 Kia ora tato and welcome to everyone again and it is my great pleasure to introduce Hazel Kiedel who is our next speaker. Hazel is a midwifery lecturer at Western Sydney University Australia and for the last seven years Hazel has researched women's experiences of vaginal birth after caesarean section. First for women who did this at home and now for women who access a variety of models of care. Hazel is passionate about educating both women and healthcare professionals on the importance of VBAC and Hazel aims to reinforce the importance for all midwives to embrace supporting and encouraging women to have their own VBAC journey. So welcome Hazel and I'll just turn you into a presenter. Hi there and thank you very much for that introduction. So this presentation today will be called The Journey from Pain to Power and it looks at a meta ethnography that I did on women's experiences of having a VBAC and I'll go into more detail on what that is in just a second. So yes I am at Western Sydney Uni as a midwifery lecturer but also as a PhD candidate and this meta ethnography gosh I can't get my word around it was the first part of my PhD. So a bit of a background vaginal birth after caesarean or VBAC as I'll be calling it is known to be a safe and satisfying option for many women who've had a previous caesarean. Yet the rates of VBAC remain low in the majority of countries. In Australia for example in 2015 only 19 percent of women who birthed that year had a vaginal birth after caesarean. Now we don't know how many of those chose to have a VBAC and have a repeat emergency caesarean or how many chose to have a caesarean to begin with but still those statistics are very low. And we also know from the research that we need to improve health practitioners understanding of the factors that facilitate or hinder women in the journey to having a VBAC. So like I said this is part of my PhD study and the title for my PhD is the antenatal experiences of women planning a VBAC in Australia and there are a few parts to it. So the first part was this meta ethnography and I'll go into more detail on what that is and that's been published in women birth and then I've done a qualitative study because the PhD is a mixed methods study and so the next part was qualitative and that was called the my VBAC app study. So I'm going to tell you a bit more about that later and even a little bit of insight into some of the results but that paper is currently being written. What hasn't been done yet is an online survey and that's the last part of my PhD study and that will be a national survey across Australia looking at the themes asking women about the main themes of my VBAC app study and that'll be for women who in the last five years have planned to have a VBAC in Australia, don't necessarily have to have had the VBAC at the end because I'm really interested in that in those antenatal experiences and what drives women to have a VBAC but also what are the challenges that they have along the way. So just looking at the PhD now I've used a transformative framework with a critical fomious lens and these are the different phases, the phase one, the qualitative one is phase two and phase three is the quantitative. So just showing you that in a diagram. So mesoethnography has lots of different phases and that comes from knoblet and hair. So the first part is getting started and having an idea of what you want to look at which for me was women's experiences of having a VBAC. You then decide what is relevant to the initial interest so you do a literature research and you find the studies that you need to. You then read those studies, you determine how the studies are related to each other and you express the synthesis, you synthesize the translation, oops I've gone the way around there, you translate the studies into one another, you synthesize that and then you express the synthesis. So lots of fancy terms there. I do kind of see it as you look for all the qualitative work on that particular topic, you put it all together, you read them all and then you go through and see what are the links and what are the common themes so that you can come out with your own overarching theme and theme. So it's a bit like a thematic analysis of work that's already been done. So to find out what was relevant and that phase two I've got the Prisma diagram here and there wasn't a heap of studies really done on just the qualitative experiences of women having a VBAC. So by the time I got to the end I found 20 studies and after I had looked at them and I had translated the research into each other and done all that I came up with an overarching theme which was the journey from pain to power and along that were many other themes and it starts as we do with the journey you start at A and you get to B and so the starting part of the journey for the women in these studies was the beginning of their was their previous cesarean and that was described as the hurt me. So the women really looked into the expressing how they felt about their cesarean. Now I'm going to go into each of these in detail so I'll just quickly give you a quick overview. Then they got all the way to the end which is the powerful me which is the VBAC then the onward journey which is the effects of having the VBAC. In the middle here we have armed of knowledge seeds of doubts and feeling encouraged and supported and they were the journey and this is the big themes that the women came up against in their journey. So looking at the hurt me the hurt me really describes the experience women had having a cesarean and how they felt after they had the cesarean. So we have a couple of our extra sub things here one was caught between life and death and failing as a woman. So the caught between life and death was where women really described the impact of having the cesarean and having an emergency cesarean being told that you know we have to go for a cesarean right now or maybe we'll die and sometimes then that actually really being the fact. The the that they described how it was being taken into theatre and maybe having brand new strangers around you and and really the fear that having that cesarean experience caused them. The failing as a woman was as you can see here with this quote was looking at how they felt about their body and I felt a total sense of failure I felt my body had let me down it wasn't the birth I had imagined and I just couldn't get over that. So you know really thinking well that you know this ideal that I had this birth I really wanted it just didn't happen and maybe that was my fault that maybe that was because of my body. So then you know the women start their feedback journey and the women in these studies they didn't just take information at face value they actually looked up their information now with the internet obviously the women can access academic journals like academics can and professionals can and they often would and they would become they would find that getting this information would arm them with knowledge so you can see with this statistic here you know there might be one in a hundred chances that I have uterine rupture but they kept focusing on the fact that I might be that as in be that one might be that one person that has it me I was thinking look I'm most likely going to be one of the 99 so this woman actually had read studies and had got the statistics of what it would be for her to have a uterine rupture and was able to reconcile that and the two sub things that come under here is reconciling the risk as can be Shannon in that quote but also seeking birth care options so early on and sometimes not not very early on sometimes well into their pregnancy they would realize that who they went to see as their healthcare provider would have an impact on their ability to have a feedback and so those options were often often sought that might even be birthing at home and with the studies that I had out of the 20 there was one study that based in I think it was Scotland that was birth centre births and one that was home births so women that had a home birth so they were across the different birth care options which is a little bit different being able to bring in those those different birth care options so the women really did see can certainly the women that chose the birth centre or chose the home birth you know they really did look up their information and they were knowledgeable about why they were making those decisions now the seeds of doubt is the next next theme and this is with the negative part of their journey and it really encompasses all the negative issues that happened the negative attitudes were what the women experienced from their healthcare providers and you can see here when I was pregnant with Joe I was told by a doctor that I was most likely going to die and that my son Jack wouldn't have a mother to go home to and to the bark on a feedback was stupidity so I knew that was ridiculous but it still affects you and those negative attitudes I'd like to say that you know these are because these studies are a little bit older but unfortunately they're not and even on the qualitative work we're doing right now you know these these attitudes are out there and and and even when a woman can try and brush off like she did here she she's telling me that was ridiculous but you know it's just there and it's there to act as a as a seed to make you doubt your actual decision the fighting for a better birth um that was when I mean you know they they knew what they wanted they knew that they wanted to have a feedback and they had a real fight on their hands and that fight is seen as a negative because it's it's an added stress to have to continuously say this is what you want and why you want it when you have healthcare professionals around you saying well that's just not safe you shouldn't do that you know is a negative aspect of their um of their pregnancy journey I do apologize my son is in the background I told him to be quiet but he's not been very good at it okay um then on to another positive aspect of the journey um was feeling encouraged and supported and um you know there there were some great positive healthcare practitioners that were reflected in the research um and not just from there but also the social support from strong women was really important so the women might access um um online groups that are specific for v-bank uh in Australia we have a very large one that's got over 5 000 members now and there would be in other um countries as well and international groups as well and they were there for when the women really started having those doubts in the in the previous slide they're able to go on to their online forums and say this is what I've just been told and then they would have instant um um support from the women on the group and that was the benefit of of the online community there and the same as if the women were having doubts themselves they would then get that instant encouragement support from family and friends was really important but there was a little bit of selective telling with this um so the women would really gauge who they could um and who they wouldn't share their plans for v-bank for and some would have a very supportive family member such as a grandma um or a mother-in-law or some and others would know who not to really tell because they don't want those negative influences the women did speak about having a supportive partner um and how important that was and especially what hasn't really been looked at much in research and only touched on in these is the importance of the v-bank for the partner because if they are the same partner from before and they had seen the traumatic experience that happened before how validating a v-back in their partner can be for them as well for more work needs to be done in that area so you can see here um the quote is I was feeling more confident too I was getting a lot of positive feedback and support from friends and family and that's really important so then once they had got their v-back um they they really felt powerful um and this was a lovely thing because it's all about the positive aspects of having a v-back um the three sub themes here are achieving v-back against the odds I felt like superwoman and reclaiming why my womanhood so achieving v-back against the odds is where the women reflected on the fact that they achieved it you know even with all the negative experiences that they had all the naysayers throughout their pregnancy um the fighting against um not wanting to have interventions and going down the same path they still managed to achieve their v-back um and there were some beautiful quotes in there the I felt like superwoman was was really women in that initial um phase I don't even know if it would be initial but when they reflect back um I know in the home birth after caesarean study that I did that was included in this um I had the joy of being able to ask women um in their postnatal interviews how did you feel after your v-back at home and this is where exactly where the quote came from I felt like superwoman um and just that elation that the woman was able to to birth in the way that she wanted to and that beautiful quote there I believe my scar is now mentally healed it just really you know I I agree that is a brilliant quote and it really does sum up the link between you know the the physical aspects of birthing um but the emotional and um psychological um aspects of birthing as well the reclaiming my womanhood was when women reflected back um on the importance of of having a vaginal birth which to the majority of women who are planning a v-back they may have not had um a vaginal birth before you know caesarean may have been their first birth and this is their second and subsequent and they don't know what they don't know they don't know what it's going to feel like to have a vaginal birth they don't know if they're actually going for the you know for the right option um and the reclaim my womanhood was really where women look back and go well yeah I'm I'm really glad that I did that and it really was important to to have a vaginal birth for me now what I have and one of the ones that I've skipped through in there is with the seeds of doubt um is also the and the fighting for a better birth it's the fighting that women had about not wanting to have the repeat interventions that they had before you know women were coming to this journey already knowing that the interventions didn't work for them you know they may have been um a particular they may have had you know the the standard primary who goes post dates who gets induced and gets every single intervention under the sun and has a repeater's area and they're already able to articulate well I don't want to be induced and I don't want to have that CTG I don't want to have um the IV fluids that keep me to the bed but when women then approach the healthcare providers during their pregnancy about that they would get shouted down and said well that's in policy that's what you have to do um and when you look at the feedback policies that's certainly what is in there for their own reasons and that was quite a challenge for women well they're they know what they need to do to have a normal birth and to have an active labor but then they're being given these restrictions because of policy to make it even harder to achieve to achieve their feedback and they didn't stop there so once they had their feedback and they felt like superwoman there was this confidence and that affected other areas of their life immediately affected their role as a mother and as you can see here my onward uh my onward journey after birthing jack who was my second birth at home I was competent as a mother I was never competent as a mother with faith so her first one had been a planned birth at home and um emergency cesarean and then this time she did have her be back at home and that confidence also then impact breastfeeding um and impact the way that they were were um feeling in their postnatal period but it didn't always sorry one more I'll just go back to that one again it didn't just stop there either so not just becoming a confident mother but often these women would go on and become birth advocates for other women who are going through their journey especially their be back journey so many would stay on their on the be back forums online so they could give confidence to other women that are going through the journey they may even go into formal doula training and that certainly was something that came out of the hpec study for in the papers that I looked at there was one paper in particular that looked at women who planned a v back but didn't achieve a v back and had a repeat cesarean and in a couple of the papers there were um a few women that had been um that had had a repeat cesarean when they've been recruited during during their pregnancy and this is an area that really needs some more um research really because we've only got very small numbers on this but what I found from looking at the the paper and the few others mentions of it in their papers was that women often felt like a failure again um and this really does link in with the um not being able to negotiate different um not having interventions as you can see here I was taking the time of the first labor first birth but I had the time constraints of a second birth and a v back thankfully we do know now that um certainly in the new acog guidelines there is criticism of giving such um small time constraints on women planning a v back um and that these these should be lifted and thought more of more likely to be like women who have in their first labor and birth because we really do um set women up to fail and that's one of the sub themes there you know we we will enforce these policies and these time constraints for women have never may have never even labored before um and then having um having the issues there gaining resolution was that some women actually had a repeat emergencies there in for the same reasons that they had before and that actually gave them some resolution um that maybe this was just going to happen anyway but they didn't regret being having the option of going for a v back um because it meant that they could have a second chance so this has been published um in women and birth and so if you want to read some more information um that would be that that's where you would go for that so I'm just going to tell you a little bit about what else I have been doing so the next phase was um the my v back app study um so what I wanted to to capture next uh was for for my qualitative phase I wanted to get that moment when the woman has gone to see her midwife on a doctor she's had the appointment she's come home and she's having the what if moment you know when you've gone to see a gp or your doctor you've got this whole big speech in your head you go in there and you completely forget absolutely everything you were going to say and you come out and you go oh god why didn't I say this or why didn't I do that and sometimes those appointments were positive and sometimes they were negative but I really wanted to find out what were women thinking when they come home from their appointments so not so much what we told women but what did they perceive that they were told and I didn't really know how to do that I couldn't go interviewing women after every single appointment so I came up with this idea of an app that women would have on their smartphones so that after every appointment they could go home and they could record even audio in a video log on their smartphones and it would be sent straight to me as the researcher I did that I've had 11 women on the study and in total I got 53 logs so that's 53 times after appointments that women did um shared with me their experiences and it was I'm just in the writing up of the paper of this and it was just amazing it was a little bit addictive for me I would be checking my side of the researcher side of the app all the time to see if somebody had put a new segment in a bit like a soap opera and it had its challenges as well sometimes I would hear something that was that I would want to step in and go my god why were you told that as a practicing midwife myself but I had to have the researchers stance and not be involved although if there was something particularly serious I would send an email just to check in to see if they were okay and so that that was done and I think it was you know the data we've got is so rich which is why it's making writing it into one paper particularly hard um but I'm certainly trying and so the actual development of the app is also going to be available for researchers soon to be able to use for their own types of studies and I already have two researchers um I believe in Canada who are interested in using the app that's just being um developed further now and um so I wrote a paper on how to do the app um not particularly the ins and outs of the app development because I'm not an app developer I did have to recruit somebody to do that for me but I did learn a whole lot about app development and learning a second language really so I wrote a paper on the design the development and the evaluation of a qualitative data collection app for pregnant women and that's in the Journal of Nursing Scholarship so feel free to have a look in there and it's got some pretty pictures about the about the app there um and so from the um my review back app study I had like I said I had 11 women there were a mix of care providers and birth locations so as you can see here um there was private obstetricians ppm is privately practicing midwife so this is based in Australia um so privately practicing midwife would be um outside of the hospital system and the woman would have to pay for that although there are Medicare rebates so the women can get some money back from appointments um and they may be offering support um midwifery services in the hospital if they have visiting rights which is growing in Australia or planning to birth at home mgp is midwifery group practice um which is hospital hospital provided and based gp stroke obst is a gp obstetrician where they would do shared care with their gp who's also obstetrician um certified in the community and the clinic is fragmented care so coming along to the hospital clinic and seeing whoever's there that might be doctors or midwives um you can see from there that six had a wee back and five had an emergency cesarean so I've got some more data now on um the experiences of women that've had to repeat cesarean when they plan to be back so that adds to that knowledge which is really useful um and um just giving you a quick snip into please don't take a photo of this page um because I haven't published it yet but a little snippet into what the um findings have been is that we found four factors to having a wee back or feeling resolved so um if you imagine these has been a bit of a like heart scale and the higher the woman was up on one of these so each one of these the higher she was up on that scale the more likely she was to have a wee back or feel resolved after having a repeat cesarean the lower she was on these scales the less likely she the she was to have a wee back to more likely to have a repeats cesarean or feeling disappointed although that probably should go together because none of the women who had a wee back felt disappointed and these four are feeling in control so the woman feeling in control of um the labor and the birth and even just the pregnancy and her decision making skills the confidence this is the confidence of the woman in her own ability to have a wee back but also the confidence in the that she felt the healthcare provider had in her ability to have a wee back and that's a very important point relationship based care is like contingency of care um but actually a contingency of care that has a relationship or partnership model to it um so there were some that had five obstruction or had that contingency of care but there wasn't a deep relationship there and that's what i'm going to be talking about in the paper and then again and then active labor so the more of an active labor that the woman had the more likely she was to have a wee back and we know that um and the more restricted um or the more intervention she had the less likely she was to have the wee back but it was an important factor um within the four so a little bit of a snippet there for you and a little bit of an insight and there will be a paper on that soon and so the last stage will be doing an online survey which i hope to get out later on this year and we will i'll be asking questions around those four factors and so we'll see if we can improve that on a on a quantitative scale and that's me great presentation hazel everybody was very very concentrating i'd say really carefully on what you were saying just a few questions there was one from um chiral about what was the incidence of feedback after ivy ivy f so so there wasn't in the papers that under 20 papers i looked at there wasn't any um identification that women had had um ivy f um in my recent study um in the vbac app i've had one woman who um had ivy f and then went on the vbac journey um so yeah we don't really have very much information on that particularly i think that would be a really interesting paper on its own indeed indeed it would um and uh there was a question from selena i think were there any guidelines for midwives in australia in new zealand other than the medical um guidelines not specifically um i guess we we do kind of get governed by the medical guidelines because they then um form our policies which we then follow um certainly in australia we have the national um the different um consultation referral guidelines and they don't specify much on vbac unless it was um a a classical scar for example then that would be um a referral to tertiary services but otherwise it's not really um vbac isn't really mentioned um but yeah there's not a lot of guidance really just for just for midwifery care though although the the acog guidelines the american um college oppositions and gynecologists have put out some new vbac guidelines and i do encourage um the viewers to go and look look at them they came out in october november last year and they are quite progressive actually um to support midwifery and obstetricians so they support women who are having a vbac after two cesareans um they you know they recognize that women shouldn't be coerced into their decisions so they're quite um interesting reading actually and hopefully um that will have an impact on um practitioners and guidelines i can just see sorry can i just um answer penny there who says regional access to vbac is a huge hurdle i completely um agree it's really difficult i did have one woman in the vbac app study actually a couple of women in regional locations and what they were told to do um to be able to access a vbac was crazy exactly that she would need to travel um in in this particular scenario she was told um the they would have to get an obstetrician from from at least an hour away to come because their obstetricians aren't happy to do that it is really really um difficult to uh to access regional locations and regional locations in australia is there any more what about what about forbidding out of hospital vbac so selen i'm not quite sure what you mean by that by by us saying that they shouldn't do that or the fact that it is um forbidden um in australia women can access um out of hospital vbac through a privately practicing midwife if that privately practicing midwife is um confident and happy to do that um although we know that without a hospital vbac you do have higher chances of having a vbac usually over um an 80 percent um rates of having a bit of being able to have a vbac compared to about 60 in hospitals um there are um there are higher rates of um neonatal morbidity mortality and and you know when you look at the studies it it's not it's not massive um but it is there so women just need to be informed on that um it doesn't mean that an out of hospital vbac is going to cause a dead baby although many many women have been told that um but they're you know they just need to be aware that it's a slightly higher risk and to think about their access to the hospital um like all out of hospital births if there is a good referral pathway and good relationships between the healthcare providers and the hospitals that certainly goes in a long way um and i'm not quite sure you informed choice of for place of birth uh what have you got they have you looked at you looked at our provider and choice of choices i haven't so i was particularly looking at all the papers i was doing for this for this metaphor it was looking at women's experiences um and also in my phd um work i'm looking at women's experiences um there have been some papers that have looked at um healthcare practitioners experiences and confidence um we do know though that insurance has had a major impact certainly in the usa um and that is somewhat um addressed or mentioned in the new a called guidelines that it shouldn't obviously be an issue but um and that more places should be offering um vbac but you know i can i can see that would be a real issue in there and in that way women are you know either being made to make the decision because their healthcare provider won't you know won't support that or the hospital won't support that and there are some shocking stories that come out about this um or they go searching for somebody that will or they go without care and um and they look at the free birth option although there's a very small amount of women that do that um but the more that we make it difficult for women to access the birth they want the the the more that will happen thank you are there any more questions for um hazel sounds like you've done really well lee hazel all right thank you