Background
Methods
Literature search
Eligibility criteria
Study selection
Data extraction
Assessment of methodological quality
Data synthesis
Assessment of overall quality of evidence
Results
Intervention Category | Strategy/Outcome Themes | TOLACa | VBACa | Study (study design) |
---|---|---|---|---|
System-level | Education and training of providers | NA | + | Ayres-de-Campos 2015 (NCC) |
Targeted CD rates with hospital funding | NA | + | Ayres-de-Campos 2015 (NCC) | |
Targeted VBAC rates with hospital funding | NA | + | Liu 2013 (NCC) | |
Hospital peer-review of CD/VBAC | NA | NS; | Bickell 1996 (BA); | |
+, NC | Liu 2013 (NCC) | |||
Provider-level | Opinion leader VBAC | + | + | Lomas 1991 (RCT) |
Hospital with laborists | + | +NS | Feldman 2015 (CS) | |
Second opinion requirement for all CDs | + | + | Myers 1993 (NCC) | |
Provider characteristics | Midwifery vs. non-midwifery provider | + | + | Zhang 2016 (RCT); |
White 2016 (NCC) | ||||
Family physician vs. obstetrician | + | + | Russillo 2008 (CS) | |
Night float call vs. traditional call | + | + | Yee 2017 (RC) | |
Provider guidelines/information | Education and management direction | + | + | Bellows 2016 (NCC); |
Kosecoff 1987 (RC); | ||||
Sanchez-Ramos 1990 (NCC); | ||||
Santerre 1996 (NCC); | ||||
– | – | Pinette 2004 (NCC); | ||
Zweifler 2006 (NCC); | ||||
NA | NC | Studnicki 1997 (NCC) | ||
Patient-level | Obstetric information vs. no information | + | + | Wong 2014 (PC) |
Verbal vs. written patient information | +NS | +NS | Fraser 1997 (RCT); | |
Dedicated VBAC clinic vs. standard care | NA | + | Gardner 2014 (NCC) | |
Decision analysis (computerized) vs. brochures | NA | +NS | Eden 2014 (RCT) | |
Decision analysis vs. information vs. usual care | NA | +NS | Montgomery 2007 (RCT) | |
One-on-one antenatal VBAC counseling vs. standard care | + | – | Cleary-Goldman 2005 (PC) |
Study; Design; Country, setting; Funding | Population; Study period | Intervention & comparator (no. of participants) | TOLAC ratea | VBAC ratea | VBAC/TOLAC ratea | ||
---|---|---|---|---|---|---|---|
Ayres-De-Campos (2015) Non-concurrent cohort Portugal, state-owned hospitals, private hospitals & home births No funding | All deliveries from state-owned hospitals, private hospitals & home births during study period January 1, 2000–September 30, 2014 | Grp 1 (2000–2009): no concerted action (n = 913,219) | Grp 2 (2010–2014): concerted action by independent committee (visits to state—owned hospitals with CS rates > 35%; meetings with obstetric & midwifery staff; training courses) (n = 346,157) | NR | 2000: 14,993 (14.5%); 2001: 13,298 (13.7%); 2002: 15,360 (15.8%); 2003: 13,890 (14.8%); 2004: 13,710 (15.0%); 2005: 13,147 (14.6%); 2006: 15,700 (17.9%); 2007: 15,431 (18.1%); 2008: 13,837 (16.2%); 2009: 13,399 (16.4%) vs. 2010: 14,834 (17.9%); 2011: 17,624 (22.8%); 2012: 18,076 (25.1%); 2013: 16,365 (25.8%); Jan–Sept 2014: 16,859 (32.8%) | NR | |
Bickell (1996) Controlled before-after US, hospitals with high/average/low cesarean rate Funding NR | Hospitals from eight designated Health Service Areas of New York State 1988 & 1993 | I: reviewed hospitals, external peer reviews by ACOG trained team (audit & feedback) (45 hospitals; mean 1400–1500 deliveries) | C: non-reviewed hospitals, had an obstetric service (120 hospitals; mean 1700 deliveries) | NR | 1988: I: mean 10.1 ± 1.4% C: mean 12.1 ± 0.9% NS (p > 0.01) 1993: I: mean 24.8 ± 2.0% C: mean 24.8 ± 1.1% NS (p > 0.01) | NR | |
Liu (2013) Non-concurrent cohort Taiwan, tertiary hospital Funding NR | All pregnant women delivering by cesarean section June 2001–August 2010 | Period 1 (June 2001–July 2002): before implementation of budget systems (n = 800) | Period 2 (July 2002–August 2005): global budget system (n = 1887) | Period 3 (August 2005–2010): hospital-based self-management program (n = 2621) | NR | P1: 38 (4.8%) P2: 231 (12.2%) P3: 298 (11.4%) Period 1 vs. 2, p < 0.001 Period 2 vs. 3, p = 0.3950 | NR |
Study; Design; Country, setting; Funding | Population; Study period | Intervention & comparator (no. of participants) | TOLAC ratea | VBAC ratea | VBAC/TOLAC ratea | Study; Design; Country, setting; Funding | |
---|---|---|---|---|---|---|---|
Feldman (2015) Cross-sectional US, community hospitals Non-industry funded | Women with live-born, singleton, vertex gestations, with prior CS January 2012–January 2014 | I: hospitals employing laborists (≥1 physician in hospital, primary focus is to care for patients in labor and delivery) (n = 2621) | C: hospitals without laborists (n = 2111) | I: 356 (13.6%) C: 201 (9.5%), p = 0.0318 | I: 253 (9.7%) C: 137 (6.5%), p = 0.0302 | I: 253 (71.0%) C: 136 (67.9%), p = 0.2943 | |
Lomas (1991) RCT, 3-arm Canada, community hospitals Non-industry funded | Study site inclusion needed 100 beds (10+ obstetrical), no status as teaching institution, not in county with teaching institution 1988–1989 | I 1: audit and feedback (n = 524) | I 2: opinion leader education (n = 739) | C: eight control hospitals, practice guideline mailed to obstetrical care (n = 1233) | I 1: 112 (21.4%) I 2: 282 (38.2%) C: 349 (28.3%), p = 0.007 | I 1: 62 (11.8%) I 2: 187 (25.3%) C: 179 (14.5%), p = 0.003 | I 1: 62 (55.4%) I 2: 187 (66.3%) C: 179 (51.3%) |
Myers (1993) Follow-up to non-concurrent cohort (1985–1987) US, level 3 prenatal center Funding NR | All patients in obstetric department 1985–1991 | Grp 1 (1985): before hospital initiative (n = 122) | Grp 2 (1986–1991): after hospital initiative; 2nd opinion required for all CS, VD was preferred, dystocia accepted as indication for CD (n = 1840) | 1985: 55 (45.0%) vs. 1986: 132 (68.4%) 1987: 233 (86.0%) 1988: 243 (88.3%) 1989: 255 (91.3%) 1990: 312 (85.4%) 1991:374 (81.8%) | 1985: 29 (23.8%) vs. 1986: 106 (54.9%) 1987: 162 (59.8%) 1988: 167 (60.1%) 1989: 188 (67.4%) 1990: 242 (66.3%) 1991: 291 (63.7%) | 1985: 29 (52.7%) vs. 1986: 106 (80.3%) 1987: 162 (69.5%) 1988: 167 (73.7%) 1989: 188 (73.7%) 1990: 242 (77.5%) 1991: 291 (77.8%) |
Study; Design; Country, setting; Funding | Population; Study period | Intervention & comparator (no. of participants) | TOLAC ratea | VBAC ratea | VBAC/TOLAC ratea | |
---|---|---|---|---|---|---|
Russillo (2008) Cross-sectional Canada, secondary care urban hospital Non-industry funded | Pregnant women with at least one previous CS, singleton delivery, birth weight at least 500 g January 1995–December 2003 | Grp 1: deliveries performed by obstetricians (n = 3493) | Grp 2: deliveries performed by family physicians (n = 201) | Grp 1: 1768 (50.6%) Grp 2: 163 (81.1%), p < 0.001 | Grp 1: 1136 (32.5%) Grp 2: 124 (61.7%) | Grp 1: 1136 (64.3%) Grp 2: 124 (76.1%), p = 0.002 |
White 2016 Non-concurrent cohort UK, tertiary teaching hospital Non-industry funded | Women with one previous CS who received antenatal and intrapartum care during study period 2008 & 2011 | Grp 1 (2008): obstetrician-led antenatal care (n = 209) | Grp 2 (≥2011): midwife-led antenatal care (n = 196) | Attempted VBAC: Grp 1: 143 (68.4%) Grp 2: 153 (78.1%) | Actual VBAC: Grp 1: 98 (46.9%) Grp 2: 120 (61.2%); aOR 1.79 (95% CI 1.17–2.75), p < 0.05 Spontaneous VBAC: Grp 1: 67 (32.1%) Grp 2: 85 (43.4%); OR 1.62 (95% CI 1.08–2.43) | Successful/attempted VBAC: Grp 1: 98 (68.5%) Grp 2: 120 (78.4%); OR 1.67 (95% CI 0.99–2.82), NS (p > 0.05) |
Yee 2017 Retrospective cohort US, large teaching hospital Funding NR | Women ≥18 years old with one prior low transverse CD, a term, cephalic singleton gestation, and no prior VD January 2008–June 2013 | Grp 1: night float schedule (n = 556) | Grp 2: traditional call schedule (n = 946) | Grp 1: 184 (33.1%) Grp 2: 156 (16.5%), p < 0.001 | Grp 1: 104 (18.7%) Grp 2: 88 (9.3%), p < 0.001 | Grp 1: 104 (56.5%) Grp 2: 88 (56.4%), p = 0.98 |
Zhang 2016 RCT China, hospital obstetric department No funding | Women with a history of previous CS in labor willing to undergo a VD May 2013–November 2014 | I: continuing midwifery care (n = 48) | C: standard maternity care (n = 48) | NR | I: 42 (87.5%) C: 32 (66.7%), p < 0.05 | NR |
Study; Design; Country, setting; Funding | Population; Study period | Intervention & comparator (no. of participants) | TOLAC ratea | VBAC ratea | VBAC/TOLAC ratea | |
---|---|---|---|---|---|---|
Bellows (2016) Non-concurrent cohort US, tertiary care academic hospital Funding NR | All women who underwent TOLAC, at least one prior CD & live, singleton gestation in cephalic presentation, 24 0/7 weeks of gestation July 1, 2009-December 31, 2013 | Grp 1 (2009–2011): pre-2011 guideline (n = 450) | Grp 2 (2011–2013): post-2011 guideline implementation (offering TOLAC; inducing labor; administering oxytocin) (n = 781) | NR | Grp 1: NR (26.0%) Grp 2: NR (33.3%) | Grp 1: 351 (78.1%) Grp 2: 616 (78.9%), p = 0.75 |
Kosecoff (1987) Retrospective cohort US, acute, non-specialty, nonfederal hospitals > 150 beds. Non-industry funded | Women with previous low transverse CS January 1979–December 1979 (time 1) January 1980–September 1980 (time 2) July 1981–June 1982 (time 3) | Period 1 (January–December 1979) & Period 2 (January–September 1980): before NIH Consensus Development conference recommendations (n = 35 & n = 64) | Period 3 (1981–1982): after conference recommendations; women should be given TOLAC for potential VD (n = 70) | Period 1: 2 (5.7%) Period 2: 7 (10.9%) vs. Period 3: 20 (28.6%) | Period 1: 2 (5.7%) Period 2: 4 (6.3%) vs. Period 3: 11 (15.7%) | Period 1: 2 (100%) Period 2: 4 (57.1%) vs. Period 3: 11 (55.0%) |
Pinette (2004) Non-concurrent cohort US, birth certificate & hospital reported data Funding NR | All women with previous CS giving birth at 20 weeks of gestation or more 1998–2001 | Grp 1 (1998): pre-exposure (birth certificate n = 1410; hospital data n = 1386) | Grp 2 (1999–2001): ACOG guideline revision (birth certificate data n = 4463; hospital data n = 4015) | NR | Birth certificate data: 1998: 424 (30.1%) vs. 1999: 327 (22.6%) 2000: 277 (17.9%) 2001: 193 (13.1%) 1988 vs. 2001, RR 2.8 (95% CI 2.5–3.2), p < 0.01 Hospital-reported data: 1998: 489 (35.3%) vs. 1999: 411 (28.2%) 2000: 321 (23.1%) 2001: 156 (13.3%) RR 3.5 (95% CI 3.1–4.2), p < 0.01 | NR |
Sanchez –Ramos (1990) Non-concurrent cohort US, regional perinatal center Funding NR | Women with one or two previous CS, with low transverse or vertical scars not extending into uterine corpus 1986–1989 | Grp 1 (1986–1987): before July 1, 1987 department-wide guideline change (n = 899) | Grp 2 (1988–1989): after July 1, 1987, new guidelines for intrapartum management (n = 1105) | 1986: 139 (31.7%) 1987: 193 (41.9%) vs. 1988: 402 (76.6%) 1989: 487 (84.0%); Difference: 52.2%, p < 0.0001 | 1986: 90 (20.5%) 1987: 142 (30.8%) vs. 1988: 342 (65.1%) 1989: 403 (69.5%); Difference: 48.9%; p < 0.0001 | 1986: 90 (64.7%) 1987: 142 (73.6%) vs. 1988: 342 (85.1%) 1989: 403 (82.8%); Difference: 18.0%; p < 0.0001 |
Santerre (1996) Non-concurrent cohort US, hospitals Funding NR | Women with a previous CS 1987–1991 | Grp 1 (before 1987–1988): before practice guideline implementation (n = NR) | Grp 2 (after Oct. 1988): ACOG practice guideline, prior cesarean section no longer a reason for repeat cesarean (n = NR) | NR | VBAC rate in US (data for Massachusetts hospitals NR) 1985: 6.6% 1986: 8.5% 1987: 9.8% 1988: 12.6% vs. 1989: 18.5% 1990: 20.4% 1991: 24.2% 1992: 25.1% 1993: 25.4% | NR |
Studnicki (1997) Non-concurrent cohort US, nonfederal acute care provider hospitals Funding NR | Women with prior CS 1990–1993 | Grp 1 (1990–1992): before practice guidelines (n = 66,702) | Grp 2 (1993): after legislatively imposed practice guidelines (n = 23,142) | NR | 1990: 4816 (21.8%) 1991: 5540 (25.6%) 1992: 6133 (26.7%) vs. 1993: 7151 (30.9%) | NR |
Zweifler (2006) Non-concurrent cohort US, California Department of Health Services Birth Statistical Master Files Funding NR | Women who previously gave birth by cesarean delivery & had singleton birth planned in a California hospital 1996–2002 | Grp 1 (1996–1999): before ACOG VBAC guideline revision (n = NRb) | Grp 2 (2000–2002): after ACOG VBAC guideline revision (n = NRb) | Attempted VBAC: Grp 1: NR (24.0%) Grp 2: NR (13.5%) Difference: 44% decrease, p < 0.001 | 1996–2002: 61,684 (16.0%) | NR |
Study; Design; Country, setting; Funding | Population; Study period | Intervention & comparator (no. of participants) | TOLAC ratea | VBAC ratea | VBAC/TOLAC ratea | Population; Study period | |
---|---|---|---|---|---|---|---|
Cleary-Goldman (2005) Prospective cohort with controls US, tertiary care center Non-industry funded | Women eligible for a TOLAC 12-month period | I: one-on-one VBAC counselling, in 2nd and 3rd trimesters (n = 95) | C: no extra counselling, standard care (n = 221) | I: 44 (46.3%) C: 85 (38.5%) | I: 26 (27.4%) C: 70 (31.7%) | I: 26 (59.1%) C: 70 (82.4%) | |
Eden (2014) RCT US, clinics Non-industry funded | Pregnant women with one prior CS, 18 years or older, pregnant with one fetus, low transverse uterine scar, and providers had given option of TOLAC September 17, 2005-May 4, 2007 | I: Evidence-based, interactive decision aid (n = 66) | C: two evidence-based educational brochures about cesarean delivery and VBAC (n = 65) | NR | I: NR (41.0%) C: NR (37.0%), p = 0.724 | NR | |
Fraser (1997) RCT Canada, hospitals Non-industry funded | Women with single previous low transverse CS, gestational age < 28 weeks. April 1992–November 1994 | I: Verbal prenatal education program – pamphlet + 2 individualized contacts (n = 641) | C: Document prenatal education program – written information (n = 634) | I: 465 (72.5%) C: 440 (69.4%); RR 1.1 (95% CI 1.0–1.1) | I: 339 (52.9%) C: 310 (48.9%); RR 1.1 (95% CI 1.0–1.2) | I: 339 (72.9%) C: 310 (70.5%) | |
Gardner (2014) Non-concurrent cohort Australia, metropolitan teaching hospital Funding NR | Women with a single prior CS, presenting in their next pregnancy 2006 (before) & May 2009–October 2010 | Grp 1 (2006): routine care, counselling for mode of birth on ad-hoc basis (n = NR) | Grp 2 (2009–2010): two combined management strategies – Risk Associated Pregnancy consultant & NBAC clinic (n = 396) | Grp 1: NR Grp 2: 164 (41.4%) | VBAC rate for NBAC Grp 1: NR (17.2%) Grp 2: 107 (27.0%), p < 0.001 | Grp 1: NR Grp 2: 107 (65.2%) | |
Montgomery (2007) RCT UK, maternity units Non-industry funded | Pregnant women with one previous lower segment CS, delivery expected at ≥37 weeks; most recent delivery is cesarean. May 2004–August 2006 | I 1: decision analysis aid (n = 235) | I 2: information program (n = 241) | C: usual care (n = 239) | NR | I 1: 88 (37.4%) I 2: 70 (29.2%) C: 72 (30.3%) I 1 vs. C: aOR 1.42 (95% CI 0.94–2.14), p = 0.22 I 2 vs. C: aOR 0.93 (95% CI 0.61–1.41), p > 0.9 I1 vs. I2: aOR 1.53 (95% CI 1.01–2.30), p = 0.11 | NR |
Wong (2014) Prospective cohort UK, district general hospital Funding NR | Women with one previous lower segment CS, no contraindications for VBAC 12-month period commencing January 1, 2012 | I: one-stop obstetrician-led cesarean education and antenatal sessions (OCEANS) (n = 188) | C: did not attend OCEANS (n = 78) | I: 108 (57.4%) C: 33 (42.3%), p = 0.02 | I: 59 (31.4%) C: 20 (25.6%) | I: 59 (54.6%) C: 20 (60.6%) p = 0.69† |
Methodological quality of included studies
MMATa criteria | Screening questions | Quantitative/ control group | Quantitative non-randomized | Totalb | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Study | Clear research questions or objectives? | Do collected data address the research questions/objective? | 2.1 Clear description of randomization? | 2.2 Clear description of allocation concealment (or blinding)? | 2.3 Complete outcome data (≥80%)? | 2.4 Low withdrawal/drop-out (< 20%)? | 3.1 Participants/organizations recruitment - minimizes selection bias? | 3.2 Appropriate measurements used for intervention & outcomes? | 3.3 Participants/organizations comparable, or are differences accounted for? | 3.4 Complete outcome data (80% or above) or acceptable follow-up rate? | |
Ayres-De-Campos (2015) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | ✰ | ✰✰✰ (75%) |
Bickell (1996) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |
Bellows (2016) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |
Cleary-Goldman (2005) | ✰ | ✰ | NA | NA | NA | NA | – | ✰ | – | ✰ | ✰✰ (50%) |
Eden (2014) | ✰ | ✰ | ✰ | – | – | ✰ | NA | NA | NA | NA | ✰✰ (50%) |
Feldman (2015) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |
Fraser (RCT) | ✰ | ✰ | ✰ | ✰ | ✰ | NA | NA | NA | NA | ✰✰✰ (75%) | |
Gardner (2014) | ✰ | ✰ | NA | NA | NA | NA | ✰ | – | – | ✰ | ✰✰ (50%) |
Kosecoff (1987) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | – | ✰✰ (50%) |
Liu (2013) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | ✰ | ✰✰✰ (75%) |
Lomas (1991) | ✰ | ✰ | ✰ | – | ✰ | – | NA | NA | NA | NA | ✰✰ (50%) |
Montgomery (2007) | ✰ | ✰ | ✰ | ✰ | ✰ | ✰ | NA | NA | NA | NA | ✰✰✰✰(100%) |
Myers (1993) | ✰ | ✰ | NA | NA | NA | NA | – | ✰ | – | ✰ | ✰✰ (50%) |
Pinette (2004) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | ✰ | ✰✰✰ (75%) |
Russillo (2008) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | ✰ | ✰✰✰ (75%) |
Sanchez-Ramos (1990) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | ✰ | ✰✰✰ (75%) |
Santerre (1996) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | ✰ | ✰✰✰ (75%) |
Studnicki (1997) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |
White (2016) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |
Wong (2014) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | – | – | ✰✰ (50%) |
Yee (2017) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |
Zhang (2016) | ✰ | ✰ | – | – | ✰ | – | NA | NA | NA | NA | ✰ (25%) |
Zweifler (2016) | ✰ | ✰ | NA | NA | NA | NA | ✰ | ✰ | ✰ | ✰ | ✰✰✰✰(100%) |