Trying for a VBAC : an ethnography of cultural change within a radomised trial aimed at increasing vaginal birth after caesarean section : The OptiBIRTH study

Abstract

Background: There is a real and valid concern worldwide around increased caesarean section (CS) rates. The OptiBIRTH Study was designed to address these concerns through the implementation of a complex intervention in a cluster randomised trial aimed at increasing vaginal birth after caesarean section (VBAC). The overall aim of the OptiBIRTH Study was to improve maternal health service delivery and optimise childbirth, by increasing VBAC through enhanced patient-centred maternity care across Europe. However, birth is not only influenced by medicine, but it is also influenced by culture and this requires consideration. Aim: The aim of the thesis is to detail the implementation of the OptiBIRTH intervention in one trial site, to determine if the intervention affects cultural change around VBAC as a viable mode of birth. Engaging with all of the stakeholders and exploring their perspectives, allows for a more complete view of the organisational culture surrounding the intervention, and also for an evaluation as to whether cultural change has taken place in making decisions around mode of birth after a previous CS. This ethnography aims to contribute more to the understanding of the implementation of the OptiBIRTH study so that, in moving forward, if the OptiBIRTH intervention is deemed to be effective, it will have the appropriate knowledge and understanding regarding perspectives of the participants and how the intervention could potentially be modified so as to be implemented more effectively. Method: Ethnography was the chosen method for this thesis. The ethnography was conducted over a period of 16 months, with interviews conducted with the key stakeholders of the intervention; that is the women, clinicians, and Opinion Leaders (OLs) who are part of the intervention. Ethical approval was granted by Trinity College Dublin and the Health Service Executive (trial site). Data collection consisted of detailed observation in the field-site, field-notes generated from the observation and interviews with the participants. The outcome of the data analysis is presented in the findings chapters as the analysis process was integral to the findings of the thesis. I have presented them in this way as both the data analysis and the development of the findings was a concurrent process. Findings: The findings indicated that the process of ritualization of the intervention, the changing of women’s identities, the transference of authoritative knowledge, and the effect of various power positions affected the intervention and its status in the field-site. This ethnography determined that, while the overall culture in the field-site did not change, smaller, more individual cultural changes were observed, from both the women and clinicians’ taking part. However, the absence of participation by senior consultants and doctors was found to hinder the implementation of the intervention and it was the women who were driving change around mode of birth after CS; suggesting that the women who participated did not hamper VBAC uptake, rather the clinicians who did not engage with the intervention. This suggests, moving forward, that the clinician component of the intervention should be more focused in targeting the clinicians than the women. The findings from this research provide insights into the factors that are associated with cultural change during the implementation of the OptiBIRTH study. Implications: This ethnography revealed the interrelationships between power, knowledge, ritual, and identity that developed during the course of the intervention. It is these factors that relate to cultural change around VBAC and for the future implementation of the OptiBIRTH study in other maternity services. Through the active incorporation of the OptiBIRTH intervention into the field-site, thought around the subject of VBAC and repeat CS has slowly changed but needs further time to change the culture completely. Yet, commitment from consultants and other doctors could further change in the fieldsite and give coherent support to women trying for a VBAC. The conclusions from this ethnography may contribute in some way to the broader OptiBIRTH Study, if the intervention is deemed to be effective, and if it is to be instated in maternity units in Ireland, in the future.