Strengths and limitations
The strength of this study is that a deeper understanding of clinicians’ views of VBAC has been reached by using a qualitative approach. For this study, a qualitative approach was suitable because of the complexity of the studied phenomenon. We were unable to find any earlier research on the phenomenon from countries with high VBAC rates.
A further strength of this study, which is also a limitation, is that both focus groups and individual interviews were used. The strength in using two or more methods for data gathering is that they provide greater variation in the data [
20]. In addition, the advantage of a focus group is that the participants can discuss and help each other with describing the studied phenomenon from the perspective of the group [
13]. In our study, this was from the perspective of two professions, midwives and obstetricians. However, a limitation is that some participants may be invisible as a result of others wielding more influence in the group. In contrast, individual interviews permit all participants to take part in the same way [
13]. The limitation of this study is that different methods were used in the participating countries. Focus groups were held in one country only, while individual interviews were conducted in the other two countries.
As for all qualitative studies, the findings must be interpreted in relation to the study’s context [
20]. To facilitate transferability to other contexts, the researcher should clearly describe the context, selection and characteristics of the participants, the method or methods of data collection and the process of analysis [
15,
20], which we sought to do. However, the context was different in the participating countries, which is a limitation.
Interpretation
The findings from this study are based on interviews in Finland, Sweden and the Netherlands. It is interesting that all previous studies on VBAC and professionals that we found were from countries with low VBAC rates [
8‐
10,
21]. One of the aims of the OptiBIRTH project, which this study is part of, is to learn from the best. What could professionals from other countries learn from Sweden, Finland and the Netherlands? Important factors in improving the VBAC rate are having a common approach; viewing VBAC as the first alternative; maintaining good communication between professionals; and ensuring all clinicians work together as a team, work in accordance with a model and make agreements with the woman. A common approach is nothing that an obstetrician or midwife could have as an individual, since it must be related to the structure of the maternity care system. It is interesting that Finland and Sweden differ from the Netherlands with regard to the structure of care for women with VBAC. In the Netherlands, VBAC is a responsibility for obstetricians at hospitals, while in Sweden and Finland, VBAC is a responsibility for midwives in hospitals if everything is progressing normally. However, what is similar for these countries is that midwives have an independent responsibility for normal pregnancy and childbirth. The midwives and obstetricians have clear professional responsibilities that may contribute to having a common approach and working as a team. In Sweden, a national health strategy of giving midwives and obstetricians complementary roles in maternity care, as well as equal involvement in setting public health policy, was introduced during the 1800s [
22]. The maternal mortality rate in Sweden in the early 20th century was one third that in the United States. The 19th-century decline in maternal mortality largely resulted from improvements in obstetric care, but was also helped along by the national health strategy of giving midwives and doctors complementary roles in maternity care [
22]. A similar development in the Netherlands was the introduction of the ‘law of medical practice’ in 1865, where for the first time, responsibilities were formally divided between doctors and midwives for pathological and physiological labour, respectively [
23,
24]. Could these clear professional roles have an impact on the current low VABC rates? More research is needed on how the organisation of maternity care, including the professionals’ roles, is related to VBAC and overall CS rates.
The results from this study show that obstetricians should make the final decision on the mode of birth. The women should be involved, but only clinicians can make the final decision, according to the obstetricians and midwives who participated in this study. The fact that the women do not have a right to decide about the mode of birth without individual counselling and a structured care programme [
25] is one answer to the high VBAC rates, according to the clinicians. The Swedish obstetricians and midwives who participated in this study thought that the CS rates would increase without these conditions. However, the national recommendations state that women with certain circumstances could have a CS even if there are no medical or obstetric reasons for it [
17], which is in line with a relational model of decision-making [
26].
A study from New Zealand that entailed interviews with midwives showed that decision-making is influenced by complex human, contextual and political factors [
26]. Fear of litigation is one reason for the high VBAC rates [
6,
10]. To work in a care system with national guidelines on CS [
17,
25] makes it easier for the individual obstetrician and midwife, according to the findings from this study. Only the clinicians from the Netherlands mentioned fear of litigation as a growing problem. Since we did not ask about legal issues, more research is needed on this question. A study of obstetricians’ attitudes to CS in eight European countries (Luxembourg, the Netherlands, Sweden, France, Germany, Italy, Spain and the United Kingdom) found that fear of litigation was less relevant to physicians’ decision-making in Sweden and the Netherlands, a finding consistent with the low medico-legal burden in these countries, according to the authors [
27].
The findings from this study show that during the birth, the woman who has a previous CS has a similar need for support as other labouring women, but with a need for some extra precautions. This recommendation is in line with the intrapartum management of TOLAC described by Scott [
28], who stated that the care for women undergoing VBAC differs primarily in the need for caution with induction of labour in women with an unfavourable cervix, the avoidance of overstimulation with oxytocin augmentation and surveillance for prompt recognition of the rare case of uterine rupture. The clinical recommendations from our study verify this management, but our data also include suggestions on how to support a woman during a birth – in particular, be present, create a secure atmosphere and give good pain relief. In addition, for the woman who has had a previous emergency CS, the same phase of labour where the CS was performed is critical. Professionals need to be observant and give her extra and focused support during this stage. The importance of support is verified by a meta-analysis showing that continuous support during labour by professionals and non-professional positively influences both the delivery outcome and the woman’s satisfaction with her care [
29]. A planned study from Australia will answer the question of whether continuity of midwifery care through pregnancy, labour, birth and the early postnatal period impacts decision-making in the next VBAC [
30]. Furthermore, the clinicians pointed out the importance of strengthening the woman’s trust in giving birth vaginally. The clinicians mentioned both the problems that could be connected to VBAC and the strengthening factors. Much of the earlier research on VBAC concerns risk factors [
21]. A meta-synthesis of women’s experiences confirmed only focusing risks [
21]. Women need evidence-based information on not only the potential risks involved in VBAC, but also the risks of CS, as well as the positive aspects of VBAC [
21].