Cesarean delivery is defined as the birth of a fetus through incisions in the abdominal wall and uterine wall . An increase of in the cesarean delivery has been observed worldwide. However, the World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15%. According to the WHO, cesarean delivery rate of more than 15% is indicative of inappropriate use of resources .
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According to Department of Health, the Philippines’ 2006 national cesarean rate is 24%. In Davao Medical Center (DMC), the rate as of 2008 is recorded at 19% as depicted in the OB-Gyne department’s annual cesarean review statistics. In the US, most common indication of cesarean section is repeat cesarean which accounts for 35% of all cases as reported by the United States Public Health Service. The rates have been steadily increasing due to a higher number of sections for fetal distress as electronic fetal monitoring has been used extensively for presumed fetal compromise, the many breech presentations delivered abdominally as well as the increasing acceptability of cesarean delivery by maternal request.
Before the 1970s, deliveries by cesarean section were considered as an indication for cesarean section in the subsequent pregnancies, reflecting a concern that uterine scar tissue might rupture during labor. However, in the 1980s, the dictum”once a cesarean, always a cesarean,” espoused by Craigin (1916) was revised in many countries, and a trial of labor in women with history of cesarean section was proposed as an attempt to reduce cesarean section rates. However, an apparent increase in the incidence of uterine rupture and concern about maternal and fetal safety have challenged the choice of vaginal delivery in women having a scarred uterus. As a consequence, clinicians are increasingly being faced in deciding the mode of delivery in pregnant women whose first delivery was by cesarean section.
This scenario has also been observed in the Philippine setting. DMC, as a specific case, recorded increasing cesarean deliveries accounting to a third of all deliveries for 2008, of which, 11.53% for repeat CS while 19.8% for primary CS. In contrast, Vaginal Birth after Cesarean Section is a measly 1.2% of the total deliveries for 2008. This is due to the fact that patients who underwent VBAC were admitted for imminent delivery. Majority of these patients were not prepared during their prenatal visits and were unaware of the complications and risks of VBAC. The confounding reason of such practice is primarily economics: the high cost of undergoing an elective CS delivery as compared with the cost of vaginal delivery. These patients would rather risk undergoing VBAC without the benefit of intrapartum monitoring specifically for those attempting to deliver at lying-in clinics or at home. Based on the National Institute of Child Health and Human Development (NICHD) study, the incidence of uterine rupture is low at .2-.7% (Landon,2006). But despite its low incidence, ACOG guidelines on VBACS specifically mentioned that VBAC be performed in an institution where an obstetric, anesthesia, pediatric, and operating-room staff is available. This scenario provided impetus for the conceptualization of this study which is aimed at determining the knowledge, attitudes, and practices of repeat C-section patients and their willingness to undergo vaginal birth after C-section at DMC.
Review of Related Literature
In 2004, the number of C-sections had reached an all-time high, accounting for 29% of all births – or 1 million babies (National Center for Health Statistics). This is despite the convention that vaginal delivery is associated with less maternal and fetal morbidity and mortality as compared with repeat cesarean section (Chauhan, 2004).
For example, observational studies data from around 90,000 deliveries, have shown an increased risk of neonatal respiratory morbidity among term infants delivered by caesarean section (3.5-3.7%) compared with vaginal birth (0.5-1.4%). The following maternal risks significantly increase with increasing number of repeated caesarean deliveries: placenta accreta, injury to bladder, bowel or ureter, ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, blood transfusion requiring four or more units and the duration of operative time and hospital stay (Russen et. al. 2004).
Moreover, authors speculated that a prolonged inter-pregnancy interval may allow time for the previous cesarean delivery scar to reach its maximal tensile strength before the scar undergoes the mechanical stress and strain with a subsequent intrauterine pregnancy (Shipp et. al., 2000).
Menacker et al. (2006) noted that cesarean rates fell between 1991 and 1996, and then began to rise rapidly. In 2004, over 29% of all births were by cesarean section. The rise in both the total and repeat cesarean rate has been widespread for women of all ages, races, medical indications, and for all infant gestational ages. The study also noted steep decrease in VBAC rate from 1996 to 2004 (see Figure 1). From this trend, the authors opined that the influence of recent medical opinion discouraging VBAC has had a strong effect on practice patterns, and had led to greater uniformity as well as a large increase in repeat cesarean deliveries by 2003.
(Source: Menacker et al. pp. 236)
The dramatic increase in cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response, clinical guidelines recommending vaginal birth after cesarean-section (VBACS) have been promulgated by international organizations from different countries such as the United States, Canada, Europe, New Zealand and Australia.
It is construed that adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment.
Neff (2004) discussed the risks and benefits of VBAC. Successful VBAC generally is associated with shorter maternal hospitalizations, fewer infections, less blood loss and fewer transfusions, and fewer thromboembolic events than cesarean delivery. However, a failed trial of labor may be associated with major maternal complications, such as hysterectomy, uterine rupture, operative injury, increased maternal infection, need for transfusion, and neonatal morbidity. Multiple cesarean deliveries are associated with an increased risk of placenta previa and accreta.
With VBAC (Landon, 2004), the incidence of maternal death is extremely low. The incidence of perinatal death is less than 1 percent, and is more likely to occur during a trial of labor than an elective repeat cesarean delivery. Uterine rupture during a trial of labor after a previous cesarean delivery is a life-threatening complication directly associated with attempted VBAC. The patient’s obstetric history influences the risk of uterine rupture. A previous vaginal birth significantly reduces the risk of uterine rupture. Also, the longer the length of time between deliveries, the lower the risk of rupture. Women who attempt VBAC who have interdelivery intervals of less than 24 months have a two- to three-fold increased risk of uterine rupture compared with women whose interdelivery interval is more than 24 months.
A study conducted Hopkins and Potter (1998) on C-sections patients in Brazil concluded that while many women fear the pain associated with childbirth and the consequences of a vaginal birth for the baby, they do not clamor for C-section delivery. Obstetricians were observed to have overplayed these fears to their advantage thereby overly estimating safety of C-section delivery. In fact, it has become a routine practice and is considered as safe or safer than a vaginal delivery.
The study further documented that majority of first-time mothers in public and private hospitals wanted to deliver vaginally and considered vaginal birth superior in terms of recuperation. A majority believed that vaginal delivery does not have effect to their or their partner’s sexual life. Though majority was found to have considered normal childbirth more painful than a cesarean, but most also believed a cesarean causes a lot pain after the delivery. Less than 33% agreed that a cesarean is safer for the baby and less than 20% of women agreed that a C-section is safer for the woman.
Objectives of the Study
The objectives of the study are twofold:
To come up with a profile of the knowledge, attitudes and practices (KAPs) towards vaginal birth after C-section (VBACS) among repeat C-section patients
Determine whether the KAPs of the respondents significantly influence their willingness to undergo VBACS
Statement of the Problem
This present study seeks answers to the following questions:
What is the profile of the respondents in terms of their knowledge, attitudes and practices about VBACS?
What is the frequency distribution of the respondents in terms of their willingness to undergo VBACS?
Do the KAPs of the respondents significantly influence their acceptance to undergo VBAC in their next delivery?
Does counseling about VBACS affect the respondents’ willingness to undergo vaginal birth after C-section?
It is hypothesized that the KAPs of the respondents toward VBAC significantly influence their willingness to deliver vaginally after having experienced C-section in their previous delivery.
Significance of the Study
The most common reason that a C-section is performed is that the woman has had a prior C-section delivery. DMC is not spared from the increasing trend of repeat C-section rate. Since vaginal delivery is undoubtedly associated with less maternal and fetal morbidity and mortality, not to mention, medical supplies and other hospital resources, there is a need to find ways in order to reduce repeat C-section rate in DMC.
DMC, a tertiary and referral hospital in the Southern Mindanao Region, has no available data on KAPs of women towards VBACS. Thus, the range information that this investigation will generate could provide baseline information that can be used to design appropriate interventions aimed at reducing the overall C-section rate in the institution. One of which is by counseling and encouraging patients to undergo VBACS. One of the significant risks when considering VBACS is uterine rupture because it has been the belief and fear of many repeat cesarean patients that a previously scarred uterus is too weak to withstand trial of labor hence discouraging them from going into VBACS.
The information that would be gathered from this study would be of help in counseling repeat C-section patients ante-nataly and post-nataly to enable them to plan their preferred spacing intervals for the subsequent pregnancies. This is because women with prior C-section birth is considered high risk and so to optimizing maternal well being and healthcare. Moreover, data about the knowledge, attitude and practices of patients who had prior CS birth on VBACS would be of help to assess the level of acceptance of these patients and hopefully allay their fears thereby coming up with the best informed choice.
Lastly, the results of the investigation could spur future research in the subject VBACS.
The willingness of the respondents to undergo vaginal birth after cesarean section in their next delivery
The profile of the respondents in terms of their knowledge, attitude and practices towards vaginal birth after cesarean section.
A descriptive cross-sectional survey design would be employed to address the research questions.
Outpatient department of the OB clinic in Davao Medical Center
Respondents and Sampling
All patients who had a prior C-section birth seen at the high risk clinic of the DMC OB OPD will be included in the sampling frame from February to April 2010. The sample size will be determined using the model , where n is the sample size, N is the population size and e is the margin of error.
All patients who had a prior CS birth will be included in the study.
Patients who will not give their consent will be excluded from participating.
The questionnaire will be pilot tested among ten patients with previous CS at the DMC OB OPD.
A structured survey form will be used for gathering data about the respondents’ KAPs
towards VBACS and their willingness to undergo vaginal delivery (see Attachment 1).
The principal investigator (PI) will conduct a one-on-one administration of the survey form. Prior to gathering information pertinent to the questions in the survey, informed consent (see Attachment 2) will be secured by the PI.
After data gathering, the principal investigator will counsel the respondents about VBACS, its indication and absolute contraindication, complications and the VBACS ACOG guidelines. A post-test question will be done on their willingness to undergo VBACS after being counseled.
Approval from the hospital ethics committee will be sought before the study will be
conducted. After thoroughly discussing the nature, methodology and objectives of the study to the respondent, a
written consent will be asked from each participating patient.
The KAPs of the respondents towards VBACS will be profiled using descriptive statistics such as the mean, standard deviation, frequency and percentage distribution. Their willingness to undergo vaginal delivery before and after counseling about VBACS will also be described using frequency and percentage distribution. Logistic regression analysis will be used to determine whether or not the KAPs of the respondents significantly influence their willingness to undergo VBACS.
The study will be conducted in February-April 2010.
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