CHOOSING MODE OF DELIVERY AFTER A PREVIOUS CAESAREAN: A QUALITATIVE INVESTIGATION OF FACTORS INFLUENCING IMPLEMENTATION OF SHARED DECISION-MAKING

Purpose: To explore attitudes toward and experiences with decision-making for mode of birth after previous caesarean section and identify factors that influence implementation of SDM.

Method: In-depth, semi-structured interviews were conducted with women eligible for vaginal birth after caesarean (VBAC), care providers, and health service decision makers recruited from three rural and two urban communities in British Columbia (BC). Interviews explored the patient (micro), health services (meso), and policy (macro) factors that influence decision-making for mode of delivery. Interview guides were informed by a) previous systematic reviews of the literature on patient and health care professional barriers and facilitators to implementation of SDM, and b) previous literature on the factors that influence high rates of repeat caesarean in developed nations. Implementation and knowledge translation principles guided study design, and constructionist grounded theory informed iterative data collection and analysis. Findings were interpreted using complex adaptive systems theory (CAS).

Result: Analysis of interviews (n=57) revealed that the factors influencing birth after caesarean decisions resulted from interactions between the micro, meso, and macro levels of the health care system. Women formed early preferences for mode of delivery (after the primary caesarean) through careful deliberation of the social risks and benefits of mode of delivery. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from perceptions of limited access to surgical resources, which had resulted from budget constraints. In small rural hospitals, adequate access to the health care resources that support planned VBAC facilitated SDM for mode of delivery. Throughout data collection and analysis, we engaged in activities to facilitate mutual understanding among stakeholder groups, including knowledge exchange through policy dialogues and the use of a policy brief.

Conclusion: To facilitate the effective implementation of SDM in clinical practice for mode of delivery after a previous caesarean section, it is necessary to address the needs of women, care providers, and decision makers. These needs include initiating decision support immediately after the primary caesarean, assisting women to address the social risks that influence their preferences, managing perceptions of risk related to patient safety and litigation among physicians, and adequate access to the health care resources that support planned VBAC.