Objectives: The objective of this Future Research Needs project is to develop a future research agenda in the area of vaginal birth after cesarean (VBAC) that builds on the research gaps identified in the 2010 evidence review conducted for the National Institutes of Health (NIH) Consensus Development Conference.
Data Sources: In phase 1, stakeholders participated in semistructured interviews to identify and describe evidence gaps and future research needs. In phase 2, stakeholders participated in a modified Delphi process to rank the top 10 research priorities. Ongoing studies and recently completed research between March 2010 and August 2011 were identified by searching Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Reviews of Effects (DARE), Ovid MEDLINE®, Scopus, the Annals of Internal Medicine Web site, Google Scholar, clinical trial registries, grant databases, and individual funders' Web sites.
Results: Sixteen of the 30 stakeholders invited to participate in the semistructured interviews agreed. Overall, 6 of the 6 legal/liability or hospital administrators (100 percent), 2 of the 6 patient/consumer advocates (33 percent), 5 of the 13 clinicians (30 percent), 1 of the 2 researchers (50 percent), and 2 of the 3 research funders (66 percent) were interviewed. We invited 11 stakeholders to participate in the phase 2 Delphi process. In compliance with Federal guidelines, only nine of the stakeholders were not Federal employees. All stakeholders invited to participate in the Delphi prioritization process completed the first questionnaire, and 10 of the 11 completed the second questionnaire (81 percent). A list of the top 10 research priorities was developed.
Conclusions: The top 10 future research needs as prioritized by stakeholders fall into three overarching categories: health systems and contextual issues (category A), standardized measurement and collection of data on maternal and infant outcomes (category B), and understanding how patients perceive risk and how best to communicate risk of mode of delivery after prior cesarean (category C). Within category A, stakeholders highlighted the need for research on institutional and systems-level barriers and facilitators to providing and delivering safe trials of labor after cesarean, including how the “immediately available” requirement is understood and implemented and concerns about legal liability. Within category B, stakeholders emphasized measurement of both short- and long-term outcomes and the importance of agreement on clear and precise definitions and methods of ascertainment both within and across hospitals. With regard to category C, stakeholders prioritized research about how patients perceive the risks of trial of labor (TOL) compared with repeat cesarean delivery, how best to frame and communicate the risks of each option, and the most effective way to present information so that women can make an informed choice that incorporates their preferences. Overall, stakeholders felt that defining what constitutes a “safe” TOL after cesarean and safe birth in general, at the level of the individual, the provider, and the institution or setting of care was important across all top priority research needs.