Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 257–261
DOI: 10.1111/ajo.12326
Original Article
Concordance of maternal and paternal decision-making and its effect on choice for vaginal birth after caesarean section Stephen ROBSON,1 Beth CAMPBELL,2 Gabrielle PELL,3 Anne WILSON,4 Kate TYSON,3 Caroline DE COSTA,5 Michael PERMEZEL3 and Cindy WOODS5 1
Australian National University Medical School, Canberra, Australian Capital Territory, 2Townsville Hospital, Townsville, Queensland, Mercy Hospital for Women, Melbourne, Victoria, 4Calvary John James Hospital, Canberra, Australian Capital Territory, and 5School of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
3
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. Key words: caesarean section, decision-making, paternal, vaginal birth after caesarean.
Introduction The rate of caesarean section (CS) in Australia currently exceeds 30% and has almost doubled over the past two decades.1 Despite international interest, strategies that aim to reduce the rate of CS have not been successful.2,3 Factors known to increase the risk for CS, such as increased maternal age4–6 and maternal obesity7,8, are not easily amenable to modification. The majority of women whose first child is born by CS are likely to give birth to subsequent children by CS9,10 so an important area that influences the CS rate is decision-making about whether to try for vaginal birth after previous caesarean section (VBAC). In recent years, increasing emphasis has been placed on women’s choice in decision-making.11 For example,
Correspondence: A/Prof Stephen J. Robson, Australian National University Medical School, PO Box 5235, Garran LPO, ACT Australia. Email: [email protected] Received 27 September 2014; accepted 15 January 2015.
the British National Institute for Clinical Excellence (NICE) guidelines emphasise that decision-making regarding mode of birth after a previous caesarean section should consider maternal preferences and priorities, as well as discussion of risks.12 A systematic review of maternal decision-making for VBAC reported that many methods had been evaluated, including decision aids, one-on-one counselling, group sessions, protocols and algorithms.13 None of these interventions affected the planned mode of birth, the actual mode of birth, nor an effect on women being ‘unsure’ about which to choose.13 Other studies have examined the effect of obstetricians’ and midwives’ opinions about attempted VBAC and how these opinions might affect maternal decision-making.14 However, to date, there appear to have been no large studies directly addressing paternal influences on decisionmaking regarding VBAC. We have hypothesised that paternal attitudes to attempted VBAC will affect maternal decision-making. This study aimed to determine whether maternal and paternal perception of risk for, and
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
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importance of, attempted VBAC was associated with an intention to attempt VBAC.
Materials and Methods Recruitment took place at three hospitals, two metropolitan and one regional, in the states of Queensland, Victoria and the Australian Capital Territory in Australia from January of 2012 until December 2013. Eligible couples were those with a singleton pregnancy, a normal second-trimester morphology ultrasound, and the placenta not covering the internal cervical os. Additional criteria were both father and mother were over the age of 18 years; both speak English without the need for an interpreter; the previous pregnancy was within this relationship, not with a different paternity; the partners were cohabitating for the duration of the study and were not separated, separating or divorced; the first CS did not contraindicate subsequent vaginal birth (for example, a CS with a vertical uterine incision); and where there was no condition in the new pregnancy that might potentially preclude a vaginal birth. Sample size was not calculated, the sample was pragmatic based on the number of women seen in the clinic over the study period. Couples who fulfilled the inclusion criteria were approached for recruitment at the antenatal booking visit, after the morphology ultrasound. Information statements were provided, and eligible couples who agree to participate were asked to sign the consent documents. Questionnaires were sent separately to each partner with an accompanying addressed and stamped envelope for return. The questionnaires were scheduled for completion at by the end of the second trimester, at between 32 and 36 weeks’ gestation and six weeks postnatal. If a questionnaire was not returned within two weeks of posting, a reminder telephone call was made and second questionnaire was sent. The first questionnaires obtained basic demographic information, including the ages of both partners, the indication for the primary CS and whether it had been performed prelabour or as an intrapartum procedure, first child’s birthweight and complications of the primary CS for either mother or neonate. Each partner was then asked to rate their level of satisfaction with the first birth using a Likert scale from 1 (not satisfied at all) to 10 (could not be more satisfied). Both partners were asked, ‘How important to you is trying for a vaginal birth in this pregnancy’? and asked to rate this on a ten-point Likert scale. Both partners were also asked, ‘How do you rate the risk, to either you and/or your baby, of trying for a vaginal birth after your previous caesarean section’? with a tenpoint Likert scale. The second questionnaires, completed in the third trimester, asked whether any complications had developed (such as hypertension, suspected growth restriction or diabetes) and whether the couple had been advised to have a repeat CS. Both partners were asked their intention 258
for birth (planned prelabour CS, trial of vaginal birth or undecided) and, again, to rate the importance of trying for a vaginal birth and rating of risk. The final questionnaires, completed at approximately six weeks postnatal, asked about the mode and outcome of birth, for both mother and baby, and whether there were any complications. Both partners were asked, ‘Looking back, how well did the discussions you had with your doctor at the antenatal clinic prepare you for birth this time’? and were asked to rate their satisfaction with birth. There were numerous spaces left for free text answers on all questionnaires. Data were entered in to Excel spreadsheets and then imported into SPSS version 20 (IBM SPSS Inc., Chicago, IL, USA). Logistic regression analyses were undertaken to estimate the odds ratios and 95% confidence intervals for significant predictors of desire for attempted VBAC at the final prelabour survey. Univariate analyses were performed to estimate the associations between desire for VBAC and each of the candidate variable survey results. Factors associated with an intention to attempt VBAC demonstrating an unadjusted P-value of 0.10 or less were then included in the multivariate regression analysis. The study received prospective approval from the James Cook University Human Research Ethics Committee and the Mercy Health Research Ethics Committee.
Results Of 102 couples who agreed to participate, a total of 75 completed the full set of questionnaires during the study period (Fig. 1). The demographic information for the study group is presented in Table 1. At the time of the first questionnaire, two couples reported that they had been advised they should have a planned CS in their next
Couples completing consent forms N = 102 Incomplete from both partners N=6 Both partners complete first questionnaires N = 96 Incomplete from both partners N = 11 Both partners complete second questionnaires N = 85 Incomplete from both partners N = 10 Both partners complete final questionnaires N = 75
Figure 1 Flowchart of subject recruitment for study.
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Paternal influence on choice for VBAC
Table 1 Demographic characteristics of participants and selfreported clinical characteristics of index caesarean Maternal age range 35 years Timing of index caesarean section Prelabour Intrapartum Indications for index caesarean section Prelabour (n = 21) Breech Placenta praevia Growth restriction Macrosomia Maternal request Other Intrapartum (n = 54) Breech No progress ‘Fetal distress” Other Birthweight at index caesarean 4 Kg Complications at primary caesarean section Maternal Haemorrhage Blood transfusion Infection Other Neonatal NICU/SCBU admission Oxygen resuscitation
3 (4%) 59 (79%) 13 (17%) 21 (28%) 54 (72%)
9 1 1 4 2 4
(43%) (5%) (5%) (19%) (10%) (19%)
4 20 22 8
(7%) (37%) (41%) (15%)
9 (12%) 57 (76%) 9 (12%)
12 1 6 6
(16%) (1%) (8%) (8%)
3 (4%) 1 (1%)
pregnancy. By the time, second questionnaires were completed (between 32 and 36 weeks’ gestation), complications reported included gestational diabetes (6, 8%), breech presentation (5, 7%), suspected fetal growth restriction (4, 5%), hypertension (2, 3%), low-lying placenta (2, 3%), threatened preterm labour (1, 1%) and other complications (5, 7%). 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’. Those who responded ‘yes’ were not included in the denominator of some results. In response to the question, ‘Have you attended any classes, courses or meetings specifically about trying for a vaginal birth after a caesarean section’? 65 couples (87%) responded ‘no’ and 10 couples (13%) responded ‘yes’. 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. To examine the effect of discordant perceptions, we defined discordance as a difference of three or more points comparing maternal and paternal Likert scores. Examining discordant perceptions of risk in the third trimester (‘How do you rate the risk, to either you and/or your baby, of trying for a vaginal birth after your previous caesarean section’), in 30 couples (40%), the paternal risk was discordantly lower; in 38 couples (51%), the ratings were concordant; and in seven couples (9%), the paternal rating was discordantly greater than the maternal rating. Between the second-trimester and third-trimester questionnaires, the Likert scores for maternal perception of risk fell in 30 couples (40%), showed no change in 37 couples (49%) and increased in eight couples (11%). However, the Likert scores for paternal perception of risk fell in 20 couples (27%), showed no change in 25 couples (33%) and increased in the remaining 30 couples (40%). 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. 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). Where the maternal rating was between 4 and 7, 47% had a planned CS, compared to 52% for the same paternal scores (P = 0.27) and 19% vs 18% (P = 1.0) for maternal and paternal, respectively, where the scores were 8–10. To assess predictive factors for couples choosing to attempt VBAC, unadjusted odds ratios and confidence intervals were calculated for candidate variables and logistic regression was performed using the three candidate variables with a P -value of 0.1 or less, and the adjusted odds ratios are presented in Table 2. 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).
Discussion This study found perception of risk between second and third trimester differed by gender – 40% of women perceived a reduction in risk associated with VBAC, while 40% of their male partners perceived an increase in risk. Women’s self-rated importance of trying for a vaginal birth was more predictive of plan for birth than the selfrated importance of their male partners. After adjusting for other variables such as maternal index birth complications and low paternal risk perception, a fall in
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Table 2 Logistic regression for VBAC candidate variables
Maternal complication at index birth Low paternal risk perception Fall in paternal risk perception
Planned VBAC (N = 31) %
Planned caesarean (N = 44) %
aOR (95% CI)
P value
13
34
0.40 (0.11, 1.46)
0.12
19
39
0.51 (0.16, 1.61)
0.20
42
20
3.20 (1.03, 10.1)
0.04
VBAC, vaginal birth after caesarean.
paternal risk perception from second to third trimester was associated with an increase in VBAC attempt by their partner. Small numbers may be responsible for wide confidence intervals shown in the model. This finding suggests that time spent providing information and education for fathers might increase the chance that a couple will attempt VBAC. Limitations to this study include the relatively small sample size, with few couples willing to participate and a high dropout rate despite close contact between researchers and participant couples. We have no way of discerning the characteristics of the couples who were approached but declined to participate, and whether they differ from those who completed the study. Couples from a non-English speaking background were excluded from the study. Potential bias was introduced by the homebased questionnaire format; couples may have filled out their surveys together instead of separately. Also, we did not specifically gather chart review information about the index birth; thus, clinical information regarding the index caesarean and any associated complications and the outcome of the current birth are based on self-report and subject to recall bias. However, the couple’s perception of complications was the important consideration. Population data reveal that fewer eligible women are attempting VBAC, falling from 49 to 35% over a decade, with a similar fall in the rate at which vaginal birth is achieved, from 64 to 53%.10 The probability of achieving a vaginal delivery after a previous CS is variable, ranging between 43 and 80%.15–17 A systematic review of various strategies implemented to increase the uptake and success of attempted VBAC found that all of them either had no effect or actually reduced the success rate.18 The reason for a fall in the uptake of VBAC remains unclear. One prospective study suggested that the many women believe attempted VBAC carries a higher risk than repeat caesarean section, and the authors concluded that most mothers have already made up their minds about birth options following a prior CS and sought psychosocial support in their decision, rather than detailed clinical information about risks and benefits.19 Other studies have identified ‘family factors’ – speed of recovery in particular – as an important considerations when considering attempted VBAC.20,21 It is clear that many women find decision-making challenging, and that the 260
process is associated with prolonged anxiety.11 To address this, a randomised trial of use of a decision-aid tool, conducted by the same investigators, found the tool ‘reduced decisional conflict’ and may have contributed to a nonsignificant trend towards increased rates of vaginal birth.22 Further studies of ‘decision support interventions,’ incorporating use of an educational DVD and home visit by a dedicated midwife, was well received by candidate women, but did not appear to increase rates of vaginal birth.23 To date, almost no work has been undertaken examining the effect of paternal influences on a couple’s choices. This seems unusual, since studies of partners’ wishes have been addressed in other contexts.24 For example, studies have demonstrated that both maternal25 and paternal26 satisfaction with birth experiences is increased by direct involvement in decision-making. A study of men whose partners had undergone CS reported that men generally held a positive view of CS.27 The procedure was considered ‘safe and routine’ and afforded fathers a sense of control, safety and certainty. However, the communication provided by maternity staff was an important influence in making the experience seems positive. Research suggests that the majority of women do not change their opinion about mode of birth as their pregnancy progresses – a study of women facing the choice about attempting VBAC reported that 57% of women held the same preference for mode of delivery in mid- and late pregnancy, and 65% had the mode of birth they wished for.21 Other studies have suggested that women were strongly influenced by ‘family and friends’ when making their choice.28 A study of 26 women in Scotland reported that final decisions about VBAC were often not made until during the course of the pregnancy, but that maternal involvement in decision-making was important.29 Other studies have highlighted the value of informed choice and noted that psychosocial implications may supersede concerns about the physical aspects of birth.30
Conclusion A great deal of work has been undertaken examining the interventions that might increase the uptake rate of couples for attempted VBAC, but none have revealed a
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Paternal influence on choice for VBAC
strong influence. 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.
References 1 Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s Mothers and Babies 2010. Perinatal statistics series no. 26. Cat. no. PER 50. Canberra: AIHW, 2012. 2 Delbaere I, Cammu H, Martens E et al. Limiting the caesarean section rate in low risk pregnancies is key to lowering the trend of increased abdominal deliveries: an observational study. BMC Pregnancy Childbirth 2012; 12: 3. 3 Khunpradit S, Tavender E, Lumbiganon P et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2011; 15: CD005528. 4 Baghurst P, Robson S, Georgiou A et al. The association between increasing maternal age at first birth and increased rates of dysfunctional labour and caesarean section in South Australia from 1991-2009. Aust N Z J Obstet Gynaecol 2014; 54: 237–243. 5 Essex HN, Green J, Baston H, Pickett KE. Which women are at increased risk of caesarean section or an instrumental vaginal birth in the UK: an exploration within the Millennium Cohort Study. BJOG 2013; 120: 732–742. 6 Klemetti R, Gissler M, Sainio S, Hemminki E. Associations of maternal age with maternity care use and birth outcome in primiparous women: a comparison of results in 1991 and 2008 in Finland. BJOG 2014; 121: 356–362. 7 Athukorala C, Rumbold AR, Willson KJ, Crowther CA. The risk of adverse pregnancy outcomes in women who are overweight or obese. BMC Pregnancy Childbirth 2010; 10: 56. 8 Dodd JM, Grivell RM, Nguyen AM et al. Maternal and perinatal health outcomes by body mass index category. Aust N Z J Obstet Gynaecol 2011; 51: 136–140. 9 Brennan DJ, Robson MS, Murphy M, O’Herlihy C. Comparative analysis of international caesarean delivery rates using 10-group classification identifies significant variation in spontaneous labour. Am J Obstet Gynecol 2009; 201: 308.e1-8. 10 Homer CS, Johnston R, Foureur MJ. Birth after caesarean section: changes over a nine-year period in one Australian state. Midwifery 2011; 27: 165–169. 11 Emmett CL, Shaw ARG, Montgomery AA, Murphy DJ. Women’s experience of decision making about mode of delivery after a previous caesarean section: role of health professionals and information about health risks. BJOG 2006; 113: 1438–1445. 12 National Institute for Health and Clinical Excellence (NICE). Caesarean section. NICE Clinical Guideline 132. National Institute for Health and Clinical Excellence (NICE), 2011. 13 Horey D, Kealy M, Davey MA et al. Interventions for supporting pregnant women’s decision-making about mode of birth after a caesarean. Cochrane Database Syst Rev 2013; 30: CD010041.
14 Kamal P, Dixon-Woods M, Kurinczuk JJ et al. Factors influencing repeat caesarean section: qualitative exploratory study of obstetricians’ and midwives’ accounts. BJOG 2005; 112: 1054–1060. 15 Cowan RK, Kinch RA, Ellis B, Anderson R. Trial of labor following caesarean delivery. Obstet Gynecol 1994; 83: 933–936. 16 Stone C, Halliday J, Lumley J, Brennecke S. Vaginal births after caesarean (VBAC): a population study. Paediatr Perinat Epidemiol 2000; 14: 340–348. 17 Crowther CA, Dodd JM, Hiller JE et al. Planned vaginal birth or elective repeat caesarean: patient preference restricted cohort with nested randomised trial. PLoS Med 2012; 9: e1001192. 18 Catling-Paull C, Johnston R, Ryan C et al. Clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. J Adv Nurs 2011; 67: 1646–1661. 19 Guise JM, Denman MA, Emeis C et al. Vaginal birth after caesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 2010; 115: 1267–1278. 20 McGrath P, Phillips E, Vaughan G. Vaginal birth after caesarean risk decision-making: Australian findings on the mothers’ perspective. Int J Nurs Pract 2010; 16: 274–281. 21 Eden KB, Hashima JN, Osterweil P et al. Childbirth preferences after caesarean birth: a review of the evidence. Birth 2004; 31: 49–60. 22 Montgomery AA, Emmett CL, Fahey T et al. Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial. BMJ 2007; 334: 1305. 23 Farnworth A, Robson SC, Thomson RG et al. Decision support for women choosing mode of delivery after a previous caesarean section: a developmental study. Patient Educ Couns 2008; 71: 116–124. 24 Tough S, Tofflemire K, Benzies K et al. Factors influencing childbearing decisions and knowledge of perinatal risks among Canadian men and women. Matern Child Health J 2007; 11: 189–198. 25 Spaich S, Welzel G, Berlit S et al. Mode of delivery and its influence on women’s satisfaction with childbirth. Eur J Obstet Gynecol Reprod Biol 2013; 170: 401–406. 26 Johansson M, Hildingsson I. Intrapartum care could be improved according to Swedish fathers: mode of mirth matters for satisfaction. Women Birth 2013; 26: 195–201. 27 Johansson M, Hildingsson I, Fenwick J. Important factors working to medicate Swedish fathers’ experiences of a caesarean section. Midwifery 2013; 29: 1041–1049. 28 Fenwick J, Gamble J, Hauck Y. Believing in birth – choosing VBAC: the childbirth expectations of a self-selected cohort of Australian women. J Clin Nurs 2007; 16: 1561–1570. 29 Moffat MA, Bell JS, Porter MA et al. Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study. BJOG 2007; 114: 86–93. 30 Meddings F, Phipps FM, Haith-Cooper M, Haigh J. Vaginal birth after caesarean section (VBAC): exploring women’s perceptions. J Clin Nurs 2007; 16: 160–167.
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DOI: 10.1111/ajo.12326
Original Article
Concordance of maternal and paternal decision-making and its effect on choice for vaginal birth after caesarean section Stephen ROBSON,1 Beth CAMPBELL,2 Gabrielle PELL,3 Anne WILSON,4 Kate TYSON,3 Caroline DE COSTA,5 Michael PERMEZEL3 and Cindy WOODS5 1
Australian National University Medical School, Canberra, Australian Capital Territory, 2Townsville Hospital, Townsville, Queensland, Mercy Hospital for Women, Melbourne, Victoria, 4Calvary John James Hospital, Canberra, Australian Capital Territory, and 5School of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
3
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. Key words: caesarean section, decision-making, paternal, vaginal birth after caesarean.
Introduction The rate of caesarean section (CS) in Australia currently exceeds 30% and has almost doubled over the past two decades.1 Despite international interest, strategies that aim to reduce the rate of CS have not been successful.2,3 Factors known to increase the risk for CS, such as increased maternal age4–6 and maternal obesity7,8, are not easily amenable to modification. The majority of women whose first child is born by CS are likely to give birth to subsequent children by CS9,10 so an important area that influences the CS rate is decision-making about whether to try for vaginal birth after previous caesarean section (VBAC). In recent years, increasing emphasis has been placed on women’s choice in decision-making.11 For example,
Correspondence: A/Prof Stephen J. Robson, Australian National University Medical School, PO Box 5235, Garran LPO, ACT Australia. Email: [email protected] Received 27 September 2014; accepted 15 January 2015.
the British National Institute for Clinical Excellence (NICE) guidelines emphasise that decision-making regarding mode of birth after a previous caesarean section should consider maternal preferences and priorities, as well as discussion of risks.12 A systematic review of maternal decision-making for VBAC reported that many methods had been evaluated, including decision aids, one-on-one counselling, group sessions, protocols and algorithms.13 None of these interventions affected the planned mode of birth, the actual mode of birth, nor an effect on women being ‘unsure’ about which to choose.13 Other studies have examined the effect of obstetricians’ and midwives’ opinions about attempted VBAC and how these opinions might affect maternal decision-making.14 However, to date, there appear to have been no large studies directly addressing paternal influences on decisionmaking regarding VBAC. We have hypothesised that paternal attitudes to attempted VBAC will affect maternal decision-making. This study aimed to determine whether maternal and paternal perception of risk for, and
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
257
S. Robson et al.
importance of, attempted VBAC was associated with an intention to attempt VBAC.
Materials and Methods Recruitment took place at three hospitals, two metropolitan and one regional, in the states of Queensland, Victoria and the Australian Capital Territory in Australia from January of 2012 until December 2013. Eligible couples were those with a singleton pregnancy, a normal second-trimester morphology ultrasound, and the placenta not covering the internal cervical os. Additional criteria were both father and mother were over the age of 18 years; both speak English without the need for an interpreter; the previous pregnancy was within this relationship, not with a different paternity; the partners were cohabitating for the duration of the study and were not separated, separating or divorced; the first CS did not contraindicate subsequent vaginal birth (for example, a CS with a vertical uterine incision); and where there was no condition in the new pregnancy that might potentially preclude a vaginal birth. Sample size was not calculated, the sample was pragmatic based on the number of women seen in the clinic over the study period. Couples who fulfilled the inclusion criteria were approached for recruitment at the antenatal booking visit, after the morphology ultrasound. Information statements were provided, and eligible couples who agree to participate were asked to sign the consent documents. Questionnaires were sent separately to each partner with an accompanying addressed and stamped envelope for return. The questionnaires were scheduled for completion at by the end of the second trimester, at between 32 and 36 weeks’ gestation and six weeks postnatal. If a questionnaire was not returned within two weeks of posting, a reminder telephone call was made and second questionnaire was sent. The first questionnaires obtained basic demographic information, including the ages of both partners, the indication for the primary CS and whether it had been performed prelabour or as an intrapartum procedure, first child’s birthweight and complications of the primary CS for either mother or neonate. Each partner was then asked to rate their level of satisfaction with the first birth using a Likert scale from 1 (not satisfied at all) to 10 (could not be more satisfied). Both partners were asked, ‘How important to you is trying for a vaginal birth in this pregnancy’? and asked to rate this on a ten-point Likert scale. Both partners were also asked, ‘How do you rate the risk, to either you and/or your baby, of trying for a vaginal birth after your previous caesarean section’? with a tenpoint Likert scale. The second questionnaires, completed in the third trimester, asked whether any complications had developed (such as hypertension, suspected growth restriction or diabetes) and whether the couple had been advised to have a repeat CS. Both partners were asked their intention 258
for birth (planned prelabour CS, trial of vaginal birth or undecided) and, again, to rate the importance of trying for a vaginal birth and rating of risk. The final questionnaires, completed at approximately six weeks postnatal, asked about the mode and outcome of birth, for both mother and baby, and whether there were any complications. Both partners were asked, ‘Looking back, how well did the discussions you had with your doctor at the antenatal clinic prepare you for birth this time’? and were asked to rate their satisfaction with birth. There were numerous spaces left for free text answers on all questionnaires. Data were entered in to Excel spreadsheets and then imported into SPSS version 20 (IBM SPSS Inc., Chicago, IL, USA). Logistic regression analyses were undertaken to estimate the odds ratios and 95% confidence intervals for significant predictors of desire for attempted VBAC at the final prelabour survey. Univariate analyses were performed to estimate the associations between desire for VBAC and each of the candidate variable survey results. Factors associated with an intention to attempt VBAC demonstrating an unadjusted P-value of 0.10 or less were then included in the multivariate regression analysis. The study received prospective approval from the James Cook University Human Research Ethics Committee and the Mercy Health Research Ethics Committee.
Results Of 102 couples who agreed to participate, a total of 75 completed the full set of questionnaires during the study period (Fig. 1). The demographic information for the study group is presented in Table 1. At the time of the first questionnaire, two couples reported that they had been advised they should have a planned CS in their next
Couples completing consent forms N = 102 Incomplete from both partners N=6 Both partners complete first questionnaires N = 96 Incomplete from both partners N = 11 Both partners complete second questionnaires N = 85 Incomplete from both partners N = 10 Both partners complete final questionnaires N = 75
Figure 1 Flowchart of subject recruitment for study.
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Paternal influence on choice for VBAC
Table 1 Demographic characteristics of participants and selfreported clinical characteristics of index caesarean Maternal age range 35 years Timing of index caesarean section Prelabour Intrapartum Indications for index caesarean section Prelabour (n = 21) Breech Placenta praevia Growth restriction Macrosomia Maternal request Other Intrapartum (n = 54) Breech No progress ‘Fetal distress” Other Birthweight at index caesarean 4 Kg Complications at primary caesarean section Maternal Haemorrhage Blood transfusion Infection Other Neonatal NICU/SCBU admission Oxygen resuscitation
3 (4%) 59 (79%) 13 (17%) 21 (28%) 54 (72%)
9 1 1 4 2 4
(43%) (5%) (5%) (19%) (10%) (19%)
4 20 22 8
(7%) (37%) (41%) (15%)
9 (12%) 57 (76%) 9 (12%)
12 1 6 6
(16%) (1%) (8%) (8%)
3 (4%) 1 (1%)
pregnancy. By the time, second questionnaires were completed (between 32 and 36 weeks’ gestation), complications reported included gestational diabetes (6, 8%), breech presentation (5, 7%), suspected fetal growth restriction (4, 5%), hypertension (2, 3%), low-lying placenta (2, 3%), threatened preterm labour (1, 1%) and other complications (5, 7%). 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’. Those who responded ‘yes’ were not included in the denominator of some results. In response to the question, ‘Have you attended any classes, courses or meetings specifically about trying for a vaginal birth after a caesarean section’? 65 couples (87%) responded ‘no’ and 10 couples (13%) responded ‘yes’. 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. To examine the effect of discordant perceptions, we defined discordance as a difference of three or more points comparing maternal and paternal Likert scores. Examining discordant perceptions of risk in the third trimester (‘How do you rate the risk, to either you and/or your baby, of trying for a vaginal birth after your previous caesarean section’), in 30 couples (40%), the paternal risk was discordantly lower; in 38 couples (51%), the ratings were concordant; and in seven couples (9%), the paternal rating was discordantly greater than the maternal rating. Between the second-trimester and third-trimester questionnaires, the Likert scores for maternal perception of risk fell in 30 couples (40%), showed no change in 37 couples (49%) and increased in eight couples (11%). However, the Likert scores for paternal perception of risk fell in 20 couples (27%), showed no change in 25 couples (33%) and increased in the remaining 30 couples (40%). 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. 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). Where the maternal rating was between 4 and 7, 47% had a planned CS, compared to 52% for the same paternal scores (P = 0.27) and 19% vs 18% (P = 1.0) for maternal and paternal, respectively, where the scores were 8–10. To assess predictive factors for couples choosing to attempt VBAC, unadjusted odds ratios and confidence intervals were calculated for candidate variables and logistic regression was performed using the three candidate variables with a P -value of 0.1 or less, and the adjusted odds ratios are presented in Table 2. 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).
Discussion This study found perception of risk between second and third trimester differed by gender – 40% of women perceived a reduction in risk associated with VBAC, while 40% of their male partners perceived an increase in risk. Women’s self-rated importance of trying for a vaginal birth was more predictive of plan for birth than the selfrated importance of their male partners. After adjusting for other variables such as maternal index birth complications and low paternal risk perception, a fall in
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S. Robson et al.
Table 2 Logistic regression for VBAC candidate variables
Maternal complication at index birth Low paternal risk perception Fall in paternal risk perception
Planned VBAC (N = 31) %
Planned caesarean (N = 44) %
aOR (95% CI)
P value
13
34
0.40 (0.11, 1.46)
0.12
19
39
0.51 (0.16, 1.61)
0.20
42
20
3.20 (1.03, 10.1)
0.04
VBAC, vaginal birth after caesarean.
paternal risk perception from second to third trimester was associated with an increase in VBAC attempt by their partner. Small numbers may be responsible for wide confidence intervals shown in the model. This finding suggests that time spent providing information and education for fathers might increase the chance that a couple will attempt VBAC. Limitations to this study include the relatively small sample size, with few couples willing to participate and a high dropout rate despite close contact between researchers and participant couples. We have no way of discerning the characteristics of the couples who were approached but declined to participate, and whether they differ from those who completed the study. Couples from a non-English speaking background were excluded from the study. Potential bias was introduced by the homebased questionnaire format; couples may have filled out their surveys together instead of separately. Also, we did not specifically gather chart review information about the index birth; thus, clinical information regarding the index caesarean and any associated complications and the outcome of the current birth are based on self-report and subject to recall bias. However, the couple’s perception of complications was the important consideration. Population data reveal that fewer eligible women are attempting VBAC, falling from 49 to 35% over a decade, with a similar fall in the rate at which vaginal birth is achieved, from 64 to 53%.10 The probability of achieving a vaginal delivery after a previous CS is variable, ranging between 43 and 80%.15–17 A systematic review of various strategies implemented to increase the uptake and success of attempted VBAC found that all of them either had no effect or actually reduced the success rate.18 The reason for a fall in the uptake of VBAC remains unclear. One prospective study suggested that the many women believe attempted VBAC carries a higher risk than repeat caesarean section, and the authors concluded that most mothers have already made up their minds about birth options following a prior CS and sought psychosocial support in their decision, rather than detailed clinical information about risks and benefits.19 Other studies have identified ‘family factors’ – speed of recovery in particular – as an important considerations when considering attempted VBAC.20,21 It is clear that many women find decision-making challenging, and that the 260
process is associated with prolonged anxiety.11 To address this, a randomised trial of use of a decision-aid tool, conducted by the same investigators, found the tool ‘reduced decisional conflict’ and may have contributed to a nonsignificant trend towards increased rates of vaginal birth.22 Further studies of ‘decision support interventions,’ incorporating use of an educational DVD and home visit by a dedicated midwife, was well received by candidate women, but did not appear to increase rates of vaginal birth.23 To date, almost no work has been undertaken examining the effect of paternal influences on a couple’s choices. This seems unusual, since studies of partners’ wishes have been addressed in other contexts.24 For example, studies have demonstrated that both maternal25 and paternal26 satisfaction with birth experiences is increased by direct involvement in decision-making. A study of men whose partners had undergone CS reported that men generally held a positive view of CS.27 The procedure was considered ‘safe and routine’ and afforded fathers a sense of control, safety and certainty. However, the communication provided by maternity staff was an important influence in making the experience seems positive. Research suggests that the majority of women do not change their opinion about mode of birth as their pregnancy progresses – a study of women facing the choice about attempting VBAC reported that 57% of women held the same preference for mode of delivery in mid- and late pregnancy, and 65% had the mode of birth they wished for.21 Other studies have suggested that women were strongly influenced by ‘family and friends’ when making their choice.28 A study of 26 women in Scotland reported that final decisions about VBAC were often not made until during the course of the pregnancy, but that maternal involvement in decision-making was important.29 Other studies have highlighted the value of informed choice and noted that psychosocial implications may supersede concerns about the physical aspects of birth.30
Conclusion A great deal of work has been undertaken examining the interventions that might increase the uptake rate of couples for attempted VBAC, but none have revealed a
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Paternal influence on choice for VBAC
strong influence. 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.
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