Maternal and newborn plasma oxytocin levels in response to maternal synthetic oxytocin administration during labour, birth and postpartum - a systematic review with implications for the function of the oxytocinergic system.

BACKGROUND: The reproductive hormone oxytocin facilitates labour, birth and postpartum adaptations for women and newborns. Synthetic oxytocin is commonly given to induce or augment labour and to decrease postpartum bleeding. AIM: To systematically review studies measuring plasma oxytocin levels in women and newborns following maternal administration of synthetic oxytocin during labour, birth and/or postpartum and to consider possible impacts on endogenous oxytocin and related systems. METHODS: Systematic searches of PubMed, CINAHL, PsycInfo and Scopus databases followed PRISMA guidelines, including all peer-reviewed studies in languages understood by the authors. Thirty-five publications met inclusion criteria, including 1373 women and 148 newborns. Studies varied substantially in design and methodology, so classical meta-analysis was not possible. Therefore, results were categorized, analysed and summarised in text and tables. RESULTS: Infusions of synthetic oxytocin increased maternal plasma oxytocin levels dose-dependently; doubling the infusion rate approximately doubled oxytocin levels. Infusions below 10 milliunits per minute (mU/min) did not raise maternal oxytocin above the range observed in physiological labour. At high intrapartum infusion rates (up to 32 mU/min) maternal plasma oxytocin reached 2-3 times physiological levels. Postpartum synthetic oxytocin regimens used comparatively higher doses with shorter duration compared to labour, giving greater but transient maternal oxytocin elevations. Total postpartum dose was comparable to total intrapartum dose following vaginal birth, but post-caesarean dosages were higher. Newborn oxytocin levels were higher in the umbilical artery vs. umbilical vein, and both were higher than maternal plasma levels, implying substantial fetal oxytocin production in labour. Newborn oxytocin levels were not further elevated following maternal intrapartum synthetic oxytocin, suggesting that synthetic oxytocin at clinical doses does not cross from mother to fetus. CONCLUSIONS: Synthetic oxytocin infusion during labour increased maternal plasma oxytocin levels 2-3-fold at the highest doses and was not associated with neonatal plasma oxytocin elevations. Therefore, direct effects from synthetic oxytocin transfer to maternal brain or fetus are unlikely. However, infusions of synthetic oxytocin in labour change uterine contraction patterns. This may influence uterine blood flow and maternal autonomic nervous system activity, potentially harming the fetus and increasing maternal pain and stress.

WHO Standards-based questionnaire to measure health workers' perspective on the quality of care around the time of childbirth in the WHO European region: development and mixed-methods validation in six countries.

OBJECTIVES: Develop and validate a WHO Standards-based online questionnaire to measure the quality of maternal and newborn care (QMNC) around the time of childbirth from the health workers' perspective. DESIGN: Mixed-methods study. SETTING: Six countries of the WHO European Region. PARTICIPANTS AND METHODS: The questionnaire is based on lessons learnt in previous studies, and was developed in three sequential phases: (1) WHO Quality Measures were prioritised and content, construct and face validity were assessed through a Delphi involving a multidisciplinary board of experts from 11 countries of the WHO European Region; (2) translation/back translation of the English version was conducted following The Professional Society for Health Economics and Outcomes Research guidelines; (3) internal consistency, intrarater reliability and acceptability were assessed among 600 health workers in six countries. RESULTS: The questionnaire included 40 items based on WHO Standards Quality Measures, equally divided into four domains: provision of care, experience of care, availability of human and physical resources, organisational changes due to COVID-19; and its organised in six sections. It was translated/back translated in 12 languages: Bosnian, Croatian, French, German, Italian, Norwegian, Portuguese, Romanian, Russian, Slovenian, Spanish and Swedish. The Cronbach's alpha values were ≥0.70 for each questionnaire section where questions were hypothesised to be interrelated, indicating good internal consistence. Cohen K or Gwet's AC1 values were ≥0.60, suggesting good intrarater reliability, except for one question. Acceptability was good with only 1.70% of health workers requesting minimal changes in question wording. CONCLUSIONS: Findings suggest that the questionnaire has good content, construct, face validity, internal consistency, intrarater reliability and acceptability in six countries of the WHO European Region. Future studies may further explore the questionnaire's use in other countries, and how to translate evidence generated by this tool into policies to improve the QMNC. TRAIL REGISTRATION NUMBER: NCT04847336.

How much synthetic oxytocin is infused during labour? A review and analysis of regimens used in 12 countries.

OBJECTIVE: To compare synthetic oxytocin infusion regimens used during labour, calculate the International Units (IU) escalation rate and total amount of IU infused over eight hours. DESIGN: Observational study. SETTING: Twelve countries, eleven European and South Africa. SAMPLE: National, regional or institutional-level regimens on oxytocin for induction and augmentation labour. METHODS: Data on oxytocin IU dose, infusion fluid amount, start dose, escalation rate and maximum dose were collected. Values for each regimen were converted to IU in 1000ml diluent. One IU corresponded to 1.67µg for doses provided in grams/micrograms. IU hourly dose increase rates were based on escalation frequency. Cumulative doses and total IU amount infused were calculated by adding the dose administered for each previous hour. Main Outcome Measures Oxytocin IU dose infused. RESULTS: Data were obtained on 21 regimens used in 12 countries. Details on the start dose, escalation interval, escalation rate and maximum dose infused were available from 16 regimens. Starting rates varied from 0.06 IU/hour to 0.90 IU/hour, and the maximum dose rate varied from 0.90 IU/hour to 3.60 IU/hour. The total amount of IU oxytocin infused, estimated over eight hours, ranged from 2.38 IU to 27.00 IU, a variation of 24.62 IU and an 11-fold difference. CONCLUSION: Current variations in oxytocin regimens for induction and augmentation of labour are inexplicable. It is crucial that the appropriate minimum infusion regimen is administered because synthetic oxytocin is a potentially harmful medication with serious consequences for women and babies when inappropriately used. Estimating the total amount of oxytocin IU received by labouring women, alongside the institution's mode of birth and neonatal outcomes, may deepen our understanding and be the way forward to identifying the optimal infusion regimen.

Nutri-Epigenetics and Gut Microbiota: How Birth Care, Bonding and Breastfeeding Can Influence and Be Influenced?

Maternal lifestyle is an important factor in the programming of an infant's epigenome, in particular when considered alongside the mode of birth and choice of feeding method (i.e., breastfeeding or formula feeding). Beginning in utero, and during the first two years of an infant's life, cells acquire an epigenetic memory of the neonatal exposome which can be influential across the entire lifespan. Parental lifestyle (e.g., malnutrition, alcohol intake, smoke, stress, exposure to xenobiotics and/or drugs) can modify both the maternal and paternal epigenome, leading to epigenetic inheritance in their offspring. This review aims to outline the origin of early life modulation of the epigenome, and to share this fundamental concept with all the health care professionals involved in the development and provision of care during childbirth in order to inform future parents and clinicians of the importance of the this process and the key role it plays in the programming of a child's health.

OptiBIRTH: a cluster randomised trial of a complex intervention to increase vaginal birth after caesarean section.

BACKGROUND: Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries. METHODS: OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women. RESULTS: The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. CONCLUSIONS: Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances. TRIAL REGISTRATION: The OptiBIRTH trial was registered on 3/4/2013. Trial registration number ISRCTN10612254.

Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates - A hermeneutic study.

BACKGROUND: Caesarean section (CS) rates are increasing worldwide, an increase that is multifactorial and not well understood. There is considerable variation in the rates of vaginal birth after previous Caesarean section (VBAC). Cultural differences could be one explanation of the varying rates. OBJECTIVE: To interpret cultural perspectives on VBAC. METHODS: A hermeneutic approach for analysing findings from four published qualitative studies that were part of the OptiBIRTH study, focusing on clinicians and women's views of important factors for improving the rate of VBAC. 115 clinicians and 73 women participated in individual interviews and focus group interviews in countries with low rates (Germany, Italy and Ireland) and countries with high rates (Sweden, Finland and the Netherlands), in the original studies. RESULTS: Three themes demonstrated how the culture differs between the high and low VBAC rate countries; from being an obvious first alternative to an issue dependent on many factors; from something included in the ordinary care to something special; and from obstetrician making the final decision to a choice by the woman. The fourth theme, preparing for a new birth by early follow-up and leaving the last birth behind, reflects coherence between the cultures. DISCUSSION: The findings deepen our understanding of why the VBAC rates vary across countries and healthcare settings, and can be used for improving the care for women. CONCLUSION: In order to improve VBAC rates both maternity care settings and individual professionals need to reflect on their VBAC culture, and make make changes to develop a 'pro-VBAC culture'.

Preference of birth mode and postnatal health related quality of life after one previous caesarean section in three European countries.

OBJECTIVES: Women who have had a caesarean section may have a preference for birth mode during their subsequent pregnancy, either 'vaginal birth after caesarean' (VBAC) or 'elective repeat caesarean section' (ERCS). A mismatch between the preferred and actual birth mode may result in an impaired postnatal Health Related Quality of Life (HRQoL). This study examined the associations between antenatal birth mode preferences, the actual birth mode and postnatal HRQoL in women with one previous caesarean section in three European countries. DESIGN: Prospective longitudinal survey, as a part of a cluster randomised trial (OptiBIRTH) SETTING: Fifteen maternity units in three European countries: Germany (5), Ireland (5) and Italy (5). PARTICIPANTS: Women (≥ aged 18 years) living in Germany, Ireland and Italy with one previous caesarean section. The sample consisted of 862 women with complete antenatal and postpartum data. MEASUREMENTS: Women's preference for birth mode after one previous caesarean section was assessed at inclusion to the trial, and HRQoL was assessed antenatally and at three months postpartum using the Short-Form Six-Dimension health survey. Based on women's preferences and actual birth mode six groups were determined: "match VBAC-VBAC" (preference for vaginal birth, actual mode of birth vaginal birth), "match ERCS-ERCS" (preference for caesarean section, actual mode of birth elective repeat caesarean section), "match ERCS-EMCS" (preference for caesarean section, actual mode of birth emergency repeat caesarean section), "mismatch VBAC-ERCS" (preference for vaginal birth, actual mode of birth elective repeat caesarean section), "mismatch VBAC-EMCS" (preference for vaginal birth, actual mode of birth emergency repeat caesarean section) and "no preference". Associations between the preferred and actual birth mode were examined using univariate and multivariate analyses. FINDINGS: Women with preference for vaginal birth but who gave birth by elective repeat caesarean section (mismatch VBAC-ERCS) had a lower postnatal HRQoL compared to women with a preference for vaginal birth who actually had a birth vaginally (match VBAC-VBAC, p = 0.02). Poor antenatal HRQoL scores (p < 0.01) and maternal readmission postpartum (p = 0.03) are cofounding factors for poorer postnatal HRQoL scores. KEY CONCLUSIONS: The results show that women with a preference for a vaginal birth who gave birth by an elective repeat caesarean section had a significantly lower HRQoL at three months postnatal. The long-term consequences and psychological health of women who do not achieve a vaginal birth after caesarean require further consideration and research. IMPLICATIONS FOR PRACTICE: Attention should be given to the long-term impact of a mismatch in preferred and actual mode on the psychological health of women.

Labour characteristics of women achieving successful vaginal birth after caesarean section in three European countries.

OBJECTIVE: Knowledge about labour characteristics of women achieving successful vaginal birth after caesarean section (VBAC) might be used to improve labour and birth management. This study examined sociodemographic and labour process-related factors regarding a) differences between countries, b) the comparison of successful VBAC with unplanned caesarean section, and c) predictors for the success of planned VBAC in three European countries. DESIGN: We analysed observational data collected within the OptiBIRTH trial, a cluster-randomised controlled trial. SETTING: Fifteen study sites in Ireland, Italy and Germany, five in each country. PARTICIPANTS: 790 participants going into labour for planned VBAC. MEASUREMENTS: Descriptive statistics and random-effects logistic regression models were applied. FINDINGS: The pooled successful VBAC-rate was 74.6%. Italy had the highest proportion of women receiving none of the four intrapartum interventions amniotomy (ARM), oxytocin, epidural or opioids (42.5% vs Ireland: 26.8% and Germany: 25.3%, p < 0.001). Earlier performance of ARM was associated with successful VBAC (3.50 hrs vs 6.08 hrs, p = 0.004). A positive predictor for successful vaginal birth was a previous vaginal birth (OR=3.73, 95% CI [2.17, 6.44], p < 0.001). The effect of ARM increased with longer labour duration (OR for interaction term=1.06, 95% CI [1.004, 1.12], p = 0.035). Higher infant birthweight (OR per kg=0.34, 95% CI [0.23, 0.50], p < 0.001), ARM (reference spontaneous rupture of membranes (SROM), OR=0.20, 95% CI [0.11, 0.37], p < 0.001) and a longer labour duration (OR per hour=0.93, 95% CI [0.90, 0.97], p < 0.001) decreased the odds of a vaginal birth. KEY CONCLUSION: Women with a previous vaginal birth, an infant with a lower birth weight, SROM and a shorter labour duration were most likely to have a successful vaginal birth. If SROM did not occur, an earlier ARM increased the odds of a vaginal birth. IMPLICATION FOR PRACTICE: Labour progress should be accelerated by fostering endogenous uterine contractions. With slow labour progress and intact membranes, ARM might increase the chance of a vaginal birth.

Optimal settings for childbirth.

Many studies highlight how health is influenced by the settings in which people live, work, and receive health care. In particular, the setting in which childbirth takes place is highly influential. The physiological processes of women's labor and birth are enhanced in optimal ("salutogenic," or health promoting) environments. Settings can also make a difference in the way maternity staff practice. This paper focuses on how positive examples of Italian birth places incorporate principles of healthy settings. The "Margherita" Birth Center in Florence and the Maternity Home "Il Nido" in Bologna were purposively selected as cases where the physical-environmental setting seemed to reflect an embedded model of care that promotes health in the context of childbirth. Narrative accounts of the project design were collected from lead professional and direct inspections performed to elicit the key salutogenic components of the physical layout. Comparisons between cases with a standard hospital labor ward layout were performed. Cross-case similarities emerged. The physical characteristics mostly related to optimal settings were a result of collaborative design decisions with stakeholders and users, and the resulting local intention to maximize safe physiological birth, psychosocial wellbeing, facilitate movement and relaxation, prioritize space for privacy, intimacy, and favor human contact and relationships. The key elements identified in this paper have the potential to inform further investigations for the design or renovation of all birth places (including hospitals) in order to optimize the salutogenic component of any setting in any country.

Humanities in the undergraduate medical and midwifery curriculum: a descriptive Italian comparative study.

There is an increasing emphasis on humanized care in obstetric and midwifery practice. The goal of this paper is to investigate if and how medical humanities content was present in the undergraduate medical syllabus and how similar or different this is from the undergraduate midwifery program in Italy. A review of the 2017-18 curriculum for Italian Schools of Medicine and of Midwifery was carried out through institutional websites or mailing requests. The following details were collected for each program: the type of humanities content; the academic credits allocated, whether it was taught as a stand-alone (independent) topic or not, and the year(s) of the program when it was provided. Programs were included for 39 Schools of Medicine and 36 Schools of Midwifery. All midwifery schools included at least one subject with humanities content. Five medical schools (12.9) did not appear to have any subjects in this area. Psychology and ethics/bioethics were the most frequently found topics in both disciplines, but, apart from history of medicine, midwifery was much more likely than medicine to include other humanities topics, and especially pedagogy, anthropology, sociology and communication studies, philosophy and cross-cultural studies were rarely or never included in either discipline. A greater breadth of humanities studies was included in midwifery schools. However, their relative importance appears to be low, given the low level of academic credits and lack of presence as independent subjects.

Optimal outcomes and women's positive pregnancy experience: a comparison between the World Health Organization guideline and recommendations in European national antenatal care guidelines.

BACKGROUND: The publication of the World Health Organization (WHO) recommendations on antenatal care in 2016 introduced the perspective of women as a necessary component of clinical guidelines in maternity care. WHO highlights the crucial role played by evidence-based recommendations in promoting and supporting normal birth processes and a positive experience of pregnancy. This paper aims to explore and critically appraise recommendations of national antenatal care guidelines across European countries in comparison with the WHO guideline. METHODS: We collected guidelines from country partners of the EU COST Action IS1405. Components of the documents structure and main recommendations within and between them were compared and contrasted with the WHO guideline on antenatal care with a particular interest in exploring whether and how women's experience was included in the recommendations. RESULTS: Eight out of eleven countries had a single national guideline on antenatal care while three countries did not. National guidelines mostly focused on care of healthy women with a straightforward pregnancy. The level of concordance between the national and the WHO recommendations varied along a continuum from almost total concordance to almost total dissonance. Women's views and experiences were accounted for in some guidelines, but mostly not placed at the same level of importance as clinical items. CONCLUSIONS: Findings outline convergences and divergences with the WHO recommendations. They highlight the need for considering women's views more in the development of evidence-based recommendations and in practice for positive impacts on perinatal health at a global level, and on the experiences of each family.

Variation in caesarean section rates in Cyprus, Italy and Iceland: an analysis of the role of the media.

INTRODUCTION: Cyprus has Europe's highest rate of births by caesarean section (CS). In 2015 56% of all babies were born by CS. This compares with 36% in Italy, and 16% in Iceland, which is among the lowest rates in Europe. There is some evidence that CS rates are partly driven by maternal request and media representation. The aim of this review is to explore the depiction of childbirth by CS in the media, and more specifically in newspapers, television, web and informational leaflets in Cyprus, Italy and Iceland. EVIDENCE ACQUISITION: A thematic review of the depiction of CS in the media of Cyprus, Italy and Iceland was carried out through an examination of newspapers, television, web, and informational material published or presented in the included countries in 2017. Materials were identified by searches in PubMed and Google Scholar, using pre-determined key words, inclusion and exclusion criteria, and inclusion was agreed by at least two of the authors. Key themes in each data source were triangulated with each other and between the three countries. EVIDENCE SYNTHESIS: The review comprised 81 articles, 10 videos, six birth shows, two informational leaflets and one scientific paper. The central themes were: 1) CS as risky and unnecessary intervention, failure of maternity system; 2) CS as a necessary, life-saving intervention; 3) the ethical dimensions of CS; 4) the changing landscape of childbirth and medicalization; and 5) informed choices. In both Cyprus and Italy, the media focus was on a need to reduce high levels of CS. The focus in Iceland was on normal birth and midwife led care. The differing media messages in the three countries could partly explain the differing CS rates, suggesting that high CS rates are a social phenomenon, rather than a result of clinical need. The media may have a significant influence on the beliefs and choices of maternity service users, their families, and society in general, as well as health professionals and policy makers. CONCLUSIONS: Those working in the media have an ethical responsibility to critically examine the impact of high national CS rates, and to report on solutions that could optimize both the safety and the wellbeing of mothers and babies.

Findings from the Italian Babies Born Better Survey.

BACKGROUND: The most recent WHO recommendations "Intrapartum care for a positive childbirth experience" highlight the need to identify women-centered interventions and outcomes for intrapartum care, and to include service users' experiences and qualitative research into the assessment of maternity care. Babies Born Better (B3) is a trans-European survey designed to capture service user views and experiences of maternity care provision. Italian service users contributed to the survey. METHODS: The B3 Survey is an anonymous, mixed-method online survey, translated into 22 languages. We separated out the Italian responses and analyzed them using computer-assisted qualitative software (MAXQDA) and SPSS and STATA for quantitative data analysis. Simple descriptives were used for the numeric data, and content analysis for the qualitative responses. Geomapping was based on the coded qualitative data and postcodes (using Tableau Public). RESULTS: There were 1000 respondents from every region of Italy, using a range of places of birth (hospital, birth center, home) and experiencing care with both midwives and obstetricians. Most identified positive experiences of care, as well as some practices they would like to change. Both positive and critical comments included provision of care based on the type of providers, clinical procedures, the birth environment, and breastfeeding support. There were clear differences in the geomapped data across Italian regions. CONCLUSIONS: Mothers highly value respectful, skilled and loving care that gives them a strong sense of personal achievement and confidence, and birth environments that support this. There was distinct variation in the percentage of positive comments made across Italian regions.

Process evaluation for OptiBIRTH, a randomised controlled trial of a complex intervention designed to increase rates of vaginal birth after caesarean section.

BACKGROUND: Complex interventions encompassing several interconnecting and interacting components can be challenging to evaluate. Examining the underlying trial processes while an intervention is being tested can assist in explaining why an intervention was effective (or not). This paper describes a process evaluation of a pan-European cluster randomised controlled trial, OptiBIRTH (undertaken in Ireland, Italy and Germany), that successfully used both quantitative and qualitative methods to enhance understanding of the underlying trial mechanisms and their effect on the trial outcome. METHODS: We carried out a mixed methods process evaluation. Quantitative and qualitative data were collected from observation of the implementation of the intervention in practice to determine whether it was delivered according to the original protocol. Data were examined to assess the delivery of the various components of the intervention and the receipt of the intervention by key stakeholders (pregnant women, midwives, obstetricians). Using ethnography, an exploration of perceived experiences from a range of recipients was conducted to understand the perspective of both those delivering and those receiving the intervention. RESULTS: Engagement by stakeholders with the different components of the intervention varied from minimal intensity of women's engagement with antenatal classes, to moderate intensity of engagement with online resources, to high intensity of clinicians' exposure to the education sessions provided. The ethnography determined that, although the overall culture in the intervention site did not change, smaller, more individual cultural changes were observed. The fidelity of the delivery of the intervention scored average quality marks of 80% and above on repeat assessments. CONCLUSION: Nesting a process evaluation within the trial enabled the observation of the mode of action of the intervention in its practice context and ensured that the intervention was delivered with a good level of consistency. Implementation problems were identified as they arose and were addressed accordingly. When dealing with a complex intervention, collecting and analysing both quantitative and qualitative data, as we did, can greatly enhance the process evaluation. TRIAL REGISTRATION: Current Controlled Trials Register, ISRCTN10612254 . Registered on 3 April 2013.

Mode of birth and postnatal health-related quality of life after one previous cesarean in three European countries.

BACKGROUND: How a woman gives birth can affect her health-related quality of life (HRQoL). This study explored HRQoL at 3 months postpartum in women with a history of one previous cesarean in three European countries. METHODS: A prospective longitudinal survey, embedded within a cluster randomized trial in three countries, exploring women's postnatal HRQoL up to 3 months postpartum. The Short-Form Six-Dimensions (SF-6D) was used to measure HRQoL, and multivariate analyses were used to examine the relationship with mode of birth. RESULTS: Complete data were available from 880 women. Women with a spontaneous vaginal birth had the highest HRQoL scores, whereas women with an emergency repeat cesarean (P = .01) had the lowest. Postnatal readmission of the mother (P = .03), having public health insurance (P = .04), and a low antenatal HRQoL score (P < .01) contributes to poorer HRQoL scores. More specifically, women with a spontaneous vaginal birth had significantly higher HRQoL scores on the vitality dimension compared with women with an emergency repeat cesarean (P = .04). CONCLUSIONS: In women with low-risk factors, repeat cesareans result in a poorer HRQoL compared with vaginal birth. When there are no contraindications for vaginal birth, women with a history of one previous cesarean should be encouraged to give birth vaginally rather than have an elective repeat cesarean.

Vaginal birth after caesarean: Views of women from countries with low VBAC rates.

PROBLEM AND BACKGROUND: Vaginal birth after caesarean section is a safe option for the majority of women. Seeking women's views can be of help in understanding factors of importance for achieving vaginal birth in countries where the vaginal birth rates after caesarean is low. AIM: To investigate women's views on important factors to improve the rate of vaginal birth after caesareanin countries where vaginal birth rates after previous caesarean are low. METHODS: A qualitative study using content analysis. Data were gathered through focus groups and individual interviews with 51 women, in their native languages, in Germany, Ireland and Italy. The women were asked five questions about vaginal birth after caesarean. Data were translated to English, analysed together and finally validated in each country. FINDINGS: Important factors for the women were that all involved in caring for them were of the same opinion about vaginal birth after caesarean, that they experience shared decision-making with clinicians supportive of vaginal birth, receive correct information, are sufficiently prepared for a vaginal birth, and experience a culture that supports vaginal birth after caesarean. DISCUSSION AND CONCLUSION: Women's decision-making about vaginal birth after caesarean in these countries involves a complex, multidimensional interplay of medical, psychosocial, cultural, personal and practical considerations. Further research is needed to explore if the information deficit women report negatively affects their ability to make informed choices, and to understand what matters most to women when making decisions about vaginal birth after a previous caesarean as a mode of birth.

Clinicians' views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates.

BACKGROUND: Caesarean section (CS) rates are increasing worldwide and the most common reason is repeat CS following previous CS. For most women a vaginal birth after a previous CS (VBAC) is a safe option. However, the rate of VBAC differs in an international perspective. Obtaining deeper knowledge of clinicians' views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Focus group interviews with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of "OptiBIRTH", an ongoing research project. The study reported here aims to explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates. METHODS: Focus group interviews were held in Ireland, Italy and Germany. In total 71 clinicians participated in nine focus group interviews. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country. RESULTS: The findings are presented in four main categories with several sub-categories: 1) "prameters for VBAC", including the importance of the obstetric history, present obstetric factors, a positive attitude among those who are centrally involved, early follow-up after CS and antenatal classes; 2) "organisational support and resources for women undergoing a VBAC", meaning a successful VBAC requires clinical expertise and resources during labour; 3) "fear as a key inhibitor of successful VBAC", including understanding women's fear of childbirth, clinicians' fear of VBAC and the ways that clinicians' fear can be transferred to women; and 4) "shared decision making - rapport, knowledge and confidence", meaning ensuring consistent, realistic and unbiased information and developing trust within the clinician-woman relationship. CONCLUSIONS: The findings indicate that increasing the VBAC rate depends on organisational factors, the care offered during pregnancy and childbirth, the decision-making process and the strategies employed to reduce fear in all involved.

Improving the organisation of maternal health service delivery and optimising childbirth by increasing vaginal birth after caesarean section through enhanced women-centred care (OptiBIRTH trial): study protocol for a randomised controlled trial (ISRCTN10612254).

BACKGROUND: The proportion of pregnant women who have a caesarean section shows a wide variation across Europe, and concern exists that these proportions are increasing. Much of the increase in caesarean sections in recent years is due to a cascade effect in which a woman who has had one caesarean section is much more likely to have one again if she has another baby. In some places, it has become common practice for a woman who has had a caesarean section to have this procedure again as a matter of routine. The alternative, vaginal birth after caesarean (VBAC), which has been widely recommended, results in fewer undesired results or complications and is the preferred option for most women. However, VBAC rates in some countries are much lower than in other countries. METHODS/DESIGN: The OptiBIRTH trial uses a cluster randomised design to test a specially developed approach to try to improve the VBAC rate. It will attempt to increase VBAC rates from 25 % to 40 % through increased women-centred care and women's involvement in their care. Sixteen hospitals in Germany, Ireland and Italy agreed to join the study, and each hospital was randomly allocated to be either an intervention or a control site. DISCUSSION: If the OptiBIRTH intervention succeeds in increasing VBAC rates, its application across Europe might avoid the 160,000 unnecessary caesarean sections that occur every year at an extra direct annual cost of more than €150 million. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10612254 , registered 3 April 2013.

Outcomes of the first midwife-led birth centre in Italy: 5 years' experience.

OBJECTIVE: To assess the experience of the first 5 years of the first midwife-led birth centre (MLBC) in Italy. STUDY DESIGN: Data were prospectively collected to analyse the first 5 years' experience of the MLBC. MLBC is located alongside a University hospital maternity unit and it offers care to women with a straightforward pregnancy and midwives take primary professional responsibility for care. Women with maternal diseases, complicated obstetric history, height < 150 cm, maternal age > 45, or multiple pregnancy were excluded. Transfer was request in case of antenatal, intrapartum and postpartum pathological conditions. RESULTS: During the 5-year period (1 January 2001-31 December 2005), 1,438 low-risk women were admitted in labour to the MLBC. Of these, 203 (14.1%) were transferred during labour to consultant care (138 because of pathologies and 65 because of request of epidural analgesia). Among the transfers, the caesarean sections were 87, corresponding to 6.1% (87/1,438) of the total of women admitted to MLBC, while the operative vaginal deliveries were 14, corresponding to 1.0% (14/1,438) of the total of women admitted to MLBC. Among women who gave birth in the MLBC, episiotomy rate was 17.1%. CONCLUSIONS: In Italy, in the passed 10 years, the caesarean section rate reached 60%, in some regions. According to our data, the first 5 years of activity of the first MLBC in Italy had been associated with a low rate of medical interventions during labour and birth, with high rates of spontaneous vaginal birth and without signs of complications. We hope that this experience could be taken as a model to improve the quality of maternity care in Italy.