Priority of factors affecting the implementation of vaginal birth after Cesarean in Isfahan based on Talbot and Verrinder model

doi:10.21203/rs.3.rs-4827192/v1

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Priority of factors affecting the implementation of vaginal birth after Cesarean in Isfahan based on Talbot and Verrinder model

https://doi.org/10.21203/rs.3.rs-4827192/v1

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Introduction: Today, Cesarean section, as a normal surgical procedure, is accompanied by maternal and fetal complications. The most common reason mentioned for high cesarean section rates is the repeat Cesarean section. Vaginal birth after Cesarean (VBAC) is an alternative to repeat Cesarean section. The first step to investigate VBAC status and plan to improve it in Isfahan city is to know and prioritize the attitude of key individuals.

Method: This cross-sectional study is a multi-method study (April, 2023 to August, 2023) conducted in Isfahan with participation of 75 Health Managers in the field of Treatment and Health Deputy, gynecologists and midwives, and 75 pregnant women. The eligible women were selected using a quota sampling method, and managers, gynecologists and midwives were selected using a convenience sampling method. Research instruments included the Attitude towards the Mode of Delivery Questionnaire and Factors Affecting the Choice of Type of Delivery Questionnaire developed by Valiani et al. The collected data were analyzed with SPSS software version 26.00 and using descriptive statistics and t-test Statistical tests.

Findings: As the gynecologists achieved lower scores in the third quartile than the key individuals (pregnant women, midwives, and health managers), the interventions to change their attitudes are of higher priority. There was a statistically significant relationship between the mothers' attitude mean score and their number of child delivery (p<0.05). A statistically significant relationship was also observed between the gynecologists' attitudes and their work experience (p<0.05).

Conclusion: Although teamwork in performing VBAC is essential, mothers are the final decision makers in performing VBAC. In planning for VBAC, measures thus should be taken to change mothers' attitudes, remove barriers, and obtain their consent to perform VBAC guidelines.

Priority of effective factors

Vaginal Birth after Cesarean (VBAC)

Talbot and Verrinder model

Cesarean section is defined as the exit of a fetus through surgical incisions made through the abdominal wall and the uterine wall. This action saves the life of the mother and child in emergencies (1). Cesarean section is a surgical procedure with short- and long-term risks, such as surgery complications, hospitalization in neonatal intensive care unit, and high cost compared to vaginal birth (2). The prevalence of severe intrauterine adhesions (Asherman's syndrome) and placental adhesions is on rise due to the increased Cesarean rate (3). The increased rate of Cesarean sections, especially unnecessary ones, indicates the health care system's improper performance, affecting the demographic structure of the country. Cesarean sections are effective in reducing the fertility rate of a country. It prevents the next baby birth and reduces childbearing rate due to its complications (e.g., preeclampsia, abnormal placental penetration into the uterine wall, preterm labor) (4). The unjustified increase in Cesarean section causes a significant increase in the financial burden on the health system and is considered as the allocative inefficiency of the health care delivery system of a country (4). According to the World Health Organization (WHO) report, cesareans accounted for 10%-15% of all births. However, the global rate of Cesarean deliveries has significantly increased over the past years (5). The global Cesarean section rates have increased by 14.3% (from 6.7% in 1990 to 21% in 2021) (6). Cesarean section prevalence varies from 40–60% in different regions of Iran (7). The Cesarean section rate in 2021 was 51.02% in this country, which is far from the global standard. The mean Cesarean section rate in public and private hospitals of Isfahan city was 58.84% in 2021, 59.33% in 2022, and 60.69% in 2023 (8). The most common reason mentioned for the high rate of Cesarean section is the repeat cesarean section (9). The repeat Cesarean section was reported to be the cause of 50.47% of Cesareans in 2021 and 51.3% of Cesareans in the first three months of 2021 in Isfahan (8).

Among the objectives of WHO to reduce Cesarean section rate is decreasing repeat Cesarean section in low risk women (10). Vaginal Birth after Cesarean (VBAC) is an alternative to the repeat Cesarean section (11). National Institute of Health (NIH) (2010) recommended the medical community "to remove VBAC barriers for women, in order to reduce the total Cesarean rate safely" (12). In a Consultative Conference in 1980, it was recommended that women who have undergone a Cesarean section delivery can opt for vaginal birth in their next deliveries. After that, within four years, Cesarean section rates decreased from 22.7–20.7% and the vaginal birth rates increased from 22.7–28% and the statement “once a Cesarean, always a Cesarean” stated by Cragin was reviewed in many countries (13). The VBAC guidelines show that it is possible for women who have had a low-transverse uterine incision from a previous cesarean delivery and who have no contraindications for vaginal birth to be candidates for a trial of labor (14). A successful VBAC reduces the risk of maternal morbidity and complications in future pregnancies for mothers. On the other hand, it reduces the risk of surgical complications and hospital stay (15). The evidence obtained from the study by Guise JM shows that maternal mortality was significantly increased for repeat Cesarean delivery (13.4 per 100,000) as compared to VBAC (3.8 per 100,000) (16). In September, 2016, the Ministry of Health, Medicine and Medical Education of Iran announced the clinical guidelines for VBAC in accordance with the last international guidelines (17) and recommended VBAC for most women with a low-transverse uterine incision (with or without the previous history of vaginal birth) (18). In the first half of 2019, the VBAC rate was reported to 2%> (1.73) in Iran, which is far from the global standards (17). VBAC is still a controversial issue and despite the existence of international guidelines, pregnant women are recommended by gynecologists both in private and public sections to have repeat Cesarean section (19). The Association of Midwives and Active Women Groups reported the lack of selection of vaginal birth by pregnant women to be the main cause of the high rate of Cesarean section. On the other hand, health care providers in Iran do not accept the risk of VBAC (19). The health care providers' unwillingness is among the factors associated with the low rate of VBAC (20). In a study, Firouzi et al. found the fear and negative attitude of the health care providers and pregnant women to be among the existing barriers to VBAC (21). Correct and unbiased consultation is the main factor of care provision affecting VBAC selection for mothers, and women have the right to make an informed choice to opt for the type of delivery (17).

Considering the high rate of repeat Cesarean section, the first step to investigate the VBAC status and plan to improve it in Isfahan city is to know about and prioritize the key individuals' attitudes because their attitudes can provide a suitable foundation for proper planning. On the other hand, VBCA is among the important issues in modern midwifery and taking measures to promote it in Iran is essential. Knowing about the attitudes of those involved in the midwifery profession and the attitudes of mothers is a necessary step towards preliminary investigation of the status of this issue in medical society. Therefore, the researchers decided to set the ground for a detailed plan to be provided to improve VBAC by investigating the attitudes of health managers, gynecologists, midwives, and women in Isfahan city.

This cross-sectional study is a part of a multi-method research (Code of Ethics: IR.MUI.NUREMA.RE C.1401.175) approved by Isfahan University of Medical Sciences. The research uses Talbot and Verrinder model. In the first step, a literature review was done to identify factors affecting the choice of VBAC. In the next step, a cross-sectional study was conducted to prioritize these factors. The literature review found five factors: healthcare organizations, gynecologists, midwives, pregnant women and people around them to be the most important factors affecting the choice of VBAC (22). In order to prioritize these factors, a cross-sectional study was conducted (from April, 2023 to August, 2023) in Isfahan with the presence of pregnant women with a history of Cesarean section (n = 75), as well as gynecologists, midwives, and health managers at the Deputy of Health and Deputy of Treatment level (n = 75). The inclusion criteria for mothers were having Iranian nationality, living in Isfahan city, being pregnant, having a history of one cesarean section, being mentally healthy, having no history of underlying medical conditions, and willingness to participate in the study. The inclusion criteria for managers, gynecologists, and midwives were having Iranian nationality, having willingness to participate in the study, working in their specialized fields, and living in Isfahan city. The exclusion criterion was the participants' unwillingness to respond to questions. In order to determine the pregnant women's attitude, the Attitude toward the Mode of Delivery Questionnaire was used. The validity of this questionnaire was examined and confirmed by Khalesi(23) et al. using content validity, and its reliability was calculated to be 0.85 using Cronbach's alpha reliability method. This questionnaire’s items were rated on a 5-point Likert scale. In order to determine factors associated with the choice of type of delivery from the perspective of gynecologists, midwives, and managers in the Deputy of Treatment and Deputy of Health area, the Factors Affecting the Choice of Type of Delivery Questionnaire was used, whose reliability and validity were confirmed by Valiani et al (24). Using a quota sampling method, the researcher distributed the Attitude toward the Mode of Delivery Questionnaire in Comprehensive Health Centers among all pregnant women who met the inclusion criteria. The researcher then attended the place of employment of gynecologists and midwives, and offices of health managers at the Deputy of Treatment and Deputy of Health level in Medical University of Isfahan to measure their attitude toward factors affecting the choice of type of delivery. To prioritize factors affecting VBAC, first both questionnaires were standardized and the scales became the same. The collected data were analyzed with SPSS software version 26.00 and using descriptive statistics and t-test Statistical tests. A p-value of less than 0.05 was considered statistically significant.

The participants of this study consisted of 25 managers employed in the health-treatment sections, 25 gynecologists, 25 midwives, and 75 women with a history of Cesarean section. The mean age of women participated in this study was 32.61 ± 6.129, and their mean age of pregnancy was 31.13 weeks. The education level of most of the mothers participated in this study was at high school level or they held a Diploma (45.3%). They had opted for Cesarean section for their current pregnancy (94.7%).

Most of the gynecologists who participated in this study were married (80%). Their mean age and mean years of experience was 43 ± 9.996 years and 11.52 ± 9.993 years, respectively. All gynecologists worked both in hospital and their personal offices (100%). The mean age and mean years of experience of midwives was 38 ± 8.05 years and 12 ± 7.81 years, respectively. The majority of midwives who participated in this study were married (84%), and 48% worked in hospitals, 36% in university, and 16% in health care centers. The mean age and mean years of experience of managers who participated in this study was 48 ± 6.07 years and 21 ± 4.37 years, respectively. Most of the managers who participated in this study were married (68%), held a Master's degree (72%), and worked in a hospital (56%) (Table 1).

Table 1

Demographic and fertility characteristics of mothers and demographic characteristics of Health group (managers, gynecologists, midwives)
Mothers	Mean age	32.61 ± 6.129
	Mean number of pregnancies	2.73 ± 1.095
	Mean number of births	1.48 ± 760
	Education level	Number (%)
		Illiterate Elementary school Holding a Diploma Academic Education	(5.3)4 (10.7)8 (45.3)34 (38.7)29
	Deciding about the type of current delivery	Vaginal birth Cesarean section Unknown	(1.39)1 (94.7)71 (4)3
	Type of previous delivery	Vaginal birth Cesarean section	(2.7)2 97.3)73
Gynecologists	Mean age	9.996 43±
	Mean years of work experience	9.993 11.52±
	Education level	Number (%)
		Specialist Super-specialist	(100) 25 0
	Marital status	Single Married	(20)5 (80)20
Midwives	Mean age	38 ± 8.05
	Mean years of work experience	12 ± 7.81
	Education level	Number (%)
		Bachelor's degree Master's degree Ph.D	(56)14 (20)5 (24)6
	Marital status	Single Married	(16)4 (84)21
	Place of employment	Hospital Healthcare centers University	(48)12 (16)4 (36)9
Managers	Mean age	6.07 ± 48.04
	Mean years of work experience	4.37 ± 21.36
	Education level	Number (%)
		Bachelor's degree Master's degree	(28)7 (72)18
	Marital status	Single Married	(32)8 (68)17
	Place of employment	Hospital University Health deputy Treatment deputy	(56)14 (12)3 (16) 4 (16)4

The obtained results showed a statistically significant relationship between the attitudes mean score of mothers and their number of child-delivery (p < 0.05). There was a statistically significant relationship between the attitudes mean score of gynecologists and their work experience (p < 0.05). Most of the gynecologists (60%) and midwives (36%) reported their skill in VBAC to be high. The effect of mothers' opinions on choice of delivery method was evaluated to be very high and very low from the perspective of the most gynecologists (28%) and midwives (36%), respectively. According to the results of the study, from the perspective of most gynecologists (32%) and midwives (36%), gynecologists and midwives have a significant effect on the choice of delivery method in mothers with a history of Cesarean section. In the view of most gynecologists (44%) and midwives (52%), the level of mothers' awareness of the choice of their delivery method was moderate. Table 2 show the mothers, gynecologists, midwives, and managers' attitudes toward VBAC. As the instruments and methods used to compute the attitude score in the following groups are different, the scores were at first standardized for more accurate comparison and prioritizing. They were then compared in different quartiles.

Table 2: 3rd quartile of standardized scores by key individuals

The analysis results for mothers, gynecologists, midwives, and health managers showed that in Isfahan it is the first priority to change the gynecologists' attitude and changing the mothers' attitude comes in the next place and is dependent on the former.

This study aimed to determine the priority of factors affecting the implementation of VBAC in Isfahan city. The results of the study showed that none of the background variables of mothers (level of education, type of current delivery, type of previous delivery) has a statistically significant relationship with their attitude mean score. This study is in agreement with the research by Karimi (25) that showed there is no significant relationship between the education level and type of delivery, but is inconsistent with the study by Janati (26) and Joshi et al. (27) that found a significant relationship between the low level of education and positive attitude toward vaginal birth. The experimental evidence shows that the better the socio-economic conditions and the higher the education level, the more requests for Cesarean section.

This study found no statistically significant relationship between the attitudes mean score of key individuals (gynecologists, midwives, and managers) and their marital status and education level. The results of this study are inconsistent with those obtained by Firouzi et al. (28) showing that the attitude of key individuals (gynecologists, midwives, and managers) toward VBAC differs significantly in terms of their occupation and education level. In this study, the mothers' attitudes score was less than that of the health group, which is inconsistent with the study by Akinlusi et al. (29) in which most mothers opted for trial of labor after Cesarean (TOLAC) for their current pregnancy. The results of this study are inconsistent with those obtained by Bairami et al. (30) in which most mothers acknowledged the benefits of the vaginal birth and had, in general, a positive attitude toward VBAC. Among the main factors affecting the negative attitude of mothers toward VBAC is their lack of awareness of VBAC. Scaffidi (31) and Tuba Ucar (32) found the mothers' knowledge and awareness of the advantages and disadvantages of both types of delivery to be an important factor affecting the choice of VBAC.

Regarding key individuals, the gynecologists' attitudes score was less than other individuals (managers, midwives, mothers). This findings is in agreement with the results of the study by Tuba Ucar (32) and khulod (33) that showed the gynecologists are not willing to accept the responsibility of VBAC, but inconsistent with the results of the study by Firouzi et al. (28) and George Lin (34). Gynecologists play the final and critical role in choosing and implementing VBAC, and measures should be taken to get their agreement to perform VBAC. Taking measures to change attitudes and remove barriers and get the agreement of gynecologists seem to be effective in implementing VBAC guidelines and reducing the rate of repeat Cesarean section. Firouzi et al. (28) found the lack of legal support to be the most important barrier to performing VBAC. Amendment of the rules in this regard appears to be among the ways to remove barriers, which have a significant effect on enhancing the gynecologists and midwives' motivation.

The results of this study showed that there is a statistically significant relationship between the gynecologists' work experience and their attitude toward VBAC score. This finding is in agreement with the study by Tuba Ucar (32). As the work experience is increased and experiences are acquired, the gynecologists' fear is reduced and their confidence is increased.

This study found a statistically significant relationship between the mothers' attitude score and their number of child deliveries, which is in agreement with the study by Akinlusi et al. (29). In comparison to vaginal birth, Cesarean section is accompanied by some complications of which the most important one is the limitation of women's fertility due to uterine wall damage, placental adhesion and removal of the uterus. An increase in the number of repeat Cesarean sections and its complications can adversely affect childbearing. That is why the women who tend to have more children prefer VBAC over repeat Cesarean section.

In the perspective of gynecologists and midwives in this study, the awareness of mothers of their type of delivery was moderate. This finding is in agreement with the results of the study by Janati (26) that reported the awareness of participants of their type of delivery to be moderate. Moreover, Akbari (35) found 47.6% of women to have moderate awareness of their type of delivery, indicating inefficiency of the required training during pregnancy offered in health care or private centers. Using targeted training programs to empower pregnant women and promote vaginal birth is of paramount importance. Training pregnant women and enhancing their awareness of methods of analgesia in labor, encouraging to participate in prenatal classes designed for making pregnancy pleasurable and preparation for childbirth, making attempts to modify the attitudes, and putting emphasis on pharmacological and non-pharmacological methods of pain reduction are among important issues to be addressed as the health priorities of any country, and the role of mass media, including television and radio in advertising this important issue as much as possible should not be ignored.

In this study, mothers play a significant role in choosing their type of delivery, which is in agreement with the study by Mohammadi (36). Although pregnant women have the right to choose the type of their pregnancy, this choice should be deliberate and based on information. Pregnant women encounter two problems in performing this important issue: 1. Decisions that are not based on knowledge and information, 2. Slight or superficial knowledge that has not led to correct performance (36). Sometimes mothers' slight knowledge and information is neglected by gynecologists, and they say to the mothers: "what I say is in your favor". That is why the mothers' knowledge and tendency is neglected. As the gynecologists and midwives are regarded as the most important source of information for pregnant women, offering proper guidelines can increase the acceptance rate of the instructions of these people by the target group, i.e., pregnant women.

In this study, most of the gynecologists and midwives reported their skill in implementing VBAC to be high, which is inconsistent with the available evidence due to the low number of VBAC. Perhaps, legal barriers prevent the application of these skills. The knowledge and skill of midwives, as the nearest and most effective team that provides health care, significantly affect the results of VBAC. Teaching VBAC instructions to the midwifery students and obstetrics and gynecology residents seems to considerably affect the correct implementation of instructions in their workplace.

Although teamwork is essential in performing VBAC and many deliveries are directed in the form of teamwork, gynecologists seem to be the final decision makers in performing VBAC. Therefore, it is better to improve the attitude and create motivation and adjust the law more than before. Moreover, considering the gynecologists' attitude lower score than the other key individuals in Isfahan, gynecologists seem to be of higher priority in planning for VBAC, and it is necessary to take measures to change attitudes and remove barriers and get the agreement of gynecologists in implementing VBAC instructions and to reduce the rate of repeat Cesarean section.

This article is extracted from a doctoral thesis(IR.MUI.NUREMA.RE C.1401.175 ) in reproductive health supported by Isfahan University of Medical Sciences. The researchers extend their gratitude to all the pregnant mothers, gynecologists, midwives, and health managers within the medical and health deputies who collaborated on this project.

Authors’ contribution

MV and NZ contributed to the conceptualization and design of the study. ZJ collected the data. All authors participated in data analysis and writing and revising the article.

Funding

The present study was financed by the Research Center of Isfahan University of Medical Sciences.

Availability of data and materials

The data sets will be used and analyzed during the current study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

In this study, the following ethical principles will be considered and observed:

Obtaining scientific-ethical approval for project implementation from the Ethics Committee of Isfahan University of Medical Sciences )IR.MUI.NUREMA.RE C.1401.175(
Following the ethical standards of the Regional Research Committee
Obtaining the informed consent of the participants to participate in the research .
Ensuring participant information confidentiality
It is recommended to refer to competent centers in case of any questions or doubts

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Author details

1- PhD student in Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.Midwifery instructor, Islamic Azad University Health Research Center, Isfahan branch (Khorasgan), Isfahan, Iran.2-Assistant Professor, Reproductive Sciences and Sexual Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.3- Professor of Biostatistics, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran.4- Consultant Professor, Obstetrics and Gynecology Specialist, Isfahan University of Medical Sciences, Isfahan, Iran.

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No competing interests reported.

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Priority of factors affecting the implementation of vaginal birth after Cesarean in Isfahan based on Talbot and Verrinder model

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