The qualitative analysis of the women’s experiences of VBAC are presented in four themes and 10 sub themes as presented in Table 2.
Medicalization of childbirth
The first theme that emerged from the analysis of data of the women’s experiences were factors reflecting on the women’s past experiences of childbirth and how that affected their decision-making and eventual choice to attempt VBAC. The theme is supported by two subthemes: (a) A culture of CSs and (b) traumatic birth experience. The women mentioned that the medicalization of childbirth is a big issue in Cyprus, as interventions during childbirth are considered the norm and cesarean section rates are constantly high. Amidst a “culture of CSs”, it is often difficult to find an obstetrician willing to offer the choice of VBAC.
A culture of CSs
When referring to their experience with CS, six women were of the opinion that since there are no official guidelines published by the authorities about VBAC in Cyprus and no one moderating this within the healthcare system, most obstetricians find it easy to go by their preference and thus repeat a CS in the case of a previous CS. The women reported that they felt anxious as soon as they found out that they were pregnant because of this mentality. It was not uncommon for women to visit more than one obstetrician in an attempt to find an obstetrician who could help them to have a VBAC:
“In Cyprus doctors prefer to do a CS after a CS. So, for me it was difficult to find an obstetrician who would offer me this choice” (A1).
The women also described how the obstetricians eloquently explained to them the potential negative birth outcomes for their babies after a VBAC, which aimed to persuade them that a CS would be, after all, the best birthing option for them:
“The doctor told to me that we are talking about permanent brain damage for your baby. I started crying and shaking” (A1).
Traumatic birth experience
The women recall their previous caesarean section as a traumatic birth that had negative psychological effects on them, accompanied by agony and disappointment. For some, the experience made them feel like a patient in a hospital:
“And you know....you grab your suitcase and you go to the hospital healthy and well, but you leave feeling vulnerable and sick”(A2).
Often, the women reported that they felt guilty and blamed themselves for not having been persistent enough to achieve a vaginal birth for their previous child. A woman, in her attempt to describe her experience, nervously smiled and said:
“with my first baby, things didn't work out the way I wanted. But to tell you the truth, I didn't help myself enough to get what I wanted... [stops for a moment]. I didn't even go to childbirth classes for the first baby, I did nothing, I knew nothing” (A9).
The antenatal preparation was an important issue for the mothers and its importance seemed to be greatly valued, since it was a source of valuable information for them.
Preparing for a VBAC
The theme “Preparing for a VBAC” is connected to the women’s lived experiences of VBAC and it is analyzed into two interconnected subthemes: a) A need for clear answers, and b) Seeking for tailored information according to the mother’s needs. Having experienced CS as a traumatic experience led the women to seek more information and to demand for clear answers to their questions about the delivery of another baby. In contrast to their previous experience of childbirth, the women wanted to be well prepared for the birth of their next baby and to be able to exercise an informed choice regarding the mode of birth.
A need for clear answers
Many women indicated that despite having asked many questions during their pregnancy, they often received confusing answers from their obstetricians. Some obstetricians refused to give them clear answers about the possibility of a VBAC. The need for personalized and tailored to their needs information, in order to be able to take an informed decision regarding the mode of childbirth, was emphasized. Healthcare professionals’ attitudes were an important part of maternity care, as the women wished to obtain information and guidance in good time in order to prepare themselves for the birth of their baby. Several women mentioned that they were not given or knew enough information during their first pregnancy and that affected their choice of birthing mode:
“In my first pregnancy I did not have enough information, I did not know… that (the caesarean) would be a bad experience” (A3).
Some women felt cheated and misinformed by their obstetricians when they (the obstetricians) claimed that they did not know what a VBAC is:
“What is this thing - VBAC? I remember I left his office crying and upset” (A1).
Another woman explained that her doctor’s behavior made her even more determined to seek on further information and to look for another doctor to take care of her:
“I said to myself: What am I? A lamb to put me to slaughter when they want to?” (A8).
Some women believed that they had a CS in their first pregnancy because their doctors did not understand their needs and did not support them; during their second pregnancy, they felt that a female doctor would be more understanding:
“A woman would understand a woman better” (A5).
A strong desire to deliver by vaginal birth was described by all mothers. A woman, who gave birth in a public hospital described her experience as follows:
“I felt the need to … take the situation into my own hands. Therefore, I decided to find an obstetrician who supports and undertakes cases of VBAC” (A10).
To fulfil their desperation for clear and tailored to their needs answers, the women sought information about VBAC in a variety of sources besides their consultations with obstetricians. The women sought information on the internet in the form of scientific articles, reports, and newspapers, in VBAC Facebook groups, and in prenatal classes. Some women found the online support groups for VBAC to be a good source of information and support; other women’s successful personal stories made them feel stronger and empowered. Like one of the women said, the injustice she had felt as a result of her previous delivery, led her to make efforts to find people who felt the same way:
“I started looking for people to talk to. Because... I didn't want to be alone. I didn't want to believe that I'm the only one experiencing this” (A1).
On the other hand, however, there were women who described their experience with the online support groups as overwhelming; for them, the plethora of information, which was sometimes conflicting, was not particularly helpful.
Prenatal classes were a useful source of information, although the information given in these classes was not specifically related to VBAC practices. Even so, some women considered that it was important for them to attend prenatal classes. They found the prenatal classes extremely useful as they had the opportunity to meet and talk to mothers who had a positive VBAC experience. Some mothers encouraged the women to trust their bodies and suggested that prenatal classes could help them with that.
“Perhaps it would be a good thing if all mothers had been informed before. Prenatal seminars are useful and offer support.”
Many women expressed the opinion that a supportive environment was an important contributing factor for a successful VBAC. The women felt they benefited more when they received information from mothers who have had a successful VBAC and they viewed their positive experiences as inspiring examples. These mothers were viewed as idols who share their stories, in order to empower other women and stop obstetric violence:
“When I realized that there is violence against women... I looked at this idea for VBAC so seriously to protect my daughter from going through the same thing” (A1).
A woman referred to the absolute trust women have in their doctors, which prevents them from claiming their rights at the time of childbirth and experience the miracle of vaginal childbirth:
“I was very enthusiastic and I was trying to convey my experience to other mothers, but I realized that women unfortunately have complete confidence in their doctors and they did not search for reliable information” (A5).
It was not uncommon for the women interviewed in this study to change doctors when they had found a more supportive environment elsewhere, especially in circumstances when they would realize that their obstetrician was giving them biased, wrong or incomplete information from their initial doctor.
Birth environment (influences)
The women referred to the following factors, which they thought were of vital importance to them regarding their decision-making process and the factors that determined whether the birth environment was supportive or unsupportive for them: a) Father’s involvement, b) Family influences, and c) Interactions with health professionals.
The women felt that the father’s involvement during pregnancy and labour was beneficial towards their lived experience of VBAC, as it helped them reduce their stress levels and that had, overall, a positive impact on their childbirth experience. Some women felt safe knowing that their husband was there for them and supported them during childbirth. Most women described the father's participation in childbirth with gratitude. A woman reported “feeling in love” with her husband at the time of childbirth because of his support:
“My husband helped me so much. He was with me and I said to him that our daughter was born by the two of us” (A2).
On the other hand, some women described the father’s influence towards their decision-making process as a negative one and referred to their husband’s anxiety and disagreement for opting for a VBAC as a barrier towards their final decision for opting for VBAC. Especially in cases when the doctor informed them that there would be a risk for rupture of the uterus; some fathers refused to support their wife’s wish to opt for VBAC. A woman described her reaction as follows:
“I let a couple of weeks pass by and I discussed it with him again and I said to him that I know my body and I want to have a vaginal birth and I believe I can do it” (A10).
Other women, with similar influences from the father, emphasized that it is important for the mother to make sure that the father of the baby is informed and prepared about VBAC. The women were of the opinion that it could make a difference in the way they supported their wife during her decision-making process and during labour:
“I attended antenatal classes with my husband and I insisted [for him] to be there with me” (A3).
Attending antenatal classes was viewed as necessary for husbands/ partners by the women, for gaining the relevant knowledge, understanding more about childbirth and providing their wives with the necessary support, whatever their decision may be. One woman described how she was influenced by her partner:
“My partner was a 'VBAC baby' and it made me think that this was karmic and made me even more decisive about opting for it (A1)”.
While the father’s participation in the childbirth experience was essential, support from the woman’s family of origin, especially the mother of the pregnant woman, was as important. The women who had emotional/ psychological support from their families in pursuing a VBAC found this support facilitating towards their decision process. A mother who interpreted her own daughter’s birth through CS as unjust to her at the time, encouraged her daughter to opt for a VBAC for her second pregnancy.
On the other hand, several women referred to the negative comments or the disagreements they had during their discussions with family, about VBAC, as barriers to their decision making. Most women highlighted their mothers’ prejudice and distrust of VBACs. One woman admitted that her mother's negative view of VBACs was “pulling her back a little bit” but not enough to affect her final decision: “my mom thought it was risky” (A7).
Another woman commented that she wished she had more support from her family:
“Generally, around me, no one ever understood that this idea bothered me. They kept saying that the most important thing is that you and your baby stay healthy” (A5).
Another woman expressed her frustration and guilt and described the comments that she received from her family as “psychological war” (A1). Her family members advised her to go ahead and have a CS delivery right from the start, rather than going through the pain of labour. She eventually delivered her baby via a CS.
Interactions with healthcare professionals
During the interviews the women expressed how their interactions with healthcare professionals influenced their decision making and their lived experience of VBAC. During their decision-making process the women explained how their interactions with the doctors and midwives had a significant role in a woman’s choice of birthing mode. A woman explained that her doctor was very supportive and optimistic towards her choice, because when she sent her doctor a message to inform her that she was pregnant, she replied “Ok perfect, let's go for VBAC” (A9). In other, similar, cases, the doctors asked the women to create a “visual birth plan” and share it with them so they could cooperate towards a positive birth experience. In some cases, midwives informed women of their options, but without directing or guiding their decision-making process, leading the women into making a non-biased, informed choice. Some women expressed positive comments about their doctors’ and midwives’ approach, as they were offered holistic care and they paid attention to their individual needs. Some women felt immense gratitude for their doctor, who did not proceed with any intervention without their consent:
“She [the obstetrician] gave me the choice. She said to me … If you want, I’m here and I can help you give birth. If you don't want we can wait” (A5).
Regarding their lived VBAC experiences, some of the women commented on the valuable help and support they had received from midwives during childbirth especially when they felt exhausted, which made their VBAC experience a positive one to remember. A woman who gave birth in a public hospital described how encouraging the midwife was to her. Breathing exercises, walking, using balls, relaxing and showering were all mentioned as useful techniques during labour. Another woman described, whilst smiling, the moment she danced alone in the delivery room with soothing music:
“But then when the contractions become stronger, after 5-6 cm, they put the music on, I was just dancing, I was completely naked and dancing, in the room” (A1).
However, such positive experiences were in contrast with the women’s previous childbirth experiences. A woman expressed the frustration she felt during CS both because of the interventions she had and because of inadequate support from the midwife:
“She told me that I must stay in bed and she checked my cervix dilation all the time, she was an old age lady” (A8).
Healing through VBAC
Some mothers explained that after their shocking encounter of giving birth via CS, they wished to attempt VBAC as a way to heal previous trauma and ‘let go’ of the negative experience of a previous childbirth. This theme encompasses the physical, emotional, and psychological aspects of the experience. The women feel that their ‘traumatic birth experience’ has been ‘counteracted’ with a subsequent vaginal birth. Supporting subthemes identified under this theme are (a) Overcoming a negative experience with a positive one, (b) Fulfillment, and (c) Bonding with baby.
Overcoming a negative experience with a positive one
For many women, the experience of VBAC was one of healing. One woman said that she had a desire to prove that she could deliver vaginally as she felt stigmatized for having a CS.
While their experience with CS was difficult and resulted in painful memories, memories from their VBAC were vivid and made them feel nice, as they hardly faced any problems at all during the process. Overall, women described their VBAC experience as a positive experience, which was psychologically and emotionally beneficial for them.
When discussing their VBAC experience, the women expressed feelings of fulfillment. The women’s joy and enthusiasm for their successful VBAC was obvious. Descriptions of their VBAC experience included the words “euphoria”, “spectacular”, “incredible”, “powerful”, and “perfect”. Some women commented on the experience of intermittent auscultation and the freedom of movement they had during a VBAC procedure, in contrast to the continuous monitoring (i.e. cardiotocography) they had experienced during their CS birth, which they characterized as “bothersome”. A woman explained that while she had many vaginal examinations during her first childbirth, the healthcare professionals respected her desire for fewer examinations during VBAC:
“In my first pregnancy they constantly examined me… vaginally, while during my VBAC they did not, they were very cooperative” (A9).
The positive impact of VBAC was not limited only to the time of labour and postpartum recovery, but it was a healing experience that brought profound change to the lives of the women after that. A mother said “it is a victory and a closure of an open wound” (A1).
The women felt empowered and considered their experience with VBAC to be a success, as it proved to all those, who did not believe they could make it via a vaginal delivery and thus refused to support the woman of her choice, that they were wrong. A woman, who felt proud to have succeeded, stated: “to have a vaginal birth in Cyprus is an achievement” (A8), while another woman, whilst conveying an expression of victory with her hand, shouted enthusiastically “I made it!” (A10). Other women described their experiences in metaphorical and profoundly creative ways, such as "I found myself in another universe" (A2) and “I was so happy I felt I was shining” (A5). A woman, after taking a deep breath and crying out of happiness said that: “the satisfaction is incredible that you made it, that... that you climbed a mountain alone” (A1). At the same time, the women expressed their gratitude for the people who helped them achieve their goal of having a VBAC, including health professionals, family members, and other women who empowered them through their own experiences, which again, refers back to the theme and the importance of birth environment, mentioned earlier in this article.
Bonding with the baby
The participants described positive, prolonged periods of bonding with their newborns following VBAC. Some mothers explained that after the birth of their baby, their feelings and bonding with their babies were significantly different from their previous experience:
“After having a CS delivery I saw my baby and could not …. I didn’t know how I felt. With VBAC I loved my baby from the first moment” (A1).
The women’s testimonies reveal that compared with birth via CS, VBAC results in women feeling better and able to offer their newborn the love and care they need.