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Planning a VBAC? You’ll Do Better with a Midwife

midwife comforts laboring woman

A study finds that women planning VBAC feel more in control, are better supported emotionally, and use more options such as upright birth positions and water birth when attended by a midwife of their choice. The press release provides the highlights of the study’s results, but if you would like more details, I’ve summarized the study here in “Taking a Deeper Dive,” and if you really want the nitty-gritty, the study is accessible for free.

Taking a Deeper Dive

Background

To set the stage, Australia, where the study was conducted, has a public/private maternity care system. In the public system, care is free, but it is fragmented. Women do not choose their care providers and see multiple providers, who may be midwives, obstetricians, or general practitioners, during pregnancy and labor. The private system is not free and offers continuity of care in that women can choose their physician or midwifery practice.

The study’s investigators conducted a survey to compare the experience of Australian women planning VBAC according to whether women received the usual fragmented care, continuity of care with a physician, or continuity of care with a midwife. Based on their earlier research, the survey focused on four arenas:

  • Control: “how ‘in control’ the woman felt over her decisions, choices and outcomes”
  • Confidence: “the woman’s belief in her ability to have a VBAC but also how confident she felt her health care provider was in her ability to have a VBAC”
  • Relationship: “how respected and supported she felt from her health care provider and the quality and continuity of that support”
  • Active labor: “whether the woman was able to stay active in labour, including minimizing interventions, and how this impacted her experience”

Results

Overall, 490 women from all parts of the country were included in the survey, of which 204 had continuity of care from a midwife, 119 from a doctor, and 167 had the usual fragmented care.


midwife comforts a laboring womanTaken from: Keedle H et al. Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy Childbirth. 2020;20(1):381


As you can see in the figure, in three of the four arenas: control, confidence, and relationship, fragmented care scored lowest, continuity of care with a doctor was intermediate, and continuity of care with a midwife scored highest. In active labor, the sole exception, continuity of care with a doctor scored lower than fragmented care, and as with the others, continuity of care with a midwife scored highest.

The model more typical in the United States is continuity of care with a doctor or midwife. Focusing on this model, some of the individual results offer some interesting insights. Starting with control, similar percentages of women felt in control of decision making (84% vs. 89%), but only 55% of those attended by a doctor felt that their care provider supported all of their birth plan versus 75% of women attended by a midwife. With respect to confidence, 61% felt their doctor was confident during the labor of their ability to birth vaginally while 83% said the same of their midwife. As for relationship, 31% responded that their doctor thought they should have scheduled a repeat cesarean versus 20% of women with a midwife. Prenatal visits, an important component of building a relationship, mostly ranged from 10-15 minutes with a doctor compared with 30-60 minutes with a midwife. Finally, in regard to staying active in labor, women were more likely to labor in a deep tub (34% vs. 11%), use a shower (48% vs. 29%), engage in position changes or be mobile (81% vs. 66%), use massage or acupressure (47% vs. 29%), push and give birth in an upright position (45% vs. 18%), and have a water birth (21% vs. 3%) with a midwife.

The next question logically is whether difference in practice style made a difference in VBAC rate. It did not. Rates were in the 60 percents regardless of whether the woman received continuity of care from a doctor, a midwife, or, for that matter, whether she received fragmented care. However, we can’t put too much weight on this. Participants were a self-selected group recruited through social media posts to relevant groups and social media ads to targeted populations. Their characteristics, how they became aware of the survey, and why they chose to participate could have affected their likelihood of VBAC. That being said, the conclusion that women attended by a known midwife are more likely to have care that is woman-centered, supportive, and respectful is almost certainly sound because it is consistent with the conclusion of numerous studies comparing physician care with midwifery care.

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