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The authors describe how Intervention Mapping was used to develop a midwife-led intervention to prevent or reduce maternal distress during pregnancy. An extensive needs assessment showed that both pregnant women and midwives needed to be taught to recognise the vulnerability for developing maternal distress during pregnancy and how to identify maternal distress when it occurs. In addition to these mutual learning needs, women needed to learn to disclose their problems, how to handle maternal distress in their daily lives, and the value of seeking help when necessary. Midwives needed to prepare themselves to provide (collaborative) care for maternal distress. Screening and psycho-education were pathways to support self-disclosure, self-management, mobilizing support and treatment of maternal distress. Theory-based methods - such as tailoring, communicative support, individualization, advance organisers, cultural similarity, consciousness raising, elaboration, and cue altering - were built into a web-based tailored program for women. Information processing, intergroup dialogue training, verbal persuasion, providing cues, facilitation of means, and structural organization were the theory-based methods that were built into a training program and a toolbox for the midwife-delivered program. The program was introduced by means of the training given to midwives from 17 midwife-led practices in the Netherlands and proved to be effective. Finally, process and effect evaluations were planned.

Background: The most common reason for caesarean section (CS) is repeat CS following previous CS. Vaginal birth after caesarean section (VBAC) rates vary widely in different healthcare settings and countries. Obtaining deeper knowledge of clinicians’ views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Interview studies with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of ‘OptiBIRTH’, an ongoing research project. The study reported here is based on interviews in high VBAC countries. The aim of the study was to investigate the views of clinicians working in countries with high VBAC rates on factors of importance for improving VBAC rates. Methods: Individual (face-to-face or telephone) interviews and focus group interviews with clinicians (in different maternity care settings) in three countries with high VBAC rates were conducted during 2012–2013. In total, 44 clinicians participated: 26 midwives and 18 obstetricians. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country. Results: The findings are presented in four main categories with subcategories. First, a common approach is needed, including: feeling confident with VBAC, considering VBAC as the first alternative, communicating well, working in a team, working in accordance with a model and making agreements with the woman. Second, obstetricians need to make the final decision on the mode of delivery while involving women in counselling towards VBAC. Third, a woman who has a previous CS has a similar need for support as other labouring women, but with some extra precautions and additional recommendations for her care. Finally, clinicians should help strengthen women’s trust in VBAC, including building their trust in giving birth vaginally, recognising that giving birth naturally is an empowering experience for women, alleviating fear and offering extra visits to discuss the previous CS, and joining with the woman in a dialogue while leaving the decision about the mode of birth open. Conclusions: This study shows that, according to midwives and obstetricians from countries with high VBAC rates, the important factors for improving the VBAC rate are related to the structure of the maternity care system in the country, to the cooperation between midwives and obstetricians, and to the care offered during pregnancy and birth. More research on clinicians’ perspectives is needed from countries with low, as well as high, VBAC rates.

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 > 24 weeks 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.