Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review

BMC Pregnancy and Childbirth, Feb 2015

Background The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. Methods The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, ‘Effective Public Health Practice Project’. The primary outcome measure was VBAC rates. Results 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. Conclusions This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

http://www.biomedcentral.com/content/pdf/s12884-015-0441-3.pdf

Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review

Lundgren et al. BMC Pregnancy and Childbirth Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review Ingela Lundgren 0 Valerie Smith Christina Nilsson 0 Katri Vehvilainen-Julkunen Jane Nicoletti Declan Devane Annette Bernloehr Evelien van Limbeek Joan Lalor Cecily Begley 0 Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg , Box 457, SE-405 30 Gothenburg , Sweden Background: The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. Methods: The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, 'Effective Public Health Practice Project'. The primary outcome measure was VBAC rates. Results: 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. Conclusions: This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only. VBAC; Systematic review; Interventions; Clinicians - Background Caesarean section (CS) rates have risen globally in the past decade, causing concern among clinicians. The lack of evidence of any decrease in morbidity associated with this rise raise questions about clinical effectiveness and the role of evidence ([1], p. 78). Reasons suggested for the continuing increase in CSs include decreased training for clinicians in instrumental vaginal and vaginal breech births, medico-legal issues, the increased use of electronic fetal heart rate monitoring in labour [2-4], and maternal request [5,6]. Repeat CS after a previous CS birth is a significant contributor to overall increased CS rates and accounts for more than one-third of all CSs in the US [7]. Although a necessary and sometimes life-saving operation, CS is associated with more than double the rate of severe maternal morbidity and maternal mortality when compared with vaginal birth [8]. The challenge then is to reduce those CSs that are unnecessary, while retaining those that are needed to save lives and decrease morbidity. Planned vaginal birth after CS (VBAC) compares favourably with routine elective repeat CS. A systematic review and meta-analysis of 203 studies [9], demonstrated that maternal mortality was increased significantly with elective repeat CS (ERCS) compared with planned VBAC (1.34 versus 0.38 per 10,000). In contrast, perinatal mortality was significantly increased with planned VBAC (13 per 10,000) compared with ERCS (5 per 10,000) although absolute rates are low [9]. This complicates the decision-making process as clinicians and women attempt to balance the risks involved. However, as maternal morbidity is also greatly increased with ERCS when compared to planned VBAC [9], the evidence, on balance, suggests that VBAC is a reasonable and safe option for most women. In Europe, VBAC rates vary widely, and have declined considerably in recent years, with significantly lower rates in Spain and Portugal (20-30%) than in Sweden, the Netherlands and Finland (45-55%) [10]. Although difficulties accessing tertiary care and medico-legal reasons may influence VBAC rates, variations are more likely to arise from an individual clinicians approaches to dec (...truncated)


This is a preview of a remote PDF: http://www.biomedcentral.com/content/pdf/s12884-015-0441-3.pdf

Ingela Lundgren, Valerie Smith, Christina Nilsson, Katri Vehvilainen-Julkunen, Jane Nicoletti, Declan Devane, Annette Bernloehr, Evelien van Limbeek, Joan Lalor, Cecily Begley. Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review, BMC Pregnancy and Childbirth, 2015, pp. 16, 15, DOI: 10.1186/s12884-015-0441-3