Inconsistent Evidence: Analysis of Six National Guidelines for Vaginal Birth After Cesarean Section

Authors

  • Maralyn Foureur BA, GradDipClinEpi, PhD,

    1. Maralyn Foureur is Professor of Midwifery; Clare L. Ryan is Research Assistant; Caroline Homer is Professor and Director of Midwifery, Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology Sydney; and Michael Nicholl is Clinical Director, Division Women’s Children’s and Family Health, Royal North Shore Hospital, St. Leonards, Sydney, New South Wales, Australia.
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  • Clare L. Ryan BMid, BSc, MPH,

    1. Maralyn Foureur is Professor of Midwifery; Clare L. Ryan is Research Assistant; Caroline Homer is Professor and Director of Midwifery, Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology Sydney; and Michael Nicholl is Clinical Director, Division Women’s Children’s and Family Health, Royal North Shore Hospital, St. Leonards, Sydney, New South Wales, Australia.
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  • Michael Nicholl MBBS, FRANZCOG,

    1. Maralyn Foureur is Professor of Midwifery; Clare L. Ryan is Research Assistant; Caroline Homer is Professor and Director of Midwifery, Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology Sydney; and Michael Nicholl is Clinical Director, Division Women’s Children’s and Family Health, Royal North Shore Hospital, St. Leonards, Sydney, New South Wales, Australia.
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  • Caroline Homer MN, MMedSc (ClinEpi), PhD

    1. Maralyn Foureur is Professor of Midwifery; Clare L. Ryan is Research Assistant; Caroline Homer is Professor and Director of Midwifery, Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology Sydney; and Michael Nicholl is Clinical Director, Division Women’s Children’s and Family Health, Royal North Shore Hospital, St. Leonards, Sydney, New South Wales, Australia.
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  • The Australian Research Alliance for Children and Youth (ARACY) Canberra, ACT, provided funding for a workshop/seminar to discuss the preliminary findings of this research.

Address correspondence to Maralyn Foureur, PhD, Professor of Midwifery, Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia.

Abstract

Abstract:  Background:  Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice.

Methods:  English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made.

Results:  Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent.

Conclusions:  VBAC guidelines are characterized by quasi-experimental evidence and consensus-based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice. (BIRTH 37:1 March 2010)

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