"I can't make it safe, so I don't do it": Exploring obstetricians' views on barriers and enablers to promoting vaginal birth after caesarean section in Bangladesh.

The rise in the number of facility-based births in Bangladesh has been accompanied by a caesarean section (CS) epidemic. The current CS rate is 45% and while many are performed when medically unnecessary, there is still maternal mortality due to lack of access to CS. A significant contributor to the rising CS rates in Bangladesh is repeat CS. Evidence from high-income settings has shown that vaginal birth after caesarean section (VBAC) is safe and should be recommended for women with one previous CS, however, its practice in Bangladesh is low. VBAC has the potential to help reduce unnecessary CS in Bangladesh. As obstetricians play a significant role in birth decision-making, their opinions, and perspectives on barriers to VBAC need to be explored. This study will address a gap in the literature exploring barriers and enablers to promoting VBAC from the level of the obstetric decision-maker. This qualitative study was conducted in the Dhaka Division of Bangladesh in July 2023. Criterion sampling was used to select obstetricians for in-depth semi-structured interviews. Seven interviews were conducted in a private hospital in Dhaka city and five interviews were conducted in a non-governmental organisation (NGO) hospital outside Dhaka city. Ethical approval was received from the relevant organisations in both Liverpool and Bangladesh. The thematic analysis gave rise to three main themes: "policy awareness and national situation", "reasons for practice decisions" and "ways to improve service delivery". Despite good awareness of VBAC policies and appreciation of its benefits, obstetricians expressed a preference for repeat CS. From the perspective of obstetricians, the main barriers to VBAC practice are related to the structure and function of the health system. To create an environment that will enable safe practice of VBAC, health system improvement and community awareness of the benefits of normal vaginal birth are required.