Determinants of vaginal birth after caesarean (VBAC) decisions in rural and resource-limited settings: A systematic literature review
Author(s): Siti Fathiyah Sapsuha and Willy Hendrico Ogi
Abstract: Vaginal birth after caesarean (VBAC) is a pivotal strategy to reduce unnecessary repeat caesarean sections and improve maternal neonatal outcomes. Yet in rural and resource-limited settings, the decision to attempt a trial of labour after caesarean (TOLAC) is shaped by a complex interplay of clinical, interpersonal, systemic, and socio-cultural forces. This systematic literature review synthesised 31 Scopus-indexed studies (2021-2025) following PRISMA procedures. Searches combined the terms “VBAC”, “decision-making”, and “rural/resource-limited” contexts. Inclusion criteria were peer-reviewed, empirical studies in English; both qualitative and quantitative designs were eligible. Data were extracted and thematically synthesised across a priori domains. Automated and manual coding mapped studies to four domains: individual (n = 19), interpersonal/professional (n = 16), healthcare system/policy (n = 13), and socio-cultural (n = 14), with frequent cross-domain overlap. Individual determinants included obstetric history (parity, prior vaginal birth, inter-delivery interval), clinical risk markers, psychological readiness, and health literacy. Interpersonal dynamics centred on provider counselling quality, continuity of midwifery or family-physician care, and respectful maternity care; conversely, medico-legal defensiveness and discriminatory encounters reduced VBAC advocacy. System capacity 24/7 theatre and anaesthesia availability, blood products, referral/transport reliability, induction protocols, and post-placental contraception access predicted whether facilities confidently offered VBAC. Policy signals (e.g., user-fees, early discharge norms) altered care-seeking, observation time, and emergency preparedness. Socio-cultural norms around motherhood, pain, and bodily integrity, plus community narratives (including effects of female genital cutting and antibiotic beliefs), shaped trust in facility guidance and willingness to pursue VBAC. Across contexts, “safe VBAC” required four co-conditions: culturally sensitive counselling, credible emergency readiness, respectful woman-centred care, and community engagement. Priority actions include haemoglobin optimisation, targeted screening, stillbirth risk stratification, removal of financial/logistical barriers, appropriate length-of-stay, and integration of post-placental contraception. VBAC thus functions as both a clinical option and a systems indicator of equity, dignity, and reproductive autonomy.
Pages: 86-93 | 59 Views | 35 Downloads
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