Barriers and facilitators of choosing a vaginal birth after cesarean: A mixed-methods systematic review

Vaginal birth after cesarean is an effective way of reducing cesarean section rates and preventing a variety of short- and long-term complications associated with cesarean deliveries. Additionally, vaginal birth after cesarean can enhance breastfeeding rates, expedite postpartum recovery, and minimize hospitalization duration for women. Despite these benefits, the prevalence of vaginal birth after cesarean remains low in many countries, and only limited reviews have investigated the factors contributing to the low vaginal birth after cesarean rates.

This review aims to explore the barriers and facilitators influencing decision-making during the process of vaginal birth after cesarean.

A mixed-methods systematic review.

Ten electronic databases were systematically and comprehensively searched for qualitative, quantitative, and mixed-methods studies. Two reviewers critically appraised the eligible studies independently using the Joanna Briggs Institute Critical Appraisal Tool. We converted quantitative findings to narrative form and employed a convergent synthesis design to synthesize the data thematically.

This review included 55 studies published between 2002 and 2024. These studies originated from 19 countries and comprised 21 quantitative studies, 31 qualitative studies, and three mixed-methods studies. The methodological quality of the included studies was assessed as moderate to high. We divided the barriers and facilitators influencing vaginal birth after cesarean decision-making into four categories and nine subcategories: individual factors of pregnant women (sociodemographic characteristics, physiological factors, cognition, and psychological factors); interpersonal relationships (emotional support and communication); healthcare system factors (healthcare professionals' acceptance and commitment to action as well as healthcare facilities); and social factors (culture and ethnicity, along with law and policy).

This study broadens the understanding of the various factors that influence vaginal birth after cesarean decisions and may provide valuable insights for future modifications in vaginal birth after cesarean practices to enhance its availability for women. We conclude that successful implementation of vaginal birth after cesarean requires the concerted efforts of all stakeholders. Hospitals should improve the quality of care, enhance the capacity of the healthcare system to support vaginal birth after cesarean, and respect the preferences of pregnant women by providing support and encouraging their active participation in decision-making.

This systematic review was registered in PROSPERO on June 24, 2022 (CRD42022339434).