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

Journal article
Authors Mike Clarke
Declane Devane
Mechthild M Gross
Sandra Morano
Ingela Lundgren
Marlene Sinclair
Koen Putman
Beverly Beech
Katri Vehviläinen-Julkunen
Marianne Nieuwenhuijze
Hugh Wiseman
Valerie Smith
Deirdre Daly
Gerard Savage
John Newell
Andrew Simpkin
Susanne Grylka-Baeschlin
Patricia Healy
Jane Nicoletti
Joan Lalor
Margaret Carroll
Evelien van Limbeek
Christina Nilsson
Janine Stockdale
Maaike Fobelets
Cecily Begley
Published in BMC Pregnancy and Childbirth
Volume 20
Issue 1
ISSN 1471-2393
Publication year 2020
Published at Institute of Health and Care Sciences
Language en
Subject categories Reproductive health, Nursing, Other Medical Sciences


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 >24weeks 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

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