 At this juncture, I'm going to introduce our speaker for today. Ali Anderson is a qualified midwife at the James Cook University Hospital in Middlesbrough, UK. She is a practice development midwife and is the VBAC specialist midwife. Ali was a secondary science teacher for 13 years before embarking on a change of career to midway free. Ali commenced on an MSc in Global Maternity Health at City University of London in 2021. Due to Ali's previous law, she is passionate about midway free education for students, preceptor midwifes and qualified midwifes for their continued professional development. Ali and Jay is being on the VIDM committee to put together this amazing conference. Ali, you have the presentation now. Thank you, Jackson. My camera keeps flitting on and off, so I'm just going to leave it off and then the screen is a little bit bigger and then towards the end, when we're having a discussion, I can try and turn it back on again. So this session is really an exploration of the literature on the care of women with the previous Caesarean out how we can improve their experiences in subsequent pregnancies and deliveries. And hopefully there'll be chances throughout the session to discuss and reflect. I really would like as much interaction as possible. So feel free to add things in the chat box as we go along and I can try and include them. But there's options for you to get involved as well. So we're just going to start, first of all, with a little question here. So I'm just and I want you to think about just from the latest available data, which was from the Trinital in 2021 and it was on the Caesarean section rates in 2018. And just have a think about what you might know as the highest country Caesarean section rate was at 56.7, 42.8, 37.6 or 23.9. So quite varied answers there to give anybody a few more minutes to answer. So interestingly, all of the people that answered thought it might be 56.7 percent. It's actually answered B, 42.8 percent. And that was the Latin America and the Caribbean. And there was quite a disparity in the percentage of Caesarean section rates in that report by Bertrand et al. in 2021, as you can see from this graph here. So it's known that this nationally across high, middle and low income countries. Despite this rising rate decreases in maternal and perinatal mortality are not seen when more than 10 percent of births in the population are by Caesarean section. Out of 94.5 percent of live births across the world in this data analysis, 21.1 percent on average gave birth by Caesarean section with averages ranging from as high as we've seen there of 42.8 percent in Latin America and the Caribbean to three to five percent in places like sub-Saharan Africa. This is a long way from the World Health Organization's recommendation of a 10 to 15 percent Caesarean section rate in 1985. Repeat Caesarean section following a previous Caesarean section is the most common reason for this rising rate according to Lundgren et al. in 2016. So this disparity that you can see from that graph in Caesarean section use across the world was described as a too little too late and too much too soon phenomena by the Lancet series conducted by Miller et al. in 2016. So in 2010 an estimated 3.5 to 5.7 million unnecessary Caesarean sections were completed in high to middle income countries compared to one to three and a half million Caesarean sections that were needed but not performed in low income countries. Too much too soon or overuse of Caesarean section for non-medical indications like repeat Caesarean section has been associated with an increase in adverse outcomes for mothers and their babies as well as becoming a financial burden on health systems and creating a barrier to universal health coverage. So a few of you are commenting there on hospitals that you know so Lunders visited a hospital where their Caesarean section rate was over 80% and in Brazil we've got private hospitals with 92 to 93% Caesarean section rate and I'm going to come on to Brazil a little voice and then Karen from South Africa said that they've got a 78% Caesarean section rate. So obviously that data that I've just shared there was the most recent that's been publicized from 2018 so I've got no doubt that Caesarean section rates are most likely to have changed since then and by the looks of it it's probably an increase. OK, so I've just got another little poll for you to think about here. So for this one I want you to think about the country that you live in and I want you to think whether Caesarean section is used too much even when they're not needed. Just a few more seconds for those still filling in that poll. OK, thank you for taking part in that one. So that's a really interesting percentage, the 88% of you think that Caesarean section is used too much even when they're not needed and only one of you think that it isn't. So that just shows actually that it's becoming more prevalent and there's lots of reasons for that and some of them might come up in this discussion. So let's have a look at Caesarean section and maternal morbidity. So the increasing maternal morbidity related to rising Caesarean section rates has been widely studied. It's been linked to an increased blood loss, abdominal organ injury, risk of anesthesia complications, venous thromboembolism, a need for hysterectomy, an increased risk of infection, post-operative pain and longer hospital stays which all add to the financial burden of these increasing Caesarean rates as well as the woman's length of recovery often being a lot longer. And in subsequent pregnancies, the woman can also be affected with an increased risk of uterine rupture, placenta accreta or previa, ectopic pregnancy and infertility according to the World Health Organization in 2018. And as well as maternal morbidity, there's a link between Caesarean section rate and neonatal morbidity and mortality. Babies born by Caesarean section are at higher risk of respiratory distress syndrome, an increased likelihood of admission to neonatal intensive care units, persistent pulmonary hypertension, stillbirth, 1.7 to 1.9 higher risk of neonatal mortality and an increased long-term risk of asthma, type 1 diabetes and obesity in childhood. And I know in the clinic that I run at the hospital I work in, where women are coming to their first booking appointment, having had a previous Caesarean section, they're often not aware of these risks. And then when I tell them that there's going to be some longer term effects of being born by Caesarean section, they've often never heard of those links to asthma, diabetes and obesity in childhood. So it's really important to give that full picture, so they're making that really truly informed decision. So just another little quiz just for some thought here. So I want you to think about the risk of repeat Caesarean section. So just three options to think about here. So do you think the risk of repeat Caesarean section is higher than the first Caesarean, lower than the first Caesarean or the same as the first Caesarean section? If you chance to click on which option you think there. I'm not trying to trick you with these quiz questions, some of them are a bit easier than others. So yes, all of you have got the right answer there, that repeat Caesarean section does have higher risk factors than for your first Caesarean section. Research by several groups of researchers, Silver et al, Canary et al and Lou et al, have all shown that repeat Caesarean section is associated with significantly higher maternal and neonatal morbidity and mortality, compared with the first Caesarean section. So what other options are there for women that are coming in their subsequent pregnancies? So VBAC, vaginal birth after Caesarean section, can be a safe and satisfying option for many women who have had a Caesarean section in their first pregnancy. And it's associated with a reduction in overall maternal and neonatal morbidity and a lower incidence of maternal mortality. However, according to a study by Hazel Kiedel et al, who was a speaker at the VIDM a couple of years ago, in her study she showed that VBAC rates across Europe range from 20 to 55%. So a big disparity there in the number of women undertaking a VBAC and only 14% and 12% of women in 2016 had a VBAC in Australia and the United States respectively, respectively. So studies by Martin et al and David et al have shown the implementation of a midwife-led model of care for women planning their next birth after a previous Caesarean section has been shown to empower women in their decision being more informed about their options, being more informed about the care that they can ask for. For example, having a water birth, being mobile, refusing cannulas if they're spontaneously laboring. And it also has been linked to improve intended and actual VBAC rates. So let's think about maternal choice for a moment. National reviews in the UK of maternity care have consistently and increasingly recommended midwifery-led continuity of care as key to improving women's experience of maternity services. So changing childbirth in 1993 insisted choice, continuity and control should inform the development of services and maternity care should be woman-centered. However, conversely Cox in 2007 argued that women were given more choice over their maternity care with the publication of changing childbirth. And this may have led to more women choosing to have a repeat Caesarean section over a VBAC. And I said I'd come back to Brazil after Paloma mentioned the Caesarean section rate there. And that maternal choice has been shown by Bahia Gitao in 2002 to result in a steep increase in Caesarean section rates in that country. A UK study by Meding Gitao in 2007 highlighted that informed choice is key to effective woman-centered care and highlighted that psychosocial implications may supersede women's physical concerns about birth after Caesarean section. So consideration should be given as to why women choose repeat Caesarean section when evidence does highlight good success rates and advantages of a VBAC. In a 2012 meta-synthesis of women's experiences of VBAC it was suggested that health professionals often presented risk-focused options to women with a lack of balanced information about the positive aspects and benefits of a VBAC. And that meta-synthesis was by Lund Gitao in 2012. And so this may be related to the provision of risk-focused maternity care we see in a technocratic model of contemporary childbirth. Lund is mentioned there that women are not told the risks of Caesarean section when they're offered their option of a VBAC versus an elective Caesarean section. And in the hospital that she mentioned earlier, there's sole Caesarean section on the grounds that it keeps them tight for their husbands. So there's lots of different reasons that medical professionals do give to women that might skew their thought processes when choosing options. Brazil, there's an increased presence of retrograde doctors and politicians promoting women's right to choose Caesarean section. So I think there's obviously a discussion here about right to choose versus them having all of the information to make that truly informed choice. So just another little poll here. So just three options this time. Now we're just thinking about that risk-focused care. And I want you to think about in modern studies, what is the risk of uterine rupture when aiming for a VBAC? So three options there. So one in 100 or option B, one in 200 or option C, one in 1,000. Just a few more seconds. So there's quite a difference in the way that that risk is portrayed in those three different answers there. Let's have a look. So a bit more difference in the answers there, but 50% of you have gone for option C, one in 1,000. And some of you have gone for the one in 200 and one person for the one in 100. So the answer in modern studies is C. And two recent studies have shown that the risk of uterine rupture is 1.3 in 1,000 births. That was by Dekker et al in 2010. And a more recent one by Clark et al in 2020 had the risk of one in 1,000. So I'm going to come on to the Auckland report in a moment Pauline, so hold that thought. But yes, she's asking what are your thoughts on the recent UK Auckland report that suggests not using Caesarean section rate as an indicator of good practice? Yes, let's hold that thought and we'll come back to it, don't worry. So Begley et al did a lot of work on risk-focused options compared to evidence-based options. And as we saw in that question there, that uterine rupture is often portrayed as a risk factor of one in 200 or one in 100. In fact, in my own trust, we still give the risk factor as one in 200 or 0.5% to women. Two studies that included these higher risk factors did include partial ruptures in their analysis. And there were other studies, so there's one in 2019 where the risk factor was one in 500. And we've seen those two other recent modern studies where it was about one in 1,000. Two studies also have shown that there are no differences in level of morbidity when aiming for a V-back after one or two previous Caesarean sections. And that's with relation to uterine rupture. And a study in 2016 showed there was no indication that V-back after three previous Caesareans carried any more risk. And that was by Vigorito et al in 2016. So perinatal mortality. Women can be told there is more risk to their baby during the year 2019 per 10,000 for a V-back, which is higher than an elective Caesarean section of five per 10,000, is actually the same risk as for a prima paris woman. So again, it's how you portray that risk factor, whereas often they're just told that if you lace it with the idea that it's the same as for a prima paris woman, it puts a different slant on that risk. Moving on to maternal death. So there's a risk factor of 3.8 per 100,000 of maternal mortality with the V-back, whereas the risk of mortality is 13.4 per 100,000 with an elective repeat Caesarean section. So it's definitely a lower maternal mortality rate when cared bought for by a qualified midwife. So the risk of elective repeat Caesarean section. A systematic review of 21 studies across the world by Marshall et al in 2011, it included over 2 million births, showed that for elective repeat Caesarean section, there was an increase in rates of blood transfusions, hysterectomy, surgical injury and adhesions as the number of Caesarean births increase. And women at 8.4 times more likely to have invasive placentation in their next pregnancy after a Caesarean than to have a ruptured uterus. But that risk isn't often portrayed as much as the uterine rupture risk is. Invasive placentation when compared with uterine rupture is associated with a significantly greater risk of neonatal respiratory morbidity, hysterectomy, maternal complications and longer length of maternal hospital stay. And that was a study in 2020 by Ulster Natal. The risk of adhesions increases by 10% with each repeat Caesarean section and can lead to chronic pelvic pain, infertility, bowel obstruction and other complications. These risks often aren't portrayed to women when they're having this decision-making conversation. And then the last risk there is the success rate of a VBAC. So often health professionals can talk about long labours that may then end up with a Caesarean section. And that's quite off-putting for women who've been faced possibly with that in their first pregnancy. But if we tell women that if they spontaneously lay they're always around 75% and that if they've had a previous vaginal birth, their success rates actually go up to about 90%. They're much better. So I just wanted to take some time to think about midwife-led care. We've obviously had the state of the world's midwifery report in 2021. And that advocated for midwife-led care to facilitate positive birth experiences, to improve health outcomes for mothers and their babies, to allow collaboration within a multidisciplinary team and to reduce Caesarean section rates. Midwifery continuity of care has been widely studied and I'm sure people have read the paper by Sandra Letal. And it has been shown that women with midwife-led care are less likely to use regional analgesia, less likely to have an instrumental birth, more likely to experience spontaneous vaginal birth, feel in control during labor and birth. And trials have shown that midwifery continuity of care significantly reduced the Caesarean section rate. Midwifery care is important for women planning a VBAC and it is, as we've said, associated with increased rates of intended and actual VBAC. Hazel Kiedel in 2019 with her team showed that four factors are really important, control, confidence, relationship and active labor. Women who had midwifery care in their study when planning a VBAC felt more in control with their decision-making. Their midwife had confidence in their ability to achieve a VBAC. They had more support and more time spent on their antenatal appointments, to build a relationship with the midwife. And they were more active in labor with lower incidences of epidural use than if they had continuity of care with a doctor or fragmented care. Hazel Kiedel talks about this journey from pain to power in her research. This journey from pain to power after a previous Caesarean section is strongly influenced by both negative and positive support provided by healthcare professionals. Women who had that fragmented care experienced lower autonomy and lower respect. And women found that having a VBAC, it was less traumatic than their previous Caesarean section and women planning the VBAC benefited particularly from midwifery continuity of care. So if we think about these questions here, in the country that you come from or where you work, what are your experiences of caring for women who've had a previous Caesarean section? And how do you think care for these women could improve? And while people are thinking and maybe typing in the chat box, I did want to address Pauline's question there. In the UK, we've obviously had the reporting of Caesarean section rates removed. And obviously with this, there is a risk that those Caesarean section rates may increase or already are increasing. And obviously by reporting Caesarean section rates, the Ockenden report highlighted that there was that ethos perhaps of trying to keep the numbers as low as possible and not having that intervention when needed. So there definitely is a balance between carrying out Caesarean sections when they're truly needed, but not avoiding them just to keep rates low. So anybody who looked after anybody that has had a previous Caesarean section, I know from my experience that the trauma-related birth conversations are really important. A lot of the women that I see do need some kind of birth reflection in their subsequent pregnancy to really have that thought process about how they can improve their situation, how they can reflect on their previous birth experience and move forward. Several people typing there. Sorry, Grace, I missed yours, because I hadn't spoken about birth as highly advocated because there is this belief that when a woman starts with Caesarean section, then she will continue to deliver through Caesarean section. Yeah, I think that's right, Grace. I think in my hospital, certainly 50% of women opt for the elective Caesarean section, and then we've got about a 70% success rate for those that opt for a rebax or the actual percentage of people having a Caesarean section is higher than that 50%. Linda's saying, I think we need to go back to basics and relearn the value of the oxytocin-rich environment to minimise Caesarean sections. Yeah, I'm quite keen to tell the women that come to my clinic that they don't have to have a cannula, according to nice guidelines. If they're in spontaneous labour and there's no other risk factors that they can labour and deliver in the pool if there's no other risk factors as well. But these are often things that are neglected to be told to these women. And I think sometimes when they know, they can have that bit of normality after that complicated first pregnancy, then that can often be a little bit of a ray of sunshine when they're thinking about this subsequent pregnancy and their birth choices. Yeah, I think there definitely is a fear in midwives that they're looking after a high-risk woman and they want to have a monitor and a cannula in case of an emergency, definitely. Any other thoughts about how any midwife-led models for women with a previous Caesarean section? So Pauline's saying also, even if they do not, if they do need a repeat Caesarean, the process of labour, they had help lump preparation for the newborn, so it's still very helpful. Few couples know of this and feel the labour part was for nothing. Yeah, yeah. I think a lot of women choose an elective Caesarean because they don't want to go through that labour and then have a Caesarean at the end, but again, it's how you frame that risk to the women and if there are any benefits that you can bring into that discussion. I think Karen's agreeing there with Linda's idea of this fear of the midwife. And the obstetricians as well. I think when a lady comes into the delivery suite with a previous Caesarean section, they are labelled with this high risk factor and then it's sometimes a battle between what the woman maybe has made a decision with, with wanting a water birth and having the mobile telemetry if the unit has it versus that fear of the obstetrician that they want better monitoring and overseeing of that labour. It's a, I agree in some circumstances, Linda, definitely. We also see this idea of epiduals as ideal for VBACs. Yeah, so there's a really good website called Labour Pains and the other thing that I really like about that website is it has translations for women that don't speak English as well and it really goes through birth pain relief options and it's about giving them all options as well. So mobility and not every unit has telemetry CTG monitoring but if you do have them, it's explaining that they can ask for that and that they can be on a birthing ball, they can be in a pool or a bath. They may not want to birth in there but it actually is a really good pain relief for labour as well. Any other comments or offers of improvements? Are you from the UK, Pauline? Have you got any comments about the Auckland report? I think certainly there's a lot of panic or worry in you improved education and training that has to come from this report and I think it'll end up being a lot more risk-focused care unfortunately rather than evidence-based. I'm from Malta, it's another country we haven't had yet. Welcome. Okay, so a lot of you train in the UK. I've never been to Malta. So let's just summarise what we've discussed there. Yes, I'm doing a map of all the people that have attended the VIDM so it's nice to see another country. So just to summarise but feel free to keep chatting because there's still some time and it sometimes takes a bit of time for the internet to catch up with your comments so I'll try and catch them as they come up there. But to summarise, Caesarean section rates are rising over the world and in part this is due to repeat Caesarean section. Caesarean section we've heard is linked to increased maternal and neonatal morbidity and mortality. Midwifery care is important for women considering a V-BAC as it is linked to increased intended and actual V-BAC rates. And we should wherever possible endeavor to give evidence-based options rather than risk-focused options. And midwife-led models of care for women considering a V-BAC. We now know are linked to them having confidence in themselves and their body. Feeling in control of their birth choices, having that supportive relationship with their care provider and staying active in labour. Wouldn't it be wonderful if we could offer this to all women considering a V-BAC. Pauline's saying there, unfortunately locally some obstetricians have interpreted this report as the endeavor for physiological birth. Yes I think that's true and I think initially that was what had come out of it. That's not the overriding message but it's unfortunate, isn't it? What media picks up. Caesarean saying there, if we did all those things that are recommended to care for V-BAC moms the first time they labour, we might not have so many V-BACs. That's very true, very true. Thank you. I must really appreciate your interactivity. It makes it a lot more interesting and I think it's one of the benefits of this conference is that we can have this conversation and interaction and sharing of ideas. It's one of the things that I love about the V-IDM. So thank you very much for interacting and sharing your experiences and thoughts. I'll hand over to Jackson but if anybody that's listening wants to put a proposal in for next year, get thinking now what you could present on while looking particularly for presentations on anatomy and physiology as well. So always welcome. I hand the presentation to you. Thank you, Jackson.