Birth outcomes for women planning Vaginal Birth after Caesarean (VBAC) in midwifery led settings: A systematic review and meta-analysis

Problem: There is a limited knowledge base available to midwives, obstetricians and women planning vaginal birth after caesarean (VBAC), impeding their ability to make informed choices regarding planned place of birth. Background: A VBAC is associated with fewer complications for both mother and baby, but little is known on the safety and success of planning a VBAC in midwifery led settings such as birth centres and home birth, compared to obstetric led settings. Aim: To synthesise the findings of published studies regarding maternal and neonatal outcomes with planned VBAC in midwifery setting compared to obstetric units. Methods: PubMed, EMBASE, CINAHL complete, Maternity and Infant Care, PsycINFO, and Science Citation Index databases were systematically searched on 16/08/2022 for all quantitative research on the outcomes for women planning VBAC in midwifery led settings compared to obstetric led settings in high income countries. Included studies were quality assessed using the CASP Checklist. Binary outcomes are incorporated into pairwise metaanalyses, effect sizes reported as risk ratios with 95 % confidence intervals. A tau 2 estimate of between-study variance was performed for each binary outcome analysis. Other, more heterogeneous outcomes are narratively reported. Findings: Two high-quality studies, out of 420 articles, were included. VBAC planned in a midwifery-led setting was associated with a statistically significant increase in unassisted vaginal birth (RR=1.42 95 % CI 1.37 to 1.48) and decrease in emergency caesarean section (RR= 0.46 95 % CI 0.39 to 0.56) and instrumental birth (RR= 0.33 95 % CI 0.23 to 0.47) compared with planned VBAC in an obstetric setting. There were no significant differences in uterine rupture (RR= 1.03 95 % CI 0.52 to 2.07), admission to special care nursery (RR= 0.71 95 % CI 0.47 to 1.23) or Apgar score of 7 or less at 5 min (RR= 1.1695% CI 0.66 to 2.03). Conclusion: Planning VBAC in midwifery led settings is associated with increased vaginal birth and a reduction in interventions such as instrumental birth and caesarean section. Adverse perinatal outcomes are rare, and further research is required to draw conclusions on these risks.