1. OptiBIRTH OptiBIRTH WG2:Development of the women-centred intervention Leader: Ingela Lundgren, University of Gothenburg, Sweden

2. WG2: Intervention development Focus groups interviews with women, their partners (if desired), physicians and midwives Countries with high VBAC-rates 45-55% - Finland, Sweden and the Netherlands 2 groups with 6-8 women (one urban and one rural) and 2 with 6-8 professionals in each country, total 12 groups Countries with low VBAC-rates 29-36 % - Italy, Germany, and Ireland 1 groups with 6-8 women and 1 with 6-8 professionals (in each of 7-8 maternity units allocated randomly to the experimental group), total 14-16 groups

3. OptiBIRTH OptiBIRTH Questions to the focus groups Five major questions will be asked: 1) In your opinion, what are the important factors for a successful VBAC?; 2) What are the barriers to successful VBAC?; 3) What was/is important to you as a birth-giving woman/professional?; 4)What is your view on shared clinical decision-making (i.e. making decisions on aspects of your/women’s/ partner’s care and sharing decision-making with others)?; 5) How can you support women to be confident with VBAC (for example women with fear of childbirth).

4. Data analysis: Conduct month 3 (in countries with low VBAC randomized) Analysis complete month 5 Data analysis: Content analysis based on the 5 questions, analysed in main categories and sub- categories; one for women and one for professionals Data analysis first level in different countries (5-10 subcategories/ question in English) Skype meeting analyse in whole group WG-leader next step analyse all text New Skype meeting for feed-back Completed January 2013

5. Status – focus groups Ethical approval in October Finland: ethical approval in process, Kuopio and Helsinki or Tampere Sweden: ethical approval in process, Gothenburg and Borås/Skövde The Netherlands: ethical approval in process Ireland: ??? Italy: ethical approval for Genoa, other regions in process Germany: ethical approval in process, Hannover and ?? Interviews with women postpartum and during pregnancy (Ireland) Interviews with obstetricians and midwives in one group or different groups

6. Systematic reviews 1. Women-centred antenatal interventions for increasing VBAC rates and reducing fear of childbirth 2. Clinician-centred interventions for increasing VBAC rates and reducing fear of childbirth in women and apprehension in clinicians Keywords VBAC, vaginal birth after caesarean section (spelling) women-centred (spelling), interventions, clinician-centred (spelling), experiences, decision-making, success, barriers, professionals, health care professionals, midwives, obstetricians., preferences, fear of childbirth, choice, options, tocophobia, anxiety, PTSD, traumatic birth, TOL, medical litigation Complete Month 4

7. Background ‘ Groping through the fog’: a metasynthesis of women´s experiences on VBAC (Vaginal birth after Caesarean section) Ingela Lundgren, Cecily Begley, Mechthild M Gross and Terese Bondas BMC Pregnancy and Childbirth 2012, 12:85 (21 August 2012) The objective of this metasynthesis is to integrate the findings and deepen the understanding of women’s experiences of VBAC.

8. 1981 articles (VBAC) ↓ 142 articles (Keywords VBAC, vaginal birth after caesarean section, qualitative study, experiences, qualitative and women´s experiences in various combinations) Exclusion: quantitative studies, studies about health care professionals’ experiences ↓ 22 articles (read) Exclusion: not focusing women´s experiences, only focusing experiences of CS in relation to VBAC ↓ 11 articles Exclusion: Quality check by 45-items based by COREQ 32-item [27] and Walsh and Downe [28]. ↓ 8 articles included in the metasynthesis Figure 1. Flow chart summarizing search strategy.

9. Results Studies from UK (1), US (3) and Australia (4) Metaphor; groping through the fog giving birth vaginally after a previous CS is experienced as paradoxical Four main themes and sub-themes

10. Own strong responsibility for giving birth vaginally In relation to the women themselves In relation to information In relation to health-professionals

11. Vaginal birth after CS is a risky project To have to confront serious risks mediated by health- professionals Lack of information about the benefits of vaginal birth Not supported if you want a VBAC

12. Vaginal birth has several positive aspects mainly described by women Good for the baby and the mother- baby relationship A meaningful experience of importance for them as women An easier birth in relation to recovery afterwards Some health professionals are pro VBAC

13. To be involved in decision about mode of delivery is difficult but important Not being informed enough Conflicting information Important to have a choice Uncertainty in relation to choice Information/support from others not the hospital Support from professionals Experiences from the last birth influence the choice

14. Questions: Language for transcriptions? Data-analysis in the different countries to which level? Last step by the responsible scientific person (IL)? Involvement by IL in the different countries? Analysis in two steps?

15. Questions for Cecily: Pregnancy or after birth CS? Different groups in low and high VBAC- countries? New questions from the groups Is it OK with individual interviews; Ireland the Netherlands. Randomization low VBAC countries Focus groups as part of the intervention?