Nationwide implementation of a decision aid on vaginal birth after cesarean: a before and after cohort study

D.M. Koppes*, M.S.F. van Hees, V.M. Koenders, M.A. Oudijk, M.N. Bekker, M.T.M. Franssen, L.J. Smits, R. Hermens, S.M.J. van Kuijk, H.C. Scheepers

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Objectives: Woman with a history of a previous cesarean section (CS) can choose between an elective repeat CS (ERCS) and a trial of labor (TOL), which can end in a vaginal birth after cesarean (VBAC) or an unplanned CS. Guidelines describe women's rights tomake an informed decision between an ERCS or a TOL. However, the rates of TOL and vaginal birth after CS varies greatly between and within countries. The objective of this study is to asses nation-wide implementation of counselling with a decision aid (DA) including a prediction model, on intended delivery compared to care as usual. We hypothesize that this may result in a reduction in practice variation without an increase in cesarean rates or complications.Methods: In a multicenter controlled before and after cohort study we evaluate the effect of nation-wide implementation of a DA. Practice variation was defined as the standard deviation (SD) of TOL percentages.Results: A total of 27 hospitals and 1,364 women were included. A significant decrease was found in practice variation ( SD TOL rates: 0.17 control group vs. 0.10 intervention group following decision aid implementation, p=0.011). There was no significant difference in the ERCS rate or overall CS rates. A 21% reduction in the combined maternal and perinatal adverse outcomes was seen.Conclusions: Nationwide implementation of the DA showed a significant reduction in practice variation without an increase in the rate of cesarean section or complications, suggesting an improvement in equality of care.
Original languageEnglish
Pages (from-to)783-790
Number of pages8
JournalJournal of Perinatal Medicine
Issue number7
Publication statusPublished - 2021


  • cesarean delivery
  • decision aid
  • practice variation
  • trial of labor
  • vaginal birth after cesarean

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