OptiBIRTH

1. OptiBIRTH WG2:Development of the women-centred intervention Leader: IngelaLundgren, University of Gothenburg, Sweden

2. WG2: Intervention development Focus groups interviews with women, their partners (if desired), physiciansand midwives Countries with high VBAC-rates 45-55% - Finland, Sweden and theNetherlands 2 groups with 6-8 women (one urban and one rural) and 2 with 6-8 professionals in each country, total 12 groups Countries with low VBAC-rates 29-36 % - Italy, Germany, and Ireland 1 groups with 6-8 women and 1 with 6-8 professionals (in each of 7-8 maternity units allocated randomly to the experimental group), total 14-16 groups

3. Questions to the focus groups Five major questions will be asked: 1) In your opinion, what are the important factors for a successful VBAC?; 2) What are the barriers to successful VBAC?; 3) What was/is important to you as a birth-giving woman/professional?; 4)What is your view on shared clinical decision-making (i.e. making decisions on aspects of your/women’s/ partner’s care and sharing decision-making with others)?; 5) How can you support women to be confident with VBAC (for example women with fear of childbirth). OptiBIRTH

4. Data analysis: Conduct month 3 (in countries with low VBAC randomized) Analysis complete month 5 Data analysis: Content analysis based on the 5 questions, analysed in main categories and sub- categories; one for women and one for professionals Data analysis first level in different countries (5-10 subcategories/ question in English) Skype meeting analyse in whole group WG-leader next step analyse all text New Skype meeting for feed-back Completed January 2013

5. Status – focus groups • Ethical approval in October • Finland: ethical approval in process, Kuopio and Helsinki or Tampere • Sweden: ethical approval in process, Gothenburg and Borås/Skövde • The Netherlands: ethical approval in process • Ireland: ??? • Italy: ethical approval for Genoa, other regions in process • Germany: ethical approval in process, Hannover and ?? Interviews with women postpartum and during pregnancy (Ireland) Interviews with obstetricians and midwives in one group or different groups

6. Systematic reviews • 1. Women-centredantenatal interventions for increasing VBAC rates and reducingfearofchildbirth • 2. Clinician-centred interventions for increasing VBAC rates and reducingfearofchildbirth in women and apprehension in clinicians • KeywordsVBAC, vaginal birth after caesarean section(spelling) women-centred (spelling), interventions, clinician-centred (spelling), experiences, decision-making, success, barriers, professionals, health care professionals, midwives, obstetricians., preferences, fear of childbirth, choice, options, tocophobia, anxiety, PTSD, traumatic birth, TOL, medical litigation • Complete Month 4

7. Background ‘Groping through the fog’: a metasynthesis of women´s experiences on VBAC (Vaginal birth after Caesarean section) Ingela Lundgren, Cecily Begley, Mechthild M Gross and TereseBondas BMC Pregnancy and Childbirth 2012, 12:85 (21 August 2012) The objective of this metasynthesis is to integrate the findings and deepen the understanding of women’s experiences of VBAC.

8. 1981 articles (VBAC) ↓ • 142 articles (Keywords VBAC, vaginal birth after caesarean section, qualitative study, experiences, qualitative and women´s experiences in various combinations) • Exclusion: quantitative studies, studies about health care professionals’ experiences ↓ • 22 articles (read) • Exclusion: not focusing women´s experiences, only focusing experiences of CS in relation to VBAC ↓ • 11 articles • Exclusion: Quality check by 45-items based by COREQ 32-item [27] and Walsh and Downe [28]. ↓ • 8 articles included in the metasynthesis • Figure 1. Flow chart summarizing search strategy.

9. Results • Studies from UK (1), US (3) and Australia (4) • Metaphor; groping through the fog • giving birth vaginally after a previous CS is experienced as paradoxical • Four main themes and sub-themes

10. Own strong responsibility for giving birth vaginally • In relation to the women themselves • In relation to information • In relation to health-professionals

11. Vaginal birth after CS is a risky project • To have to confront serious risks mediated by health-professionals • Lack of information about the benefits of vaginal birth • Not supported if you want a VBAC

12. Vaginal birth has several positive aspects mainly described by women • Good for the baby and the mother- baby relationship • A meaningful experience of importance for them as women • An easier birth in relation to recovery afterwards • Some health professionals are pro VBAC

13. To be involved in decision about mode of delivery is difficult but important • Not being informed enough • Conflicting information • Important to have a choice • Uncertainty in relation to choice • Information/support from others not the hospital • Support from professionals • Experiences from the last birth influence the choice

14. Questions: • Language for transcriptions? • Data-analysis in the different countries to which level? • Last step by the responsible scientific person (IL)? • Involvement by IL in the different countries? • Analysis in two steps?

15. Questions for Cecily: • Pregnancy or after birth CS? • Different groups in low and high VBAC-countries? • New questions from the groups • Is it OK with individual interviews; Ireland the Netherlands. • Randomization low VBAC countries • Focus groups as part of the intervention?