School of Nursing, Guizhou Medical University, Guiyang, China.
The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.
BMC Pregnancy Childbirth. 2021 Jan 28;21(1):89. doi: 10.1186/s12884-021-03559-1.
As the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS). Undertaking an elective repeat CS (ERCS) has been taken for granted and has thus become a major contributor to the increasing CS rate in China. Promoting trial of labor after CS (TOLAC) can reduce the CS rate without compromising delivery outcomes. This study aimed to investigate Chinese obstetricians' perspectives regarding TOLAC, and the factors associated with their decision-making regarding recommending TOLAC to pregnant women with a history of CS under the two-child policy.
A cross-sectional survey was carried out between May and July 2018. Binary logistic regression was used to determine the factors associated with the obstetricians' intention to recommend TOLAC to pregnant women with a history of CS. The independent variables included sociodemographic factors and perceptions regarding TOLAC (selection criteria for TOLAC, basis underlying the selection criteria for TOLAC, and perceived challenges regarding promoting TOLAC).
A total of 426 obstetricians were surveyed, with a response rate of ≥83%. The results showed that 31.0% of the obstetricians had no intention to recommend TOLAC to pregnant women with a history of CS. Their decisions were associated with the perceived lack of confidence regarding undergoing TOLAC among pregnant women with a history of CS and their families (odds ratio [OR] = 2.31; 95% CI: 1.38-1.38); obstetricians' uncertainty about the safety of TOLAC for pregnant women with a history of CS (OR = 0.49; 95% CI: 0.27-0.96), and worries about medical lawsuits due to adverse delivery outcomes (OR = 0.14; 95% CI: 0.07-0.31). The main reported challenges regarding performing TOLAC were lack of clear guidelines for predicting or avoiding the risks associated with TOLAC (83.4%), obstetricians' uncertainty about the safety of TOLAC for women with a history of CS (81.2%), pregnant women's unwillingness to accept the risks associated with TOLAC (81.0%) or demand for ERCS (80.7%), and the perceived lack of confidence (77.5%) or understanding (69.7%) regarding undergoing TOLAC among pregnant women and their families.
A proportion of Chinese obstetricians did not intend to recommend TOLAC to pregnant women with a history of CS. This phenomenon was closely associated with obstetricians' concerns about TOLAC safety and perceived attitudes of the pregnant women and their families regarding TOLAC. Effective measures are needed to help obstetricians predict and reduce the risks associated with TOLAC, clearly specify the indications for TOLAC, improve labor management, and popularize TOLAC in China. Additionally, public health education on TOLAC is necessary to improve the understanding of TOLAC among pregnant women with a history of CS and their families, and to improve their interactions with their obstetricians regarding shared decision making.
随着中国生育政策从一孩一夫妻调整为普遍二孩一夫妻，越来越多的妇女在剖宫产后再次怀孕。选择择期再次剖宫产（ERCS）已被视为理所当然，因此成为中国剖宫产率上升的主要原因。提倡剖宫产后试产（TOLAC）可以降低剖宫产率，而不会影响分娩结局。本研究旨在调查中国产科医生对 TOLAC 的看法，以及与他们决定在二孩政策下向有剖宫产史的孕妇推荐 TOLAC 相关的因素。
2018 年 5 月至 7 月进行了横断面调查。使用二元逻辑回归确定与产科医生向有剖宫产史的孕妇推荐 TOLAC 的意愿相关的因素。自变量包括社会人口统计学因素和对 TOLAC 的看法（TOLAC 的选择标准、选择标准的基础以及促进 TOLAC 面临的挑战）。
共调查了 426 名产科医生，应答率≥83%。结果显示，31.0%的产科医生不打算向有剖宫产史的孕妇推荐 TOLAC。他们的决定与孕妇及其家属对有剖宫产史的孕妇进行 TOLAC 的信心不足有关（比值比[OR] = 2.31；95%可信区间：1.38-1.38）；产科医生对有剖宫产史的孕妇进行 TOLAC 的安全性不确定（OR = 0.49；95%可信区间：0.27-0.96），以及担心因不良分娩结局而引起医疗诉讼（OR = 0.14；95%可信区间：0.07-0.31）。进行 TOLAC 主要报告的挑战是缺乏明确的指南来预测或避免与 TOLAC 相关的风险（83.4%）、产科医生对有剖宫产史的妇女进行 TOLAC 的安全性不确定（81.2%）、孕妇不愿意接受与 TOLAC 相关的风险（81.0%）或对 ERCS 的需求（80.7%），以及孕妇及其家属对 TOLAC 的信心不足（77.5%）或理解不足（69.7%）。
中国有一定比例的产科医生不打算向有剖宫产史的孕妇推荐 TOLAC。这种现象与产科医生对 TOLAC 安全性的担忧以及孕妇及其家属对 TOLAC 的态度密切相关。需要采取有效措施帮助产科医生预测和降低 TOLAC 相关风险，明确 TOLAC 的适应证，改善分娩管理，并在中国推广 TOLAC。此外，需要对有剖宫产史的孕妇及其家属进行 TOLAC 的公共卫生教育，提高他们对 TOLAC 的理解，并改善他们与产科医生在共同决策方面的互动。
