As a researcher and community-based doula, Sarah Munro knows firsthand the difficult choice women face after having a C-section: whether to deliver their next baby vaginally or by C-section.
C-sections expose mothers and newborns to excess risk, so current Canadian clinical guidelines recommend that eligible women be offered a vaginal birth after caesarean, referred to as a VBAC. British Columbia has the highest repeat C-section rates in Canada, with just 33 per cent of women eligible for VBACs between 2012 and 2013 attempting a vaginal birth.
Munro, a postdoctoral fellow in family practice in the faculty of medicine at UBC and Dartmouth College, recently published two articles examining this issue.
You interviewed women about how they make their decision to have a C-section or attempt a vaginal birth for their next baby. What stood out for you?
I was really surprised to find that women start to form a clear preference about their next birth fairly soon after their C-section, sometimes within the first few weeks. Moreover, women formed this preference with little collaboration from health-care professionals.
Instead, their decisions were often based on reflections on their previous birthing experience, coupled with information from friends, family and the Internet.
In reflecting on their birth experiences, few of the women who had had an emergency caesarean fully understood why it occurred. Even after multiple opportunities to “de-brief,” many of the women felt dissatisfied at the information they had received from health-care providers.
So they turned to their friends, blogs and even Pinterest to gain clarity about how to move forward. For most women, engaging in this research was part of the therapeutic process of coming to terms with an unplanned caesarean.
You also spoke to health-care providers and decision makers about their experiences with providing women access to VBAC. What did you learn?
Care providers strongly supported women’s right to choose between a planned VBAC and an elective caesarean but there was a disconnect between when women began to form preferences and when health-care professionals began exploring future plans.They also had different perspectives on the factors that were most important to the decision.
Some women strongly desired a vaginal birth but were instead planning a C-section for any number of reasons that were not health-related: they wanted to select a date for the birth, plan for things like childcare if they lived in rural areas, or have more control of their birthing experience than they previously had.
But these social and relational outcomes that were really important to the mother’s well-being and decision-making were rarely part of discussions with health-care providers. Instead, many health-care providers, administrators, and health service decision makers I interviewed were focused on good clinical outcomes. They were also concerned with having the hospital resources that support timely access to caesarean section if they’re offering planned VBAC.
How can women be better supported in making this choice?
I am in the process of developing a new patient decision aid in collaboration with patients, health-care providers, and decision makers. To date, most decision aids have been implemented toward the end of a woman’s next pregnancy. We’re proposing to start much earlier so that women can have high quality evidence on their options before they start to form a preference.
It will include an online interactive tool for use across the province. It builds on patient decision aids that are currently available in B.C. by addressing women’s social and psychological concerns post-caesarean as well as issues about hospital resources and health services. We hope that this tool will help women, families and care teams make informed, shared decisions and to plan births that reflect women’s values and preferences.
Munro recently published a qualitative study in Women and Birth, examining why women opted for repeat C-sections. In a second study, published in Birth, she interviewed health-care providers and decision-makers about their experiences.
Munro’s research was supported by a Frederick Banting and Charles Best Canada Graduate Research Scholarship from the Canadian Institutes of Health Research and the UBC Public Scholars Initiative. She is currently supported by a Postdoctoral Trainee Award from the Michael Smith Foundation for Health Research.