 and experiences of choosing a home birth following a Caesarean section, which I think is going to be a great follow-up to Amy's presentation a couple hours ago. Hazel is in the final stages of a Masters of Nursing with Honors at the University of Western Sydney, where she has undertaken research on women's experiences of home birth after a previous Caesarean. Hazel is also an independent practice midwife in regional New South Wales, Australia, and she coordinates the Central West Better Birth Group, which offers support and advocacy for birthing women in that region. So Hazel, I'm going to turn it over to you now. Hello. Okay, hi Hazel. Thank you very much for your introduction. Hello. Can anyone hear me okay? Excellent. Okay, so my name is Hazel, and I first of all want to shout out to my wonderful supervisors for my Masters, which is Professor Hannah Darlin, Professor Virginia Schmeid and Dr Elaine Burns, all from the University of Western Sydney, who started. For the outline of this presentation, we'll talk very briefly about what is a VBAC and the aims and objectives of the research that I did, which was that VBAC rate, which will review methodology results and then the implications of the research. So the aim of the study that I did was to explore the women's reasons for and experiences of choosing a home birth following a Caesarean section. And there was a bit of history to this, which comes from my own personal history. So first of all, I was a midwife, and I was a midwife supporting women at home. I was also a woman that had a Caesarean, a home birth transfer Caesarean for my first birth, and then a VBAC, Regina Birth after Caesarean for my second birth. So I had a very keen interest in this area. So what is a VBAC? You guys know this. It's a vaginal birth. It's achieved following a previous Caesarean section. Other terms that are often used as end-back or next or normal birth, and particularly for this study, is HBAC or home birth after Caesarean. The VBAC rates internationally are not particularly great. There was an interesting discussion earlier in aiming session about the different VBAC rates around the world, which I took note of, and they were very interesting. In Europe, we were looking in the third is in the fourth is in higher. In America, Amy told us it was 8.5%. In Australia-wise, it was 12.3% at the last Australian mothers report, Muslim babies report. Now, I'm in a state of New South Wales. Those of you that don't know Australia are made up of states and territories. And we have figures put out for our specific states. So for New South Wales, right down in 2011, as you can see on this graph, it's 11.5%. This is women that have had a vagina birth after Caesarean. It doesn't tell you the amount of women that went for VBAC and had a repeated Caesarean. It just tells you the amount of women that went for VBAC and achieved that. So as you can see, there's been a steady decline in the 2000, which is the first statistics that we've got on that. Obviously, for part of my research, I had to look at the literature review, and I did an extensive literature review. I found that generally VBAC rates are low, as we've just discussed. And yet there was a difference. So when you look in the literature around VBAC rates out of hospitals, so birth centres and home births, they're a lot higher, often 75% to 90% success rate. In the research when there was a study that was done in a hospital or group of hospitals, they could achieve 50 to 65% of VBAC rates in hospitals. And as we know, in reality, these are a lot lower. We know that rupture rates are minimal. So any woman that's gone for VBAC and anyone that's looking after women having VBAC, we know that the big issue is all about the rupture. But rupture rates are low, 0.15 to 0.9 for most. And if you add hormones and inductions, such as intostinal and prostaglandin, that goes up to 1.4 to 1.9. And if you have only a six-months interpregnancy rate, that went up to 2.7. These are still very low rates. We know that repeats of zones are risky to both mother and baby, and Amy touched on this a bit earlier. We know for mothers who are high rates of endometritis, there's more need for blood transfusions and there's more chances of not for operated injury. For baby, there's a high need for oxygen at birth, high in NICU admissions, and higher number of newborn infections compared to women having a VBAC. We know from the qualitative studies around VBAC that women seem to prefer VBAC. They tend to say that they get a better recovery. They find they have a better bonding with their baby. They often choose to have a VBAC because they're avoiding intervention and they want to feel they've got more informed choice. The guidelines for the management around VBAC, they are written by national and professional bodies. There's a disparity often between the success and the rupture rates. They approve of interventions and they often necessitate them, such as CTG monitoring. And we could say maybe they're not woman-centered. They certainly don't really give a chance to negotiate. So the study that I did, I looked at women that had a VBAC at home in the last five years. That was a couple of years ago now, so it would have been in the last seven years. They had to be happy to be interviewed and these were done by face-to-face or telephoned interviews and speak English. It was advertised through social media interest groups. I had a lot of interest. Once the interviews were done, they were transcribed in software programs called MVVO and I used thematic analysis to analyse that data. So overall, I had 14 women as part of the study. There was one overarching theme and that came up as it's never happening again. This overarching theme covers the reflection from previous Sazerian experience and their motivation for a different experience this time. So on each of these slides, you'll find some quotes. I won't read them out to you. So if you think you can just have a read. These are quotes that have come from the women that have been interviewed. There are two arms of this overarching theme. The why it's never happening again and how it's never happening again. In why it's never happening again, we will look at these and the titles were treated like a piece of meat traumatised by it for years. You can smell the fear in the room and re-traumatised by the system. I know these are quite powerful terms but these titles came from the women's own world. So a piece of meat on a cold slab. I'll just let you read that. This is how women describe their Sazerian experience. They describe feelings of a loss of control, feeling a loss of dignity, feeling like there was just a number in the system and also feeling quite separated from their body and having a Sazerian experience. I was traumatised by it for years. So this is how women felt about the Sazerian experience and their ongoing feelings of this. A lot of women explained how they felt gutted or they felt that they were a failure. Some women were replaying the surgery over and over in the pad in their head. There were some women who identified as post-traumatic stress disorder or post-natal depression. And often this was picked up by a healthcare provider in their post-natal period and they were referred to counselling for it. This particular little picture has come from a larger artwork that was done by one of the interviewees and is in her journey and her healing from her Sazerian. You can smell the fear in the room. So some women attempted to be back in the hospital after their first Sazerian and some of the women achieved that. And the smell of the fear in the room really explains how women found this experience. They often identified that obstetricians didn't believe in birth and they also felt there was a lot of focus around their scar. One woman saying, she says it was all about my scar and she goes on to say that she was in labour and she was doing great. And then midwives came in and said, so does your scar hurt? And she thought, oh, damn you. I wasn't even worried about that at that point. And then it came up and then she was having to process that in her mind. And the women felt that they were very vulnerable and they were vulnerable to the fears of the professionals and also they felt that they didn't understand. They didn't maybe have enough knowledge to be able to stand up for themselves. The hospital at Trauma looks at the women once they had had Sazerian and whether or not they had a V back in the hospital afterwards. So this particular pregnancy that they had a home birth for, they didn't automatically decide they were going to have a home birth. They did approach the hospital first of all. So this time they approached the hospital with a lot more knowledge. They wanted to avoid the interventions that obviously didn't work for them last time. And they found that really the system was very inflexible. They were often told no. Even if the woman was saying in this example that she's going to put it in her birth plan, the hospitals were saying, well, you can't. They found the system was inflexible. They also found that they were feeling that they were being bullied again, all over again. And the women were worried that if they continued with this pregnancy and birthing in the hospital, they just wouldn't be able to say no. So then that is the why. They don't want that to happen again. Now it's how it's never happened again. So the women in the study, they really got informed. And they started looking at risk in perspective. They were able to access lots and lots of information. And some of that might be the research and medical information. And some of it was women's experiences and other women's stories. And they really balanced that up, with the scientific information with the storytelling. They realized that the system was not going to support their feedback in the way that they wanted to have a feedback. They weighed it all up and decided that a home birth after a home birth after Caesarean was a safe option for them. And they found that this knowledge became their armor and they became strong with that information. So avoiding judgments for selective telling, once the women had decided to have a home birth after Caesarean, this was a challenge to tell people. And as we know, people always like to share their opinions with pregnant women once you get that bump. And they really didn't want to be around that negativity. So some women didn't tell anyone. Some women only told those that were going to be involved in the birth. And some only told them when they did the birth announcement by text message. They'd be born at home, which was planned. Preparing for birth was in different ways. So they may have trained themselves up physically. They may prepare themselves mentally for it. I'd be setting up the home so that it's ready for a home birth. They definitely dealt with the what ifs. So they may have got some ambulance cover just in case. They would tell me in the interview how far they were from the hospital, how long in kilometres or in time it would take to get there what their backup plans were going to be. So there was a lot of preparation once that decision had been made. Gathering support was a vital part in this preparation for an HBAC. And this was in three different areas. So the first person, if they had one, was their partner. And that was really getting their partner on board to be their support. The second person was a hired help. So that could be a doula. And we'll talk about midwives in a minute, but this was particularly doulas. And there were some extremely positive things to say about doulas. Sometimes it was the doulas that maybe suggested to them about a home birth. And then thirdly, there was support groups. And this was really quite an interesting part of it. The support groups, because Australia were a very big country and had very big distances, they weren't always face-to-face. They were often online. They might have been using the social networking sites that they're so familiar with. And some of them were face-to-face as well. But this support from the women, as Felicity mentioned in the previous session, women love sharing stories. So having that contact with other women that had been through a VBAC or been through an HBAC was really important for these women. All about safety, but I came first. So this is where the women talked about their relationship with a private midwife. The majority of women did hire private midwives. And they talked about this relationship as the midwives gave support and friendship. They found that their care that the midwives gave them was tailor-made. They were often long appointments, one or two hours sitting at home. And often these appointments were going through in detail what a woman had gone through last time, what a woman's experiences were at the facility, so that the midwives were aware what her triggers were and what her story was. Obviously, there was continuity of care, and this was obviously from when they booked their midwife for the labour and birth and for postnatally as well. They also described their time as a midwife during the labour and birth and described it as she would sit back and observe. So the midwife wasn't always right in there doing all the physical care to the woman. It was more an observation and more support when the women needed it most. So then we looked at the impact of H-Banks. So you had your two arms of the overarching theme and then there was the impact. I felt like a superwoman. Now this is where I'm going to play you a sound bite now. This is when I asked the women a question, how did you feel after your feedback at home? And when I was listening and transcribing these interviews, I just thought, I'm never going to get this out to my audiences on just writing out what the women are saying because I would listen to these interviews. There would be a lot of emotion around them talking about their previous experiences. And then when I would ask them this question, you could just hear them inflate with their pride. So I thought I would make that into a sound bite. So I'm just going to play that now and I hope you guys can all hear it. How did you feel after having your feedback at home? Ah, euphoric. Absolutely euphoric. It was amazing. It was just overwhelming. It was just the most magical experience. Absolutely awesome. It was everything that I wanted it to be. It was ecstatic. Powerful. I don't think going back down to Earth for that two weeks. Awesome. It was the most amazing experience. Amazing. Amazing. No drugs. Just wonderful. It's the new power of God. I don't know what to say. Yeah, it just felt very normal. I suppose that's kind of the best way I could describe it. Yeah, it was great and it was very positive. And it was relaxed. And yeah, it was a really healing experience. It was just what most people would have felt really normal and good. Yeah. Just blown away. It was my best experience of my life. And it wasn't because it was a V back, it was because it was just giving birth. I felt like I needed to run around with a big fat, I told you so, sign. To my GP, you know, to everybody. I felt like, I felt like finally I could relate to a lot of the mothers I know. Who have human birth, vaginally. And actually I felt I had run up on them because they could be in hospital under, you know what I mean? I felt like a superwoman. It was wonderful. It was wonderful. Initially, fantastic. This is the best thing that's ever happened. And I want everyone in the whole world to know how fantastic it is. And the high was just so high. I stayed as one of the best moments of my life. Still. And that was, you know, five or five years ago. I would not ever forget, I don't think, how amazing I was to have actually done it. I feel so, you know, complete. And, you know, I got to enter into this. I feel like, you know, this is what I was meant to do as a woman, not just to have the baby at the end of it, but actually to give birth to my own child. And so those were the women's experiences on how they felt. It was, having this feedback, it was really, it seems to have been a stepping stone for women. And they went on, they were able to really discuss the differences. Because obviously these women had had a hospital experience and maybe one or more hospital experiences. They experienced many different models of care such as private obstetricians for some of these women and some women had group practice, some of them had standard anti-vacare where they would see a different midwife each time. And then they had private midwifery care. So, you know, one thing that we found was there was just no comparison. As you can see in that photo there, used with permission, there was a multi-generational event and the woman could read to who was going to be there and who weren't going to be there. So in Australia in particular, there is a lot of politics around home birth and insurance and that would be a whole other presentation to go through that now. But there was, because of the changes that seem to be happening all the time, I asked the women during their interview, what would you do if home birth after steering was no longer an option? And this was a really interesting response that we got from the women. There was one woman who would basically say, no, I definitely wouldn't do a free birth and then while she was talking about it, she was convincing herself of doing a free birth by the end of it. And it was a very difficult situation to put these women into. The second comment that I haven't discussed is that we did a focus group for midwives as well. And the same question was asked for these private midwives what would you do if you could no longer attend a home birth, a woman having an age back? And there was a discussion on whether the midwife would go unregistered, whether she would work under the radar and one midwife here very honestly said that she doesn't feel that she would be able to do that. And I thought that was a really interesting point to it. So really in summarising this slide, the women really, those women that said they wouldn't free birth, they said that they would go back to the hospital but it would be on their terms and others really thought they would probably would free birth. So free birth means having a home birth without any qualified professionals such as a midwife present. Where I didn't discuss with, I felt like superwoman just going back to that one. A lot of women after their age back, it really seems to catapult them into the birthing world. Some of the women trained and became qualified as doulas to be able to share that information. Others just shared it amongst their friends and so if somebody, one of their friends was discussing what kind of birth they would want to have, then these women felt they really could share their knowledge and share their passion for birth. So the main points we came from the study in the discussion is that impact of birth trauma, that we know that it can stay with women for years and I believe that some women, they probably bury that and take that with them to their elective caesarean rather than trying for a view back but this particular group of women were interesting because they bucked the trend, they decided to go for a view back and then to do that at home. But disrespect and abuse of women in maternity care, and we know from the Lancet series that it was published last year that this is still very true and where it comes into relation with women in this study is the threats that the obstetricians or the other healthcare providers gave the women if they went on to have their home birth and they were given the dead baby cards and that you wouldn't be able to get to hospital in time if there was a problem. But there was also from their original caesarean experience was their lack of informed consent. They often experienced the cascaded interventions that ended up with their caesarean and they felt that they weren't given the full information about that. In flexible guidelines is where the women, they actually did approach the hospitals first in the majority of cases. They went to the hospital and they said, I want to have a feedback, but I don't want to have continuous monitoring or I don't want to have a cannula institute for the whole of my labour. I don't want to be put on a time and I want to be able to eat and drink when I can. And those guidelines would seem to be so rigid from the hospital staff or maybe the hospital staff were too fearful to change their actions that the women really felt they had nowhere else to go than find a private midwife and do that at home. But when we look at the research around home birth after caesarean, the rupture rates are no higher. They are comparable to hospitals and all we know that the feedback rates are, we know the success rates are higher. But what is it that we're doing at home or is the fact that women not being continuously monitored or not having to stick to in flexible guidelines do so much better? But really, I guess we can take from that as practitioners in hospitals, can we have some flexibility? What does that mean to myself as a practitioner? Am I going to get into trouble for that? Or can we actually look at putting women's wishes first? The importance of women's support groups really came out. And I think from our standard hospital point of view, we put women in a... We love them together for an antenatal class where it is very didactic. We do the talking and the women do the listening a large majority of the time. But maybe if we could actually put women together where they can share their stories and not with just women that are planning that pregnancy so they just breathe their fear together, but actually with other women that have already been through it and to share those stories because that seems to be that kind of sharing and identifying of stories seems to have a great impact. And then lastly, what came up from this study was the role and the support from the privately pregnant midwife. The midwife that isn't being employed by the hospital system has guidelines, but they may not be as rigid as the ones in the hospital and they very much can be women-centered. And how vital that is to walking alongside the woman and not telling her what she can and she can't do it. What do you want to do and how do you feel about that? And that certainly came through in this study. The implications for the study, I know it's a small study, but it has highlighted some interesting points. We need to be able to identify the factors that could improve feedback rates and is that maybe being not quite very rigid with the guidelines, for example. We need to improve our services to support women rather than saying, no, you cannot do this and you will be doing this and you will be doing that. As she's saying, well, what is it that's important to you? And with that improving attitudes towards women, making care in the hospital more flexible and continued care, we know from the DERF of Midwifery Research that is out there about the benefits of continued care. And this small study helps support that. I seem to wish to do that quite quickly, which gives us plenty of time to answer some of the questions that are on the side here. Sam, have you picked up on any questions? Well, if anybody wants to raise their hand and ask a question, this is a great time to do it. It seems like a lot of what's been going on in the chat is just talking about experiences that so many of us have had with women being told the horror stories by other women, by family members, by providers, about the uterine rupture in the baby that's going to die and ultimately how selfish a woman is for wanting to choose a VBAC. And, you know, in light of what you've told us, Hazel, that just seems so unfair and so crazy. But is that something you felt like you encountered a lot with the women that you talked to that they had really been almost scared into either having a repeat C-section or having an H-BAC because providers were just so negative or so full of fear? Well, that's interesting. This particular group of women were far from scared. In fact, they seemed very frustrated. A lot of these women were really able to access the information that might have been even more up-to-date than the professionals that were telling them the statistics. When I was interviewing them, I had not long done my literature review, a lot of these women were able to throw back the statistics and the studies that I had not long read. So this particular group of women, they were very highly educated. Many of them had university degrees and they were on a whole, you know, white middle class, well-educated women. So instead of being scared, I think they were just frustrated. They were annoyed. They felt that they were being gambosled into something that they didn't really want to do, so they had to find something else. And for that, that initial step was looking elsewhere and then finding out about home birth and finding out about private midwives and trying to help women achieve that goal. Yeah, I think that's a really great answer. And we have a really nice comment here from Kat Humphries, too, that our language plays a big role in women's decision-making and also in how we kind of encourage each other to think about this subject. And if we're in an environment where we're constantly surrounded with a language of fear, that's what we're going to, in turn, give to the women we take care of. See, we have some more people typing questions here, perhaps. Yeah, that's right, Sam. That reminds me of one of the interviews that I did and the woman, Hal, was going for her, a V-back-after-two caesarean, and she had been going through different models of care during pregnancy to try and find an obstetrician or to try and find an hospital that would accept her. And she just got a bout of noes continuously. She rang up, I think she said to me, she rang up five different private midwives and every single one of them said yes and every single one of them believed in her. And she said that was the turning point for her to get to turn it from one situation where she was just getting a whole load of noes and negativity to one where there was somebody going, I understand why you want to do that and I'm willing to help you do that rather than being told what you should and what you shouldn't do. Which of comments and questions that just came up here is the answer for it. Hazel, isn't the home birth option pretty much gone for V-back in Australia? Well, things seem to be on shifting stands a lot in here in Australia. At this current time, we do have guidelines for the National Midwifery Consultation Referral Guidelines. And if the woman chooses to have a V-back at home, you would have a discussion with them. They would probably get a second opinion from a doctor. And then you could set up a record of understanding with the woman to write down the information that she's been given, the information that you've told her and then what her ultimate decision is. So it is still the woman's choice and a private midwife can at this point support her but something you don't quite need in the future. That's good to hear. That's also a question here in the United States. There are certain states where private home birth midwives cannot attend V-backs at home legally and it creates a lot of problems for women and for midwives. We have a comment from Kat Humphries. Oh, yep. Go ahead, Hazel. So I'm saying that probably to do with, I'm not sure for the U.S., but I'm guessing that might be to do with the insurance and the insurance saying that you can, that you can't. And that could be an issue for home birth midwives in the future in Australia. At the moment we have an exemption for our professional identity insurance for the labor and birth part. So that means we don't have any insurance for that part. But if that did come in, then there is thought that there could be stipulations on that and where would V-backs fit in that. So this is something that we will need to watch. Insurance definitely plays a big role in this decision-making process, unfortunately. We have a bunch of comments on the side here about birth trauma and obstetricians and midwives really coming to grips with the importance of birth trauma in counseling women about future births and just taking into account the emotional experience of childbirth more generally. Here's another question. We have, do you hear much of the scar tissue will keep you from having a V-back argument? No, not really. If you have, if the woman has had a lower-segment uterine, lower-segment uterine, then, yeah, I guess the woman would really need to explore what happened during that time. And there's a good fight for women to be able to access their own notes and to be able to read what happened in the operation report. Were there any complications with the caesarean? Were there any reasons why maybe a V-back isn't the safest option for the woman? So that would, I think, come into the woman exploring and also on the woman being told the correct information. But on the whole, there's some research that shows a slight increase in uterine rupture rates if the pregnancy is very close together. But usually if you go, once you get past the 18-month mark, then that is still less than 1%. And yeah, I mean, other than that, if you've got a classical caesarean that still doesn't say that you can't, but obviously the rupture rate is much higher. Oh yeah, and I see there there's a support, the ultrasound scar thickness. There's been a couple of studies looking at ultrasounds and scar thickness and using lots of different mathematical stuff that they use with their fancy ultrasounds. There hasn't been a big move towards that. But I guess because at the end of the day, you don't know what your uterus is going to do in labour. Not all ruptures happen when you're in labour. And not all ruptures happen to women who have had a previous exam, you know that. But at the end of the day, you don't really know what it's going to do. And the amount of hormones that you've got thrown through as we heard from Sarah Buckley, they have very protective factors on the women in general. So, you know, it is hard to come up with a measurement as much as we also found out that pelvic x-rays don't really much use either. Well, thank you so much for those insight, Hazel. It looks like we're about wrapped up with questions. So everyone will have a few minutes to take a break. Yeah, and that's it. Thank you so much, everybody, for listening. I don't want to hear it again. And thank you, Sam, and thank you, Hazel. That was wonderful. We're going to, yes, we do have about 15 minutes before the start of the next session. So take some time. We're now heading into the fifth presentation. I would like you to take some time to remember to fill in the survey. And there are a couple of slides through at the end. So we need to remember to turn off that.