I’m always looking for research which relates to the topic of how we can help keep birth normal, and my latest find in this area is an Australian study of maternal and paternal decision-making and its effect on choice for vaginal birth after caesarean section (VBAC) which has concluded that interventions that seek to explore dads’ perceptions of risk during a pregnancy might increase the chance that a couple will attempt VBAC.
The premise for the study was relatively simple. Couples in three Australian hospitals who were eligible** for VBAC were invited to complete a series of three questionnaires (sent at different stages of pregnancy and postpartum) asking about their experiences, views and knowledge relating to VBAC and their current pregnancy and birth experience. Seventy-five couples completed the full sets of questionnaires during the study period. Of the women in those couples, 31 (41%) aimed for a VBAC, and 44 (59%) had a planned caesarean section.
** yes, analysis of the word ‘eligible’ in relation to birth decisions could be a whole blog post on its own. Not today though 😉
Some of the key results included that:
- When asked, ‘have you been told by your doctor or antenatal clinic** that you must have a caesarean section in this pregnancy?’, 67 couples (89%) responded ‘no’, 4 couples (5%) responded ‘yes’, and 4 couples (5%) responded ‘not sure’.
** In the UK, antenatal clinics are buildings and do not give professional recommendations as such, so it is interesting to see how this differs cross-culturally 😉
- Only 13% of couples (10/75) said that they had “attended any classes, courses or meetings specifically about trying for a vaginal birth after a caesarean section”. (Robson et al 2015: 3)
It strikes me that this is another area which, if addressed, might make a difference?
- “When asked, in the third trimester, ‘how are you planning to have the baby this time’? 32 women (43%) responded, ‘planned caesarean section, before I go into labour’, 32 (43%) responded, ‘a trial of vaginal birth’ and 11 (14%) responded ‘I am not sure yet’. Responses revealed that all of the women wanting prelabour CS were delivered by CS, and of the 32 who wished for a trial of vaginal birth, six ultimately had a prelabour CS. Of those who reported being undecided in the third trimester, five attempted vaginal delivery and six had a CS. In total then, 31 women (41%) ultimately attempted vaginal delivery, and 44 (59%) were delivered by planned CS.” (Robson et al 2015: 3)
- “Considering the rated importance of attempting a vaginal delivery at the time of the third-trimester questionnaire (‘How important to you is trying for a vaginal birth in this pregnancy’?), the maternal scores better predicted the plan for birth than paternal scores.” (Robson et al 2015: 3)
So it looks like women’s views and wants were more important in the overall decision-making, however:
- The only predictor of a couple attempting VBAC was the partner’s perception of risk falling between the second and third trimester (aOR 3.2, 95% CI 1.03, 10.1). (Robson et al 2015: 3)
The latter finding is what led to the authors’ suggestion that “time spent providing information and education for fathers might increase the chance that a couple will attempt VBAC” (Robson et al 2015: 4). The change in people’s perception of risk between the second and third trimesters of pregnancy differed between men and women. While 40% of women perceived a reduction in risk associated with VBAC over that time, 40% of their male partners perceived an increase in risk.
All studies have limitations, and some of the key issues which we need to bear in mind with this one include that:
- The sample size is relatively small for a study of this kind, and some of the confidence intervals are quite wide. So we need to be careful to take that into account when we interpret the results.
- The study focused on asking about couples’ views of information they were given by doctors. Doctors are only one source of professional information, however, and although one of the questions asked whether couples had attended a class or course that specifically addressed VBAC and whether their received information from the antenatal clinic, we don’t know if the couples received information from midwives, childbirth educators or others, or how that affected their decision-making. Many couples are also, of course, influenced just as much or more by non-professional sources of information, such as their families.
- Quite a number of couples dropped out during the study. This isn’t the fault of the researchers, and it isn’t uncommon – we all know how all-consuming pregnancy and parenting can be – but it does leave us unable to know whether those parents who didn’t complete the questionnaires of the study were different in a relevant way from those who did.
- The study only included English-speaking couples who were planning hospital birth and who decided to have an ultrasound, so the study wouldn’t have included the views of people who didn’t fit those criteria, and their views may be different in important ways. In this type of study, for instance, it could be especially important to consider whether some women and their partners were choosing a different place of birth and/or model of care, as this could tell us important things about their decision-making. There was no mention of single-sex couples or differently-shaped families, so those are other areas that may warrant further exploration.
- Because the questionnaires were filled out at home, there is a chance that couples might have completed them together, which could have affected what they wrote and thus altered the results.
Overall though, this is an interesting study which helps add further to our knowledge of how important dads are in decision-making about place and type of birth. It does raise some questions for me about how dads will feel about the authors’ suggestions, and there are, of course, lots of wider questions around decision-making, autonomy and control which can be debated, so I’m going to focus on the idea that it might be valuable to spend more time engaging with dads and exploring their perceptions of risk with them. I’m not sure how doable this is for midwives though, especially in areas where midwives don’t currently have enough time to answer women’s questions adequately, let alone offer further exploration of decision-making for them and their partners, but this is another area where childbirth educators have a vital role to play, and it’s great to have studies like this one which give us clues about the things that might make a difference.
Background: The proportion of women who plan for a repeat elective caesarean section (CS) is one of the major determinants of the overall rate of CS, and programs aiming to reduce the rate of CS have not been greatly successful. To date, there appear to have been no large studies directly addressing paternal influences on decision-making regarding vaginal birth after caesarean (VBAC). This study aimed to compare the reactions of fathers and mothers to the prospect of VBAC.
Methods: Couples were recruited from three Australian hospitals and were eligible with a singleton pregnancy, a normal morphology ultrasound, and where there was no condition in the new pregnancy that would preclude a vaginal birth. Questionnaires were scheduled for 20 weeks’ gestation, 32–36 weeks’ gestation and six weeks postnatal and were sent separately to each partner.
Results: Seventy-five couples completed the full sets of questionnaires during the study period. In total, 31 women (41%) ultimately attempted vaginal delivery, and 44 (59%) were delivered by planned CS. When the paternal rating of risk fell between the second and third trimesters, the couple were likely to attempt VBAC (P < 0.05). Where the maternal rating of importance was 3 or less, 92% had a planned CS compared to 63% for the same paternal scores (P = 0.02).
Conclusion: This study suggests that interventions that improve the paternal perceptions of risk during a pregnancy might increase the chance that a couple will attempt VBAC.
Robson S, Campbell B, Pell G et al (2015). Concordance of maternal and paternal decision-making and its effect on choice for vaginal birth after caesarean section. Australian and New Zealand Journal of Obstetrics and Gynaecology DOI: 10.1111/ajo.12326