Improving the rate of VBAC

Discuss clearly.
Recruitment process is clearly explained and discussed in terms of ethical requirements.
Threats/limitations to generalisation are identified and clearly described.
Data Collection: Methods of gathering data were described and appropriateness discussed.
References included. Data triangulation attempts identified and implications identified.
Attempts to minimize behavioral distortions such as Hawthorne Effect are identified.
Training of staff is mentioned and analysed in detail. Relevance of data to research
question is discussed clearly.
Ethical considerations: HREC and other necessary permissions included. Principles such
as beneficence, self-determination etc are mentioned. Process of informed consent, privacy,
confidentiality is very detailed. Voluntary participation/right to withdraw mentioned.
Adverse event protocol clearly described. Any possible power imbalances highlighted. Data
storage discussed, implications of it discussed – confidentiality assured.
Data Analysis and Findings: Analysis methods very clearly discussed in terms of
appropriateness to design and research question. Use of investigator triangulation
mentioned if relevant. Potential biases discussed clearly. Effectiveness of presentation of
findings discussed in good detail – use of quotes, figures, models etc. Logical connection of
themes and patterns to make a convincing whole is mentioned.
Trustworthiness: Credibility, confirmability, transferability and dependability all
addressed succinctly and thoroughly with mention of consequences of not addressing them.

Improving the rate of VBAC – Article Critique


The increased proportion of births by primary caesarean section has resulted in a larger
proportion of pregnant women that present for delivery with a history of caesarean. There are
two options for childbirth available to women who have previously undergone caesarean
delivery. Vaginal birth after caesarean section (VBAC) is recommended as compared to a
repeated caesarean section (ERCS). Available research shows that there is a reasonable clinical


case for VBAC for women with a history of CS, but mostly non-clinical reasons that are not
evidence-based usually guide the decision on the mode of birth to use (Knight et al., 2014). The
article by Ingela Lundgren, Evelien van Limbeek, Katri Vehvilainen-Julkunen and Christina
Nilsso that appeared in the BMC Pregnancy and Childbirth journal volume 15 issue number 196
in 2015 reports a research study on the factors of importance in increasing VBAC rates. The
study is part of the OptiBIRTH research project funded by the EU with the aim of increasing the
rates of VBAC amongst women giving birth (Lundgren, van Limbeek, Vehvilainen-Julkunen
and Nilsso, 2015). The study conducted interviews to obtain the deeper knowledge of clinicians
and their views on the important factors for increasing the rate of VBAC amongst expectant

Recruitment and Sampling

The study was conducted in three European countries, Finland, Sweden, and the
Netherlands, that have the highest rates of VBAC. Data was collected from interviews with 44
clinicians in total, which comprised of 26 midwives and 18 obstetricians/ physicians/
gynecologists in the three countries. The selection of these countries was guided by their
appropriateness for investigating the particular factors that contribute to the high acceptance of
VBAC amongst mothers in these countries. The choice of the three countries was also guided by
the differences in the national systems of maternity care prevalent in these countries. While
maternity care in Finland and Sweden is wholly funded by government taxes, maternity care
costs in the Netherlands are covered by health insurance and sometimes co-payments from the
mothers. The role of clinicians in maternity care is also different in the three countries, with
Finland and Sweden having all births taking place in hospital settings and the Netherlands having


up to 20 percent of all births happening in home settings. The selection would facilitate
generalisability of the research findings to countries with similar health care systems.

Data Collection

The study utilized a qualitative method of data collection owing to its suitability for
researching a phenomenon that is little known and lack sufficient knowledge from previous
studies (Cunningham, Ranmuthugala, Westbrook and Braithwaite, 2012). Data collection for the
interviews used five central questions concerning the important factors that influence the uptake
of VBAC amongst expectant mothers. The study made telephone interviews with 11 clinicians
in the Netherlands and held two focus groups with a total of 13 clinicians. In Finland, data
collection was made using face-to-face individual interviews with 20 clinicians. The research
was conducted by a group of four research assistants that administered the interviews, and coded
and analyzed the data.

Ethical Considerations

The ethical considerations in the study were informed consent of participants and formal
approval to conduct the research. Before each interview, the researchers obtained informed
consent in written form from each of the participants. Approval to conduct the research was
obtained for the entire OptiBIRTH project from relevant national bodies of the Medical Ethical
Examination Board of the Netherlands, the Regional Ethical Review Board in Sweden and the
Committee on Research Ethics in Finland.

Data Analysis

Data analysis for the study utilized inductive conventional content analysis that aimed to
build a conceptual model for describing the phenomenon. The method is useful for clinical
research in extending theoretical knowledge of human experiences with health and illness to


practical aspects of care delivery (Velengtas, Mohr and Messne, 2012). Coding and Coding
sheets were used for data analysis of the responses to ensure that the same unit of analysis was
used throughout and that the answers were traceable to particular qualitative categories and


The interviews asked the same five questions and recorded the answers in the same order
to minimize distortion of information during analysis. The interviews were held in the native
languages of each county to preserve the contextual meaning and credibility and conformability
of the responses. One person to ensure dependability and uniformity of method did the
translation of the responses to English. The use of native languages and one translator would
ensure trustworthiness of the data collection and analysis used in the study.


The findings of the research are presented in four main categories with subcategories.
The four categories are the uses of a common approach to VBAC by clinicians, according to
clinicians the final decision to choose the mode of birth, providing support to mothers during
birth, and strengthening the mothers’ trust in VBAC. According to the findings of the study, the
most important factors for improving the uptake of VBAC amongst mothers are linked to the
structure of the national system for maternity care. The rate of VBAC is also linked to the views
and level of cooperation amongst clinicians, and also to the quality of care offered during
pregnancy and tat birth.



Cunningham, Frances C., Ranmuthugala, G., Westbrook, Johanna I. and Braithwaite, J. (2012).
“Net benefits: assessing the effectiveness of clinical networks in Australia through
qualitative methods,” Implementation Science, 7(108).
Knight, H. E., Gurol-Urganci, I., van der Meulen, J. H., Mahmood, T. A., Richmond, D. H.,
Dougall, A. and Cromwell, D. A. (2014). Vaginal birth after caesarean section: a cohort


study investigating factors associated with its uptake and success”, British Journal of
Obstetricians and Gynaecologists, 121, 183–193.
Lundgren, I., van Limbeek, E., Vehvilainen-Julkunen, K. and Nilsso, C. (2015). “Clinicians’
views of factors of importance for improving the rate of VBAC (vaginal birth after
caesarean section): a qualitative study from countries with high VBAC rates,” BMC
Pregnancy and Childbirth, 15(196).
Velengtas, P., Mohr, P. and Messne, Donna, A. (Eds) (2012). Making Informed Decisions:
Assessing the Strengths and Weaknesses of Study Designs and Analytic Methods for
Comparative Effectiveness Research – A Briefing Document for Stakeholders. National
Pharmaceutical Council