitative data were collected simultaneously, analyzed separately, and then merged.³² The merged results were interpreted through a joint display to determine if convergence existed.

Questionnaire development and measures

The cross-sectional web-based, self-administered questionnaire (online supplement) was administered via the Qualtrics (Qualtrics, Provo, UT) platform. The questionnaire was comprised of a patient screening and birth history form and three validated instruments: the Mother’s Autonomy in Decision Making scale (MADM),³³ the Mothers on Respect Index (MOR),³⁴ and the Generalized Self Efficacy Scale (GSE).³⁵ Qualitative data were collected from an optional open-ended prompt: “Please share anything you feel is unique, interesting, or notable about your pregnancy and birth experiences.” The screening and birth history form was content validated prior to the start of the study³⁶ by vetting the questions with 21 individuals who had recently given birth. Based on their feedback, the questionnaire was edited for clarity and sensitivity.

Participants completed instruments that measure agency (MADM scale)³³ and experiences of respectful maternity care (MOR Index). ³⁴ Both display high internal consistency and reliability. On the 7-item MADM scale, participants rate their ability to state their preferences in decision-making, whether different care options were presented, and if their choices were respected (scores range 7–42). On the 14-item MOR scale, participants describe their level of comfort in the decision-making process (scores range 14–84). Higher scores on each scale indicate greater autonomy and respect when engaging in decision-making during pregnancy. The GSE is a reliable and validated 10 item Likert scale instrument where higher scores indicate higher levels of self-efficacy (Scores range 10–40).^{35, 37–39}

Data collection, sampling, and recruitment

To maximize diversity of geographic location and participation rate, we administered a web-based questionnaire. Each participant provided informed consent prior to completing the screening form and questionnaire. Data were collected May-October 2018.

The Yale University Institutional Review Board granted approval (protocol # 2000021384) prior to initiation of the study. After we obtained permissions, Facebook group administrators placed recruitment notices on two Facebook pages^40,41 relevant to birth. The pages targeted for recruitment were nonprofit, women-led, peer support organizations, and each had more than 50,000 followers. The recruitment graphic directed interested participants to the study website for further information, to participate in screening and, if eligible, complete the questionnaire.

Adults who had experienced cesarean birth and had a subsequent child in the United States within 5 years prior were eligible. We sought to explore the experiences of people who desired a VBAC and thus included participants who planned a VBAC and those who were interested in, but ultimately did not plan a VBAC. We encouraged participants to refer others who experienced a pregnancy and birth after cesarean, a form of snowball sampling.⁴² In order to capture the broadest range of experiences possible, participants were not excluded based on their knowledge related to their eligibility criteria for VBAC¹ nor on their ultimate mode of birth. While the questionnaire was active, we noted a lack of racial and ethnic diversity in our sample, and significant efforts were made to reach out to multiple birth advocacy groups for women of color.

Statistical analysis.

Descriptive statistics and MADM, MOR, and GSE mean scores were calculated for the entire sample and stratified by participants who planned a VBAC and those who did not. Bivariate statistics were computed to determine if there were significant differences between demographic characteristics and experiences of those who planned a VBAC and those who did not, and between the group of participants who provided qualitative data and those who chose not to answer the optional, open-ended question in the questionnaire. T-tests were calculated to compare scores on the MADM, MOR, and GSE by planned mode of birth. Statistical analyses were completed using SAS Version 9.4 for Windows.

Qualitative data analysis

Thematic and content analyses were used to interpret the open-ended question where participants described their individual experiences.⁴² Qualitative data were analyzed using Atlas.ti 8 (Berlin, Germany) software. Descriptive and in vivo codes were identified and developed from the narrative information participants provided.⁴³ Coding was conducted by the first author with confirmatory coding by the last author for 25% of the data. A codebook was developed and coding comparisons continued until inter-coder consensus was achieved. Codes were clustered into themes to capture processes of participants’ navigating a pregnancy and birth after cesarean. Analytic memos were generated and the software’s networking capacity enabled identification of relationships across the codes and dataset. A research log was updated at the conclusion of each research team meeting and data analysis session. These documents served as an audit trail to ensure rigor. STROBE guidelines for cross-sectional studies⁴⁴ were followed.

Results

Sample

A total of 1711 participants, from all 50 states, completed the questionnaire (Table 1). They experienced a total of 4591 births. Individuals who planned a VBAC comprised 88% (n=1498) of the participants; of these, 73% (n=1107) had a vaginal birth for their first birth after cesarean. Most (55%) had a parity of two; an additional 27% had parity of three. Most self-identified as non-Latinx ethnicity (94%) and white race (92%). Some participants reported life adversity including being unable to secure health insurance (18%), meet financial obligations (16%), or buy enough food to feed their families (10%).

TABLE 1.

Descriptive and bivariate statistics for women in the United States with a history of cesarean and a recent subsequent birth who completed an online self-administered questionnaire in 2018

Characteristic a	Total Completed N(%)	Plan VBAC Yes n(%)	Plan VBAC No n(%)
	N=1711	n=1498(87.6)	n=213(12.4)
Mean Maternal Age (years)	34	34	34
Year of most recent birth (mode)	2017	2017	2017
Knew that VBAC was an option***	1657(96.8)	1474 (98.4)	183(85.9)
Desired a VBAC ***	1628 (95.1)	1494 (99.7)	134 (62.9)
Had a VBAC ***	1107 (64.7)	1099 (73.4)	8 (3.8)
Region of residence b
Northeast	194 (11.3)	171 (11.4)	23 (10.8)
South	729 (42.6)	628 (41.9)	101 (47.4)
Midwest	421 (24.6)	370 (24.7)	51 (23.9)
West	367 (21.4)	329 (22.0)	38 (17.8)
Community of residence
Urban	375 (21.9)	333 (22.2)	42 (19.7)
Suburban	1037 (60.6)	904 (60.3)	133 (62.4)
Rural	299 (17.5)	261 (17.4)	38 (17.8)
Highest level of education completed***
No high school diploma	13 (0.8)	8 (0.5)	5 (2.3)
High school diploma/ GED	106 (6.2)	83 (5.5)	23 (10.8)
Some college/ 2 year degree	515 (30.1)	441 (29.5)	74 (34.5)
4 year degree (Bachelor’s degree)	649 (37.9)	591 (39.4)	58 (26.6)
Postgraduate degree	428 (25.1)	375 (25)	53 (24.5)
Paid work at time of birth	950 (55.5)	822 (54.9)	128 (60.1)
Married/ cohabiting ***	1672 (97.7)	1472 (98.3)	200 (93.9)
Annual household income
Less than $20,000	75 (4.4)	65 (4.4)	10 (4.7)
$20,000-$50,000	474 (27.9)	408 (27.4)	66 (31.0)
$50,000-$80,000	468 (27.5)	415 (27.9)	53 (24.9)
$80,000-$125,000	441 (25.9)	394 (26.5)	47 (22.1)
> $125,000	244 (14.3)	207 (13.9)	37 (17.4)
Parity **
2	950 (55.5)	834 (55.7)	116 (54.5)
3	463 (27.1)	411 (27.4)	52 (24.4)
4	182 (10.6)	154 (10.3)	28 (13.1)
5+	116 (6.8)	99 (6.6)	17 (8.0)
Race
White	1568 (91.9)	1371 (91.8)	197 (92.5)
Black	31 (1.9)	27 (1.8)	4 (1.9)
American Indian/ Alaskan Native	18 (1.1)	16 (1.1)	2 (0.9)
Asian	22 (1.3)	21 (1.4)	1 (0.5)
Other/ NHPI	30 (1.8)	25 (1.7)	5 (2.3)
Multiracial	38 (2.2)	34 (2.3)	4 (1.9)
Latinx ethnicity	105 (6.1)	91 (6.1)	14 (6.6)
Born in United States	1638 (95.7)	1433 (95.7)	205 (96.2)
Practice an organized religion	923 (54.0)	802 (53.6)	121 (56.8)
Christianity	882 (95.8)	762 (95.3)	120 (99.2)
Judaism	27 (2.9)	27 (3.4)	1 (0.8)
Islam/Buddhism/Hindu/Other	11 (1.1)	11(1.1)	0 (0)
Challenges since birth of first child c
Not able to buy enough food	158 (14.2)	142 (14.3)	16 (13.3)
Lack of health insurance	301 (27.0)	273 (27.5)	28 (23.3)
Heat or electricity turned off	68 (6.1)	59 (5.9)	9 (7.5)
Not able to meet financial obligations	272 (24.4)	238 (23.9)	34 (28.3)
Not able to find work	117 (10.5)	103 (10.4)	14 (11.7)
Child protective services	35 (3.1)	31 (3.1)	4 (3.3)
Housing instability	91 (8.2)	81 (8.1)	10 (8.3)
Problems with drug/alcohol dependency	10 (0.9)	8 (0.8)	2 (1.7)
Imprisonment of self or partner	12 (1.0)	10 (1.0)	2 (1.7)
Intimate Partner Violence	50 (4.5)	49 (4.9)	1 (0.8)

^aX² of demographic characteristics between the group of women who were able to plan/ attempt a VBAC and those who were not able to plan/ attempt a VBAC (based on their answer to question #11);

^*p< 0.05

^**p<0.01

^***p<0.001

^bRegions of residence: Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South (AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX,VA, WV), Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI), West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY).

^cEach participant could report more than one answer for this question. (ie. Check all that apply)

Most (98%) who planned a VBAC were aware that VBAC was an option for mode of birth after cesarean, compared with 86% of respondents who did not plan a VBAC (p<0.001). Among those who planned a VBAC, 64% had a baccalaureate or advanced degree compared with 51% of respondents who did not plan a VBAC (p<0.001). Participants who planned a VBAC were more likely to be married/cohabiting (98% vs. 94%; p<0.001). There were no statistically significant differences between the groups for other sociodemographic characteristics collected.

Those who planned a VBAC had a certified nurse-midwife for their prenatal care for their first (21%) and second (30%) births more often than the participants who did not plan a VBAC (8% first birth, 3% second birth; p< 0.001) (Table 2). Participants who planned a VBAC were more likely to travel for over an hour to access care for their second birth (7%) compared to those who did not plan a VBAC (4%, p=0.025).

Table 2.

Provider and birth-related statistics collected from women in the United States with a history of cesarean and a recent subsequent birth who completed an online self-administered questionnaire in 2018

	Total Completed	Plan VBAC Yes (%)	Plan VBAC No (%)
	N=1711	n=1498(87.6)	n=213(12.4)
Discussed options for care with: ***
Family Doctor	40 (2.3)	31 (2.1)	9 (4.2)
Midwife	569 (33.3)	554 (37.0)	15 (7.0)
Obstetrician	1097 (64.1)	908 (60.6)	189 (88.7)
N/A	5 (0.3)	5 (0.3)	0 (0)
Provider for first pregnancy***
Certified Nurse Midwife	333 (19.5)	316 (21.1)	17 (8.0)
Family Doctor	52 (3.0)	44 (2.9)	8 (3.8)
Obstetrician	1246 (72.9)	1058 (70.7)	188 (88.3)
Other Midwife	74 (4.3)	74 (4.9)	0 (0)
Other	4 (0.2)	4 (0.3)	0 (0)
None	1 (0.1)	1 (0.1)	0 (0)
Provider for second pregnancy***
Certified Nurse Midwife	462 (27.0)	455 (30.4)	7 (3.3)
Family Doctor	36 (2.1)	29 (1.9)	7 (3.3)
Obstetrician	1053 (61.6)	859 (57.4)	194 (91.1)
Other Midwife	142 (8.3)	141 (9.4)	1 (0.5)
Other	9 (0.5)	5 (0.3)	4 (1.9)
None	7 (0.4)	7 (0.5)	0 (0)
Insurance for second birth
Private	1270 (74.2)	1115 (74.4)	155 (72.8)
Medicaid or other govt insurance	359 (21.0)	306 (20.4)	53 (24.9)
Other	51 (3.0)	47 (3.1)	4 (1.9)
No insurance	31 (1.8)	30 (2.0)	1 (0.5)
Travel time from home to second birth location*
Less than 30 minutes	1145 (67.0)	986 (66.0)	159 (74.6)
30–60 minutes	447 (26.2)	401 (26.8)	46 (21.6)
> 60 minutes	116(6.8)	108 (7.2)	8 (3.8)
Homebirth after cesarean (HBAC)	182 (10.6)	182 (10.6)	0 (0)
Planned unassisted HBAC	13 (0.8)	13 (0.8)	0 (0)
Unplanned unassisted HBAC	6 (0.4)	6 (0.4)	0 (0)

^aX² of demographic characteristics between the group of women who planned a VBAC and those who did not plan a VBAC;

^*p< 0.05

^**p<0.01

^***p<0.001

Quantitative Results

Participants who planned a VBAC had higher scores for autonomy in decision-making (MADM) (p<0.001) and respectful maternity care (MOR) (p<0.001) compared to those who did not plan a VBAC (Table 3). Levels of low or very low respect, indicated by a MOR score of less than 50,³⁴ were experienced by 14% (239) of participants. More participants (19%) who did not plan a VBAC experienced low or very low levels of respect, compared with 13% of participants who planned a VBAC. When participants felt treated poorly by their provider, it was most often due to a difference in opinion about the right care for themselves or for their baby (22%), and their type of health insurance (6%). There were no significant differences in GSE scores between the groups.

Table 3.

Mean scores on MOR, MADM, and GSE by planning a VBAC for first birth after cesarean in 1711 women with a history of cesarean in the United States collected in 2018

Mean Scores	Total Completed	Plan VBAC YES	Plan VBAC NO	t-testa
	N=1711	n=1498	n=213
MORb	67.77	68.37	63.51	p < 0.001***
MADMb	30.82	31.57	25.54	p < 0.001***
GSEb	33.37	33.36	33.46	0.7481

^at-test of scores on instruments between the group of women who planned/ attempted a VBAC and those who did not plan/ attempt a VBAC;

^*p< 0.05

^**p<0.01

^***p<0.001

^bHighest score possible: Mothers on Respect Index (MOR)=84; Mothers Autonomy in Decision Making (MADM) scale =42; Generalized Self Efficacy Scale (GSE)=40

Qualitative Results: “I had to fight for my VBAC”

Of the 1711 participants who completed the questionnaire, 1151(67%) provided qualitative data, totaling over 400 pages of text. Those who provided qualitative date differed from the overall sample on three characteristics: knew VBAC was an option (p=0.020), total number of births ( p=0.040), type of provider for first birth (p=0.045) (Supplemental Tables 1–3).

The analysis revealed complex experiences of navigating a pregnancy and birth after cesarean. The overarching theme: “I had to fight for my VBAC” reflected the many obstacles participants navigated to access VBAC care. The quantitative and qualitative data are merged and triangulated in a joint display (Table 4).

Table 4.

Joint display for integration of quantitative and qualitative results

Qualitative Data	Qualitative “Navigation” Themes	Convergent Quantitative Data
“I did, in the end, do everything I could, read all I could, participate in the local ICAN group, and read all I could, watch documentaries, etc. because I wanted to be successful…and in my mind, I would be more prepared with the more knowledge I had.”-Eleanor	Knowledge	98.4% of those who planned a VBAC knew VBAC was an option vs 85.9% of those who did not (p<0.0001)
“I went into labor and after 21 hours I had reached a successful VBAC with no drugs or intervention. I felt so great (however) I know I was my biggest advocate.” -Jordyn	Self-advocacy	64.8% of those who planned a VBAC agreed with MADM question 6: “I was able to choose the best care possible” vs. 37.5% of those who did not (p<0.0001)
“My OB/GYN was super supportive of me having a VBAC as was the whole staff in the hospital. The delivery nurse even took me aside afterwards and told me how impressed they were that my OB/GYN let me go for a VBAC considering 1) my age 2) how overdue my baby was and 3) my history of large babies! It was a great experience and the recovery was so much better.” -Trina	Support: provider	Higher MOR scores for women who planned a VBAC (p<0.0001) indicate a greater incidence of respectful maternity care. Midwives provided care for 40% of second births to women who planned a VBAC vs 4% of those who did not (p<0.0001).
“I also noticed a huge difference in having a doula at my two VBACs. I tell everyone who is going to give birth how important they are now!” – Madelyn	Support: doula	44.4% of women who planned a VBAC used a doula for their second birth vs 1.2% of women who did not plan a VBAC (p<0.0001).
“If it weren’t for my …community of attachment parenting caregivers, I probably would’ve just gone with another c section.” -Sera	Support: peers	23 women specifically mentioned the International Cesarean Awareness Network (ICAN) as helpful in their VBAC navigation.
“I was fired as a patient by 3 separate OB/GYNs at multiple different stages of my pregnancy, all of which occurred after refusing to consent to a c-section.” -Odessa	Difficulty finding supportive provider	More women who did not plan a VBAC (52.2%) held back asking their provider questions due to differences in opinion about the best care vs. those who planned a VBAC (38.1%)
“We joined our local ICAN group through Facebook and asked for recommendations. This is how we ended up switching by my 32nd week and found a VBAC friendly/supportive doctor.” -Willamina	Changing providers	No relevant quant data collected on questionnaire.
“My nearest VBAC hospital was about 2.5 hours away. My local hospital (5 minutes away) has a VBAC ban.” -Jen	Distance	7.2% of women who planned a VBAC travelled > 60 min for their second birth vs 3.8% of those who did not (p<0.0253)
“All prenatal care was at a birth center with CNMs. The only reason I birthed at the hospital is due to the fact the [State] medical board has ruled all VBAC mamas must birth in a hospital (such a fallacy).” -Emily	Legal interpretations and policy obstacles	No relevant quant data collected on questionnaire.

Planning a VBAC was not a straightforward process and many described having to “fight” for their VBAC (Figure 1). Strategies included acquiring knowledge, assembling a team of supportive individuals, and finding a provider who would support the decision to plan a VBAC. Some participants described laboring at home for as long as possible before travelling to the hospital, and some changed providers during the pregnancy.

Figure 1.

Navigating a pregnancy and birth after cesarean

Having a VBAC is not an easy thing. The first one, I had to fight for, because the on-call residents were very uncomfortable with it…No matter how many VBACs I’ve had…it is an uphill battle every time…the providers still refer to it as a “trial of labor” and want to medicalize my births as much as possible. It is stressful, also, to have choices taken away because I’m a VBAC mother…Once a [cesarean], birth is never straightforward again.

-Janine

Knowledge was described as paramount when navigating a VBAC and was gained from books, websites and blogs, social media, peers, doulas, and from providers.

We decided to take Birth Boot Camp course…intensive in gaining knowledge about your rights and what you want for your birth…I believe education and knowing when a cesarean delivery is actually necessary and when it is not allows you to be more in control of your birth experience.

-Veronica

The in vivo code (derived directly from the language of the participants) “If I had known…,” reflected the value of hindsight. Participants described gaps in knowledge during their first birth that many felt had contributed to their cesarean birth.

I feel like if I had known where to look for honest and factual information I may not have had a c-section the first time around. Birth was treated as something so medical and I was never empowered to know that my body knew what to do.

-Dierdre

Conversely, having that knowledge enabled them to effectively advocate for VBAC as an option. Gaining knowledge about the processes of labor and birth also gave participants confidence and enabled them to assert affirmations like “my body was made to do this.”

After my first birth ended in a cesarean I was determined to have a VBAC, or at least do everything in my power to be as successful as possible. I had to prove that my body could push my baby out. Having my VBAC was incredibly healing and amazing!

-Brittany

Many described surrounding themselves with people who were supportive of VBAC, including providers, doulas, and peers interested in VBAC. Partnering with and having a trusting relationship with a VBAC supportive provider was a commonly described facilitator.

Through the support of a home-birth midwife who believed in me, and that I could trust, I was able to have my first VBAC…Because I was able to do that, I have been able to have 3 more VBACs. Our local hospital has a VBAC ban.– Jackie

I had a very supportive OB who was willing to work with me for whatever choice I made with my second. I had a long induction ending in an emergency cesarean, but I was prepared this time, and even though it was difficult, I was so happy with the outcome.

-Jess

Those who planned a VBAC used a doula for their second birth (44%) more frequently than those who did not (1%, p<0.001). Participants (n=73) described that the support they felt from their doulas made a difference in their birth experiences, regardless of final mode of birth.

The hospital staff continuously tried to talk me out of a VBAC… I continuously had to defend my choice. At times it was very combative. I felt like I had to fight for my VBAC every step of the way. Our doula made a night and day difference for us.

-Liz

Some participants (n=23) described peer support specifically through the International Cesarean Awareness Network (ICAN), which has local chapters and a substantial online and social media presence.

My 2nd birth journey was extremely difficult, because no one wanted to let me do a VBAC (I was even told it was because “We live in a litigious society”). I only found a doctor who would do it at 37 weeks of my pregnancy… thanks to the [State 1] Facebook group of ICAN…I was one of the very first VBACs at that hospital.

-Julie

The most significant obstacle when “fighting for a VBAC” was finding a supportive provider. Many participants had multiple providers during the course of a pregnancy after cesarean and many were denied care. Participants who did not plan a VBAC (52%) were more likely to hold back asking their provider questions due to differences in opinion about the best care for them and their baby, compared to those who planned a VBAC (38%).

During my second pregnancy, my OB was extremely unsupportive regarding my choice to try for a VBAC. She told me my pelvis was too small [and] if I tried for a VBAC, my baby would get stuck & die. Thankfully, my husband supported my choices. When I finally went into labor… we chose to go to a different hospital than the one my OB delivered at because by that point I had no trust in her whatsoever. I had my medical records with me. I delivered with the on-call OB, who was great.

-Brenda

Changing providers was a strategy used for seeking a VBAC. As in Brenda’s experience described above, change often occurred well after 30-weeks gestation. A common reason for switching was that a provider claimed to be supportive of a VBAC, but then through their actions or policies were revealed to be unsupportive, behavior referred to by the participants as a “bait and switch.” Sometimes this came in the form of setting restrictions such as requiring a person to go into labor by their due date in order to attempt a VBAC, or supporting a person in their plan for a VBAC until making an assessment late in pregnancy that their body would not be “capable of birthing a big baby.”

The hospital said I had to go into labor by 40 weeks on my own or they would only do a c-section…I requested another week. They denied this even though they had not examined me — it was based off of policy not need…a midwife was so upset by how I was treated that she was willing to monitor me and baby while I waited for labor to begin … my labor began at 42 weeks. My doula followed us to the hospital which was 45 minutes away. We arrived at 4pm and baby born successful VBAC eight minutes later … sad that you have to fight so hard for your birth.

-Carrie

Distance was another significant obstacle for many participants seeking a VBAC. Many had to travel more than an hour, some more than two hours, to find a hospital that would provide VBAC care. Nearly twice as many participants (7%) who planned a VBAC had to travel more than an hour for their second birth compared with those who did not (4%, p=0.025).

My second birth (first VBAC) was in a hotel room 2 hours from where I lived because I could not find a local and affordable option for my birth

-Marina

Many participants cited state laws concerning provider licensing as obstacles to planning a VBAC. These licensing restrictions meant that they were not able to have the type of provider they desired or that they could not give birth in a location they desired. The questionnaire did not capture quantitative data regarding policies or laws.

The OB/GYN I used with my first child insisted on a repeat cesarean. I ended up driving an hour one way to find a midwife that would work with me for a VBAC…currently the law prohibits VBAC at birthing centers in [State 2]. -Sarah-Beth

When I met with her for my 6-week follow-up and asked about the possibility of a VBAC again in the future her response was: “No you’re not a candidate. They’re illegal in [State 3], ya know?”

-Maryanne

Many described hospitals that had a “VBAC ban;” per policy they did not routinely provide care for those who desired a VBAC.

The closest hospital to my house had a VBAC ban and most others nearby were not considered friendly for VBAC’s though some certainly occurred here or there. No OBGYN practices allowed them either.

-Stacey

Delaying presentation to a hospital until late in labor was a strategy to avoid a cesarean, especially at hospitals with VBAC bans.

Every doctor within an hour’s radius to me told me that a VBAC would not be allowed … I assumed since I was in active labor when I went to the hospital I would be allowed to TOLAC; however, I was wrong. The first hospital told me that I needed to leave if I didn’t consent immediately to a c-section. They would not allow me to labor any longer there and I needed to find a different hospital… A woman should have the right to refuse a c-section and still be treated like a human being and not told to leave the hospital. -Sasha

I had completed hours of research on VBAC following the birth of my first child, so I was well-educated in the pros and cons. This, however, was never presented as an option for me … and no providers in my area support VBAC. The hospital I had both of my children at actually has a ban … I was told the only way I could have a successful VBAC with my doctor at my preferred hospital was if I came into the hospital already in labor and the baby was already crowning.

-Hayley

Sometimes this meant waiting too long and resulted in unintentional unassisted births.

“I had hoped to have a homebirth… but as a VBAC patient, that is not currently a possibility in [State 4]. I gave birth in my car on the way to the birth center.”

-Amanda

Discussion

This mixed methods study illuminated multiple obstacles faced by US individuals who desire a VBAC and strategies used to overcome them. We sought to describe their experiences and to explore associations between planning a VBAC and autonomy in maternal decision making, respectful maternity care, and self-efficacy.

The most significant obstacle identified by participants was finding a VBAC supportive provider. Their search was complicated by VBAC bans in hospitals, sometimes requiring them to travel more than an hour to obtain a VBAC. Similar to the findings of our integrative review,³¹ researchers in high resource countries have noted that VBAC rates correlate with levels of maternal knowledge about options for birth after cesarean, and access to VBAC supportive providers and birth settings.^45–48 In this study, as in others, participants viewed their provider as a valuable source of information about pregnancy and birth,⁴⁹ and perceived a supportive clinician as a key facilitator for a successful VBAC.^31,45,47 A positive relationship with a provider is of critical importance⁵⁰ and provider preference for mode of birth significantly affects a person’s choice.^51,52

Participants who were able to plan a VBAC reported greater autonomy and more respectful care than those who did not plan a VBAC. Scores on the GSE, measuring their personal levels of self-efficacy, were not significantly different between the groups, suggesting that the process of decision-making around mode of delivery, not personal agency, affected their sense of autonomy and respect, a finding in line with work by Scaffidi and colleagues.⁵³

The demographic findings of this study mirror trends in VBAC from the 2017 national birth certificate data^53,54 and the Access and Integration Maternity Care Mapping study.⁵⁵ In our sample, and in national data, individuals with higher levels of education were more likely to have a VBAC. The 72% VBAC completion rate in our sample is congruent with the 73% national rate for 2017.⁵⁴ Participants living in the South had the lowest rates of VBAC, as did the Southern Census region in the 2017 birth certificate data.⁵⁴ Future research should explore whether lower rates of VBAC in the South are related to regulatory restrictions, geographic or racial inequities in access to supportive providers, and/or lower rates of hospitals offering care for individuals desiring a VBAC.

Type of birth provider appears to be strongly associated with VBAC rates in our study and others. Vedam and colleagues found that improved access to midwives was associated with higher rates of VBAC and lower rates of cesarean in the US.⁵⁵ Similarly, a continuity of care model of care, common in midwifery practices, has been shown to increase experiences of respect and autonomy.⁵⁶ Our sample trended in this direction; nearly 40% of participants who planned a VBAC had a midwife provider for their second birth, a rate that is significantly higher than the United States as a whole where only about 10% of people give birth with a midwife.⁵⁷ Those who planned a VBAC were more likely to travel more than an hour for their second birth, indicating that access to hospitals or providers offering VBAC is a significant obstacle, echoing findings of other studies.^31,58

Strengths and Limitations

A significant strength of this study is that it captured the commonalty of experiences of a very large, geographically diverse sample of individuals who desired a VBAC. The sheer volume of responses indicates that this is an area of great concern. The mixed methods design also allowed us to triangulate narrative findings with quantitative metrics and gain in-depth understanding with a large sample.

Our sample did not fully represent the diversity of US individuals with a history of cesarean, as the majority of participants planned and achieved VBAC. Due to recruitment in social media birth advocacy groups our findings are subject to self-selection bias. Individuals may also have been more likely to participate in this study, feeling compelled to share their stories, if they had had particularly challenging or rewarding experiences seeking access to a VBAC.⁵⁹ A further limitation is the sociodemographic homogeneity of the sample. Significant efforts were made to increase the racial and ethnic diversity of the sample by reaching out to birth advocacy groups for women of color.⁶⁰ Due to the retrospective and cross-sectional nature of our study, an additional limitation is that we were not able to determine levels of self-efficacy or autonomy before or during each participant’s pregnancy and birth after cesarean journey.

Implications for Research, Practice, and Policy

Internationally, there has been an increasing recognition of respectful maternity care as an integral part of high quality care.^61,62 In our study, as well as in others, participants described supportive care as care where they felt heard, and had their care decisions respected.⁶³ Providers’ negative attitudes and disrespectful treatment of people seeking VBAC is a discouraging and disempowering factor.⁶³ In our study, when participants felt mistreated or disrespected by their provider, it was most commonly due to a difference of opinion about the best choice for care. Similarly, in the Giving Voice to Mothers Study, those who reported a difference of opinion with their providers about the right care for themselves or their baby were significantly more likely to experience mistreatment, including 1 in 3 participants who had a VBAC in the hospital.⁶⁴ These results indicate a disconnect between the aim of delivering quality care and some participants’ experiences of that care. Future research should explore the experiences of respectful maternity care and decision making among a more diverse sample of US people seeking VBAC.

Participants identified knowledge, having a midwife and/or support of a doula and peers, and a trusting relationship with a provider as key factors in obtaining a VBAC. One method of fostering a mutually respectful relationship and improving knowledge is through proactive provider-patient communication and shared decision making.^65,66 Health systems could also increase access to midwifery care and develop programs to provide doula support to those who cannot afford private services.

Policy Implications.

The difficulty of navigation and “fighting” tactics sometimes left those who desired a VBAC with no safe options, a serious public health concern. Many participants (10.6%) chose to have a homebirth after cesarean because they were unable to access VBAC in a hospital, even though homebirth after cesarean may be associated with less optimal outcomes in individuals without a prior vaginal birth.17,67 Fewer individuals may have opted for homebirth after cesarean if they perceived they had another option to plan a VBAC.68–70 Optimizing resources and revising policies71 so that they are based on the robust evidence that physiologic birth is beneficial to both birthing people and their offspring72,73 may increase access to physiologic birth and in-hospital VBAC, while also decreasing the need for VBAC by avoiding unnecessary primary cesarean.74

Conclusions.

Participants who planned a VBAC had to work extremely hard to obtain a VBAC, actively seeking out caregivers who would form a partnership that gave them more autonomy and made them feel respected. This paper captures only a small portion of possible VBAC narratives, yet it makes a few things quite clear: many people across the US want to tell their stories, to have their voices heard, and perhaps most importantly, they want access to providers committed to supporting vaginal birth after cesarean.