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An exploration of the mode of birth decision for pregnant women with a previous cesarean delivery

Burke, Ryan C
http://orcid.org/0000-0001-5327-5735
http://rave.ohiolink.edu/etdc/view?acc_num=kent1523875009553728

Abstract Details

2018, PHD, Kent State University, College of Public Health.
Introduction: The U.S. C-section rate is one of the highest in the world and has been increasing partly due to the high incidence of repeat C-sections. C-sections, compared to vaginal births, are associated with increased morbidity, longer lengths of hospital stay, and increased costs. The American College of Obstetricians and Gynecologists recommends most pregnant women with a history of a cesarean delivery be offered the option of a trial of labor after cesarean (TOLAC) to attempt a vaginal birth after cesarean (VBAC). However, in the U.S., 80% of deliveries to low-risk women with a prior cesarean occur via an elective repeat cesarean delivery (ERCD). Low VBAC rates are not due to failure of VBAC but to lack of VBAC attempts. Increasing the proportion of women undergoing a TOLAC is a potential strategy to decrease the total C-section rate. To do this, it is essential to understand the mode of birth decision-making process for women with a prior cesarean delivery, yet there is a paucity of information on this topic. Therefore, the goal of this research was to examine clinical characteristics, individual- and physician-level characteristics, and physician perspectives towards TOLAC. The specific aims of the dissertation were to: 1. Explore maternity care providers’ (MCPs) perspectives and practice patterns regarding TOLAC, VBAC, and ERCD. 2. Explore the self-reported factors in the decision-making process to attempt a TOLAC or an ERCD and identify differences between the two groups, including activation and engagement. 3. Measure the role of the MCP in whether a woman undergoes a TOLAC or an ERCD, and assess what patient and MCP characteristics are associated with TOLAC. Methods: Aim 1 consisted of a cross-sectional online survey of MCPs in the Akron, Ohio area. Descriptive analysis was conducted. Aim 2 consisted of a cross-sectional in-person survey of women immediately postpartum. Patient activation and engagement was measured with the Patient Activation Measure (PAM). TOLAC and ERCD women were compared across characteristics, and all significant variables were entered into a logistic regression model to determine significant differences between the two groups. The rankings for each factor important in the mode of birth decision-making process were summarized by group. Aim 3 consisted of a retrospective cross-sectional study of deliveries occurring from 2010-2014 at a hospital in Akron, Ohio. Both patient-level and physician-level variables were examined in a hierarchical generalized linear model (HGLM) to quantify the amount of variation in whether a woman undergoes a TOLAC accounted for by the physician as well as determine what patient and physician characteristics were associated with TOLAC. Results: Forty-seven MCPs were recruited for the Aim 1 survey; 37 (79%) completed it. Substantial practice variations existed across physicians regarding when to encourage or discourage a patient to attempt a VBAC as well as what risks are usually discussed for VBAC and ERCD. There was more consistency in risks discussed with patients for TOLAC but fewer risks consistently discussed for ERCD. Nearly all (97%) agreed that TOLAC should be presented to patients as an option and 66% agreed that women should be actively encouraged to TOLAC. Of 305 eligible women for the Aim 2 survey, 272 (89%) completed it and 248 were included in analysis. The percent of women choosing TOLAC was 43%. There were no differences between TOLAC and ERCD women across all demographics and PAM score. Results of the logistic regression found the following associated with increased odds of choosing TOLAC: gestational age 37-38 weeks or 40 or more weeks, previous vaginal delivery, how often the woman talked with her MCP about having a VBAC, whether at least one MCP recommended a VBAC, and making the decision earlier in pregnancy. How often the woman talked with her MCP about reasons to have a cesarean was associated with decreased odds of choosing a TOLAC. For both TOLAC and ERCD women, their own safety and their baby’s safety had the highest importance scores in their mode of birth decision. Other factors important for ERCD women were a desire to avoid an emergency cesarean and a worry about complications that would arise from labor or vaginal birth. For TOLAC women, other high-ranking factors were recovery time and the ability to bond with the baby. In the retrospective analysis for Aim 3, 230 (17%) of 1,353 women underwent a TOLAC. Only 4.6% of the variability in whether a woman had a TOLAC in this sample was accounted for by the delivering physicians, a non-significant finding. The results of the HGLM with patient and physician-level effects showed patient age, previous vaginal delivery, Black race, gestational age less than 37 weeks, gestational age 40 weeks, gestational age 41 weeks or more, and physician practice size of 2-4 providers were all associated with increased odds of a TOLAC. Tubal ligation during the delivery was associated with decreased odds of TOLAC. Conclusion: This research was an in-depth examination of the mode of birth decision-making process from a variety of perspectives and using a variety of methods. There were mixed results regarding the role of the MCP, with only 5% of the variability associated with whether a woman undergoes a TOLAC accounted for by the physician in the HGLM. However, logistic regression results from the survey of women indicate the MCP might play an important role. This research found differences between TOLAC and ERCD women but found for both groups safety was the factor with the highest importance in their decision-making process. The results of these studies can help researchers and practitioners better serve this population of women and determine the best approach to decreasing the number of women having an ERCD.
Melissa Zullo, PhD (Committee Chair)
Vinay Cheruvu, PhD (Committee Member)
Lynette Phillips, PhD (Committee Member)
Justin Lavin, MD (Committee Member)
Joel Hughes, PhD (Committee Member)
176 p.
Epidemiology
vaginal birth after cesarean; trial of labor after cesarean; cesarean delivery; elective repeat cesarean delivery

Recommended Citations

Citations

  • Burke, R. C. (2018). An exploration of the mode of birth decision for pregnant women with a previous cesarean delivery [Doctoral dissertation, Kent State University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=kent1523875009553728

    APA Style (7th edition)

  • Burke, Ryan. An exploration of the mode of birth decision for pregnant women with a previous cesarean delivery. 2018. Kent State University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=kent1523875009553728.

    MLA Style (8th edition)

  • Burke, Ryan. "An exploration of the mode of birth decision for pregnant women with a previous cesarean delivery." Doctoral dissertation, Kent State University, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=kent1523875009553728

    Chicago Manual of Style (17th edition)

kent1523875009553728
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This open access ETD is published by Kent State University and OhioLINK.