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Birth after caesarean : an investigation of decision-making for mode of delivery Munro, Sarah 2016

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BIRTH	AFTER	CAESAREAN:		AN	INVESTIGATION	OF	DECISION-MAKING	FOR	MODE	OF	DELIVERY	by		Sarah	Munro		B.A.	(Hon.),	The	University	of	British	Columbia,	2005	M.A.,	The	University	of	British	Columbia,	2007		A	THESIS	SUBMITTED	IN	PARTIAL	FULFILLMENT	OF	THE	REQUIREMENTS	FOR	THE	DEGREE	OF		DOCTOR	OF	PHILOSOPHY	in	THE	FACULTY	OF	GRADUATE	AND	POSTDOCTORAL	STUDIES	(Interdisciplinary	Studies)		THE	UNIVERSITY	OF	BRITISH	COLUMBIA	(Vancouver)	August	2016		©	Sarah	Munro,	2016			ii	Abstract	Background:	Clinical	practice	guidelines	indicate	that	over	80%	of	women	with	a	previous	caesarean	should	be	offered	a	planned	vaginal	birth	after	caesarean	(VBAC),	however	only	one	third	of	eligible	women	choose	to	plan	a	VBAC.	Shared	decision-making	(SDM)	interventions	support	women	to	make	choices	based	on	their	informed	preferences.	To	facilitate	implementation	of	SDM	it	is	necessary	to	understand	the	patient	(micro),	health	services	(meso),	and	policy	(macro)	factors	that	influence	decision-making.		Objectives:	My	objective	is	to	explore	attitudes	toward	and	experiences	with	decision-making	for	mode	of	birth	after	caesarean	section	in	British	Columbia	(BC)	to	identify	factors	that	influence	implementation	of	SDM.		Methods:	In-depth,	semi-structured	interviews	were	conducted	with	women	eligible	for	VBAC,	care	providers,	and	health	service	decision	makers	recruited	from	three	rural	and	two	urban	BC	communities.	Integrated	knowledge	translation	(iKT)	principles	guided	study	design,	while	constructivist	grounded	theory	informed	iterative	data	collection	and	analysis.	Findings	were	interpreted	using	complex	adaptive	systems	theory	(CAS).		Results:	Analysis	of	interviews	(n=57)	and	CAS	interpretation	revealed	that	the	factors	influencing	decisions	resulted	from	interactions	between	the	micro,	meso,	and	macro	levels	of	the	health	care	system.	Women	formed	early	preferences	for	mode	of	delivery	(after	the			iii	primary	caesarean)	through	careful	deliberation	of	the	social	risks	and	benefits	of	mode	of	delivery.	Physicians	acted	as	information	providers	of	clinical	risks	and	benefits,	with	limited	discussion	of	patient	preferences.	Decision	makers	serving	large	hospitals	revealed	concerns	related	to	liability	and	patient	safety.	These	stemmed	from	limited	access	to	surgical	resources,	which	had	resulted	from	budget	constraints.	To	facilitate	mutual	understanding	among	stakeholder	groups,	iKT	activities	included	policy	dialogues	and	the	creation	of	a	policy	brief.		Conclusion:	To	facilitate	the	effective	implementation	of	SDM	in	clinical	practice	for	mode	of	delivery	after	a	previous	caesarean	section,	it	is	necessary	to	address	the	needs	of	women,	care	providers,	and	decision	makers.	These	include	initiating	decision	support	immediately	after	the	primary	caesarean,	assisting	women	to	address	the	social	risks	that	influence	their	preferences,	managing	perceptions	of	risk	related	to	patient	safety	and	litigation	among	physicians,	and	access	to	surgical	resources.				iv	Preface	This	dissertation	was	conducted	under	the	primary	supervision	of	Dr.	Patti	Janssen	and	Dr.	Jude	Kornelsen	(University	of	British	Columbia),	and	co-supervision	of	committee	members	Dr.	Nick	Bansback	(University	of	British	Columbia)	and	Dr.	Kitty	Corbett	(University	of	Waterloo)		I,	Sarah	Munro,	designed	and	conducted	the	study	and	wrote	all	the	chapters	in	this	dissertation.	I	incorporated	feedback	from	committee	members	into	the	final	draft.		This	study	was	approved	by	the	University	of	British	Columbia	Behavioural	Research	Ethics	Board	(H15-00319),	Fraser	Health	Research	Ethics	Board	(FHREB	2015-032),	and	Northern	Health	Research	Review	Committee	(RRC	H	2015-001).			v	Table	of	Contents		Abstract	..................................................................................................................................	ii	Preface	...................................................................................................................................	iv	Table	of	Contents	...................................................................................................................	v	List	of	Tables	..........................................................................................................................	xii	List	of	Figures	.......................................................................................................................	xiii	List	of	Abbreviations	.............................................................................................................	xiv	Glossary	.................................................................................................................................	xv	Acknowledgements	............................................................................................................	xviii	Dedication	............................................................................................................................	xxi	Chapter	1:	Introduction	..........................................................................................................	1	1.1	 Background	........................................................................................................................	3	1.2	 Purpose	of	the	Dissertation	...............................................................................................	7	1.3	 Conceptual	Framework	.....................................................................................................	9	1.3.1	 Shared	Decision-Making	...........................................................................................	11	1.3.2	 Knowledge	Translation	.............................................................................................	15	1.3.3	 Complex	Adaptive	Systems	......................................................................................	17	1.4	 Significance	of	the	Dissertation	.......................................................................................	20	1.5	 Structure	of	the	Chapters	................................................................................................	25	Chapter	2:	Literature	Review	................................................................................................	26	2.1	 The	Interdisciplinary	Literature	Review	Method	.............................................................	26			vi	2.2	 Women’s	Attitudes	and	Experiences	with	Birth	after	Caesarean	...................................	30	2.2.1	 The	Role	of	Relationships	.........................................................................................	32	2.2.2	 The	Role	of	Resources	..............................................................................................	32	2.3	 Care	Provider	Attitudes	and	Experiences	........................................................................	34	2.4	 Perceptions	of	Risk	in	Childbirth	......................................................................................	38	2.5	 Access	to	Vaginal	Birth	after	Caesarean	(VBAC)	..............................................................	44	2.5.1	 Health	Services	Barriers	to	Access	of	Planned	VBAC	................................................	49	2.5.2	 The	Influence	of	Financial	Incentives	.......................................................................	55	2.6	 Interventions	to	Support	Decision-Making	for	Birth	after	Caesarean	.............................	58	2.6.1	 Patient-Centred	Interventions	for	Birth	after	Caesarean	.........................................	60	2.6.2	 Implementation	of	Shared	Decision	Making	Interventions	......................................	64	2.7	 Conclusion	.......................................................................................................................	67	Chapter	3:	Methods	..............................................................................................................	71	3.1	 Research	Design:	Constructivist	Grounded	Theory	.........................................................	71	3.2	 Setting	.............................................................................................................................	76	3.3	 Participants	......................................................................................................................	78	3.4	 Theoretical	Sampling	.......................................................................................................	80	3.5	 Data	Collection	................................................................................................................	81	3.6	 Data	Analysis	...................................................................................................................	83	3.7	 Reliability	and	Validity	.....................................................................................................	86	3.8	 Developing	a	Theory	........................................................................................................	87			vii	3.9	 Theoretical	Matching	......................................................................................................	88	3.10	 Ethics	.............................................................................................................................	91	Chapter	4:	Seeking	Control	in	the	Midst	of	Uncertainty:	Women’s	Experiences	of	Choosing	Mode	of	Delivery	after	Caesarean	........................................................................................	92	4.1	 Description	of	the	Sample	...............................................................................................	92	4.2	 Results	.............................................................................................................................	96	4.2.1	 Seeking	Control	in	the	Midst	of	Uncertainty	............................................................	99	4.2.2	 Reflecting	on	the	Prior	Birth	Experience	................................................................	101	4.2.3	 Clarifying	Values	.....................................................................................................	104	4.2.4	 Becoming	Informed	................................................................................................	106	4.2.4.1	 “De-briefing”	...................................................................................................	107	4.2.4.2	 Seeking	Knowledge	..........................................................................................	108	4.2.4.3	 Experiential	Knowledge	...................................................................................	108	4.2.5	 Feasibility	of	Options	..............................................................................................	109	4.2.6	 Deliberating	with	the	Care	Team	............................................................................	110	4.2.6.1	 Physician	Care	..................................................................................................	110	4.2.6.2	 Midwifery	Care	................................................................................................	113	4.2.6.3	 Actual	Choice	...................................................................................................	114	4.3	 Conclusion	.....................................................................................................................	119	Chapter	5:	Supporting	Women	to	Make	a	Choice:	Care	Providers’	and	Decision	Makers’	Perspectives	on	Barriers	to	Access	of	Health	Services	for	Birth	after	a	Previous	Caesarean	..	121			viii	5.1	 Description	of	the	Sample	.............................................................................................	121	5.2	 Results	...........................................................................................................................	121	5.2.1	 Supporting	Women	to	Make	a	Choice	....................................................................	123	5.2.2	 Being	an	“Information	Provider”	............................................................................	124	5.2.2.1	 Timing	the	Discussion	......................................................................................	124	5.2.2.2	 Giving	a	“Pitch”	................................................................................................	127	5.2.2.3	 Describing	“Real	World	Consequences”	..........................................................	129	5.2.3	 Listening	to	the	Woman’s	Voice	.............................................................................	130	5.2.3.1	 Recognizing	that	Women	Experience	“Failure”	...............................................	130	5.2.3.2	 “Debriefing”	a	Woman’s	Birth	Experience	......................................................	132	5.2.3.3	 Creating	a	Safe	Space	for	Sharing	....................................................................	132	5.2.4	 “Making	it	Work”	in	the	Midst	of	Limited	Access	to	Services	................................	133	5.3	 Conclusion	.....................................................................................................................	136	Chapter	6:	Patient,	Care	Provider,	and	Decision	Makers’	Perceptions	of	Barriers	to	Implementation	of	Shared	Decision-Making	for	Birth	after	Caesarean:	A	Complex	Adaptive	Systems	Perspective	............................................................................................................	137	6.1	 Introduction	...................................................................................................................	137	6.2	 Background	....................................................................................................................	139	6.3	 Discussion	......................................................................................................................	146	6.3.1	 Attractor	Patterns	...................................................................................................	150	6.3.2	 Simple	Rules	...........................................................................................................	151			ix	6.3.3	 Interconnectivity	and	Co-Evolution	........................................................................	152	6.3.4	 Self-Organization	and	Emergence	..........................................................................	153	6.3.5	 Non-linearity	and	Unpredictability	.........................................................................	154	6.3.6	 Feedback	Loops	and	Initial	Conditions	...................................................................	156	6.3.7	 Open	Boundaries	....................................................................................................	157	6.4	 Conclusion	.....................................................................................................................	158	Chapter	7:	Knowledge	Exchange	to	Implement	Shared	Decision-Making:	A	Case	Example	of	Partnering	with	Stakeholders	to	Optimize	Services	for	Birth	after	Caesarean	.......................	161	7.1	 Introduction	...................................................................................................................	161	7.1.1	 Structure	of	the	Chapter	.........................................................................................	162	7.2	 Methods	........................................................................................................................	162	7.2.1	 Terminology	............................................................................................................	163	7.2.1.1	 Integrated	Knowledge	Translation	(iKT)	..........................................................	163	7.2.1.2	 Stakeholders	....................................................................................................	164	7.2.1.3	 Knowledge	Exchange	.......................................................................................	166	7.2.2	 Design	.....................................................................................................................	168	7.3	 Results	...........................................................................................................................	173	7.3.1	 Identifying	the	Problem	..........................................................................................	173	7.3.2	 Engaging	in	Knowledge	Inquiry	and	Synthesis	.......................................................	181	7.3.3	 Assessing	Barriers	and	Enablers	to	Knowledge	Use	...............................................	182	7.3.4	 Developing	Knowledge	Products	............................................................................	184			x	7.3.4.1	 Developing	a	Policy	Brief	.................................................................................	186	7.3.4.2	 Using	the	Policy	Brief	to	Catalyze	Dialogue	.....................................................	189	7.3.5	 Adapting	Knowledge	to	Local	Context	....................................................................	192	7.3.6	 Selecting,	Tailoring,	and	Implementing	Interventions	............................................	193	7.3.7	 Monitoring	and	Evaluating	Knowledge	Use	...........................................................	194	7.3.8	 Sustaining	the	Project	through	a	Community	of	Practice	......................................	194	7.4	 Discussion	......................................................................................................................	197	7.5	 Conclusion	.....................................................................................................................	201	Chapter	8:	Discussion	and	Conclusion	..................................................................................	202	8.1	 Overview	.......................................................................................................................	202	8.2	 Summary	of	Findings	.....................................................................................................	203	8.2.1	 Women’s	Narratives	...............................................................................................	203	8.2.2	 Care	Provider	and	Decision	Makers’	Narratives	.....................................................	210	8.2.3	 Complex	Adaptive	Systems	Analysis	.......................................................................	215	8.3	 Practice	Implications	.....................................................................................................	220	8.4	 Limitations	.....................................................................................................................	225	8.5	 Implications	for	Future	Research	..................................................................................	227	References	...........................................................................................................................	229	Appendices	..........................................................................................................................	249	Appendix	A	Interview	Guides	.................................................................................................	249	A.1	 Interview	Guide	with	Women	...................................................................................	249			xi	A.2	 Interview	Guide	with	Care	Providers	........................................................................	250	A.3	 Interview	Guide	with	Decision	Makers	.....................................................................	252	Appendix	B	Code	Books	..........................................................................................................	254	B.1	 Initial	Code	Book	.......................................................................................................	254	B.2	 Revised	Code	Book	....................................................................................................	262	Appendix	C	Policy	Brief	...........................................................................................................	266				xii	List	of	Tables		Table	4.1	Demographic	Characteristics	of	Women	......................................................................	93	Table	4.2	Childbirth	Histories	of	Participants	...............................................................................	94	Table	4.3	Themes	and	Subthemes	Emerging	from	Women’s	Narratives	.....................................	97	Table	5.1	Themes	and	Subthemes	Emerging	from	Care	Provider	and	Decision	Maker	Narratives	....................................................................................................................................................	122	Table	6.1	Characteristics	of	Complex	Adaptive	Systems	............................................................	145	Table	7.1	Integrated	Knowledge	Translation	Framework	..........................................................	172				xiii	List	of	Figures			Figure	4.1	A	Conceptual	Map	of	Women’s	Decision-Making	.......................................................	98	Figure	7.1	Knowledge-to-Action	Cycle	.......................................................................................	169	Figure	7.2	Research,	Policy-Making,	and	Knowledge	Translation	Processes	.............................	175				xiv	List	of	Abbreviations		ACOG:	American	College	of	Obstetricians	and	Gynecologists	CAS:	Complex	adaptive	system	FHA:	Fraser	Health	Authority	GPESS:	General	Practitioners	with	Enhanced	Surgical	Skills	iKT:	Integrated	knowledge	translation	KT:	Knowledge	translation	KTA:	Knowledge	to	Action	NHA:	Northern	Health	Authority	PtDA:	Patient	decision	aid	SDM:	Shared	decision-making	SOGC:	Society	of	Obstetricians	and	Gynaecologists	of	Canada		VBAC:	Vaginal	birth	after	caesarean			xv	Glossary		Agency:	A	woman’s	account	of	her	capacity	for	individual	thought	and	action.	This	is	a	term	commonly	used	in	feminist	theory.		Complex	adaptive	system:	“A	collection	of	individuals	with	freedom	to	act	in	ways	that	are	not	always	totally	predictable,	and	whose	actions	are	interconnected	so	that	one	agent's	actions	changes	the	context	for	other	agents.”(1)		Comprehensive	risk:	“An	extended	definition	for	risk	for	the	health	system	that	considers	the	full	range	of	risks	and	their	interactions.”(2)	Comprehensive	risk	involves	two	core	categories:	health	services	risks	and	social	risks.	“Health	services	risks”	involve	clinical	risks,	as	well	as	legal,	political,	operational,	and	financial	risks	to	the	health	system.	“Social	risks”	involve	cultural	risks	(to	patients’	traditional	values	and	spirituality),	emotional	risks	(of	system-initiated	distress	to	patients),	and	financial	risks	(of	compromised	family	budgets	in	accessing	health	services).		Engaged	scholarship:	“A	form	of	collaborative	inquiry	between	academics	and	practitioners	that	leverages	their	different	perspectives	to	generate	useful	knowledge.”(3)		Implementation:	“The	process	of	putting	to	use	or	integrating	evidence-based	interventions	within	a	setting.”(4)		Informed	choice:	A	model	of	decision-making	in	which	the	care	provider	gives	information	on	clinical	risks	and	benefits	to	the	patient,	who	then	makes	a	decision	on	their	own.		Informed	consent:	The	principle	that	patients	have	the	right	to	be	informed	of	their	options,	to	agree	voluntarily	to	a	healthcare	decision,	and	that	the	decision	should	respect	the	wishes	of	the	patient.(5)		Integrated	knowledge	translation	(iKT):	A	process	of	engaging	with	stakeholders	throughout	the	research	process	to	co-produce	knowledge	and	facilitate	its	implementation	in	policy	and	practice.	iKT	helps	to	identify	facilitators	and	barriers	to	the	process	of	evidence	implementation,	provide	empirical	evidence	to	support	health	service	planning,	and	through	the	partnership	process	itself	is	instrumental	in	implementing	sustainable	change.			Knowledge:	The	“knowledge”	in	integrated	knowledge	translation	may	be	defined	as	evidence	in	context.	Evidence	may	be	“research-based	findings	transparently	compiled,	analysed	and	interpreted	according	to	rigorous	methodological	processes	and	standards,”(6)	while	context	refers	to	“the	conditions	or	surroundings”	in	which	evidence	exists,	“typically	referring	to	an	analytical	unit	that	is	higher	than	the	phenomena	directly	under	investigation.”(7)	These	conditions	or	surroundings	may	include	practical	wisdom,	lived	experience,	and	social	norms.			xvi		Knowledge	exchange:	“A	fluid,	dynamic	process	involving	the	proliferation	and	reinvention	of	ideas	drawn	from	many	different	sources	via	an	interactive,	interpretive	process.”(8)		Knowledge	partner:	Individuals	who	are	likely	to	use	research	results	to	make	informed	healthcare	decisions	about	practices	and	policies.	In	this	study,	they	included	childbearing	women,	their	families,	care	providers,	and	health	service	decision	makers	at	the	hospital,	regional,	and	government	level.		Knowledge	translation:	“A	dynamic	and	iterative	process	that	includes	synthesis,	dissemination,	exchange	and	ethically	sound	application	of	knowledge	to	improve	the	health	of	Canadians,	provide	more	effective	health	services	and	products	and	strengthen	the	health	care	system.”(9)		Knowledge	to	Action	(KTA)	cycle:	A	conceptual	framework	that	was	developed	by	researchers	and	members	of	the	Canadian	Institutes	of	Health	Research	following	a	review	of	31	planned	action	theories.(10)	It	conceptualizes	knowledge	to	action	as	a	fluid	and	dynamic	process	that	vacillates	between	“Knowledge	Production”	and	an	“Action	Cycle.”		Micro,	meso,	and	macro	health	system	levels:	A	framework	for	conceptualizing	the	different	actors	and	organizations	in	a	health	care	system.	The	micro-level	of	the	health	system	involves	individuals	in	clinical	and	social	encounters,	including	patients,	their	families,	and	care	providers.	The	meso-level	of	health	services	includes	the	hospitals,	organizations,	communities,	social	networks,	and	regions	in	which	individuals	act.	The	macro-level	includes	the	policy,	cultural,	and	governmental	context	of	health	services.	Decision-making	for	birth	after	caesarean	may	take	place	at	the	micro-level	between	individuals	in	clinical	encounters.	At	the	meso-level,	it	may	involve	decisions	by	hospitals	to	provide	health	services	and	resources	to	support	vaginal	and	caesarean	birth.	At	the	macro-level,	it	may	involve	system-wide	processes,	policies,	or	cultural	behaviour	that	influence	the	system	as	a	whole,	such	as	clinical	practice	guidelines	or	financial	incentives	for	physicians.		Patient	decision	aids:	Evidence-based	tools	that	provide	patients	with	individualized	information	on	the	clinical	risks	and	benefits	of	their	health	care	options,	highlight	uncertainties	about	the	evidence,	and	help	individuals	to	clarify	their	values	and	preferences.	Patient	decision	aids	can	be	used	independently	by	the	patient,	shared	face-to-face	with	a	care	provider	during	a	clinical	encounter,	or	mediated	via	telephone	or	other	media,	such	as	with	a	decision	coach.		Shared	decision-making:	A	model	of	decision-making,	in	which	the	care	provider	gives	information	on	clinical	risks	and	benefits	to	the	patient,	supports	the	patient	to	gain	clarity	about	their	values,	listens	to	the	patient’s	personal	health	goals,	lifestyle	concerns,	and	how	these	align	with	standards	of	care,	and	engages	with	the	patient	to	make	a	shared	decision	for	a	course	of	care.				xvii		Stakeholder:	Individuals	and	organizations	involved	in	receiving,	providing,	or	planning	care,	including	patients,	care	providers,	and	health	service	decision	makers.	Stakeholders	in	this	study	are	those	who	may	be	affected	by	decisions	for	birth	after	caesarean,	or	whose	behaviours	and	actions	may	have	an	effect	on	efforts	to	support	SDM	for	birth	after	caesarean.				xviii	Acknowledgements	I	extend	my	deepest	thanks	to	my	co-supervisors,	Patti	Janssen	and	Jude	Kornelsen.	Jude,	thank	you	for	taking	me	under	your	wing	ten	years	ago	at	the	Centre	for	Rural	Health	Research	when	I	was	searching	for	an	academic	home	and	for	encouraging	me	to	pursue	my	own	research	questions.	You	taught	me,	first	and	foremost,	to	listen	to	women’s	voices.	Thank	you	for	encouraging	me	to	listen	to	my	own	voice	and	always	put	family	first.	Patti,	thank	you	for	your	unwavering	support,	enthusiasm,	and	drive.	You	have	opened	so	many	doors	for	me.	Thank	you	for	our	lengthy	conversations	about	work	and	life	at	the	Child	and	Family	Research	Institute.	Your	wisdom	kept	me	focused	and	grounded	at	every	stage	of	this	process.		I	am	grateful	for	the	guidance	of	Nick	Bansback	for	introducing	me	to	the	field	of	decision	science,	and	for	nurturing	my	training	at	the	Centre	for	Health	Evaluation	and	Outcomes	Sciences.	Thank	you	to	Kitty	Corbett	for	our	long	thoughtful	chats	about	qualitative	research.	I	appreciate	that	you	always	reminded	me	to	extend	my	thinking	and	enjoy	the	creative	intellectual	process.	To	Sarah	Kaufman	and	the	members	of	Optimal	Birth	Fraser	Health	(formerly	Fraser	Health	Caesarean	Section	Task	Force),	thank	you	for	your	motivation	to	make	this	research	have	a	meaningful	impact.	I	was	privileged	to	have	qualitative	analysis	support	from	Elizabeth	Wilcox	and	transcription	support	from	research	volunteers	Nahal	Torabi	and	Shahrzad	Fatemi.	I	also	want	to	acknowledge	the	health	care	professionals	throughout	Fraser	and	Northern	Health	Authorities	who	provided	significant	assistance	in	recruiting	participants	and	scheduling	interviews.	Thank	you	for	welcoming	me	into	your	communities.	Thank	you	also	to	Dr.	Karen			xix	Buhler,	Dr.	Georgia	Hunt,	and	Paul	McGivern	for	your	expert	feedback	on	my	clinical	and	legal	questions.	Thank	you	to	the	School	of	Population	and	Public	Health	for	being	my	home	department	and	to	the	faculty	who	provided	feedback	on	my	research	proposal.	Thank	you	to	members	of	the	Society	for	Medical	Decision	Making,	the	Normal	Birth	Research	Group,	and	Students	in	Health	Research	(SHaRe)	for	conversations	about	my	work	in	progress.	I	am	grateful	to	Stefan	Grzybowski	and	Sam	Sheps	for	our	many	chats	about	health	services	complexity.	Thank	you	also	to	Marina	Morrow	and	the	Faculty	of	Health	Sciences	at	Simon	Fraser	University	for	supporting	my	early	doctorate	training	in	feminist	qualitative	methodologies.	I	also	extend	thanks	to	Hillary	Bekker	and	Leeds	University	for	the	opportunity	to	present	my	work	in	progress	and	gain	feedback	on	patient	narratives	and	shared	decision-making.	My	PhD	would	not	have	been	possible	without	the	organizations	that	provided	research	and	salary	funding	for	this	dissertation:	Canadian	Institutes	of	Health	Research,	Child	and	Family	Research	Institute,	Western	Regional	Training	Centre	for	Health	Services	Research	(WRTC),	and	the	UBC	Public	Scholars	program.		Most	of	all,	I	thank	my	family.	Thank	you	to	my	parents	for	spending	countless	days	with	my	boys	while	I	traveled	and	wrote.	I	am	especially	grateful	to	my	brilliant	mum	–	thank	you	for	planting	the	seed	for	this	study	many	years	ago.	Thank	you	to	my	boys,	Jack	and	Finn,	for	your	love,	encouragement,	and	for	mistakenly	deleting	only	one	chapter	of	this	thesis.	Thank	you	Logan	for	being	my	partner	at	home	and	at	work,	for	being	my	second	set	of	eyes,	and	always	reminding	me	of	the	big	picture.	I	got	it	done.				xx	Finally,	this	dissertation	would	not	have	been	possible	without	the	kind	and	generous	individuals	who	partnered	in	this	research,	especially	the	women	who	shared	their	birth	stories.					xxi	Dedication		For	Amy		1	Chapter	1: Introduction	In	British	Columbia,	the	caesarean	section	rate	has	been	steadily	on	the	rise	since	the	1990s.	One	key	reason	for	this	trend	is	an	increase	in	repeat	caesarean	sections,	which	have	risen	by	more	than	10%	over	the	past	10	years	and	account	for	one-third	of	all	caesareans	in	the	province.(11)	In	2012-13,	82.4%	of	BC	women	with	a	previous	caesarean	were	eligible	to	attempt	a	vaginal	birth	after	caesarean	(VBAC);	however,	only	32.7%	of	these	women	attempted	a	VBAC	with	the	remainder	giving	birth	by	elective	repeat	caesarean.(12)	Among	those	women	who	did	attempt	a	VBAC,	70.9%	had	a	vaginal	birth	as	planned.(12)	The	Society	of	Obstetricians	and	Gynaecologists	of	Canada	(SOGC)	guidelines	recommend	offering	VBAC	to	eligible	women.(13)	Since	the	publication	of	these	guidelines	in	2005,	the	repeat	caesarean	rate	has	continued	to	rise	in	British	Columbia,	demonstrating	a	clear	gap	between	best	evidence	and	practice.	Conventional	models	of	informed	consent	frame	the	process	as	individualistic,	involving	one	patient	and	one	care	provider.	In	this	context,	the	aggregate	evidence	on	medical	risks	and	benefits	of	different	modes	of	delivery	are	discussed	before	patient	values	and	preferences	are	considered.(14,15)	This	paradigm	does	not	consider	the	wider	constellation	of	factors	that	influence	choice.(16,17)	From	a	health	services	perspective,	issues	of	access	can	limit	patient	choice,	such	as	in	the	event	of	a	rural	hospital	having	a	policy	of	not	offering	planned	VBAC	or	caesarean	deliveries.(18)	In	health	care	systems	that	provide	financial	incentives	for	obstetricians	to	perform	caesarean	sections,	“physician	induced	demand”	can	increase	rates	of	repeat	caesarean	section.(19)	Thus	the	development	and	dissemination	of	best	evidence	does			2	not	guarantee	that	providers	and	decision	makers	will	be	willing	or	able	to	support	patients	to	make	informed	choices	for	birth	after	caesarean.	Given	the	health	system	emphasis	on	patient	choice,	insights	about	rising	repeat	caesarean	rates	will	likely	be	embedded	in	decision-making	for	mode	of	delivery.	Graham	et	al’s	Knowledge-to-Action	(KTA)	cycle,	a	framework	for	moving	evidence	into	practice	informed	by	planned-action	theories,	stresses	that	uptake	of	evidence	based	practices	may	be	influenced	by	issues	related	to	the	quality	and	appropriateness	of	the	evidence,	stakeholders’	attitudes	and	experiences	with	the	practice,	and	the	context	or	setting	in	which	the	evidence	is	to	be	used.(20)	Adapting	evidence	to	local	context	improves	adherence	to	and	acceptance	of	the	evidence	and	may	create	sustained	changes	in	clinical	practice	through	a	sense	of	shared	ownership	over	the	evidence.(21,22)	In	order	to	bridge	this	knowledge	to	action	gap,	in	addition	to	clinical	evidence,	it	is	necessary	provide	patients	and	clinicians	with	knowledge	on	VBAC	and	repeat	caesarean	that	is	informed	by	an	understanding	of	stakeholders’	attitudes	toward	and	experiences	with	birth	after	caesarean,	and	the	health	services	and	policy	context	in	which	decision-making	takes	place.	Through	this	study	I	aim	to	address	this	gap	in	the	literature	by	exploring	the	perspectives	of	different	stakeholder	groups	to	determine	the	factors	that	influence	implementation	of	best	practices	for	birth	after	caesarean	decision-making	in	the	local	context	of	British	Columbia,	Canada.	In	this	introductory	chapter,	I	describe	the	background,	purpose,	objectives,	and	significance	of	my	dissertation	research.	I	also	define	the	key	theories	and	terms	used			3	throughout	the	dissertation.	At	the	end	of	the	introduction,	I	give	a	short	overview	of	subsequent	chapters.		1.1 Background	Findings	on	women’s	attitudes	toward	and	experiences	with	mode	of	delivery	vary	by	jurisdiction	and	illustrate	that	context	influences	decision-making.	A	systematic	review	and	meta-analysis	of	38	international	quantitative	studies	involving	19,403	women	found	that	caesarean	preferences	vary	by	setting.(23)	Women	in	North	America	express	a	greater	preference	for	caesarean	(21.3%;	95%	CI	16.4-26.7)	in	comparison	to	women	from	Australia	(13.8%;	95%	CI	2.0-33.6)	and	high-income	countries	in	Europe	(11.0%;	95%	CI	7.6-15.0).(23)	Women	with	a	previous	caesarean	(n=4,010,	16	studies)	overwhelmingly	prefer	planned	VBAC	for	mode	of	delivery	after	caesarean,	with	less	than	one	third	expressing	a	preference	for	repeat	caesarean	(29.4%;	95%	CI	24.4-34.8).(23)	In	a	separate	systematic	review	of	11	studies	on	women’s	preferences	for	mode	of	delivery	after	caesarean,	Eden	et	al	found	that	ethnicity	influenced	attitudes	and	experiences.(24)	Nonwhite	women	were	more	likely	than	their	white	counterparts	to	cite	their	care	provider	as	an	important	influence	(39%	vs.	19%)	and	to	wish	to	avoid	labour	if	another	option	resulted	in	a	healthy	baby,	in	comparison	to	white	women	who	valued	the	experience	of	labour.(24)		While	there	are	geographic	and	ethnic	differences	in	decision-making,	qualitative	studies	have	also	identified	similarities	in	women’s	experiences	of	choosing	mode	of	delivery.	Women	feel	a	moral	obligation	to	make	the	“right”	choice	based	on	the	perception	that	they			4	are	the	primary	decision	maker	and	are	consequently	responsible	for	the	outcome	of	their	decision,	in	particular	with	regard	to	concern	about	the	potential	for	bad	outcomes	for	their	baby.(25,26)	By	allowing	another	person	(e.g.	care	provider,	partner)	to	make	the	decision	on	their	behalf,	women	may	feel	relief	and	comfort	at	no	longer	experiencing	the	responsibility	associated	with	being	the	primary	decision	maker.(27)	Further,	women	birth	after	caesarean	preferences	are	often	based	on	the	social	needs	of	their	family,	such	as	the	need	for	a	short	postpartum	recovery	in	order	to	care	for	their	partner	and	other	children,	rather	than	on	medical	risks	and	benefits	their	baby	or	their	selves.(24)	Two	qualitative	studies	involving	postpartum	interviews	with	women	who	gave	birth	after	caesarean	in	northern	England	(25,28)	found	that,	in	the	absence	of	accurate,	trustworthy,	and	complete	information	from	their	care	provider,	women	rely	heavily	on	knowledge	from	their	previous	birth	experiences,	which	are	frequently	characterized	by	feelings	of	unhappiness,	regret,	and	blame,	as	well	as	fears	of	being	physically	incapable	of	having	a	vaginal	birth.	Lack	of	knowledge	of	medical	risks	and	benefits	may	result	in	women	choosing	elective	repeat	caesarean.	In	2014	Scaffidi	et	al	surveyed	a	convenience	sample	of	45	American	women	with	a	history	of	previous	caesarean	birth	and	found	that	those	women	who	had	high	knowledge	of	their	birth	after	caesarean	options	were	more	likely	to	choose	VBAC	than	repeat	caesarean	(OR	3.9;	95%	CI	1.09-13.81).(29)	In	this	context,	maternity	care	researchers	Gee	and	Corry	recently	stated	in	an	Obstetrics	and	Gynecology	editorial	that	“Given	the	dearth	of	information	women	have	about	their	medical	choices,	more	investment	is	needed	in	patient	education	and	tools	for	shared	decision	making	in	clinical	settings.”(30)	This	evidence			5	suggests	that,	in	order	to	bridge	the	evidence	to	practice	gap	for	mode	of	delivery	after	caesarean,	it	is	important	to	understand	women’s	attitudes	and	experiences	in	different	health	system	contexts,	including	women’s	misperceptions	and	misinformation	related	to	VBAC,	what	information	they	use	to	make	their	choice,	and	what	they	perceive	to	be	the	barriers	and	facilitators	to	VBAC	in	their	communities.	No	study	has	explored	women’s	perceptions	of	health	system	factors	that	influence	decision-making	for	birth	after	caesarean.		There	is	emerging	literature	on	care	providers’	attitudes	toward	and	experiences	with	mode	of	delivery	after	caesarean.(26,31–34)	Cox	conducted	semi-structured	interviews	with	obstetricians	and	midwives	(n=24)	in	Florida	and	found	that	fear	of	liability	and	the	convenience	of	repeat	caesarean	delivery	were	the	central	reasons	why	providers	avoided	VBAC	deliveries,	particularly	in	rural	and	community	hospitals.(31)	Midwives	were	more	supportive	of	VBAC	deliveries	than	their	obstetrician	counterparts,	but	felt	marginalized	from	being	able	to	participate	in	VBAC	births	due	to	hospital	policies.	In	contrast,	in	a	UK	study	involving	semi-structured	interviews	with	midwives	and	physicians	(n=25),	Kamal	et	al.	found	that	both	care	provider	groups	supported	VBAC	deliveries	but	midwives	and	physicians	also	felt	that	the	evidence	base	underpinning	VBAC	guidelines	was	of	poor	quality	and	secondary	to	professional	experience.(32)	Further	Kamal	et	al.	observed	wide	variation	in	care	providers’	decision-making	styles,	which	they	described	as	ranging	from	“consumerist”	(patient	decides),	to	“mutualistic”	(shared	decision),	to	“paternalistic”	(provider	decides).		Such	care	provider	attitudes	and	experiences	may	effect	the	uptake	of	evidence-based	practices	and	decision-making	for	mode	of	delivery	after	caesarean.	One	UK	study	evaluated			6	the	use	of	evidence-based,	informed	choice	leaflets	on	decisions	in	maternity	care,	using	observation	of	886	antenatal	consultations	in	13	maternity	units	in	Wales	and	383	in-depth	interviews	with	women,	midwives,	and	obstetrical	specialists.(35,36)	Qualitative	analysis	revealed	that	care	provider	attitudes	and	time	constraints	were	barriers	to	the	use	of	the	KT	tools.	Informed	choice	was	not	promoted	in	the	study	setting	due	to	care	providers’	belief	that	certain	choices,	such	as	elective	caesarean	for	breech	presentation,	are	more	“clinically	secure”	and	would	afford	them	protection	against	litigation.	These	factors	contributed	to	a	culture	of	patient	compliance	with	care	providers’	recommendations.	This	previous	work	also	indicates	that	patient-oriented	tools	help	women	to	become	informed	about	their	choices	for	birth	after	caesarean,	but	may	be	insufficient	to	support	women	to	actualize	their	informed	decisions	in	partnership	with	their	care	team.		In	addition	to	patient	and	care	provider	attitudes	and	experiences,	health	service	and	policy	factors	influence	decision-making	for	mode	of	delivery.	A	2012	survey	of	all	California	maternity	hospitals	(n=243)	found	that	139	hospitals	in	the	state	offered	VBAC	services	(53%),	predominantly	urban	hospitals	and/or	had	24/7	anaesthesia	coverage	and/or	an	in-house	obstetrician.(37)	These	findings	illustrate	that	health	service	decisions	on	whether	or	not	to	provide	continuous	caesarean	section	back-up	further	influences	patient	decision-making	by	limiting	the	mode	of	delivery	options	available	to	women.	In	Australia,	a	prospective	multi-centre	randomized	controlled	trial	involving	227	women	tested	the	impact	of	a	patient	decision	aid	on	decision-making	for	mode	of	delivery	after	caesarean	and	found	that	women’s	preferences	for	mode	of	delivery	were	not	consistent	with	actual	birth	outcomes.(38)	Rather			7	the	hospital	site	at	which	women	gave	birth	was	the	variable	that	predicted	whether	or	not	patients	planned	a	vaginal	delivery.	Low	VBAC	rates	in	one	of	the	two	study	sites	may	have	been	the	result	of	“organizational	culture	and	clinical	practice	patterns”(38)	characterized	by	health	care	provider	resistance	to	VBAC	and	unsupportive	hospital	policies.(39)	These	findings	suggest	that	patient	VBAC	preferences	are	honoured	only	in	settings	that	have	supportive	infrastructure,	resources,	and	policies.		Exploration	of	health	service	decision	makers’	attitudes	and	experiences	may	provide	insight	into	why	health	services	do	not	provide	the	resources	necessary	to	fulsomely	support	women’s	choice	of	options	for	mode	of	birth	after	caesarean.	These	systems	level	factors	have	not	been	explored	in	the	literature,	which	has	focused	to	date	primarily	on	the	decision-making	experiences	of	individual	women	and	more	recently	on	the	attitudes	of	care	providers	toward	VBAC.(31–34)	Without	identifying	and	addressing	these	health	systems	issues,	efforts	to	support	women’s	decision-making	will	likely	be	unsuccessful.		1.2 Purpose	of	the	Dissertation	This	research	aims	to	expand	the	decision-making	paradigm	beyond	the	patient-provider	dyad	and	explores	the	influence	on	women	of	family	members,	peers,	and	cultural	groups,	as	well	as	the	influence	on	care	providers	of	colleagues,	health	service	decision	makers,	and	professional	organizations	and	colleges.	I	aim	to	produce	locally-derived	knowledge	on	the	factors	that	influence	decision-making	within	different	health	service	settings	and	patient	populations	to	facilitate	the	development	and	testing	of	tailored	interventions	to	support	women’s	informed			8	choice	of	mode	of	delivery	after	caesarean.	To	that	end,	in	this	dissertation,	I	explore	attitudes	toward	and	experiences	with	decision-making	for	mode	of	birth	after	caesarean	to	identify	the	factors	that	influence	decision-making	for	mode	of	delivery.	Specifically,	my	objective	is	to	explore	the	following	descriptive	research	questions.	1. What	are	women’s	attitudes	toward	and	experiences	with	mode	of	delivery	after	caesarean	in	British	Columbia?		2. What	are	care	providers’	attitudes	toward	and	experiences	with	providing	care	for	women	considering	mode	of	delivery	after	caesarean	in	British	Columbia?		3. What	are	decision	makers’	experiences	with	planning	services	for	birth	after	caesarean	in	British	Columbia?		These	research	questions	emerged	from	a	review	of	the	literature	on	the	factors	that	influence	decision-making	for	birth	after	caesarean	(Chapter	2).	Following	principles	of	“integrated	knowledge	translation,”(3,9)	the	research	questions	were	also	informed	by	discussions	with	knowledge	partners	in	one	region	of	British	Columbia,	Fraser	Health	Authority,	where	optimizing	services	for	birth	after	caesarean	is	a	key	health	services	and	policy	objective.		Integrated	knowledge	translation	(iKT)	is	rooted	in	the	paradigms	of	participatory	research	and	engaged	scholarship.	It	stresses	the	importance	of	having	researchers	engage	with	the	stakeholders	who	will	use	research	results	and	leverage	their	different	perspectives	to	create	knowledge	that	is	more	relevant,	useful,	and	usable.(40)	iKT	stems	from	a	recognition	that	academic	research	results	may	not	be	easily	transferable	into	practice	and	policy	due	to	various	barriers:	the	need	for	resources	to	support	implementation	of	evidence,	the	complexity			9	of	changing	clinicians’	and	policy	makers’	beliefs	and	behaviour,	the	importance	of	fit	between	the	research	context	and	the	setting	where	research	is	to	be	implemented,	timelines	for	policymaking,	and	the	perceived	credibility	of	research	findings.(41,42)	Research	results	may	be	more	relevant	to	stakeholders	if	the	research	questions	respond	to	problems	they	have	identified	and	the	movement	of	knowledge	is	bi-directional	between	researchers	and	stakeholders.(3)	In	this	dissertation	research	I	engaged	with	patient,	care	provider,	and	decision	maker	stakeholders	with	the	objective	of	facilitating	the	co-production	of	knowledge	and	uptake	of	study	findings	to	support	women’s	decision-making	for	birth	after	caesarean.	I	describe	this	process	in	detail	in	Chapter	7.	Stakeholders	refers	to	individuals	and	organizations	involved	in	receiving,	providing,	or	planning	care	for	birth	after	caesarean,	including	patients,	care	providers,	and	health	service	decision	makers.	Throughout	the	dissertation	I	use	the	term	“knowledge	partners”	to	describe	the	stakeholders	who	actively	engaged	in	the	study	as	participants,	expert	informants,	or	research	collaborators.		1.3 Conceptual	Framework	This	dissertation	research	is	underpinned	by	a	number	of	assumptions,	which	I	introduce	briefly	here	before	describing	in	detail	in	the	sections	below.	First,	I	proceed	with	the	assumption	that	the	optimal	model	of	decision-making	for	birth	after	caesarean	is	“shared	decision-making”	(SDM).	In	SDM	health	care	providers	and	patients	exchange	information	to	understand	the	medical	risks	and	benefits	of	health	care	options,	reveal	their	values	and	preferences,	and			10	jointly	decide	on	a	treatment	strategy	that	incorporates	both	the	clinical	evidence	and	their	preferences.(43)	SDM	is	particularly	suited	for	childbirth	decisions	where	there	is	clinical	uncertainty	or	equipoise,	or	where	the	patient	has	to	make	trade-offs	between	the	known	benefits	and	harms	of	each	option.(44)	For	such	decisions,	the	optimal	choice	depends	on	the	woman	and	her	family’s	personal	values.		Second,	I	approached	this	dissertation	research	through	the	lens	of	integrated	knowledge	translation	(iKT).	In	iKT,	as	noted	above,	knowledge	partners	participate	throughout	the	research	process	with	the	aim	of	co-producing	knowledge	that	is	relevant	and	usable	for	solving	healthcare	problems.	As	described,	knowledge	partners	are	individuals	who	are	likely	to	use	research	results	to	make	informed	healthcare	decisions	about	practices	and	policies,	and	in	this	study	include	childbearing	women,	their	families,	care	providers,	and	health	service	decision	makers	at	the	hospital,	regional,	and	government	level.	In	this	study,	knowledge	partners	(including	patient	advocates,	care	providers,	and	hospital	and	regional	decision	makers)	were	involved	from	the	start	of	the	research	process	and	participated	throughout,	including	in	defining	the	problem,	selecting	methods,	recruiting	participants,	and	interpreting	findings.	I	provide	a	full	description	of	iKT	activities	in	Chapter	7.	Third,	my	analysis	of	participants’	narratives	on	decision-making	for	mode	of	delivery	after	caesarean	was	informed	by	complex	adaptive	systems	theory.	A	complex	adaptive	system	(CAS),	drawing	from	Plsek	and	Greenhalgh’s	illustrative	definition,	is	a	collection	of	individuals	“with	freedom	to	act	in	ways	that	are	not	always	totally	predictable,	and	whose	actions	are	interconnected	so	that	one	agent's	actions	changes	the	context	for	other	agents.”(1)	As	my			11	dissertation	is	premised	on	the	assumption	that	women’s	decisions	for	birth	after	caesarean	are	influenced	by	contextual	factors	and	relationships	at	micro,	meso,	and	macro	levels	of	the	healthcare	system,	CAS	is	a	fitting	framework	for	understanding	mode	of	delivery	decision-making	and	implementation	of	SDM.		 These	three	concepts	share	an	ontological	(and	interdisciplinary)	perspective	that	different	forms	of	knowledge	are	legitimate	and	valued.	Shared	decision-making	presumes	that	care	providers	have	expert	clinical	knowledge	while	patients	are	experts	on	their	health	and	illness	experiences.	Integrated	knowledge	translation	emphasizes	the	importance	of	weaving	together	knowledge	from	practical	wisdom,	community	perspectives,	professional	experience,	and	research	evidence	to	inform	implementation.	Complex	adaptive	systems	theory	likewise	claims	that	knowledge	about	a	health	care	system	is	not	located	in	the	narrow	perspective	of	care	providers	only,	but	holistically	by	comparing	the	perspectives	of	different	agents	in	the	system,	of	other	overlapping	systems,	and	the	relationships	between	them.	In	the	following	sections	I	provide	an	overview	of	these	concepts	and	orient	the	reader	to	key	terms	used	throughout	the	dissertation.		1.3.1 Shared	Decision-Making	Patient-centred	care,	following	the	Institute	of	Medicine’s	definition,	is	“respectful	of	and	responsive	to	individual	patient	preferences,	needs,	and	values,”	and	it	aims	to	ensure	“that	patient	values	guide	all	clinical	decisions.”(45)	Shared	decision-making	(SDM)	is	said	to	be	the	“crux	of	patient-centred	care.”(43)	SDM	is	distinct	from	“informed	choice”	decision-making,			12	which	is	a	form	of	non-directive	counseling	commonly	used	in	Canadian	maternity	care.(46)	In	an	informed	choice	model	of	decision-making,	the	care	provider	gives	information	on	medical	risks	and	benefits	to	the	patient,	who	then	makes	a	decision	on	their	own.	SDM,	in	contrast,	also	involves	eliciting	the	patient’s	values,	which	may	involve	gaining	clarity	about	the	patient’s	values,	personal	health	goals,	lifestyle	concerns,	and	how	these	align	with	standards	of	care.	The	ideal	result	of	SDM	is	a	quality	patient	decision,	defined	as	one	that	is	informed,	consistent	with	personal	values,	and	acted	upon.(47)	Ideally,	the	quality	of	the	decision	should	be	judged	by	how	well	it	follows	this	process,	not	the	outcome	of	the	decision.	To	measure	whether	a	decision	is	high	quality,	researchers	assess	whether	the	patient	was	knowledgeable	of	their	health	care	options,	and	any	risks	and	benefits;	whether	the	patient’s	choice	reflected	what	matters	most	to	them;	and	whether	they	received	the	actual	health	care	option	that	matched	their	informed	values.	A	quality	patient	decision	for	planned	VBAC	should	thus	be	judged	on	the	decision-making	process,	not	by	whether	it	resulted	in	a	healthy	outcome	or	actual	VBAC.	“Informed	consent,”	a	further	concept	in	decision-making,	is	the	principle	that	patients	have	the	right	to	be	informed	of	their	options,	to	agree	voluntarily	to	a	healthcare	decision,	and	that	decision	should	respect	the	wishes	of	the	patient.(5)	SDM	has	been	variously	described	as	the	ideal	approach	for	achieving	informed	consent,	and	as	a	distinctly	separate	process.(48)	Criteria	for	SDM	developed	by	Towle	and	Godolphin	have	been	developed	and	tested	in	various	settings	and	suggest	competencies	for	both	the	care	provider	and	patient.(49,50)	For	the	care	provider,	criteria	include	ascertaining	and	responding	to	the	patient’s	values,	identifying	choices	and	evaluating	the	evidence	in	relation	to	the	patient,	and	making	or			13	negotiating	a	decision	in	partnership	with	the	patient.	The	patient,	in	turn,	should	communicate	with	the	physician	to	ensure	that	they	understand	the	research	evidence.	They	should	share	relevant	information	about	their	health	problems,	feelings,	beliefs,	and	expectations.	As	a	result	of	this	two-way	communication,	the	health	care	decision	is	a	“meeting	of	experts,”	informed	by	two	sources	of	equally	relevant	information.(51)	Légaré	and	colleagues	theorize	that	SDM	extends	beyond	this	patient-provider	dyad	and	is	actually	an	“interprofessional”	process	influenced	by	factors	at	the	micro,	meso,	and	macro	levels	of	the	healthcare	system.(52)	In	their	model,	the	“actors”	involved	in	the	decision-making	process	include:	the	patient;	the	healthcare	professional	who	initiates	the	SDM	process;	the	health	professional	who	coaches	the	patient	through	the	decision;	family	members,	surrogates,	and	significant	others;	and	various	other	“interprofessional”	healthcare	providers	who	encounter	the	patient	throughout	their	decision-making	process.(52)	The	decision-making	process,	they	posit,	is	influenced	by	contextual	factors	that	may	include	individual	behavior,	liability	concerns,	health	professional	regulations	and	policies,	as	well	as	broader	cultural	factors,	which	may	include	the	values	and	risk	attitudes	of	different	health	professions,	ethnicities,	and	religious	groups.(52)	The	context	of	decision-making	in	maternity	care	includes	an	additional	layer	of	complexity	because	two	patients	are	involved	–	the	mother	and	her	fetus.	Childbirth	decisions	thus	may	require	the	woman	and	her	family	to	make	difficult	trade-offs	that	may	benefit	the	mother’s	well-being	but	increase	risk	to	her	fetus	(and	vice	versa),	which	can	heighten	anxiety	and	uncertainty	in	decision-making	(e.g.	decisional	conflict).(53)	For	instance,	in	the	case	of	elective	repeat	caesarean	versus	planned	VBAC,	while	the	absolute	risk			14	of	mortality	is	very	small,	it	is	statistically	higher	for	the	mother	(0.13	vs.	0.04	deaths	per	1,000)	than	the	fetus	(0.5	vs.	1.3	deaths	per	1,000).(54)	To	capture	the	range	of	“risks”	involved	in	a	decision	for	birth	after	caesarean,	I	draw	from	the	concept	of	“comprehensive”	risk	developed	by	rural	maternity	health	services	researchers	Barclay	and	colleagues.(2)	Comprehensive	risk	involves	two	core	categories:	health	services	risks	and	social	risks.	“Health	services	risks”	involve	clinical	risks	(e.g.	adverse	outcomes	for	mother	and	baby),	as	well	as	legal,	political,	operational,	and	financial	risks.	“Social	risks”	to	patients,	in	contrast,	involve	cultural	risks	to	traditional	values	and	spirituality,	emotional	risks	of	system-initiated	distress,	and	financial	risks	of	compromised	family	budgets,	for	instance	due	to	costs	they	incur	in	traveling	to	access	health	services.	Ideally,	in	SDM	these	various	risks	are	discussed	through	information	exchange	between	the	patient	and	her	care	team.	I	explore	the	concept	of	comprehensive	risk	further	in	the	Literature	Review	section	of	the	Dissertation.	In	Canada,	implementation	of	SDM	has	been	slow	and	inconsistent,	but	there	is	emerging	growing	interest	in	such	strategies	to	promote	patient-centred	care.	The	Canadian	Institutes	for	Health	Research’s	multi-faceted	Strategy	for	Patient-Oriented	Research	(SPOR)	aims	to	fund	research	that	“engages	patients	as	partners,	focuses	on	patient-identified	priorities	and	improves	patient	outcomes.”(55)	There	are	also	provincial	initiatives	taking	hold.	In	Saskatchewan,	the	health	ministry	“has	identified	shared	decision-making	as	a	key	strategic	and	operational	priority…	and	directed	regions	to	incorporate	shared	decision-making	in	their	efforts	to	improve	care.”(56)	The	British	Columbia	Patient-Centred	Care	Framework	released	by	the	Ministry	of	Health	in	February	2015	includes	“shared	and	informed	decision-making”	as	a			15	component	of	patient-centred	care	and	describes	the	development	of	tools	as	one	of	four	patient-centred	care	practices:	“The	pursuit	of	patient-centered	care	can	be	supported	by	the	development	of	tools	to	assist	the	organization	in	putting	the	needs	of	patients	and	families	at	the	center	of	care.”(57)	In	developing	knowledge	to	explore	implementation	of	SDM	for	birth	after	caesarean,	I	draw	from	the	principles	of	knowledge	translation.		1.3.2 Knowledge	Translation	Knowledge	translation	(KT)	is	defined	as	“a	dynamic	and	iterative	process	that	includes	synthesis,	dissemination,	exchange	and	ethically	sound	application	of	knowledge	to	improve	the	health	of	Canadians,	provide	more	effective	health	services	and	products	and	strengthen	the	health	care	system.”(9)	In	this	dissertation,	I	draw	on	two	conceptual	frameworks	for	conducting	knowledge	translation:	the	Knowledge-to-Action	(KTA)	cycle,(20)	and	integrated	knowledge	translation	(iKT).	The	KTA	cycle	is	a	widely	used	KT	conceptual	framework	that	was	developed	by	researchers	and	members	of	the	Canadian	Institutes	of	Health	Research	following	a	review	of	31	planned	action	theories.(10)	Its	development	aimed	to	create	clarity	around	the	concepts	and	key	elements	in	the	KT	process	while	providing	a	flexible	“map”	that	researchers	may	use	to	create	the	bridge	between	research	and	action.	Integrated	knowledge	translation	(iKT),	also	known	as	“engaged	scholarship,”	furthers	this	process	to	engage	potential	knowledge	users	throughout	the	research.	While	the	KTA	cycle	identifies	what	the	key	stages	are	in	the	KT	process,	integrated	knowledge	translation	(iKT)	offers	a	perspective	on	who	should	be	engaged			16	and	how	they	might	engage.	This	approach	aims	to	“produce	research	findings	that	are	more	likely	to	be	directly	relevant	to	and	used	by	knowledge	users.”(9)	This	form	of	KT	research	is	concerned	with	understanding	or	harnessing	the	factors	that	influence	uptake	of	knowledge	in	practice	and	policy.	It	is	related	to	“implementation	science,”	which	focuses	on	the	development	and	testing	of	methods	that	influence	uptake	of	knowledge	in	practice	and	policy,	and	on	studying	the	factors	that	influence	patient,	care	provider,	and	organizational	behaviour	in	healthcare	settings.	Conducting	iKT	research	focuses	researchers	and	stakeholders	on	the	same	page,	identifies	facilitators	and	barriers	to	the	process	of	evidence	implementation,	provides	empirical	evidence	to	support	health	service	planning,	and	through	the	partnership	process	itself	is	instrumental	in	implementing	sustainable	change.(58)	By	collaborating	with	stakeholders	from	the	beginning	of	a	research	process,	researchers	are	more	likely	to	integrate	their	“capital	R”	research	(58)	with	local,	contextual	knowledge	that	“reflect[s]	the	complexities	of	the	specific	environment,”	which	may	include	“local	evaluation	data,	population	profiles,	provider	expertise,	local	resource	availability,	and	patient	preferences.”(40)		Consequently,	in	an	iKT	research	process	different	forms	of		“knowledge”	are	legitimate.	The	“knowledge”	in	KT	may	be	defined	as	evidence	in	context.	Evidence	may	be	“research-based	findings	transparently	compiled,	analysed	and	interpreted	according	to	rigorous	methodological	processes	and	standards,”(6)	while	context	refers	to	“the	conditions	or	surroundings”	in	which	evidence	exists,	“typically	referring	to	an	analytical	unit	that	is	higher	than	the	phenomena	directly	under	investigation.”(7)	These	conditions	or	surroundings	may			17	include	practical	wisdom,	lived	experience,	and	social	norms.	This	expansive	definition	of	knowledge	informs	my	study	design	–	I	have	sought	to	generate	evidence	using	rigorous	qualitative	methods	while	using	iKT	strategies	to	ensure	that	this	evidence	is	developed	and	interpreted	in	a	local	context	in	partnership	with	patients,	care	providers,	and	policy	makers.	This	approach	also	reflects	my	interdisciplinary	doctoral	training,	in	which	I	wove	together	traditionally	positivist	(health	services	research,	population	health)	and	constructivist	(qualitative)	research	paradigms	that	hold	differing	perspectives	on	what	knowledge	is	and	how	it	is	created.	In	analyzing	the	findings	of	my	dissertation,	I	continued	this	approach	in	choosing	a	theoretical	framework	(complex	adaptive	systems)	that	explains	how	context	influences	the	implementation	of	evidence	on	SDM	for	birth	after	caesarean.		1.3.3 Complex	Adaptive	Systems	Complexity	science	is	a	paradigm	commonly	used	to	explain	contextual	and	organizational	influences	on	knowledge	translation	and	to	guide	implementation	of	health	service	innovations.	Complex	adaptive	systems	(CAS),	such	as	healthcare,	exhibit	a	number	of	common	characteristics.	Their	boundaries	are	poorly	defined	and	membership	in	the	system	can	change.	Stakeholders	(e.g.	patients,	health	care	professionals,	decision	makers)	can	be	part	of	multiple	systems	at	once,	such	as	a	primary	health	care	team,	professional	college,	and	regional	authority.	Consequently	interactions	among	the	stakeholders	and	the	system,	and	between	the	system	and	its	environment,	change	as	the	system	self-organizes	in	response	to	small	triggers	in	non-linear,	dynamic,	and	unpredictable	ways.	For	instance,	one	woman’s	experience	of	uterine			18	rupture	and	the	death	of	her	baby	may	be	socially-circulated	and	result	in	a	friend	of	a	friend	opting	for	planned	repeat	caesarean	after	she	hears	the	story.	Stakeholders	respond	to	their	environments	by	acting	on	internalized	rules,	such	as	instinct	or	heuristics,	and	these	rules	may	look	illogical	to	another	agent.	“Gain	the	woman’s	informed	consent	for	mode	of	delivery”	might	be	a	rule	that	the	care	provider	follows	as	part	of	their	standards	of	practice.	“Do	not	keep	the	busy	doctor	from	getting	to	other	patients”	might	be	a	rule	that	a	woman	adopts	during	clinic	visits.		Finally,	each	individual	and	system	is	nested	in	other	systems	that	co-evolve	together	and	interact.	This	co-evolution	creates	a	natural	tension	and	paradox	that	cannot	and	does	not	need	to	be	resolved.	It	may	lead	to	creative	and	novel	approaches	to	issues.	In	the	case	of	birth	after	caesarean,	for	instance,	two	somewhat	contradictory	assumptions	underpin	strategic	planning.	From	a	population	health	perspective,	one	assumption	is	that	the	VBAC	rate	is	too	low	and	should	be	increased	to	maximize	overall	perinatal	health.(59)	From	a	patient-centred	care	perspective,	one	assumption	is	that	women	should	choose	the	mode	of	delivery	that	reflects	their	values,	preferences,	and	lifestyle,	and	thus	elective	repeat	caesarean	is	a	reasonable	option	for	informed	women.(17)		In	CAS	approaches	to	knowledge	translation,	such	paradoxes	between	different	parts	of	the	healthcare	system	are	natural,	necessary,	not	something	to	try	to	resolve	through	a	top-down	or	outside	approach,	like	a	mechanic	fixing	an	engine.	Rather	CAS	theory	offers	that	in	the	face	of	tension	individuals	will	interact	to	create	novel	behaviors	and	solutions,	more	akin	to	adaptation	in	an	ecosystem.	In	a	healthcare	system,	the	key	is	to	support	stakeholders	to			19	engage	in	“productive	interaction”	to	create	mutual	understanding	of	their	different	attitudes	and	experiences,	and	to	identify	opportunities	where	policy	and	practice	can	be	modulated.(60)	My	dissertation	research	supports	this	productive	interaction	by	first	exploring	the	phenomenon	of	decision-making	for	birth	after	caesarean	at	micro,	meso,	and	macro	levels	of	the	healthcare	system,	and	identifying	the	interactions	between	stakeholders	(Chapter	4-6).	Concurrently,	I	engaged	in	iKT	activities	to	encourage	mutual	understanding	of	this	evidence	between	different	stakeholders	(Chapter	7).	Throughout,	I	use	the	“micro,	meso,	and	macro	levels	of	the	healthcare	system”	to	conceptualize	the	different	actors	and	organizations	that	may	influence	decision-making	for	mode	of	delivery	after	caesarean.	The	micro-level	of	the	health	system	involves	individuals	in	clinical	and	social	encounters,	including	patients,	their	families,	and	care	providers.	The	meso-level	includes	the	hospitals,	organizations,	communities,	social	networks,	and	regions	in	which	these	individuals	act.	The	macro-level	includes	the	policy,	cultural,	and	governmental	context	of	health	services.	Decision-making	for	birth	after	caesarean	may	take	place	at	the	micro-level	between	individuals	in	clinical	encounters.	At	the	meso-level,	it	may	involve	decisions	by	hospitals	to	provide	health	services	and	resources	to	support	vaginal	and	caesarean	birth.	At	the	macro-level,	it	may	involve	system-wide	processes,	policies,	or	cultural	behaviour	that	influence	the	system	as	a	whole,	such	as	clinical	practice	guidelines	or	financial	incentives	for	physicians.	This	conceptualization	is	consistent	with	the	concepts	of	micro-,	meso-,	and	macro-level	decision-making	used	in	the	Canadian	Medical	Association’s	policy	for	making	choices	concerning	core	and	comprehensive	health	care	services.(61)				20		1.4 Significance	of	the	Dissertation	Research	that	illuminates	the	factors	influencing	implementation	of	SDM	for	birth	after	caesarean	has	significant	implications	for	maternal	and	newborn	health	and	wellbeing,	and	for	health	system	costs.	Understanding	and	“diagnosing”	women’s	preferences	for	mode	of	birth	after	caesarean	is	necessary	in	order	to	ensure	that	women	plan	for	their	desired	birth	experience,	a	core	component	of	patient-centred	maternity	care.	Informed	choice	decision-making,	where	the	patient	alone	decides,	may	lead	to	“silent	misdiagnosis”	of	patient	preferences	and	poor	healthcare	choices.(62)	In	Lee	et	al’s	cross-sectional	survey	of	breast	cancer	patients	and	providers	in	the	Boston	area,	doctors	misdiagnosed	patient	treatment	preferences,	believing	71%	of	breast	cancer	patients	felt	it	was	most	important	to	keep	their	breast,	while	the	actual	figure	reported	by	surveyed	patients	was	only	7%.(63)	Qualitative	research	involving	27	care	providers	and	43	women	from	three	isolated	rural	communities	in	British	Columbia	highlighted	that	in	choosing	place	of	birth	women	may	prioritize	social	outcomes,	such	as	giving	birth	in	one’s	home	community	among	family	and	friends,	over	clinical	outcomes,	such	as	having	access	to	caesarean	section	and	epidural	analgesia	in	a	“referral”	hospital	with	a	higher	level	of	obstetric	service.(64)	In	extreme	circumstances,	when	care	providers	did	not	identify	and	incorporate	women’s	preferences	for	local	birth	into	decision-making,	women	chose	to	have	an	unassisted	home	birth	or	arrived	at	the	hospital	in	advanced	labour	to	prevent	transfer	to	a	“referral”	community	with	a	higher	level	of	obstetric	service,	causing	increased	clinical	risk	of	adverse	outcomes.(64,65)				21	There	is	some	evidence	that	preference	misdiagnosis	occurs	in	decision-making	for	birth	after	caesarean	and	that	women	struggle	to	make	the	choice	for	mode	of	delivery.	Qualitative	studies	of	women’s	decision-making	for	birth	after	caesarean	in	Australia	(66)	and	the	United	Kingdom	(67)	indicate	that	women	experience	a	tension	between	their	desire	to	have	a	vaginal	birth,	what	they	felt	was	best	for	themselves,	and	to	maximize	well-being	for	their	baby,	based	on	the	perception	that	elective	caesarean	was	safest	for	neonates.	Women	frequently	base	their	choice	on	the	social	needs	of	their	family,	such	as	the	need	for	a	short	postpartum	recovery	in	order	to	care	for	their	partner	and	other	children,	rather	than	on	clinical	risks	and	benefits	to	her	and	her	baby.(24)	These	studies	illustrate	that	women	do	not	make	informed	choices	for	mode	of	delivery	after	caesarean	in	isolation,	rather	they	are	influenced	by	a	complex	web	of	social	and	professional	relationships.	In	order	to	support	women’s	decision-making,	it	is	necessary	to	understand	the	context	of	their	choices.		 When	faced	with	the	challenging	decision	of	mode	of	delivery	after	caesarean,	women	also	desire	more	decision	support.	Qualitative	studies	nested	in	randomized	controlled	trials	evaluating	SDM	tools	for	birth	after	caesarean	have	reported	that	many	women	find	informed	choice	decision-making	and/or	non-directive	counseling	to	be	unsupportive	and	would	prefer	more	guidance	in	decision-making.(38,68,69)	This	indicates	the	need	for	assessing	women’s	desired	level	of	participation	in	decision-making	rather	than	adopting	a	blanket	approach	to	“informed	choice”	for	birth	after	caesarean.			 It	is	also	important	to	have	an	understanding	of	the	context	of	women’s	decision-making	and	how	care	providers	and	health	service	decision	makers	influence	women’s	choices.			22	The	Obstetrics	and	Gynecology	Risk	Research	Group,	a	multidisciplinary	team	of	researchers	interested	in	the	ethics	of	childbirth	decision-making,	argues	that	the	power	dynamics	between	patient	and	care	provider	make	it	challenging	for	patients	to	express	their	preferences,	ask	questions	when	information	is	unclear,	and	advocate	for	their	informed	choices.(16,17)	While	such	power	imbalances	are	not	unique	to	maternity	care,	they	impact	women’s	agency	and	may	allow	care	providers	to	influence	women’s	decisions	to	match	their	clinical	recommendation,	which	is	frequently	to	opt	for	elective	repeat	caesaeran.	Klein	et	al	found	in	their	survey	of	Canadian	maternity	care	practitioners	that	obstetricians,	family	physicians,	and	midwives	as	groups	have	varying	attitudes	toward	safety	in	childbirth,	with	obstetricians	favouring	elective	repeat	caesarean	section	for	women	with	a	previous	uterine	scar.(70)	Similarly,	a	survey	of	a	representative	sample	of	2,400	US	women	who	gave	birth	between	2011-12	revealed	that	when	care	providers	expressed	an	opinion	regarding	options	for	birth	after	caesarean	(72%	of	the	time),	it	was	typically	in	favour	of	a	caesarean	(88%).(71)	This	evidence	suggests	that	care	providers’	attitudes	may	be	reflected	in	the	advice	they	provide	to	women,	which	may	in	turn	influence	women	to	plan	elective	repeat	caesareans	that	may	not	reflect	their	preferences.	It	is	thus	necessary	to	explore	the	role	of	the	context	of	women’s	decision-making	to	understand	the	constellation	of	factors	that	may	influence	implementation	of	SDM.	Understanding	these	factors	may	assist	in	the	development	of	strategies	that	could	facilitate	implementation.		Finally,	caesareans	in	circumstances	where	planned	VBAC	is	a	reasonable	option	are	associated	with	increased	costs	to	the	healthcare	system	and	adverse	health	outcomes.			23	Caesarean	delivery	costs	60%	more	than	vaginal	delivery	($4600	vs.	$2800)	and	consequently	“overdiagnosis”	of	caesarean	creates	strain	on	health	care	system	funding	and	resources.(72)	Notably,	repeat	caesareans	are	the	single	largest	contributor	to	the	overall	caesarean	section	rate	in	Canada.	In	2010-11,	multiparous	women	with	a	singleton,	cephalic	pregnancy	who	had	a	repeat	caesarean	at	term	accounted	for	32%	(n=21,947)	of	all	caesareans	for	five	Canadian	provinces	(British	Columbia,	Alberta,	Ontario,	Nova	Scotia,	and	Newfoundland	and	Labrador).(11)	In	that	same	study,	the	next	largest	contributor	to	the	caesarean	rate	was	primary	caesarean	for	nulliparous	women	with	a	singleton,	cephalic,	term	pregnancy	who	were	induced	or	had	a	caesarean	before	labour	(17%,	n=11,956)	and	the	caesarean	rate	for	the	total	obstetric	population	was	28.5%	(n=68,584).(11)	Caesareans	also	expose	mothers	to	risk	of	morbidity	and	mortality,	including	uterine	rupture,	hysterectomy,	operative	injury,	and	puerperal	fever.(13,73)	In	a	large	meta-analysis	of	the	published	literature	on	VBAC	(1966-2009)	the	rate	of	uterine	rupture	for	all	women	with	a	prior	caesarean	(regardless	of	route	of	delivery)	was	0.3%	(95%	CI	0.2-0.4)	and	the	risk	was	significantly	increased	with	planned	VBAC	(0.47%)	versus	elective	repeat	caesarean	(0.026%).(54)		With	each	subsequent	caesarean,	the	risk	of	complications	and	adverse	outcomes	increases.	After	two	caesareans,	the	risk	of	placenta	accreta	is	0.57%,(74)	which	is	similar	to	the	risk	of	uterine	rupture	after	one	caesarean.	The	overall	risk	of	perinatal	death	due	to	uterine	rupture	is	6.2%,(54)	while	the	risk	of	maternal	mortality	due	to	placenta	accreta	is	7%	(75)	and	71%	of	placenta	accreta	cases	result	in	hysterectomy.(76)	Compared	to	babies	born	vaginally,	those	born	by	caesarean	are	more	likely	to	have	respiratory	complications,	be	admitted	to			24	neonatal	intensive	care,	and	have	difficulty	breastfeeding.(77)	In	the	long-term,	children	born	by	caesarean	also	have	increased	odds	of	obesity	and	of	developing	allergic	and	autoimmune	diseases,	including	asthma	and	type	1	diabetes.(78,79)		Taken	together,	this	evidence	indicates	that	clinically	unnecessary	caesareans	come	with	significant	costs	to	the	health	care	system.	However,	SDM	has	the	potential	to	curb	these	effects	in	addition	to	enhancing	patient-centred	care.	Interventions	to	support	SDM	for	birth	after	caesarean	are	associated	with	a	significant	increase	in	women’s	knowledge	of	the	clinical	risks	and	benefits	of	mode	of	delivery.(44,80)	SDM	researchers	hypothesize	that	women	who	are	informed	of	the	risks	of	repeat	caesareans	may	be	more	likely	to	prefer	planned	VBAC,	which	would	in	turn	lead	to	decreased	caesarean	rates	and	adverse	outcomes.(81)	However,	to	ensure	that	women	receive	the	mode	of	birth	that	matches	their	informed	preferences,	it	is	necessary	that	they	have	a	supportive	context	in	which	to	act	on	that	decision.	Exploring	the	context	of	women’s	decision-making	will	lead	to	locally-derived	knowledge	on	the	factors	that	influence	choice	and	may	be	used	in	the	development	and	testing	of	tailored	interventions	to	support	SDM	for	mode	of	delivery	after	caesarean.	In	summary,	women’s	decision-making	for	birth	after	caesarean	takes	place	in	a	complex	social	and	health	services	context.	Women	struggle	to	make	difficult	trade	offs	between	the	options	of	mode	of	delivery	and	would	benefit	from	decision	support	in	the	form	of	SDM.	The	current	study	offers	such	knowledge	by	using	an	iKT	framework	to	explore	attitudes	toward	and	experiences	with	decision-making	for	birth	after	caesarean	in	the	context			25	of	British	Columbia.	Findings	may	have	significant	implications	for	the	development	and	implementation	of	strategies	to	support	SDM.			1.5 Structure	of	the	Chapters	In	Chapter	2,	I	provide	a	review	of	the	literature	relevant	to	the	qualitative	study	of	decision-making	for	mode	of	birth	after	caesarean.	In	Chapter	3,	I	describe	the	constructivist	grounded	theory	study	design	and	methods	I	used	to	answer	my	research	questions.	In	Chapters	4	and	5	I	provide	the	results	of	my	qualitative	analysis	of	interviews	with	women,	care	providers,	and	policy	makers.	In	Chapter	6,	I	synthesize	this	analysis	using	the	lens	of	complex	adaptive	systems	theory.	In	Chapter	7,	I	describe	the	integrated	knowledge	translation	(iKT)	process	that	took	place	over	the	course	of	the	dissertation	research.	Finally,	in	Chapter	8,	I	offer	a	discussion	of	the	qualitative	research	findings	and	their	implications	for	future	research,	policy,	and	practice.						26	Chapter	2: Literature	Review	In	this	chapter	I	provide	a	critical	analysis	of	the	literature	relevant	to	decision	making	for	mode	of	delivery	after	caesarean.	I	expand	on	key	concepts	presented	in	the	Introduction,	appraise	and	synthesize	the	relevant	literature,	and	provide	the	empirical	and	theoretical	rationale	for	my	methodology.	I	begin	by	discussing	the	literature	as	it	pertains	to	attitudes,	experiences,	and	risk	perceptions	with	birth	after	caesarean	at	the	micro	level	of	the	healthcare	system	among	women	and	care	providers	(section	2.1).	I	then	describe	the	literature	on	the	meso	and	macro	(organizational,	policy,	cultural)	contextual	factors	that	influence	access	to	VBAC	and	the	resources	needed	to	support	women’s	decision-making	(section	2.2).	Finally,	I	explore	research	on	interventions	to	support	decision-making	for	birth	after	caesarean	and	describe	previous	literature	exploring	implementation	of	SDM	interventions	(section	2.3).			2.1 The	Interdisciplinary	Literature	Review	Method	Grounded	theory	research	aims	to	develop	a	theory	that	emerges	from	qualitative	data,	rather	than	to	test	a	specific	hypothesis.	A	literature	review	may	contaminate	this	emergence	by	imposing	ideas	and	assumptions	on	qualitative	data	from	the	existing	literature.	Glaser	and	Strauss’s	traditional	or	classical	grounded	theory	research	contests	conducting	the	literature	review	prior	to	analysis,	seeing	it	as	a	“constraining”	exercise	that	can	compromise	the	validity	of	analysis.(82)	However,	the	notion	that	the	researcher	can	remove	all	prior	knowledge	of	an	area	of	research	is	unrealistic.	More	recent	iterations	of	grounded	theory	posited	by	Strauss	and	Corbin	(83)	and	Charmaz	(84)	take	the	epistemological	position	that	there	is	no	such	thing			27	as	neutral	or	objective	research	and	a	researcher	cannot	abandon	all	prior	knowledge	when	embarking	on	a	study.			Disciplinary	conventions	also	commonly	dictate	that	a	literature	review	be	conducted	at	the	outset	of	the	research	process.	In	health	services	research,	one	of	my	overarching	disciplines,	a	literature	review	aims	to	identify	gaps	in	the	research,	clarify	unanswered	questions,	and	critique	the	existing	literature.	The	literature	review	assists	in	justifying	the	rationale	for	the	research	project	and	assists	in	preparing	the	research	proposal	and	ethics	application	for	data	collection	and	analysis.	These	benefits	of	an	early	literature	review	also	apply	to	grounded	theory	research.	However	in	grounded	theory,	the	literature	review	also	functions	as	“data	to	be	used	by	the	analytic	strategies	of	the	research.”(85)	It	can	serve	as	a	source	of	comparison	and	analysis	to	demonstrate	how	an	author’s	theory	“extends,	transcends,	or	challenges	dominant	ideas	in	your	field.”(84)	An	early	literature	review	in	a	grounded	theory	study	can	help	the	researcher	gain	sensitivity	to	assumptions	and	preconceptions	in	their	field	of	study	and	in	their	own	perspective	on	the	research	problem.(86)	My	literature	review	was	a	recursive	process	that	began	at	the	outset	of	my	doctoral	program	of	research	to	provide	an	understanding	of	the	existing	published	research	on	decision-making	for	birth	after	caesarean.	This	was	not	a	systematic	review	of	the	literature	that	would	precede	a	hypothesis	testing	study.	Rather	I	explored	the	published	literature	on	women’s,	care	providers’,	and	organizational	attitudes	and	experiences	toward	decision-making	for	birth	after	caesarean,	as	well	as	research	on	implementation	of	SDM	for	birth	after	caesarean.	The	search	strategy	was	iterative;	I	continued	to	search	and	analyze	the	extant			28	literature	as	I	identified	new	avenues	of	inquiry	through	my	interviews.	After	completing	my	grounded	theory	data	collection	and	analysis,	I	then	added	to	the	review	to	evaluate	earlier	studies	that	observed	similar/dissimilar	findings,	and	to	set	the	stage	for	how	my	grounded	theory	responded	to	gaps	in	the	existing	literature.	I	conducted	the	literature	review	alone,	but	presented	synopses	of	the	literature	review	findings	to	knowledge	partners	at	intervals	throughout	the	research	process	and	at	their	request.	In	return,	knowledge	partners	offered	suggestions	for	tailoring	the	literature	review	to	answer	their	clinical	and	policy	questions.	This	led,	for	instance,	to	further	searching	of	the	literature	on	the	effectiveness	of	existing	SDM	interventions	in	response	to	feedback	from	the	Ministry	of	Health.		This	flexible,	adaptive	approach	also	is	encouraged	in	knowledge	translation	research	to	understand	the	mechanisms	and	circumstances	that	underpin	implementation	of	complex	interventions	such	as	SDM.(87)	Traditional	systematic	reviews	may	not	answer	the	question	of	why	interventions	work	in	some	circumstances	and	not	in	others,	while	less	traditional	review	methods	(such	as	realist	or	narrative	review)	may	be	better	suited	to	answer	such	questions	by	allowing	the	synthesis	of	heterogenous,	methodologically	diverse,	and	contradictory	evidence	from	both	qualitative	and	quantitative	studies.(88)	In	this	dissertation,	I	drew	primarily	from	the	interpretive	review	method	“narrative	summary,”	which	involves	the	selection,	chronicling,	and	ordering	of	evidence	to	produce	an	account	of	the	literature.(89)	In	narrative	reviews,	qualitative	and	quantitative	studies	are	discussed	side	by	side.	My	strategies	began	with	a	search	of	the	existing	qualitative	literature	on	my	core	research	questions,	focusing	on	literature	from	Canada	and	other	countries	with	comparable			29	health	service	settings	and	caesarean	section	rates.	My	initial	search	questions	were:		1. What	are	women’s	attitudes	toward	and	experiences	with	mode	of	delivery	after	caesarean?		2. What	are	care	providers’	attitudes	toward	and	experiences	with	providing	care	for	women	considering	mode	of	delivery	after	caesarean?		3. What	are	decision	makers’	experiences	with	planning	services	for	birth	after	caesarean?		4. What	are	the	factors	that	influence	implementation	of	SDM	in	maternity	care?	As	this	was	not	a	systematic	literature	review,	I	restricted	my	search	to	two	electronic	databases	(PubMed	and	Google	Scholar)	and	did	not	limit	my	search	by	study	design	or	year	of	publication.	My	searches	included	a	combination	of	medical	sub-headings	and	free	text	terms,	and	I	continually	added	new	search	terms	as	my	data	collection	and	analysis	progressed.	I	also	explored	the	grey	literature	(e.g.	difficult	to	locate	materials	and	non-peer	reviewed	policy	material	and	reports)	by	searching	Google	and	websites	for	organizations	that	promote	SDM	(e.g.	Childbirth	Connection,	Ottawa	Health	Research	Institute).	I	supplemented	my	searches	by	scanning	the	reference	lists	of	included	studies,	scanning	lists	of	articles	that	have	cited	included	studies,	and	discussing	the	literature	with	my	supervisory	committee	to	ensure	that	I	had	a	comprehensive	and	current	overview	of	the	literature	related	to	decision-making	for	birth	after	caesarean	and	implementation	of	SDM.	I	selected	studies	based	on	my	judgment	of	their	rigour,	relevance	to	the	study,	and	their	contribution	to	extend	or	challenge	my	theoretical	argument.	I	now	turn	to	my	critical	analysis	of	the	literature	relevant	to	decision-making	for	mode	of	delivery	after	caesarean				30		2.2 Women’s	Attitudes	and	Experiences	with	Birth	after	Caesarean	As	described	in	the	Introduction,	findings	on	women’s	attitudes	toward	and	experiences	with	mode	of	delivery	vary	by	geography	and	ethnicity.	In	addition,	women’s	decision-making	attitudes	and	experiences	vary	depending	on	their	preferred	mode	of	delivery.	Black	et	al	recently	completed	a	meta-ethnographic	synthesis	of	20	papers	reporting	the	views	of	507	women	from	four	countries.(90)	The	authors	identified	three	clusters	of	women	based	on	their	preference	for	mode	of	delivery	and	the	factors	that	influenced	each	group’s	decision-making.	Women	who	confidently	sought	VBAC	were	influenced	by	a	long-standing	anticipation	of	vaginal	birth.	Those	who	sought	repeat	caesarean	were	influenced	by	their	previous	birth	experiences	and	encouragement	from	family,	friends,	and	health	professionals	who	recommended	repeat	caesarean.	Women	who	did	not	have	a	firm	preference	were	open	to	information,	were	influenced	by	professional	guidance,	and	put	effort	into	weighing	the	attributes	of	their	birth	options	to	assess	net	benefit.	This	variation	in	women’s	decision-making	differs	from	the	earliest	work	on	patient	decision-making	for	mode	of	delivery	after	caesarean	conducted	by	McClain	(1983),	which	observed	a	more	homogenous	process.(91)	McClain	identified	three	attributes	of	women’s	decision-making	process:	(a)	that	women’s	social	goals	and	perception	of	medical	risks	were	equally	weighted	and	central	to	their	choice;	(b)	that	women	confirm	their	decisions	by	identifying	multiple	benefits	for	the	mode	of	delivery	they	prefer	and	multiple	hazards	for	the	option	they	reject;	and	(c)	rather	than	consider	the	probabilities	of	outcomes,	women	construct			31	mental	images	of	anticipated	events	and	the	potential	consequences	of	their	choice	based	on	their	past	childbirth	experiences.(91)		Other	researchers	have	explored	when	women	form	a	preference	for	their	mode	of	delivery	after	caesarean.	Two	separate	qualitative	studies	on	decision-making	for	birth	after	caesarean	conducted	in	the	UK	found	that	some	women	may	be	very	certain	about	their	choice	before	pregnancy,	while	most	make	their	choice	during	pregnancy	as	new	information	comes	available	and	they	feel	more	ready	or	pressured	to	make	a	decision,	however	some	may	feel	uncertain	about	their	decision	and	experience	this	uncertainty	during	and	even	after	delivery.(69,92)	This	suggests	that	decision-making	is	an	evolving	process	and	care	providers	should	not	assume	that	women’s	preferences	in	early	pregnancy	will	reflect	their	final	choice.	It	also	demonstrates	that	the	decision	can	be	challenging	for	women.	Qualitative	studies	with	women	who	had	a	previous	caesarean	in	the	UK	(n	=	11)	(25)	and	Australia	(n	=	18)	(26)	further	found	that	women	feel	a	moral	obligation	to	make	the	“right”	choice	based	on	the	perception	that	they	are	the	primary	decision-maker	and	are	consequently	responsible	for	the	outcome	of	their	decision,	in	particular	with	regard	to	concern	about	the	potential	for	bad	outcomes	for	their	baby.(25,26)	Taken	together,	these	findings	illustrate	that	decision-making	for	birth	after	caesarean	is	an	individual,	complex	process	in	which	women	consolidate	risk	information	and	experiential	knowledge	from	a	variety	of	personal,	social,	and	evidence-based	sources.				32	2.2.1 The	Role	of	Relationships	In	the	context	of	this	complexity,	women	include	other	people	in	their	decision-making	process	to	exchange	information,	help	them	deliberate,	or	even	make	the	decision	on	their	behalf.	Goodall,	McVittie,	and	Magill	conducted	interviews	with	10	women	pregnant	after	caesarean	in	the	UK	and	found	that	if	women	allow	another	person	(e.g.	care	provider,	partner)	to	make	the	decision	on	their	behalf,	they	may	feel	relief	and	comfort	at	no	longer	experiencing	the	responsibility	associated	with	being	the	primary	decision-maker.(27)			2.2.2 The	Role	of	Resources	The	literature	has	also	identified	the	various	resources,	in	addition	to	relationships,	that	inform	women’s	decision-making	for	mode	of	delivery.	Two	qualitative	studies	involving	postpartum	interviews	with	women	who	gave	birth	after	caesarean	in	northern	England	found	that,	in	the	absence	of	accurate,	trustworthy,	and	complete	information	from	their	care	provider,	women	rely	heavily	on	knowledge	from	their	previous	birth	experience(s),	which	are	frequently	characterized	by	feelings	of	unhappiness,	regret,	and	blame,	as	well	as	fears	of	being	physically	incapable	of	having	a	vaginal	birth.(25,28)	Lack	of	knowledge	of	clinical	risks	and	benefits	may	result	in	women	choosing	elective	repeat	caesarean.		In	2014	Scaffidi	et	al	surveyed	a	convenience	sample	of	45	American	women	with	a	history	of	previous	caesarean	birth	and	found	that	those	women	who	had	high	knowledge	of	their	birth	after	caesarean	options	were	more	likely	to	choose	VBAC	than	repeat	caesarean	(OR	3.9;	95%	CI	1.09-13.81).(29)	A	survey	of	Canadian	women	in	their	first	pregnancy	found	that			33	over	one-third	of	women	chose	“I	don’t	know”	when	responding	to	questions	about	the	clinical	risks	associated	with	caesarean	section.(93)	A	qualitative	study	of	BC	women’s	decision	making	for	primary	elective	caesarean	delivery	found	participants	relied	on	the	knowledge	of	their	peers	to	form	the	decision	for	a	caesarean,	“as	long	as	such	birth	narratives	were	technologically	inclined	and	represented	a	consolidation	of	the	listener’s	core	attitudes	and	beliefs.”(94)		The	Internet	is	now	the	most	common	source	of	information	for	women	in	pregnancy,(95)	however	a	recent	Canadian	study	reported	that	the	10	most	common	websites	for	the	keywords	“VBAC”	and	“Vaginal	birth	after	caesarean”	do	not	provide	complete	information	on	clinical	risks	and	benefits	of	VBAC,	based	on	Society	of	Obstetricians	and	Gynaecologists	of	Canada	VBAC	guidelines.(96)	A	UK	review	of	VBAC	information	websites	that	women	access	through	Google	found	that	the	majority	are	American	websites	that	portray	information	irrelevant	or	inappropriate	for	a	UK	health	services	context.(97)	Finally,	a	comparison	of	Internet	discussion	board	posts	by	women	contemplating	VBAC	versus	pregnant	women	in	general	found	that	women	contemplating	VBAC	sought	more	information	on	health	care	providers,	labour	and	delivery,	and	birth	narratives	from	other	women.(98)		Together	this	evidence	indicates	there	is	a	gap	in	the	availability	of	high	quality	online	information	for	childbearing	women	regarding	mode	of	delivery	after	caesarean	in	Canada.	However	it	is	unclear	how	knowledgeable	women	are	about	their	options	for	mode	of	delivery	after	caesarean	in	Canada,	if	such	high	knowledge	correlates	with	a	preference	for	VBAC,	or	if			34	women	in	Canada	actually	receive	the	mode	of	delivery	that	matches	their	informed	preferences.	In	order	to	bridge	to	the	evidence	to	practice	gap	for	mode	of	delivery	after	caesarean,	it	is	important	to	understand	women’s	attitudes	and	experiences	in	different	health	system	contexts,	including	women’s	misperceptions	and	misinformation	related	to	VBAC,	what	information	they	use	to	make	their	choice,	and	what	they	perceive	to	be	the	barriers	and	facilitators	to	VBAC	in	their	local	community.	Importantly,	the	recent	large	meta-ethnography	of	20	qualitative	studies	exploring	women’s	preferences	for	birth	after	caesarean	did	not	report	on	the	influence	of	health	system	factors	in	women’s	decision-making.(90)	While	VBAC	patterns	may	be	consistent	among	different	developed	countries,	the	experiences	of	women	may	vary	substantively	in	different	health	service	environments,	with	different	care	provider	types,	and	between	rural	and	urban	settings.	It	is	also	concerning	that	one	study	observed	that	women	may	defer	decision-making	to	their	care	provider	as	a	way	to	cope	with	uncertainty	and	lack	of	knowledge	about	their	options	for	mode	of	delivery.(27)			2.3 Care	Provider	Attitudes	and	Experiences	The	literature	on	care	providers’	attitudes	toward	and	experiences	with	mode	of	delivery	after	caesarean	is	limited	to	six	studies	from	international	settings.(26,31–33,99,100)	Cox	conducted	semi-structured	interviews	with	obstetricians	and	midwives	(n=24)	in	Florida	and	found	that	fear	of	liability	and	the	convenience	of	repeat	caesarean	delivery	were	the	central	reasons	why	providers	avoided	VBAC	deliveries,	particularly	in	rural	and	community	hospitals.(31)	Midwives			35	were	more	supportive	of	VBAC	deliveries	than	their	obstetrician	counterparts,	but	felt	marginalized	from	being	able	to	participate	in	VBAC	births	due	to	hospital	policies.(31)	In	contrast,	in	a	UK	study	involving	semi-structured	interviews	with	midwives	and	physicians	(n=25),	Kamal	et	al.	found	that	obstetricians,	as	well	as	midwives,	strongly	supported	VBAC	deliveries,	however	they	felt	that	the	evidence	base	underpinning	VBAC	protocols	and	guidelines	was	of	poor	quality	and	secondary	to	professional	experience.(32)	In	this	study,	Kamal	et	al.	observed	wide	variation	in	care	providers’	decision-making	styles,	which	they	described	as	ranging	from	“consumerist”	(patient	decides),	to	“mutualistic”	(shared	decision),	to	“paternalistic”	(provider	decides).(32)	Participants	did	not	report	on	the	role	of	their	hospital	environment	and	available	resources	in	decision-making	for	birth	after	caesarean,	although	the	limited	number	of	beds	available	and	sensitivity	to	the	health	system	costs	of	caesarean	section	were	mentioned	briefly	as	challenges	posed	by	high	rates	of	caesarean	section.		Findings	from	Kamal	et	al.	also	highlight	the	influence	that	care	providers	have	on	women’s	decision-making	process.	Discussions	about	options	for	mode	of	delivery	after	caesarean	were	contingent	on	what	providers	perceived	to	be	the	woman’s	preferences	and	her	physical	and	mental	capability	to	cope	with	labour	and	delivery.(32)	Of	the	providers	who	claimed	to	take	a	mutualistic	or	shared	decision-making	approach,	some	acknowledged	using	strategies	to	nudge	patients	to	make	choices	that	were	congruent	with	the	provider’s	preference	for	mode	of	delivery.(32)	These	findings	were	echoed	in	a	survey	conducted	by	Sur	et	al.	of	119	obstetricians	in	active	practice	in	London	and	Oxford	to	investigate	their	personal	preferences	for	mode	of	delivery	and	management	of	labour	after	a	caesarean	section.(33)			36	Clinicians	who	preferred	to	attempt	VBAC	themselves	were	more	likely	to	advocate	labour	for	undecided	women,	while	those	providers	who	preferred	elective	repeat	caesarean	for	themselves	were	more	likely	to	counsel	their	patients	to	choose	that	option,	regardless	of	the	clinical	indication	for	the	patient’s	previous	caesarean.(33)	These	observations	reinforce	findings	from	qualitative	studies	with	UK	women,	described	above,	which	found	that	care	providers	may	make	the	decision	for	mode	of	delivery	on	the	woman’s	behalf,	sometimes	at	her	request.(27)		Recent	evidence	out	of	the	US	suggests	that	affective	traits	may	also	play	a	role	in	care	providers’	ability	to	support	women	in	choosing	mode	of	delivery.	Yee	et	al.	surveyed	94	attending	obstetricians	at	a	Northwestern	University	and	collected	retrospective	data	on	patient	outcomes	from	2008-2013	(n=1,502)	to	identify	differences	in	delivery	outcomes	associated	with	provider	cognitive	characteristics.(101)	Using	a	random	effects	regression	model,	the	authors	found	that	physicians	with	high	proactive	coping	(i.e.	ability	to	cope	with	stress	and	distress)	were	significantly	more	likely	to	have	patients	who	attempted	VBAC	(adjusted	OR	1.86;	95%	CI	1.10-3.14)	and	those	with	low	anxiety	were	significantly	more	likely	to	have	patients	experience	VBAC	(adjusted	OR	2.08;	95%	CI	1.28-3.37).(101)	These	findings	confirm	common	wisdom	that	managing	a	planned	VBAC	labour	and	delivery	requires	self-efficacy,	and	the	ability	to	cope	with	stress	and	anxiety,	uncertainty,	and	risk.	These	attributes	may	be	associated	with	decision-making	that	takes	place	during	labour,	as	well	as	prenatally.	In	Canada,	one	survey	on	the	attitudes	of	different	care	provider	groups	in	Canada	was	conducted	by	Klein	et	al,	who	found	that	obstetricians,	family	physicians,	and	midwives	as	groups	have			37	varying	attitudes	toward	safety	in	childbirth,	with	obstetricians	favouring	elective	repeat	caesarean	section	for	women	with	a	previous	uterine	scar.(70)	These	findings	indicate	the	need	for	further	study	into	how	different	care	provider	groups	perceive	VBAC	to	be	risky	or	safe,	as	these	attitudes	may	influence	how	they	approach	decision-making	for	birth	after	caesarean.		The	existing	literature	on	care	provider	attitudes	and	experiences	with	birth	after	caesarean	has	taken	place	in	the	UK	and	US,	where	the	health	system	context	for	birth	after	caesarean	is	different	from	that	in	Canada.(26,31–33,99,100)	More	attention	has	been	paid	to	women’s	attitudes	and	experiences.	The	existing	qualitative	literature	in	that	area	suggests	care	providers	may	have	a	strong	influence	on	women’s	preferences	and	women	may	not	be	the	primary	decision	makers	for	mode	of	delivery	in	some	cases.	In	order	to	understand	women’s	decision-making	processes	better,	it	is	imperative	to	engage	in	further	study	with	the	care	providers	who	influence	those	decisions.	Another	limitation	of	the	existing	studies	with	care	providers	is	that	they	primarily	took	place	in	larger	academic	medical	centres	and	findings	may	not	be	generalizable	to	smaller	settings	with	limited	obstetric	resources.	The	attitudes	of	care	providers	in	such	smaller	community	hospitals	with	limited	resources	require	additional	study.	Findings	from	Cox	et	al.	from	the	Florida	context	suggested	there	were	different	VBAC	practice	patterns	between	rural	and	urban	settings,	with	rural	and	community	settings	expressing	fear	of	liability	around	planned	VBAC	due	to	limited	anaesthesia	resources.(31)	The	Canadian	health	services	context	is	similar	to	that	in	the	US	and	UK,	however	some	key	differences	may	have	an	influence	on	care	provider	practice	patterns.	Namely,	one	third	of	maternity	care	for	birth	after	caesarean	is	provided	by	family	physicians	in	Canada,	while	in	the	UK	care	is	provided	mainly	by			38	obstetricians	and	midwives,	and	in	the	US	largely	by	obstetricians.	Midwifery	care	differs	between	the	three	countries	with	registered	midwives	in	Canada	providing	community-based	antenatal	care	and	labour	and	delivery	in	home,	birth	centre,	and	hospital	settings.	There	is	a	need	for	further	study	into	how	attitudes	and	experiences	of	care	providers	vary	by	profession	in	a	Canadian	context,	as	findings	from	such	research	will	likely	provide	insight	into	how	care	providers	counsel	women	for	birth	after	caesarean.			2.4 Perceptions	of	Risk	in	Childbirth	Decision-making	for	mode	of	birth	after	caesarean	involves	consideration	of	the	risks	and	benefits	of	the	attributes	of	the	delivery	options	–	planned	VBAC	or	planned	elective	repeat	caesarean	–	and	their	potential	outcomes.	However,	how	patients	and	care	providers	conceptualize	“risks	and	benefits”	may	vary	depending	on	their	attitudes	and	beliefs.	As	the	above	literature	on	women’s	experiences	suggests,	the	features	of	mode	of	delivery	that	matter	most	to	women’s	decision-making	process	may	depend	on	a	range	of	personal,	social,	and	clinical	concerns	–	her	childbirth	experience,	peer	attitudes,	relationship	with	her	care	provider,	her	ethnicity,	and	geographic	location.	Kornelsen	and	Mackie	argue	that,	“for	decades,	scholars	of	risk	have	applied	their	resources	to	understand	the	break	between	social	and	scientific	rationality	and	the	relationship	–	or	dissonance	–	between	experts	and	laypersons’	conceptualizations	of	risk.	The	clash	of	medical	and	social	risk	in	childbirth	falls	directly	in	this	domain.”(102)				39	The	concept	of	“comprehensive”	risk	developed	by	rural	maternity	health	services	researchers	Barclay	and	colleagues	offers	a	clear	framework	for	considering	the	range	of	risk	perceptions	that	may	emerge	in	childbirth	decisions.	Developed	based	on	findings	from	a	series	of	qualitative	studies	involving	maternity	clinicians	and	consumers	in	rural	Australia	and	Canada,(2)	the	concept	of	“comprehensive	risk”	involves	two	core	categories:	health	services	risks	and	social	risks.	“Health	services	risks,”	as	described	by	clinicians,	involves	clinical	risks	(adverse	outcomes	for	mother	and	baby),	as	well	as	legal,	political,	operational,	and	financial	risks.	The	second	category,	“social	risks,”	as	described	by	consumers,	involves	cultural	risks	to	traditional	values	and	spirituality,	emotional	risks	of	system-initiated	distress,	and	financial	risks	of	compromised	family	budgets,	for	instance	due	to	the	cost	of	traveling	to	access	birthing	services.	A	comprehensive	perspective	toward	the	risks	and	benefits	of	mode	of	delivery	options	would	consider	clinical	outcomes,	and	potentially	also	risks	related	to	clinicians’	and	health	authorities’	fear	of	liability	in	the	event	of	adverse	VBAC	outcomes,	financial	(dis)incentives	for	clinicians	paid	in	a	fee	for	service	model,	and	social-emotional	risks	to	women	if	the	health	system	can	not	provide	the	mode	of	delivery	that	matches	their	informed	preferences.	As	discussed	in	a	later	section,	SDM	is	one	approach	for	treating	birth	after	caesarean	as	a	holistic	decision	that	considers	the	comprehensive	risks	and	benefits	of	options.	Hall,	Tomkinson,	and	Klein	observed	the	clash	between	health	services	and	social	risks	in	their	Canadian	grounded	theory	study	of	9	pregnant	women	approaching	their	first	birth	and	56	care	providers	(midwives,	family	physicians,	nurses,	obstetricians,	doulas).(103)	The	core	theme	emerging	from	analysis	was	“minimizing	risks	while	maximizing	integrity,”	in	which	risk	was			40	variously	defined	as	medical	and	psychological,	depending	on	the	context	of	relationships,	evidence,	and	local	healthcare	culture.	For	the	care	providers,	psychological	risks	included	criticism	from	others	and	fear	of	litigation.	These	risks	were	mitigated	by	open	communication,	longstanding	relationships,	and	shared	control	with	patients,	as	well	as	through	models	of	practice	that	supported	dialogue	among	colleagues.	However,	the	authors	observed	that	personal	values	and	biases	may	shape	how	care	providers	perceive	risks	and	engage	in	decision-making.	For	instance	some	care	providers	described	open	communication	as	“telling	women	what	to	do	while	pretending	women	had	control:	‘it’s	a	lie	we’re	giving	clients	control.	They	can	pretend	they	have	control,	but	we’re	just	doing	that	to	be	nice	as	practitioners,	and	really	we	are	supposed	to	keep	control.’”(103)	The	study	did	not	explore	the	experiences	of	and	care	for	multiparous	women,	however	such	insights	into	how	care	providers	perceive	risks	to	themselves	may	have	implications	for	decision-making	for	birth	after	caesarean.	Fear	of	professional	criticism	or	litigation	may	influence	what	risks	care	providers	choose	to	discuss,	how	they	frame	the	clinical	risks	of	mode	of	delivery,	and	their	willingness	to	make	a	shared	decision	with	patients.(104,105)		Additional	Canadian	studies	from	Maureen	Heaman	illuminate	the	multidimensional,	comprehensive	nature	of	risk	assessment.	Heaman,	Gupton,	and	Gregory	conducted	a	descriptive	qualitative	study	with	205	women,	half	whom	had	pregnancy	complications	(n	=	103)	and	half	of	whom	had	none	(n	=	102).(106)	Women	with	complications	voiced	greater	risk	perceptions	and	identified	specific	risks	while	women	with	no	complications	described	potential	risks	that	were	diffuse	and	hypothetical.	Participants’	histories	played	a	role	in	the	process	of			41	their	self-assessment	of	risk,	as	one	woman	with	complications	described:	“I	have	had	back	problems	and	have	had	a	spinal	fusion.	There	was	concern	about	being	able	to	have	a	baby	[carrying	to	term]	and	a	‘normal’	pregnancy.”(106)	Women	who	had	no	complications	felt	their	risks	would	decrease	if	they	had	qualified	care	providers,	followed	advice,	and	engaged	in	healthy	practices:	“I	have	prepared	myself	by	reading,	diet,	and	appropriate	doctor.	I	feel	I	have	done	everything	possible	to	ensure	my	safety	and	health.”(106)	The	study,	strengthened	by	its	Canadian	setting	and	large	sample	size,	focused	on	aspects	of	comprehensive	risk	and	explored	how	social	risks	might	impact	clinical	risks,	such	as	how	a	woman’s	previous	experience	with	system-initiated	distress	may	influence	her	perceived	and	actual	clinical	risk	in	future	pregnancies.	However,	the	study	did	not	explore	how	women’s	perceptions	influenced	their	decision-making	practices	and	no	results	were	specific	to	birth	after	caesarean.	Exploration	of	women’s	self-assessment	of	risk	in	the	context	of	birth	after	caesarean	may	provide	insight	into	how	women	make	decisions	regarding	mode	of	delivery.	In	the	same	program	of	research,	Bayrampour,	Heaman,	Duncan,	and	Tough	investigated	the	predictors	of	pregnancy	risk	perceptions	in	a	convenience	sample	of	nulliparous	women	in	their	third	trimester	in	Winnipeg	(n	=	159).(107)	Using	the	Perception	of	Pregnancy	Risk	Questionnaire	(PPRQ)	they	observed	that	high	pregnancy-related	anxiety,	high	risk	status,	advanced	maternal	age,	and	early	gestational	age	were	associated	with	increased	perception	of	risk	in	pregnancy.	Anxiety	was	the	strongest	predictor	accounting	for	30%	of	risk	perception	and	its	effect	was	most	prominent	in	older	women.	These	findings	indicate	that	risk	assessments	are	individualized	and	are	based	on	social-emotional	factors,	as	well	as	clinical			42	information.	It	is	unclear	whether	these	findings	would	apply	to	multiparous	women,	who	have	a	labour	and	delivery	experience	that	will	shape	their	perspectives.	However	it	is	plausible	that	women	who	have	had	a	previous	emergent	caesarean	section	would	have	higher	perceptions	of	risk.	Again,	these	findings	indicate	the	importance	of	exploring	how	multiparous	women	construct	notions	of	risk	and	safety	in	childbirth	after	a	previous	caesarean.		In	spite	of	the	comprehensive	nature	of	“risk”	highlighted	by	these	studies	with	pregnant	women,	clinicians	tend	to	focus	on	clinical	risk	in	decision-making	discussions	with	patients	regarding	birth	after	caesarean.	Looking	again	to	Goodall	et	al.’s	interviews	with	UK	mothers,	participants	revealed	that	the	information	physicians	provide	focuses	on	the	clinical	or	procedural	risks	of	mode	of	delivery,	such	as	you	have	“a	30%	chance	of	having	a	CS”	during	an	attempted	VBAC.(27)	Such	discussions	omit	other	health	services	and	social	risks	that	may	also	be	salient	to	women	and	providers,	such	as	the	impact	of	surgical	recovery	on	a	woman’s	ability	to	care	for	her	older	child.		Additional	research	on	risk	communication	suggests	that	statements	such	as	“you	have	a	30%	chance”	may	be	difficult	for	patients	to	comprehend.	For	instance,	Schapira	and	colleagues	conducted	focus	groups	to	evaluate	women’s	different	responses	to	breast	cancer	risk	information,	and	found	that	frequencies	(e.g.	30	out	of	100)	were	more	easily	comprehended	than	percentages	(e.g.	30%).(108)	Jasper	et	al.	examined	the	effects	of	“framing”	on	women’s	perception	of	fetal	risk	and	their	intention	to	use	a	safe	drug	in	pregnancy.(109)	They	recruited	105	women	who	were	pregnant	or	planning	a	pregnancy	through	the	Motherrisk	program	in	Toronto.	Women	who	received	negatively	framed			43	information	(1-3%	chance	of	having	a	malformed	child)	had	a	significantly	higher	perception	of	clinical	risk	than	those	who	received	positively	framed	information	(97-99%	chance	of	having	a	normal	child)	and	were	less	likely	to	want	to	take	the	drug	(14.9%	vs.	8.3%,	p	=	0.0484).		These	results	indicate	that	the	risk	attributes	selected	for	discussion	and	the	way	risk	information	is	framed	may	influence	pregnant	women	to	avoid	healthcare	choices	they	perceive	to	be	dangerous	and	care	providers	should	be	thoughtful	in	how	they	present	risk	(and	benefit)	information.	It	is	unclear	how	care	providers	actually	engage	in	discussions	about	the	risks	and	benefits	of	mode	of	delivery	after	caesarean	and,	as	discussed	above,	the	evidence	is	limited	to	studies	from	the	US	(31)	and	the	UK,(27,32,33)	where	the	model	of	care	is	substantively	different	from	that	in	Canada.	However	these	studies	suggest	care	providers’	selection	and	presentation	of	the	risks	and	benefits	of	the	attributes	of	delivery	options	and	their	potential	outcomes	influence	women’s	attitudes.		Exploring	women’s	and	care	providers	attitudes,	experiences,	and	comprehensive	risk	perceptions	with	regard	to	birth	after	caesarean	would	provide	much	needed	understanding	of	the	social	and	personal	factors	that	inform	their	decision-making	for	mode	of	delivery.	The	existing	literature	on	women’s	and	care	providers’	attitudes	and	experiences	also	suggests	that	decision-making	for	birth	after	caesarean	may	be	influenced	by	factors	related	to	environment	and	policy,	such	as	being	in	a	low-resourced	rural	community	or	in	a	highly	litigious	setting.	The	following	section	investigates	the	literature	on	these	factors	and	how	they	may	influence	access	to	VBAC	services,	beginning	with	a	discussion	of	existing	policy	for	access	to	VBAC	services	in	Canada.				44		2.5 Access	to	Vaginal	Birth	after	Caesarean	(VBAC)	In	Canada,	the	Society	of	Obstetricians	and	Gynaecologists	of	Canada	(SOGC)	guidelines	support	women’s	access	to	planned	VBAC.	Last	updated	in	2005,	the	guidelines	recommend	that	care	providers	should	support	women	as	consumers	making	informed	choices:	“provided	there	are	no	contraindications,	a	woman	with	1	previous	transverse	low-segment	Caesarean	section	should	be	offered	a	trial	of	labour	(TOL)	with	appropriate	discussion	of	maternal	and	perinatal	risks	and	benefits.”(13)	This	approach	of	non-directive	counseling	is	echoed	in	the	Canadian	Joint	Policy	Statement	on	Normal	Childbirth	(110)	and	the	College	of	Midwives	of	British	Columbia	guidelines	for	birth	after	caesarean.(111)	These	guidelines	are	also	consistent	with	the	current	American	College	of	Obstetricians	and	Gynecologists	(ACOG)	committee	opinion	on	VBAC.(111)	However	the	language	included	in	guidelines	from	the	Association	of	Ontario	Midwives	takes	a	more	persuasive	tone	and	states	that	women	not	be	offered	VBAC,	but	rather	that	care	providers	recommend	planned	VBAC	for	eligible	women.(112)	The	contraindications	for	VBAC	in	Canada	are	minimal	and	exclude	only	a	small	portion	of	women	with	a	previous	caesarean.	Exclusions	are	based	on	fair	evidence	from	well-designed	observational	studies	(II-B)	and	stated	contraindications	in	the	SOGC	guidelines	include	a	previous	classical	or	inverted	“T”	uterine	scar,	previous	hysterectomy	or	myomectomy	entering	the	uterine	cavity,	or	contraindications	to	labour	such	as	placenta	previa	or	malpresentation.(13)	Oxytocin	induction	and	augmentation	of	labour,	and	mechanical	induction	via	foley	catheter,	may	be	safely	used	in	a	planned	VBAC.(13)	Multiple	gestation,	diabetes	mellitus,	suspected	fetal	macrosomia,	and			45	postdates	are	not	contraindications	for	planned	VBAC.(13)	Similarly,	more	than	1	previous	caesarean	and	a	due	date	less	than	18-24	months	since	the	previous	caesarean	are	not	contraindications,	however	women	should	be	counseled	regarding	the	increased	risk	of	uterine	rupture	for	each.(13)	In	spite	of	these	supportive	guidelines,	there	is	emerging	evidence	that	women	face	significant	health	service	and	policy	barriers	to	access	of	VBAC	services	and	that	access	has	become	increasingly	limited	over	time	as	a	result	of	these	barriers.	Over	the	past	thirty	years	the	rate	of	planned	VBAC	has	fluctuated	in	Canada,	reflecting	trends	in	other	developing	countries.	In	the	early	1990s	VBAC	was	a	proposed	method	for	curbing	the	rising	caesarean	section	rate,	and	the	national	VBAC	rate	peaked	in	1996	at	35%.(113)	Guise	et	al.	identified	the	key	factors	that	caused	this	trend	in	developing	countries	in	an	extensive	systematic	review	prepared	by	the	Agency	for	Healthcare	Research	and	Quality	(AHRQ)	for	the	2010	NIH	Consensus	Development	Conference	on	emerging	issues	related	to	VBAC.(54)	The	downturn	in	VBAC	rates	can	be	traced	to	1996,	when	McMahon	et	al.	published	a	landmark	study	of	6,138	Nova	Scotia	women	with	a	previous	caesarean,	which	suggested	that	the	rate	of	uterine	rupture	and	consequent	morbidity	associated	with	VBAC	was	0.3%	among	women	who	underwent	planned	VBAC	(n=3,249),	higher	than	previously	thought.(114)	The	study	was	limited	by	its	design	and	setting;	results	were	not	adjusted	for	women	with	a	previous	vaginal	delivery	and	data	were	from	a	single	province.	However,	the	perceived	increased	risk	of	uterine	rupture	associated	with	planned	VBAC	resulted	in	the	American	College	of	Obstetrician	and	Gynecologists	changing	their	guidelines	in	1999	to	state	that	VBAC	should	be	attempted	only	in	settings	with	that	are	“equipped	to	respond	to	emergencies	with			46	physicians	immediately	available	to	provide	emergency	care”	(emphasis	added),	while	their	previous	guidelines	had	used	the	phrase	readily	available.(115)	Notably,	the	“immediately	available”	standard	does	not	apply	to	other	rare	obstetric	events	that	are	equally	(or	more)	precipitous	and	catastrophic	as	uterine	rupture,	such	as	prolapsed	cord	or	shoulder	dystocia,	which	may	occur	in	any	pregnancy,	not	just	to	women	with	a	previous	caesarean.	The	impact	of	this	evolving	evidence	on	women’s	access	to	VBAC	services	was	swift	and	dramatic.	In	a	study	of	all	hospitals	(n=312)	in	four	regions	of	the	United	States,	Roberts	et	al.	found	that	30.6%	of	hospitals	that	provided	VBAC	services	prior	to	1999	stopped	offering	planned	VBAC	after	the	ACOG	guidelines	were	updated.	In	Canada,	the	VBAC	rate	took	a	downward	turn	to	17.5%	in	2011/2012.(116)	However,	unlike	in	the	United	States,	no	studies	in	Canada	have	explored	the	association	between	changing	policy	and	rate	of	planned	VBAC	and	the	health	system	and	policy	factors	that	influence	women’s	access	of	these	services	are	unclear.	Unlike	in	the	United	States,	Canadian	guidelines	have	used	less	restrictive	language	regarding	when	and	how	woman	may	access	planned	VBAC.	The	SOGC	guidelines	define	timely	access	from	“decision-to-incision”	as	approximately	30	minutes.	This	means	that	settings	offering	planned	VBAC	also	should	be	prepared	to	offer	operating	room	resources,	nurses,	and	pediatric	and	anaesthesia	services	to	mitigate	the	risks	of	potential	uterine	rupture,	resources	that	are	not	readily	available	in	all	hospital	settings.(13)	The	SOGC	guidelines	do	not	provide	standards	for	whether	staff	should	be	on	site	in	order	to	provide	this	care.	However,	they	encourage	the	development	of	local	protocols	and	“women	who	live	in	areas	where	local	hospitals	cannot	provide	a	timely	Caesarean	section	should	be	offered	the	opportunity	for			47	transfer	to	a	facility	where	this	service	is	available,	in	order	to	permit	a	TOL	[trial	of	labour]	after	Caesarean.”(13)	The	more	recent	VBAC	guidelines	published	by	ACOG	in	2010	echo	this	recommendation	but	do	not	provide	a	guide	for	the	length	of	time	from	decision	to	incision;	rather,	they	continue	to	state	“that	resources	for	emergency	cesarean	delivery	should	be	‘immediately	available.’”(111)	The	nature	of	these	resources	and	the	length	of	time	denoted	by	“immediately”	are	open	to	interpretation.	Unlike	in	the	United	States,	Canadian	guidelines	have	used	less	restrictive	language	regarding	when	and	how	woman	may	access	planned	VBAC.	The	SOGC	guidelines	define	timely	access	from	“decision-to-incision”	as	approximately	30	minutes.	This	means	that	settings	offering	planned	VBAC	also	should	be	prepared	to	offer	operating	room	resources,	nurses,	and	pediatric	and	anaesthesia	services	to	mitigate	the	risks	of	potential	uterine	rupture,	resources	that	are	not	readily	available	around	the	clock	in	most	hospital	settings.(13)	The	SOGC	guidelines	do	not	provide	standards	for	whether	staff	should	be	on-site	in	order	to	provide	this	care.	However,	they	encourage	the	development	of	local	protocols	and	“women	who	live	in	areas	where	local	hospitals	cannot	provide	a	timely	Caesarean	section	should	be	offered	the	opportunity	for	transfer	to	a	facility	where	this	service	is	available,	in	order	to	permit	a	TOL	[trial	of	labour]	after	Caesarean.”(13)	The	more	recent	VBAC	guidelines	published	by	ACOG	in	2010	echo	this	recommendation	but	do	not	provide	a	guide	for	the	length	of	time	from	decision	to	incision;	rather,	they	continue	to	state	“that	resources	for	emergency	cesarean	delivery	should	be	‘immediately	available.’”(111)	The	nature	of	these	resources	and	the	length	of	time	denoted	by	“immediately”	are	open	to	interpretation.				48	The	strength	of	evidence	is	weak	regarding	the	optimal	response	time	from	indication	of	uterine	rupture	to	caesarean	section	and	in	the	SOGC	guidelines	the	evidence	is	categorized	as	III-C:	poor	evidence	based	on	expert	opinion.	The	best	available	literature	consists	of	two	case	series	conducted	in	tertiary	hospitals	with	in-house	anaesthesia	and	obstetrics.	There	is	no	evidence	from	settings	with	off-site	surgical	teams.	Leung	et	al.	investigated	all	cases	of	symptomatic	uterine	rupture	(n=99)	among	156,456	total	births	at	the	Los	Angeles	County	University	of	Southern	California’s	Women’s	Hospital	between	1983-1992.(117)	Where	prolonged	deceleration	was	the	only	indication	of	uterine	rupture	(n=32),	no	patient	had	significant	clinical	morbidity	when	delivery	occurred	within	17	minutes	of	indication.	When	prolonged	deceleration	was	preceded	by	severe	late	deceleration	(range	of	36-90	minutes;	n=18),	perinatal	asphyxia	occurred	as	early	as	10	minutes	before	the	onset	of	prolonged	deceleration	and	delivery.	Bujold	et	al.	reviewed	23	cases	of	uterine	rupture	in	a	Canadian	tertiary	setting	between	1998-2000	and	found	differences	of	4	minutes	from	decision	to	intervene	to	caesarean	between	infants	with	severe	metabolic	acidosis	vs.	not	and	extrusion	of	the	fetus	or	placenta	vs.	not	(17	vs.	13	minutes	for	each	outcome).(118)	These	differences,	while	not	statistically	significant	in	this	small	study,	suggest	that	neonatal	outcomes	may	improve	with	faster	access	to	the	operating	room.		While	the	SOGC	practice	guidelines	support	women’s	access	of	VBAC	services	and	recommend	offering	VBAC	to	the	majority	of	women	with	a	previous	caesarean,	the	surgical	staff	and	resources	required	for	emergency	caesareans	may	not	be	available	in	some	settings.	These	environmental	and	policy	requirements	may	limit	the	delivery	options	available	to			49	women	and	may	influence	how	they	are	counseled	about	the	safety	of	planned	VBAC,	particularly	in	low	resource	environments	or	in	settings	with	longer	intervals	from	decision-to-incision.	There	is	no	evidence	in	Canada	on	the	effect	of	SOGC	guidelines,	and	the	specific	recommendations	regarding	timely	caesarean,	on	women’s	access	of	planned	VBAC.	The	next	section	explores	the	evidence	on	the	impact	of	health	service	and	policy	factors	on	access	to	planned	VBAC	in	international	settings.			2.5.1 Health	Services	Barriers	to	Access	of	Planned	VBAC	In	the	United	States,	emerging	evidence	indicates	that	health	service	decisions	on	whether	or	not	to	provide	continuous	in-house	caesarean	section	back-up	limit	the	mode	of	delivery	options	available	to	women.	Barger	et	al.	conducted	a	survey	in	2012	of	all	California	maternity	hospitals	(n=243)	and	found	that	139	hospitals	in	the	state	offered	VBAC	services	(53%).(37)	This	represented	a	sharp	decrease	in	comparison	to	ten	years	previous	when	74%	of	California	maternity	hospitals	offered	planned	VBAC.(119)	In	the	Barger	survey,	among	the	hospitals	that	offered	planned	VBAC,	49.6%	were	large	teaching	hospitals	(>2500	births	per	year),	and	70.5%	were	non-profit.(37)	VBAC	was	offered	in	only	5	of	37	(96.4%)	hospitals	designated	as	rural	(population	density	of	less	than	250	persons	per	square	mile).(37)	Availability	of	24/7	anaesthesia	coverage	was	a	predictor	of	VBAC	services.	Among	hospitals	that	did	not	offer	planned	VBAC,	only	30	hospitals	(29%)	had	24/7	anaesthesia	coverage,	compared	with	110	hospitals	(79.1%)	that	offered	VBAC	services.(37)	Among	VBAC	hospitals	where	the	obstetrician			50	or	anaesthetist	was	on-call	all	or	part	of	the	time,	more	than	90%	required	that	they	be	available	within	15	minutes.(37)		Barger	et	al.	also	surveyed	nurses	on	the	reasons	why	hospitals	(n=99)	had	stopped	providing	planned	VBAC	and	the	most	commonly	cited	reasons	were	lack	of	immediate	available	anaesthesia	(70.7%),	lack	of	immediately	available	obstetrician	(54.5%),	ACOG	guidelines	(48.5%),	and/or	hospital	protocols	(44.4%).(37)	It	is	noteworthy	that	while	53%	of	the	hospitals	in	the	study	offered	planned	VBAC,	the	median	rate	of	actual	VBAC	among	eligible	women	in	those	hospitals	was	only	10.8%	(range	0	to	37.3%).(37)	The	most	commonly	cited	reason	for	low	VBAC	rates	was	practitioner	unwillingness	to	support	them,	primarily	due	to	a	requirement	to	be	continually	present	during	labour.	This	result	is	consistent	with	Cox’s	findings	from	qualitative	interviews	with	maternity	care	providers	in	Florida.(31)	While	a	hospital	may	permit	VBAC	and	have	supportive	policies,	it	may	not	routinely	provide	VBAC	services	due	to	individual	care	provider	reluctance.	However,	the	study	did	not	collect	data	from	obstetricians	to	determine	the	reasons	for	their	lack	of	support	of	planned	VBAC.	Birnbach	et	al.	suggest	strategies	for	reducing	the	health	services	risks	associated	with	offering	VBAC	in	the	absence	of	24/7	anaesthesia,	including	providing	an	antenatal	anaesthesia	consult	for	VBAC	patients,	developing	process	maps	to	improve	communication	on	labour	and	delivery	suites,	practicing	‘fire-drills,’	and	developing	care	protocols	based	on	patients’	clinical	risk	status.(120)	However,	the	effect	of	such	interventions	is	understudied	and	it	is	unclear	which	strategies	would	apply	to	a	Canadian	context	and	whether	such	measures	would	enable	Canadian	practitioners	to	offer	VBAC	within	the	context	of	limited	access	to	anaesthesia	services.			51	In	Australia,	similar	variation	in	care	provider	practice	patterns	for	planned	VBAC	was	observed	in	the	Birth	Choices	study,	a	prospective	multi-centre	randomized	controlled	trial	involving	227	women	that	tested	the	impact	of	a	patient	decision	aid	on	women’s	choice	of	mode	of	delivery	after	caesarean.(38)	Exposure	to	the	decision	aid	was	associated	with	an	2.17	point	increase	in	knowledge	scores	out	of	15	(95%	CI	1.71-2.63,	p<0.001),	but	no	significant	difference	in	preference	for	VBAC	or	elective	repeat	caesarean	between	intervention	and	control	groups.(38)	Rather	the	authors	observed	that	the	hospital	site	at	which	women	gave	birth	predicted	women’s	preferences	for	mode	of	delivery.	Specifically,	pre-study	baseline	rates	for	the	two	study	sites	for	actual	VBAC	delivery	(20%	and	80%	respectively)	were	fairly	consistent	with	actual	VBAC	rates	among	participants	at	each	site	(39%	and	70%).(38)	The	authors	hypothesized	that	low	VBAC	rates	in	one	of	the	two	study	sites	may	have	been	the	result	of	“organizational	culture	and	clinical	practice	patterns”(38)	characterized	by	health	care	provider	resistance	to	VBAC	and	unsupportive	hospital	policies.(39)	Shorten	et	al.’s	work	suggests	that	patient	VBAC	preferences	are	honoured	only	in	settings	that	have	supportive	infrastructure,	resources,	and	policies.	However,	as	with	Barger	et	al.’s	survey	in	California,(37)	Shorten	et	al.	did	not	investigate	the	reasons	for	differing	clinical	practice	patterns.	This	is	a	significant	gap	in	the	literature,	for	in	order	to	develop	interventions	that	have	a	meaningful	impact	on	practitioners’	practice	patterns	it	is	imperative	to	understand	existing	patterns,	why	they	occur,	and	the	barriers	and	enablers	to	making	practice	patterns	more	evidence-based	and	patient-centred.	Clinicians	and	health	service	decision	makers’	attitudes	and	experiences	may			52	provide	insight	into	why	health	services	do	not	provide	the	resources,	and/or	budget,	necessary	to	support	evidence-based	care	for	birth	after	caesarean.		While	no	studies	have	specifically	examined	access	to	VBAC	services	in	a	Canadian	context,	evidence	from	observational	(65,121,122)	and	qualitative	studies	(123,124)	indicates	that	there	is	variation	in	access	to	ceasarean	section	services	for	women	in	British	Columbia	due	to	environmental	and	health	system	factors.	Qualitative	studies	on	sustainability	of	rural	maternity	services	in	BC	conducted	in	the	early	2000’s	found	that	individual	hospitals	often	develop	criteria	for	eligibility	for	local	delivery	based	on	limited	availability	of	surgical	services,	and	that	these	guidelines	typically	exclude	women	with	a	previous	caesarean.(123,124)	Practitioners	in	these	settings	will	recommend	that	women	travel	to	a	facility	with	surgical	back-up	to	support	a	trial	of	labour,	per	clinical	practice	guidelines.(13)		While	there	is	evidence	from	California	(37)	that	lack	of	immediately	available	anaesthesia	influences	care	provider	willingness	to	support	VBAC,	there	is	no	evidence	to	date	of	this	relationship	in	BC.	However	the	limited	availability	of	obstetric	anaesthesia	in	BC	is	a	contentious	patient	safety	issue	that	has	received	media	coverage.(125)	The	four	tertiary	hospitals	in	the	province	(BC	Women’s	Hospital,	Royal	Columbian,	Surrey	Memorial,	and	Victoria	General)	are	required	by	Perinatal	Services	BC	standards	to	have	a	dedicated	obstetric	anaesthetist	available	in-house	24/7.	While	an	anaesthetist	may	be	in	house,	he	or	she	may	not	be	immediately	available	in	an	emergent	situation	due	to	an	overwhelming	caseload.	In	2011	an	intrapartum	stillbirth	occurred	at	Victoria	General	Hospital	(VGH).	In	a	Globe	and	Mail	interview	a	VGH	anaesthetist	asserted	that	limited	number	of	obstetric	anaesthetists	at	the			53	hospital	“could	have	caused	a	delay	in	care,	which	could	have	resulted	in	the	death	of	a	baby.”(126)	In	a	service	review	of	the	incident	conducted	by	a	multidisciplinary	panel	of	Alberta	physicians	and	patient	safety	experts,	the	authors	recommended	increasing	the	number	of	dedicated	obstetric	anaesthetists	from	two	to	three	in	order	to	increase	patient	safety	and	quality	of	care.(127)	In	the	context	of	this	controversy,	it	is	possible	that	anaesthesia	availability	may	be	a	factor	in	decision-making	for	planned	VBAC.	The	influence	of	anaesthesia	access	on	care	providers’	willingness	to	support	VBAC	should	be	studied	in	a	Canadian	context.	There	is	emerging	evidence	that	variation	in	hospital	levels	of	services	and	models	of	care	also	may	be	associated	with	variation	in	caesarean	section	rates.	The	Canadian	Hospital	Reporting	Project	indicated	in	2014	that,	in	British	Columbia,	the	repeat	caesarean	rate	ranged	from	56-93%	among	hospitals.(128)	The	report	did	not	indicate	causes	for	the	variation,	which	may	have	been	due	to	differences	in	levels	of	care	or	patient	demographics.	However	there	is	evidence	that	primary	caesarean	deliveries	vary	for	non-clinical	reasons.	Hanley	et	al.	investigated	regional	variation	in	caesarean	delivery	rates	in	the	province	between	2004-2007,	excluding	women	with	a	previous	caesarean	delivery.(121)	After	controlling	for	maternal	characteristics	and	conditions	associated	with	increased	likelihood	of	caesarean	delivery,	adjusted	primary	caesarean	rates	varied	twofold	and	ranged	from	14.7	to	27.6	per	100	deliveries	in	health	service	delivery	areas.(121)	The	authors	hypothesized	that	this	substantial	variation	likely	reflects	“differences	in	practitioners’	approaches	to	medical	decision-making,	some	of	which	may	be	explained	by	differences	in	the	resources	available	to	the	practitioners.”(121)	A	series	of	studies	by	the	Centre	for	Rural	Health	Research	further			54	illuminate	the	impact	of	model	of	care	on	caesarean	section	rates.	In	a	retrospective	cohort	study	of	maternal	newborn	outcomes	in	rural	maternity	services	in	BC,	Alberta,	and	Nova	Scotia	from	2003-2008	(n=150,797),	Grzybowski	et	al.	found	evidence	that	caesarean	section	rates	significantly	increase	when	surgical	services	are	supported	by	a	general	surgeon	in	comparison	to	models	led	by	General	Practitioners	with	enhanced	surgical	skills	(GPESS)	or	mixed	models	that	include	obstetricians.(122)	In	contrast,	BC	women	who	have	a	registered	midwife	involved	in	their	care	have	lower	caesarean	section	rates.(129,130)	Together,	this	evidence	suggests	that	geographic	location,	level	of	obstetrical	surgical	service,	and	model	of	care	influence	decision-making	for	mode	of	delivery.	Notably	the	cohort	studies	conducted	by	Hanley	et	al.	and	Grzybowski	et	al.	excluded	multiparous	women	with	a	previous	caesarean	from	analysis	and	focused	solely	on	women	with	no	history	of	caesarean.(121,122)	There	are	no	studies	that	explicitly	explore	the	impact	of	geography,	level	of	service,	or	model	of	care	on	access	to	VBAC	services	in	BC.		There	is	evidence	from	the	United	States	that	access	to	VBAC	services	has	been	restricted	due	to	malpractice	concerns.	Yang	et	al.	investigated	liability	insurance	premiums	and	tort	reforms	in	the	United	States	from	1991-2003	and	found	that	malpractice	pressure	was	negatively	associated	with	VBAC	(beta	=	-0.35,	P	=	0.01).(131)	Although	the	healthcare	climate	in	Canada	is	far	less	litigious	than	in	the	United	States,	no	Canadian	studies	have	investigated	the	effect	of	malpractice	concerns	on	access	to	VBAC	services.					55	2.5.2 The	Influence	of	Financial	Incentives	There	is	clear	economic	evidence	that	financial	incentives	influence	clinical	decision-making	for	mode	of	delivery,	with	the	strongest	evidence	emerging	from	California.	Stafford	examined	461,066	deliveries	in	California	in	1986,	finding	that	source	of	insurance	coverage	influences	caesarean	section	rates.(132)	Planned	VBAC	occurred	more	frequently	among	women	covered	by	Kaiser	health	maintenance	organizations	(19.9%)	and	Indigent	Services	(24.8%)	in	comparison	to	women	covered	by	private	insurance	(9.9%).(132)		Johnson	and	Rehavi	compared	administrative	perinatal	data	of	California	and	Texas	mothers	who	were	physicians	to	data	from	ordinary	patients	without	medical	training.(19)	They	also	compared	outcomes	between	hospitals	where	obstetricians	receive	fees-for-service	and	those	where	they	were	salaried.	The	authors	hypothesized	that	obstetricians	would	recommend	caesareans	for	patients	if	there	was	a	financial	incentive	to	do	so	(e.g.	high	reimbursement	fee	for	caesarean)	and	that	physician-patients	would	better	understand	their	options	and	be	less	likely	to	be	persuaded	to	have	a	clinically	unnecessary	caesarean.	The	analysis	confirmed	that	there	is	a	“physician-induced	demand”	for	unscheduled	(e.g.	not	medically-indicated)	caesareans.	Controlling	for	demographic	variables,	physician-mothers	were	11%	less	likely	to	give	birth	by	unscheduled	intrapartum	caesarean	in	comparison	to	their	non-physician	counterparts.	Hospitals	with	higher	incentives	for	caesarean	had	higher	caesarean	section	rates,	but	physician-patients	were	not	affected	by	financial	environment.	The	authors	suggested	that	“financial	incentives	are	an	important	determinant	of	treatment;	and	that	patient	information	is	an	effective	counterweight.”(19)	These	findings	suggest	that			56	informed	patients	make	different	(less	invasive)	childbirth	treatment	choices,	and	that	improving	patient	knowledge	could	decrease	caesarean	rates.		In	2015,	the	Pacific	Business	Group	on	Health	and	California	Maternal	Quality	Care	Collaborative	(CMQCC)	conducted	a	pilot	project	in	three	southern	California	hospitals	to	reduce	caesarean	section	rates	through	access	to	performance	data,	quality	improvement,	and	payment	reform.(133)	The	“value	based”	payment	reform	mandated	that	physicians	and	hospitals	were	reimbursed	one	flat	rate	regardless	of	mode	of	delivery	(caesarean	or	vaginal	birth),	to	remove	any	financial	incentives	for	performing	caesarean.	Within	one	year,	the	three	pilot	hospitals	experienced	an	average	20%	reduction	in	caesarean	section	rates	(e.g.	32.6%	to	24.2%	at	Hospital	1).	The	pilot	project	team	observed	that	the	changes	were	not	due	to	physician	incentives	alone.	They	cite	reports	from	hospital	physicians	that	non-fiscal	incentives,	like	schedule	constraints,	have	a	greater	influence	on	their	clinical	decision-making	than	do	payments.	In	Canada,	there	is	minimal	difference	between	physician	fees	for	vaginal	vs.	caesarean	birth.		Additional	leisure-	and	psychological-based	incentives	may	influence	Canadian	physicians’	clinical	decision-making.	A	2001	analysis	of	birth	certificate	and	financial	data	from	California	hospitals	found	that	caesarean	sections	for	physician	convenience	are	more	likely	to	be	conducted	in	the	evening	hours	so	that	staff	can	leave	work	for	leisure	time.(134)	Care	providers	may	also	perform	medically	unnecessary	repeat	caesareans	to	reduce	their	anxiety	and	psychological	distress	about	the	legal	consequences	of	an	adverse	planned	VBAC	outcome.	A	2012	survey	of	the	American	College	of	Obstetrician	and	Gynecologists’	membership			57	(n=9,002)	found	that	58%	of	respondents	said	they	changed	how	they	practiced	due	to	the	risk	or	fear	of	being	sued	and	19%	of	all	respondents	had	recently	ceased	to	offer	planned	VBAC	for	that	reason.(135)		The	scant	literature	on	the	health	service	and	policy	factors	that	influence	decision-making	for	birth	after	caesarean	is	cause	for	concern.	The	focus	of	qualitative	studies	to	date	has	been	primarily	on	women’s	attitudes	and	experiences	with	decision-making	for	VBAC	in	international	settings.	These	perspectives	are	necessary	to	understand	how	existing	services	are	meeting	women’s	needs	and	to	identify	gaps	in	patient-centred	care.	Likewise,	the	emerging	qualitative	literature	on	care	providers’	attitudes	and	experiences	provides	evidence	on	how	environment	and	professional	identity	influence	how	providers	perceive	birth	after	caesarean	to	be	risky	or	safe.	This	knowledge	provides	insight	into	the	complexity	of	decision-making	relationships	between	patients	and	providers,	and	illuminates	some	of	the	ways	care	providers	may	influence	women’s	choice	of	mode	of	delivery.	However,	the	evidence	on	environmental	and	policy	barriers	to	access	of	VBAC	services	indicates	that	there	is	a	blind	spot	in	the	current	qualitative	literature	–	the	decision-making	context.	Decision-making	for	birth	after	caesarean	appears	to	occur	between	the	patient	and	care	provider	in	the	context	of	their	environment,	which	includes	patients’	social	relationships,	providers’	professional	relationships,	and,	importantly,	health	service	resources,	policies,	and	incentives	for	birth	after	caesarean.	If	interventions	to	support	women’s	informed	choice	for	birth	after	caesarean	are	to	be	successful,	they	clearly	need	to	attend	to	barriers	at	all	three	interrelated	levels	of	the	decision-making	process	–	patient,	provider,	and	context.	The	next			58	section	introduces	the	current	literature	on	interventions	to	support	decision-making	for	VBAC,	the	strengths	of	the	evidence,	and	significant	gaps	in	intervention	approaches.		2.6 Interventions	to	Support	Decision-Making	for	Birth	after	Caesarean	The	literature	on	interventions	for	promoting	evidence-based	practice	for	VBAC	may	be	divided	into	those	that	are	practitioner-centred	and	those	that	are	patient-centred.	A	recent	systematic	review	by	Lundgren	et	al.	evaluated	the	effectiveness	of	clinician	interventions	aimed	at	increasing	VBAC	rates.(136)	Three	randomized	controlled	trial	studies	were	identified	and	all	were	conducted	during	the	late	1980s-1990s,	prior	to	the	health	service	and	policy	changes	to	VBAC	practice	that	occurred	in	the	mid-90s.	In	the	first	trial	Thubisi	et	al.	evaluated	the	effectiveness	of	antenatal	x-ray	pelvimetry	at	36	weeks	in	306	women	with	a	previous	caesarean,	and	observed	that	not	using	pelvimetry	significantly	decreased	caesarean	rates	(RR	0.66,	95%	CI	0.44-0.98).(137)	In	the	second	trial,	Bickell	et	al.	evaluated	the	effects	of	external	peer	review	on	caesarean	rates	in	45	hospitals,	and	found	no	significant	effect	on	VBAC	rates	(MD	-1.9,	95%	CI-5.39-1.59).(138)	The	final	study	conducted	by	Lomas	et	al.	evaluated	opinion	leader	education	and	audit	and	feedback	in	16	Canadian	community	hospitals	that	were	not	teaching	institutions	over	a	24	month	period	beginning	in	1988,	and	found	that	the	opinion	leader	education	intervention	significantly	increased	VBAC	rates	(25%)	in	comparison	to	controls	(14%)	(RR	1.74,	95%	CI	1.45-2.09).(139)	These	studies	indicate	that	organization-wide	behavior	change	interventions	may	be	successful	in	implementing	best	practices	for	birth	after	caesarean.			59	Specifically,	in	the	opinion	leader	intervention	conducted	by	Lomas	et	al.	staff	from	four	hospitals	were	given	a	questionnaire	and	asked	to	nominate	the	local	colleague	who	best	matched	the	descriptions	of	an	educationally	influential	opinion	leader.(139)	The	four	physicians	identified	attended	a	1	½	day	workshop	on	evidence	from	VBAC	practice	guidelines	and	principles	of	behavior	change.	They	then	engaged	in	the	following	steps:	(a)	personally	mailing	to	all	practitioners	engaged	in	their	hospital’s	obstetrical	care	a	“detailing”	sheet	that	summarized	the	1986	SOGC	VBAC	practice	guideline	in	a	visually	striking	fashion,	following	pharmaceutical	company	drug	advertising	principles;	(b)	personally	mailing	two	detailing	sheets	that	included	tailored	information	on	issues	related	to	implementing	the	practice	guidelines,	which	they	felt	may	be	of	concern	to	hospital	practitioners;	(c)	hosting	a	meeting	in	their	community	with	an	expert	on	VBAC	evidence;	and	(d)	maintaining	and	enhancing	regular	communication	with	colleagues	and	recording	these	contacts	in	logbooks.(139)	The	intervention	was	successful	in	changing	practitioner	behavior	and	VBAC	was	offered	to	74.2%	of	eligible	women,	compared	to	half	of	women	in	the	control	(51.3%)	and	audit	and	feedback	(56.3%)	groups	(p	=	0.002).	However	in	the	opinion	leader	group,	only	38.2%	of	eligible	women	attempted	VBAC.	Although	this	was	significantly	higher	than	the	attempted	VBAC	rate	among	women	in	the	control	(28.3%)	and	audit	and	feedback	(21.4%)	groups	(p	=	0.007),	practitioners	in	all	groups	reported	that	many	women	who	were	offered	VBAC	refused	it.	The	authors	argued,	“further	advances	in	the	appropriate	use	of	this	surgical	practice	may	have	to	rely	on	patient	education.”(139)	This	study	demonstrates	that	clinician-centred	interventions	alone	may	effectively	change	clinician	behavior,	but	interventions	that	address	women’s	decision-		60	making	process	may	also	be	necessary.	Intervening	with	clinicians	alone	may	not	be	sufficient	to	support	women	in	making	informed	choices	for	mode	of	birth	after	caesarean.	It	is	unclear	from	Lomas	et	al.	whether	patient	preferences	actually	contributed	to	lower	than	anticipated	rates	of	planned	VBAC.	Patients	were	not	surveyed	as	part	of	the	study	and	no	information	was	provided	on	patient	knowledge,	VBAC	intentions,	or	exposure	to	education.	Nor	did	the	study	provide	information	on	the	content	discussed	by	the	patient	and	provider	when	providers	“offered”	a	planned	VBAC.	The	patient’s	perspective	on	the	decision-making	process	is	necessary	to	understand	whether	clinician-centred	interventions	increase	patient	knowledge	of	their	options,	clarity	about	preferences,	and	motivation	to	attempt	VBAC.			2.6.1 Patient-Centred	Interventions	for	Birth	after	Caesarean	Maternity	care	researchers	Gee	and	Corry	noted	recently	in	a	2012	Obstetrics	and	Gynecology	editorial	that	“Given	the	dearth	of	information	women	have	about	their	medical	choices,	more	investment	is	needed	in	patient	education	and	tools	for	shared	decision	making	in	clinical	settings.”(30)	Patient-centred	interventions	to	support	decision-making	include	education	resources	(e.g.	pamphlets,	websites,	or	videos)	and	interactive	decision	coaching	approaches	(e.g.	peer	counselors,	childbirth	education	sessions,	doulas,	or	decision	coaches).	In	recent	years,	however,	there	has	been	a	great	deal	of	attention	paid	to	the	development	of	patient	decision	aids	(PtDAs)	for	use	in	pregnancy.	These	are	evidence-based	tools	that	aim	to	supplement	(not	replace)	the	shared	decision-making	process	between	patient	and	care	provider.	They	provide	patients	with	individualized	information	on	the	clinical	risks	and	benefits			61	of	their	health	care	options,	highlight	uncertainties	about	the	evidence,	and	help	individuals	to	clarify	their	values	and	preferences.(43,44)	PtDAs	can	be	used	independently	by	the	patient,	shared	face-to-face	with	a	care	provider	during	a	clinical	encounter,	or	mediated	via	telephone	or	other	media,	such	as	with	a	decision	coach.(80,140)	The	study	of	PtDAs	has	been	dominated	by	effectiveness	studies	focused	on	the	quality	of	the	decision-making	process,	for	which	outcomes	include	increased	knowledge,	congruence	between	patient	values	and	their	healthcare	choice,	and	decreased	decisional	conflict	(e.g.	uncertainty	about	decision	making).	There	has	been	limited	exploration	of	how	to	sustainably	implement	into	routine	care	those	decision	aids	that	are	proven	to	be	effective	in	controlled	experimental	settings.	Six	separate	systematic	reviews	were	published	between	2011	and	2014	that	investigated	tools	to	promote	SDM	in	childbirth.(44,53,80,141–143)	These	reviews	used	diverse	methods	of	analysis	but	all	included	studies	that	explored	the	effect	of	PtDAs	on	women’s	childbirth	decision-making	quality	and	effect	on	clinical	outcomes,	such	as	intended	or	actual	mode	of	delivery	after	caesarean.	Of	the	reviews,	the	first	three	investigated	the	use	of	PtDAs	in	pregnancy	and	childbirth	for	a	range	of	decisions,	including	mode	of	birth	after	caesarean,	prenatal	screening,	pregnancy	termination,	breech	delivery,	and	labour	analgesia.(53,141,143)	A	fourth	review	was	conducted	by	Horey	et	al.	for	the	Cochrane	Collaboration	and	focused	specifically	on	the	effectiveness	of	PtDAs	for	mode	of	birth	after	a	caesarean.(80)	The	fifth	review	was	also	a	Cochrane	systematic	review	conducted	by	Stacey	et	al.,	which	explored	PtDAs	for	people	facing	health	treatment	or	screening	decisions,	including	for	childbirth	decisions.(44)	Finally,	Khunpradit	et	al.	completed	a	Cochrane	systematic	review	on	non-clinical	interventions			62	to	reduce	clinically	unnecessary	caesarean	sections.(142)	The	six	reviews	explored	a	variety	of	different	outcome	measures	but	all	observed	that	in	comparison	to	usual	care	or	information	alone,	PtDAs	for	pregnancy	significantly	increased	knowledge,(44,53,80,141–143)	and	decreased	decisional	conflict.(44,53,80,141,143)		While	these	positive	decision	quality	outcomes	are	important	and	suggest	that	use	of	a	PtDA	may	improve	women’s	decision-making	process	in	pregnancy,	there	are	a	number	of	outcomes	with	non-significant	findings	that	raise	questions	about	the	utility	of	PtDAs	in	supporting	evidence-based	decision-making	for	VBAC	in	their	current	form.	All	reviews	found	that	PtDAs	have	no	effect	on	patients’	final	preferences.(44,53,80,141–143)	Looking	specifically	at	Horey	et	al.’s	meta-analysis	of	three	randomized	controlled	trials	involving	decision	support	for	mode	of	birth	after	a	caesarean	(n	=	2270	women;	high-income	countries),	the	authors	found	no	difference	in	mode	of	delivery	between	groups,	whether	women	planned	VBAC	(RR	1.03,	95%	CI	0.97-1.10)	or	repeat	CS	(RR	0.96,	95%	CI	0.62-1.20).(80)	Use	of	a	PtDA	for	birth	after	caesarean	also	did	not	change	the	proportion	of	women	who	were	unsure	about	their	preference	(RR	0.87,	95%	CI	0.62-1.20)	and	did	not	increase	the	proportion	of	women	who	achieved	congruence	between	their	preferred	and	actual	mode	of	birth	(RR	1.02,	95%	CI	0.96-1.07,	n	=	1921	women).(80)		These	findings	indicate	the	need	for	more	research	on	how	women	gain	clarity	and	confidence	regarding	their	preferences	for	mode	of	delivery,	so	that	PtDAs	can	be	designed	to	better	help	women	determine	what	matters	most	to	them	for	birth	after	caesarean.	Second,	for	women	who	were	sure	about	their	preferences,	the	lack	of	congruence	between	these			63	preferences	and	their	actual	mode	of	birth	is	concerning.	This	suggests	that	in	the	interval	between	being	exposed	to	a	PtDA	and	planning	mode	of	birth,	these	women	either	changed	their	preferences,	changed	clinical	risk	status	to	preclude	the	opportunity	for	planned	VBAC,	and/or	were	persuaded	to	make	a	different	decision	that	was	misaligned	with	their	preferences.	It	also	raises	the	question	of	when	women	form	preferences	for	birth	after	caesarean	and	the	optimal	timing	of	exposure	to	a	patient	decision	aid,	whether	during	the	inter-pregnancy	interval	or	in	early,	mid,	or	late	pregnancy.	Similar	to	the	literature	on	clinician-centred	interventions,	these	findings	indicate	that	in	order	to	make	patient-centred	interventions	effective,	it	is	necessary	to	have	the	clinician’s	perspective	on	whether	they	find	patient-centred	interventions	to	be	acceptable,	useful,	and	feasible	in	clinical	decision-making.	The	limitations	of	PtDAs	have	been	highlighted	previously	in	this	chapter,	with	reference	to	the	Birth	Choices	trial	from	Australia,	which	explored	the	effectiveness	of	a	PtDA	for	birth	after	caesarean	in	two	hospitals	with	differing	baseline	rates	for	planned	VBAC	(20%	vs.	80%).(38)	This	was	one	of	the	three	trials	included	in	Horey	et	al.	and	provides	a	case	example	of	the	challenges	of	implementing	patient-centred	interventions	that	are	intended	to	be	used	independently	by	the	woman	and	are	not	shared	in	a	clinical	encounter.	Specifically,	in	the	Birth	Choices	trial	women’s	informed	preferences	for	planned	VBAC	were	honoured	only	in	the	setting	that	had	supportive	infrastructure,	resources,	and	policies.(38)	Findings	on	the	limited	effectiveness	of	provider-	and	patient-centred	interventions	to	support	evidence-based	practice	for	VBAC	illustrate	the	importance	of	exploring	interventions	in	their	context.	Interventions	that	target	clinicians	in	isolation	may	turn	a	blind	eye	to	the	role			64	that	patients	play	in	choosing	mode	of	birth	after	caesarean.	Likewise,	patient-centred	interventions	designed	for	use	outside	of	a	clinic	visit	or	in	the	comfort	of	the	woman’s	home	ignore	the	role	of	care	providers,	the	health	service	environment,	and	policies	in	supporting	or	impeding	women’s	informed	choices.	The	following	section	explores	the	implementation	of	SDM	interventions	and	provides	further	insight	into	best	practices	and	areas	of	improvement.		2.6.2 Implementation	of	Shared	Decision	Making	Interventions	Interventions	to	support	the	adoption	of	SDM	in	practice	have	been	clinician-centred	and	have	focused	on	resolving	barriers	to	clinicians’	uptake	of	SDM,	primarily	through	continuing	medical	education	in	SDM	skills.(146)	Légaré	et	al.	conducted	a	systematic	review	of	health	professional	barriers	and	facilitators	to	implementing	SDM	in	clinical	practice	(n=38)	(147)	and	a	Cochrane	Systematic	Review	of	interventions	for	improving	the	adoption	of	SDM	by	healthcare	professionals	(n=5).(146)	Barriers	to	implementation	of	SDM	identified	at	the	practitioner	(micro)	level	included	lack	of	self-efficacy	to	engage	in	SDM	and	risk	communication	with	patients;	and	perceived	inappropriateness	of	SDM	in	particular	clinical	situations	and	patient	populations.(147)	At	the	organizational	(meso)	level,	barriers	included	lack	of	policies	to	support	widespread	adoption	of	SDM	in	practice,	organizational	routines	that	prohibit	SDM	activities,	costs	associated	with	training	care	providers	and	implementing	tools	to	support	SDM,	and	lack	of	time	and	reimbursement	for	SDM.(147)	While	these	findings	on	implementation	of	SDM	may	be	applicable	to	interventions	involving	decision	aids,	only	six	studies	included	in	Légaré	et	al’s	two	reviews	were	decision	aid	interventions	and	only	one	study	assessed			65	implementation	of	a	maternity	decision	support	intervention	–	informed	choice	leaflets	for	patients	attending	Welsh	midwifery	services.(35)		In	the	Welsh	study,	researchers	evaluated	the	use	of	evidence-based,	informed	choice	leaflets	on	decisions	in	maternity	care,	using	observation	of	886	antenatal	consultations	in	13	maternity	units	in	Wales	and	383	in-depth	interviews	with	women,	midwives,	and	obstetrical	specialists.(35)	Qualitative	analysis	revealed	that	care	provider	attitudes	and	time	constraints	were	barriers	to	the	use	of	the	KT	tools.	Informed	choice	was	not	promoted	in	the	study	setting	due	to	care	providers’	belief	that	certain	choices	(such	as	elective	caesarean	for	breech	presentation)	are	more	“clinically	secure”	and	would	afford	them	protection	against	litigation.	These	factors	contributed	to	a	culture	of	patient	compliance	with	care	providers’	recommendations.	As	the	authors	themselves	note,	the	tools	were	developed	and	passively	distributed	without	an	understanding	of	potential	barriers	and	facilitators	to	implementation.(35)	They	concluded	that	PtDAs	may	be	effective	in	controlled	experimental	settings,	but	not	in	real	world	care.(35)	This	study	illustrates	the	importance	of	patient	and	provider	engagement	to	fully	understand	system	barriers	to	implementation.	It	is	important	to	understand	how	use	of	PtDAs	may	impact	care	provider	workflow	so	that	the	tools	can	be	implemented	seamlessly	into	existing	practice	routines.	The	study	also	highlights	the	importance	of	understanding	how	maternity	care	providers	feel	about	decision	aids	and	SDM	in	the	context	of	time	limitations,	fears	of	litigation,	and	high	uncertainty	of	outcomes	for	individual	patients.				66	Elwyn	et	al.	published	a	series	of	case	studies	(n=7)	(148)	as	well	as	a	systematic	review	of	peer-reviewed	literature	(n=17),(149)	both	reporting	on	implementation	of	“decision	support	interventions,”	a	range	of	tools	including	decision	aids.	In	cases	where	some	degree	of	implementation	of	decision	support	interventions	was	achieved,	such	as	positive	intention	to	routinize	use	of	a	decision	aid	or	actual	adoption	in	routine	practice,	care	providers	trusted	the	content	of	the	tool,	including	both	its	evidence	base	and	reflection	of	“local”	data	and	clinical	realities.(149)	Facilitators	observed	in	the	literature	included	skills	training	for	care	providers	in	how	to	use	a	decision	aid	in	routine	care,	as	well	as	“buy-in”	and	uptake	of	decision	aids	by	physicians	in	leadership	positions.(149)	The	most	often	cited	facilitator	of	implementation	was	a	system	to	distribute	decision	aids	to	patients	directly	without	relying	on	care	providers	to	initiate	patient	access	to	the	tools.	This	systems	approach	attended	to	the	barriers	of	competing	priorities	and	time	pressures	by	identifying	patients	ahead	of	visits	and	providing	them	decision	aids	to	complete	in	their	own	time.	Additional	facilitators	to	implementation	of	decision	aids	involved	gaining	care	provider	trust	in	the	content	of	the	tool,	including	both	its	evidence	base	and	reflection	of	“local”	data	and	clinical	realities;	provision	of	skills	training	for	care	providers;	and	identification	of	champions	in	leadership	positions.	All	studies	(n=17)	used	a	“referral	model,”	where	care	providers	referred	patients	to	decision	support,	and	measured	uptake	of	the	decision	aid	primarily	based	on	counts	of	the	number	of	tools	provided	to	patients	and	the	number	of	patients	who	used	the	tools.(149)	This	“referral”	approach	to	implementation	was	ineffective	due	to	indifference	on	the	part	of	health	care	professionals,	which	stemmed	from	lack	of	confidence	in	the	intervention,	concern	about	its	impact	on			67	workflow,	competing	priorities,	uncertainty	about	involving	patients	in	decisions,	and	ultimately	“organizational	inertia”	toward	intervention	adoption.(149)	Given	the	studies’	heterogeneous	and	complex	implementation	approaches	and	diverse	methods	for	recording	and	reporting	implementation	outcomes,	Elwyn	et	al.	concluded	that	it	is	premature	to	draw	conclusions	about	best	practices	for	implementation	of	PtDAs	and	that	qualitative	studies	may	be	better	suited	for	exploring	the	mechanisms	that	influence	implementation	of	PtDAs	in	diverse	contexts.(149)		While	the	literature	is	not	established	enough	to	dictate	best	practices	for	implementation	of	SDM	interventions,	a	common	theme	emerges	from	the	existing	evidence.	Regardless	of	whether	the	SDM	intervention	in	question	is	primarily	patient-centered	or	clinician-centered,	the	development	and	testing	of	the	intervention	should	include	identifying	and	attending	to	the	barriers	and	enablers	to	its	use	at	the	patient,	provider,	and	systems	levels.	In	the	case	of	birth	after	caesarean	decision-making	in	Canada,	barriers	and	enablers	may	emerge	at	the	patient	and	provider	level	through	their	attitudes	and	experiences,	at	the	level	of	environment	with	regard	to	resources	that	facilitate	timely	access	to	caesarean	section,	and	through	regional	and	national	policies	that	support	access	to	VBAC	services.	Currently,	these	factors	are	under-investigated	in	Canada	and	internationally.			2.7 Conclusion	In	this	chapter,	I	provided	a	critical	analysis	of	decision-making	for	mode	of	delivery	after	caesarean	in	the	empirical	literature.	I	summarized	the	international	literature	on	women’s	and			68	care	providers’	attitudes	and	experiences	with	mode	of	delivery	after	caesarean,	including	their	perceptions	of	comprehensive	risk	in	pregnancy	and	how	these	perceptions	change	depending	on	environmental	context,	personal	experience,	and	professional	identity.	I	described	how	women’s	access	to	options	for	mode	of	delivery	after	caesarean	have	changed	over	time	in	Canada	and	comparable	international	settings	in	response	to	evolving	evidence	and	corresponding	changes	to	health	policy.	I	summarized	the	health	service	access	challenges	that	have	arisen	in	response	to	policy	changes,	with	attention	to	the	impact	of	limited	anaesthesia	and	surgical	services	on	access	to	VBAC.	I	then	described	the	clinician-	and	patient-centred	interventions	that	have	been	tested	to	date	and	their	limited	effectiveness	in	increasing	women’s	access	to	the	option	of	VBAC.	I	then	argued	that,	in	order	to	be	effective,	the	development	of	interventions	must	be	preceded	by	an	exploration	of	the	context	for	decision-making	for	birth	after	caesarean,	including	barriers	and	enablers	to	behaviour	change	and	implementation	at	the	patient,	care	provider,	and	health	service	and	policy	levels.			 I	identified	a	number	of	gaps	in	the	literature	I	synthesized	on	women’s,	care	provider’s,	and	decision	makers’	attitudes	toward	and	experiences	with	mode	of	delivery	after	caesarean,	and	on	the	factors	that	influence	implementation	of	SDM	in	maternity	care.	Specifically,	in	the	literature	on	women’s	attitudes	and	experiences	with	birth	after	caesarean	decision-making	there	is	limited	understanding	of	the	following	factors	in	a	Canadian	context:	• Women’s	knowledge	of	their	options	for	mode	of	delivery	after	caesarean	and	the	sources	of	that	knowledge.	• Women’s	perceptions	of	the	safety	of	planned	VBAC.			69	• The	factors	that	influence	women’s	attitudes	toward	mode	of	delivery	and	their	decision-making	experience.	• The	timing	of	women’s	preference	formation	for	birth	after	caesarean	and	the	optimal	timing	for	women’s	exposure	to	SDM	interventions.	• The	decision-making	experiences	of	women	in	rural	vs	urban	settings,	and	under	midwifery	vs	physician	care.	• Women’s	perceptions	of	the	barriers	and	facilitators	to	access	of	planned	VBAC	in	their	communities,	including	the	factors	related	to	their	hospital	environment.	In	the	limited	literature	on	care	providers’	attitudes	and	experiences,	there	are	a	number	of	topics	that	are	underexplored	and	warrant	further	investigation:	• Care	providers’	perceptions	of	the	safety	of	planned	VBAC	in	rural	vs	urban	settings,	in	settings	with	different	levels	of	surgical	service,	and	among	different	professions.	• Care	providers’	approaches	to	supporting	women’s	decision-making	for	mode	of	delivery	after	caesarean,	and	how	they	communicate	risks	and	benefits.	• The	influence	of	liability	concerns,	fear	of	professional	criticism,	and	access	to	anaesthesia	on	care	provider	decision-making	for	birth	after	caesarean.	• The	influence	of	the	SOGC	clinical	practice	guideline	recommendations	for	planned	VBAC	on	women’s	and	care	providers’	decision-making.	• Care	providers’	perspectives	on	the	principles	of	SDM	and	the	use	of	PtDA	tools	to	support	SDM.			70	Finally,	my	literature	review	yielded	no	studies	investigating	the	perspectives	of	decision	makers	in	planning	services	for	birth	after	caesarean.	In	response	to	these	gaps	in	the	literature,	I	explore	attitudes	toward	and	experiences	with	decision-making	for	mode	of	birth	after	caesarean	to	identify	the	factors	that	influence	decision-making	for	mode	of	delivery	in	the	context	of	British	Columbia.	The	findings	will	be	relevant	to	health	service	environments	with	similar	models	of	obstetric	care,	rural	populations,	and	rates	of	repeat	caesarean	section	(e.g.	Canada,	Australia,	western	Europe,	and	the	United	States).	Stakeholders	in	these	environments	may	consider	how	the	factors	that	influence	decision-making	for	mode	of	delivery	may	be	mediated	to	enhance	women’s	informed	choice	while	reducing	the	rate	of	clinically	unnecessary	caesareans.	In	the	following	chapter	I	describe	the	qualitative	study	design	and	methods	I	employed.			 			71	Chapter	3: Methods	The	goal	of	this	exploratory	qualitative	research	was	to	explore	attitudes	toward	and	experiences	with	decision-making	for	mode	of	delivery	after	caesarean	from	the	perspectives	of:	a)	women	with	a	history	of	caesarean,	b)	care	providers	who	provide	maternity	services,	and	c)	decision	makers	who	plan	and	manage	health	services	for	birth	after	caesarean.	I	was	specifically	interested	in	investigating	the	factors	that	support	or	impede	evidence-based	practice	for	birth	after	caesarean	in	British	Columbia.		This	study	was	conducted	in	partnership	with	knowledge	users	in	Optimal	Birth	Fraser	Health	(formerly	the	Fraser	Health	Caesarean	Section	Task	Force),	a	multidisciplinary	group	of	clinicians	and	health	service	decision	makers	with	an	interest	in	increasing	vaginal	delivery	rates.	These	partners	provided	input	in	developing	the	study	design	and	interpretation	of	data	to	ensure	that	the	study	results	would	be	relevant	to	the	needs	of	knowledge	users	in	the	BC	health	care	system,	and	to	increase	the	likelihood	that	clinicians	and	service	decision	makers	would	accept	and	trust	my	findings	on	women’s	experiences	of	decision-making	experiences	in	BC	health	authorities.	These	strategies	were	consistent	with	my	integrated	knowledge	translation	(iKT)	research	approach,	which	is	described	in	a	separate	section	(Chapter	7).(9)		3.1 Research	Design:	Constructivist	Grounded	Theory	Grounded	theory	focuses	on	the	process	of	generating	theory	through	specific	techniques	and	developing	theory	from	the	data,	as	opposed	to	from	a	priori	assumptions.(150)	As	a	theory-methods	package,	grounded	theory	emphasizes,	quite	literally,	that	theory	is	grounded	in	the			72	data	collected	and	emerges	from	the	research	process.	The	techniques	first	laid	out	by	Glaser	and	Strauss	in	The	Discovery	of	Grounded	Theory	(82)	are	systematic	strategies	for	qualitative	research	practice.	As	the	scientific	method	gained	prominence	in	institutions	during	the	1960s,	qualitative	methods	were	criticized	for	lacking	objectivity,	validity,	and	for	failing	to	fit	within	positivist	research	designs.	Glaser	and	Strauss	developed	a	qualitative	approach	that	addressed	these	criticisms,	proposing	that	qualitative	analysis	could	be	systematic,	logical,	and	could	generate	theory.	They	drew	on	their	respective	heritages	in	quantitative	methods	(Glaser)	and	Chicago	school	pragmatism	and	symbolic	interactionism	(Strauss).	In	sum,	the	characteristics	of	Glaser	and	Strauss’s	grounded	theory	approach	include:	simultaneous	data	collection	and	analysis;	generating	analysis	from	the	data,	not	from	extant,	deductive	hypotheses;	making	comparisons	between	data	throughout	analysis	(constant	comparison	method);	achieving	saturation;	developing	theory	at	each	stage	of	data	collection	and	analysis;	memo-writing	to	develop	analysis	and	identify	relationships	in	the	data;	theoretical	sampling,	not	sampling	for	population	or	representation;	and	conducting	a	literature	review	after	the	analysis.(84)		Throughout	the	last	two	decades	of	the	twenty-first	century,	qualitative	researchers	responded	to	new	criticisms	that	grounded	theory	was,	ironically,	overly	positivistic.	In	response,	they	adapted	grounded	theory	guidelines	for	post-positivist	perspectives.	While	Strauss,	with	Juliet	M.	Corbin,	began	developing	the	method	in	the	direction	of	technical	procedures	and	strategies	of	verification,	with	continued	attention	to	pragmatist	and	interactionist	processes,(151)	Adele	Clarke,(152)	Kathy	Charmaz,(84)	and	others	revised			73	grounded	theory	approaches	to	respond	to	social	constructionist	paradigms.	The	concept	of	constructionism	assumes	that	we	construct	reality	through	shared	language.(152)	Constructivist	grounded	theory	is	a	set	of	flexible	principles	and	practices	that	complement	other	methodological	approaches	to	qualitative	data	analysis.	The	approach	emphasizes	the	importance	of	researcher	reflexivity,	flexibility,	and	positionality.	In	the	founding	text	on	this	methodology,	Constructing	Grounded	Theory,	Charmaz	argues	that,	“a	method	provides	a	tool	to	enhance	seeing	but	does	not	provide	automatic	insight.	We	must	see	through	the	armament	of	methodological	techniques	…	A	keen	eye,	open	mind,	discerning	ear,	and	steady	hand	can	bring	you	close	to	what	you	study	and	are	more	important	than	developing	methodological	tools”	(p.	15).(84)	Charmaz	employs	a	visual	metaphor	to	describe	the	importance	of	standpoints	in	knowledge	construction,	and	to	emphasize	that	researchers	should	be	reflexive	about	their	positions	during	the	research	process	in	order	to	access	different	views	of	the	studied	phenomenon:	“The	flexibility	of	qualitative	research	permits	you	to	follow	leads	that	emerge	…	Like	a	camera	with	many	lenses,	first	view	a	broad	sweep	of	the	landscape.	Subsequently,	you	change	your	lens	several	times	to	bring	scenes	closer	and	closer	into	view”	(p.	14).	Following	feminist	and	standpoint	theorists,	Charmaz	emphasizes	that	researchers	and	research	participants	are	socially	located	–	they	make	assumptions	about	reality,	have	biases,	social	positions,	and	take	actions	that	reflect	their	individual/collective	views	–	and	that	researchers’	understanding	of	the	world	is	constructed	“through	our	past	and	present	involvements	and	interactions	with	people,	perspectives,	and	research	practices”	(p.	10).	Thus,	data	and	theory	are	constructed.				74	In	Constructing	Grounded	Theory,	Charmaz	adopts	a	social	construction	perspective	and	builds	on	the	work	of	Glaser	and	Strauss	to	suggest	techniques	for	consciously	constructing	research	data	and	theories.(84)	For	instance,	with	regard	to	intensive	interviewing,	she	emphasizes	a	reflexive	approach	in	which	interviewers	are	attuned	to	their	own	and	participants’	past	and	immediate	identities,	to	the	participants’	comfort	level,	to	relative	differences	in	power	and	status,	and	to	the	effect	of	gender,	race,	and	age	on	the	interviews.	Charmaz	also	encourages	researcher	reflexivity	during	data	analysis	by	questioning	one’s	perspectives	and	practices	to	avoid	forcing	data	into	preconceived	codes	and	categories:		Coding	should	inspire	us	to	examine	hidden	assumptions	 in	our	own	language	as	well	as	that	of	our	participants	…	We	may	think	our	codes	capture	the	empirical	reality.	Yet	it	is	our	view:	we	choose	the	words	that	constitute	our	codes.	Thus	we	define	 what	 we	 see	 as	 significant	 in	 the	 data	 and	 describe	 what	 we	 think	 is	happening.	(p.	47)		One	strategy,	she	suggests,	for	maintaining	this	type	of	“objectivity”	is	by	coding	closely	to	the	data	(with	in	vivo	codes	where	appropriate)	and	by	showing	actions	by	using	gerunds	(verbs	that	function	as	nouns,	e.g.	“experiencing	trauma”),	as	encouraged	in	Glaser’s	early	work.	Charmaz	argues	that	theories	evolve	as	social	constructions	and	depend	on	the	researcher’s	view.	Consequently,	researchers	must	exercise	a	great	deal	of	reflexivity	to	identify	how	the			75	studied	experience	is	embedded	within	larger,	often	hidden,	structures	and	hierarchies	of	power;	that	is,	how	the	theory	is	connected	with	its	social	context.			 A	number	of	characteristics	of	grounded	theory	can	pose	challenges	for	applied	qualitative	health	researchers.	Traditional	grounded	theorists	argued	that,	in	order	to	minimize	the	influence	of	extant	literature	on	analysis,	the	researcher	should	not	complete	a	literature	review	prior	to	the	study.(82)	As	discussed	in	Chapter	2,	this	notion	of	objectivity	makes	little	sense	for	applied	health	researchers	whose	understanding	of	the	literature	leads	to	identification	of	gaps	between	knowledge	and	practice.	Further,	a	grounded	theory	analysis	results	in	coded,	representative	selections	of	text	that	are	abstracted	from	participant	narratives.	While	this	serves	to	produce	a	theory	that	is	grounded	in	participants’	stories,	the	stories	themselves	become	fragmented.	Participant	narratives	reveal	rich	insights	into	individual	behaviour,	while	coded	interview	selections	from	grounded	theory	provide	insight	into	social	processes.			In	the	context	of	these	limitations,	and	to	enhance	the	potential	for	my	theory	to	be	relevant	and	useful	for	patients,	care	providers,	and	decision	makers,	I	sought	to	be	flexible	with	grounded	theory	methodology	and	follow	the	“methodological	emancipation”	approach	promoted	by	qualitative	nursing	researcher	Sally	Thorne.(153)	I	used	methods	and	approaches	that	logically	followed	my	applied	research	questions,	rather	than	“the	dictates	of	an	extant	methodological	package.”	For	instance,	I	revisited	my	literature	over	time	as	new	questions	emerged	from	data	collection	and	analysis,	and	attempted	to	integrate	rich	participant	narratives	into	my	analysis	(see	Chapter	6).	In	the	following	sections,	I	describe	the	methods			76	undertaken	for	this	dissertation,	which	were	inspired	by	Charmaz’s	constructivist	grounded	theory.		3.2 Setting		British	Columbia	is	a	province	of	4	million	people	located	on	the	west	coast	of	Canada.	There	are	approximately	40,000	live	births	annually	in	the	province,	of	which	25%	take	place	outside	of	major	urban	centres.	The	geography	of	the	province	is	diverse	and	its	communities	are	located	primarily	along	coastlines	and	in	mountainous	valleys.	In	many	regions,	transportation	is	a	challenge	due	to	seasonal	and	inclement	weather.	Women	who	have	had	a	previous	caesarean	section	typically	plan	future	deliveries	in	hospitals	with	obstetrical	services	capable	of	providing	“timely	access”	to	emergency	caesarean	section	(e.g.	within	30	minutes	from	decision	to	incision).	The	Society	of	Obstetricians	and	Gynaecologists	of	Canada	provide	this	recommendation	for	timely	access	in	their	clinical	practice	guidelines	for	planned	VBAC.(13)	Women	may	choose	from	a	registered	midwife,	family	physician,	or	obstetrician	for	their	primary	maternity	care,	while	nurses	provide	additional	bedside	care	during	labour	and	delivery.	Women	may	also	plan	a	VBAC	in	their	home	or	a	homelike	environment	attended	by	a	registered	midwife,	although	the	practice	of	home	VBAC	(HBAC)	is	controversial.(154)	In	rural	communities,	an	obstetrician,	general	practitioner	with	enhanced	surgical	skills	(GPESS)	or,	on	occasion,	a	General	Surgeon	may	lead	caesarean	section	services.	An	initial	purposive	sample	of	British	Columbia	communities	was	selected	to	explore	the	phenomenon	of	decision-making	for	birth	after	caesarean.	Each	“community”	was	defined	as			77	the	population	catchment	residing	within	2	hours	travel	time	of	a	hospital	facility	with	obstetrical	services	that	support	planned	VBAC.(13)	Communities	that	met	these	criteria	were	further	investigated	with	the	purpose	of	identifying	four	sites	that	represent	the	diversity	of	obstetrical	service	models	across	the	province	based	on	the	following	factors:	• Annual	numbers	of	deliveries:	Rates	of	annual	local	deliveries	were	derived	from	BC	Perinatal	Database	Registry	surveillance	reports	on	maternal	discharges	by	facility	for	2013/14.(155)	I	aimed	to	include	communities	with	low	(<500),	medium	(500-1500),	and	high	(>2500)	numbers	of	annual	deliveries.	• Surgical	obstetric	model	of	service:	Service	models	were	derived	from	the	BC	Perinatal	Database	Registry	surveillance	reports	on	delivery	provider	type	in	each	facility	with	planned	obstetrical	services	for	2013/14.(156)	There	are	four	models	of	caesarean	section	services	in	the	province:	obstetrician	led,	GPESS	led,	General	Surgeon-led,	or	mixed	(obstetrician	+	GPESS)	model	of	care.	Each	obstetrical	model	of	care	supports	primary	maternity	care	provided	by	solo	or	group	practices	of	obstetricians,	GPESS,	family	physicians,	and/or	registered	midwives.	Either	a	physician	or	a	midwife	may	lead	a	primary	maternity	care	practice.	I	aimed	to	represent	all	four	models	of	surgical	obstetric	care	in	my	sample.				• Geographic	diversity:	There	are	five	regional	health	authorities	in	the	province	(Vancouver	Coastal,	Fraser,	Interior,	Vancouver	Island,	and	Northern).	I	aimed	to	include	both	rural	and	urban	communities	in	at	least	two	regional	health	authorities.	Rural	was	defined	as	populations	living	outside	the	commuting	zones	of	larger	urban	centres	with			78	populations	of	10,000	or	more.(157)	I	aimed	to	include	both	rural	and	urban	communities.	• Annual	rate	of	VBAC	by	hospital:	VBAC	rates	were	taken	from	the	Fraser	Institute	British	Columbia	Hospital	report	card	for	the	indicator	“vaginal	birth	after	caesarean,	uncomplicated”	for	2008-2009,	which	is	the	most	recent,	publicly	available	hospital	level	report	on	the	rate	of	vaginal	births	that	occurred	among	mothers	who	delivered	previously	by	caesarean	section	in	the	province.(158)	I	aimed	to	include	communities	with	VBAC	rates	that	were	low,	average,	or	high	in	comparison	to	the	provincial	mean	actual	VBAC	rate	for	that	period.	I	identified	the	initial	sample	of	communities	in	consultation	with	my	supervisory	team	(JK,	PJ).	Additionally,	following	the	knowledge	translation	strategy	for	this	study,	I	consulted	with	Optimal	Birth	Fraser	Health	regarding	inclusion	of	study	sites	in	the	health	authority.	Members,	including	my	study	clinical	co-investigator	(SK),	requested	that	I	include	an	additional	inclusion	criterion:	in-house	vs.	on-call	access	to	caesarean	section	surgical	and	anaesthesia	services.				3.3 Participants	Participants	included:	(a)	Women	who	were	of	childbearing	age	(18-45	years	old)	in	British	Columbia,	who	had	given	birth	by	caesarean	within	the	previous	3	years,	were	considering	a	future	pregnancy,	were	eligible	for	VBAC	delivery,	and	lived	in	the	study	site	catchments;	(b)	family	physicians,	midwives,	and	primary	and	consultant	obstetricians	who	provided	maternity	care	in	the	study	sites;	and	(c)	administrators,	directors,	and	managers	who	were	responsible			79	for	maternity	services	in	the	study	sites.	Participants	had	to	be	English-speaking	in	order	to	participate.		Recruitment	of	childbearing	women	occurred	through	three	methods:	(a)	third-party	recruitment	by	maternity	clinic	staff,	public	health	nurses,	and	leaders	of	community-based	perinatal	health	programs	(e.g.	Healthiest	Babies	Possible);	(b)	poster	advertisement	in	antenatal	clinics	and	in	community	settings	frequented	by	pregnant	women	and	new	mothers	(i.e.	community	centres,	libraries,	cafés,	and	pre-	and	post-natal	fitness	classes);	and	(c)	“snowball”	sampling	whereby	participants	shared	the	study	information	with	potentially	eligible	women	in	their	social	networks,	both	in-person	and	via	Facebook,	and	interested	women	then	contacted	the	study	team.	Through	email	and/or	phone	calls	I	spoke	with	interested	women	to	determine	their	eligibility	and	schedule	an	interview.	Women	were	compensated	for	their	research	participation	by	having	their	names	entered	in	a	single	draw	for	a	$200	gift	card	to	an	online	children’s	clothing	store,	Gap	Kids.	Care	providers	and	decision	makers	were	sought	through	third-party	recruitment	by	“gatekeepers”	in	the	study	sites	who	had	collaborated	in	previous	research	studies,	and	included	community-based	research	partners,	participants	from	previous	research	studies,	or	local	opinion	leaders	identified	by	health	authority	perinatal	leads.	This	was	also	followed	by	a	“snowball”	technique	to	identify	other	key	participants.	Individuals	identified	were	contacted	initially	by	phone	and/or	email	to	provide	a	description	of	the	study,	request	their	involvement,	and	provide	contact	information	if	they	chose	to	participate.	Physicians	and	midwives	were			80	compensated	for	their	research	participation	with	a	$50	honorarium.	Nurses	and	decision	makers	were	offered	a	$25	gift	card	to	a	local	café	for	their	participation.		3.4 Theoretical	Sampling	At	the	outset	of	data	collection,	initial	purposive	sampling	provided	a	point	of	departure	by	identifying	participants	in	each	of	the	study	communities	based	on	the	demographic	inclusion	criteria	listed	above.	A	second	method,	theoretical	sampling,	began	after	analytic	categories	were	developed	in	order	to	seek	participants,	statements,	events,	or	new	settings	that	illuminated	emerging	categories.	In	my	approach	for	theoretical	sampling	I	anticipated	that	these	activities	might	include	expanding	the	initial	sample	criteria	to	include	other	participants	(e.g.	nurses,	women’s	family	members),	returning	to	re-interview	old	participants,	or	exploring	a	new	setting	or	“deviant	cases”	–	highly	unusual	or	outlier	cases	of	attitudes	or	experiences	with	birth	after	caesarean.	These	new	participant	groups	were	then	added	to	the	sampling	frame	and	their	interviews	were	used	as	data.	Sampling	continued	until	categories	suggested	by	the	data	demonstrate	what	Dey	terms	“theoretical	sufficiency,”	that	is,	“when	gathering	fresh	data	no	longer	sparks	new	theoretical	insights,	nor	reveals	new	properties	of	these	core	theoretical	categories.”(84)	I	anticipated	that,	based	on	sampling	in	similar	qualitative	studies,	that	with	1-2	interviews	per	person,	20-30	participants	may	be	needed	in	each	of	the	participant	categories	(i.e.	childbearing	women,	community	care	providers,	decision	makers).(159)				81	Finally,	I	engaged	in	informal	interviews	with	key	informants	outside	of	my	participant	sample,	including	a	malpractice	lawyer	and	opinion	leaders	from	BC	Women’s	Hospital,	the	largest	maternity	unit	in	western	Canada	located	in	Vancouver	Coastal	Health	Authority.	These	were	not	formal	research	interviews	and	their	purpose	was	to	further	understand	the	context	of	decision-making	for	birth	after	caesarean	in	British	Columbia.	I	did	not	include	these	interviews	in	analysis.		3.5 Data	Collection	Data	were	collected	between	April	and	August	2015.	I	conducted	all	in-depth,	open-ended	interviews.	Interviews	were	audio-recorded	and	took	place	either	in	the	participants’	home,	place	of	work,	or	a	location	convenient	to	them,	and	lasted	60-90	minutes.	Although	one-on-one	interviews	were	sought,	opportunistic	group	interviews	were	also	conducted	with	pairs	of	participants	where	it	was	difficult	to	conduct	interviews	individually	due	to	participants’	time	or	space	constraints.(160)	Additionally,	participant	observation	took	place	during	study	site	visits,	and	was	documented	through	empirical	observation	field	notes	and	interpretive	memos.(160)	These	notes	were	not	included	in	analysis	as	one	might	do	in	an	ethnographic	study.	Rather,	my	participant	observation	functioned	as	“hanging	around	a	scene”	(161)	to	gain	information	about	the	study	setting	and	interactions	between	stakeholders.	For	instance,	in	one	small	rural	community	a	decision	maker	gave	me	an	informal	tour	of	the	labour	and	delivery	ward,	where	I	documented	posters	and	pamphlets	in	clinic	waiting	rooms,	layout	of	rooms,	interactions	between	the	decision	maker	and	other	care	providers,	and	the	distance	between	the	ward	and			82	operating	room.	I	used	these	field	notes	to	document	my	hunches	and	insights	outside	of	formal	interviews,	which	informed	my	recruitment	and	interview	process.		 Informed	consent	was	an	ongoing	and	iterative	process.	Each	participant	received	a	copy	of	the	consent	form	at	least	two	days	prior	to	their	interview	to	allow	them	time	for	review.	During	each	interview,	I	took	aims	to	be	“ethically	vigilant”	and	respond	if	the	participant	was	experiencing	distress.(162)	If	the	participant	went	off	topic	in	order	to	“tell	their	story”	I	let	the	story	unfold	before	redirecting	the	discussion	back	to	my	interview	guide,	so	as	not	to	coerce	the	participant	and	honour	their	priorities	for	the	interview	as	well	as	mine.	I	also	recognized	that	many	women	participants	treated	the	interview	as	a	therapeutic	space	where	they	could	reveal	for	the	first	time	their	emotions	about	their	birth	experiences.	During	the	interview	I	warned	women	if	we	were	about	to	discuss	potentially	emotional	or	sensitive	topics	and	reminded	them	that	they	had	the	right	not	to	answer	any	question.	I	took	time	after	these	interviews	to	recoup	with	participants,	discuss	something	lighthearted,	and	ensure	that	they	felt	emotionally	capable	of	returning	to	work	or	to	caring	for	their	child.	At	the	outset	of	the	interview,	the	lead	question	for	interviews	with	childbearing	women	was,	“Tell	me	briefly	about	your	labour	and	delivery	experiences.”	Subsequent	opening	probes	asked	about	participant	behavior	and	experiences	and	included,	“What	did	you	plan	for	your	birth(s)	after	caesarean	–	a	planned	VBAC	or	an	elective	caesarean?,”	“Tell	me	how	you	made	the	decision	to	have	a	VBAC/repeat	caesarean,”	“Tell	me	about	your	care	provider’s	role	in	making	the	decision,”	and	“What	information	did	you	use	to	help	make	your	decision?”	Intermediate	interview	questions	explored	participant	attitudes	toward	repeat	caesarean	and			83	VBAC.	Interviews	with	care	providers	and	decision	makers	explored	similar	questions	related	to	individual	behavior,	attitudes,	and	experiences,	in	addition	to	policy	and	organizational	barriers	and	facilitators	to	VBAC.	Appendix	A	provides	the	detailed	interview	guides	for	women,	providers,	and	decision	makers.	These	guides	functioned	as	the	point	of	departure	for	interviews,	however	concepts	emerging	from	data	analysis	were	pursued	through	additional	or	different	questions	and	probes,	following	Charmaz’s	grounded	theory	approach.(84)		Further,	following	Charmaz’s	interpretation	of	Glaser	and	Strauss’s	constant	comparison	method,(84)	memo-writing	occurred	throughout	data	collection	and	analysis.	Memos	are	informal	notes	taken	successively	from	the	beginning	of	data	collection	to	capture	thoughts,	identify	patterns,	processes,	and	assumptions	embedded	in	the	data,	identify	gaps	in	data	collection,	and	crystallize	questions	and	directions	to	pursue.	As	an	analytic	method,	memo-writing	helped	move	focused	codes	into	conceptual	categories,	helped	to	test	and	compare	the	categories	against	other	concepts	in	the	area	of	behavior	change	(i.e.	capability,	opportunity,	motivation),(163)	and	functioned	as	a	record	of	the	research	and	the	analytic	process.				3.6 Data	Analysis		Data	analysis	took	place	from	August-November	2015.	Audio-recordings	were	transcribed	and	to	develop	the	codebook	(a	list	of	derived	themes	and	categories)	for	analysis,	my	supervisor	(JK)	and	I	independently	read	a	sample	of	six	transcripts	(two	from	each	participant	group).	She	and	I	each	first	analyzed	interview	transcripts	using	open	and	in	vivo	coding	to	explore	for	analytic	ideas	and	identify	properties	of	emerging	concepts.	Constant	comparison	of	data			84	identified	similarities	and	differences	within	and	among	transcripts.	As	provisional	categories	were	developed	and	relationships	between	them	identified,	analysis	shifted	to	focused	coding	to	identify	and	organize	codes	into	batches	of	similar	or	related	phenomena.	By	comparing	data	to	data,	she	and	I	then	developed	focused	codes.	Finally,	theoretical	coding	allowed	for	sorting,	synthesizing,	and	organizing	the	data	into	major	conceptual	categories.	The	evolving	codebooks	are	included	in	Appendix	B.	Together	with	my	supervisor,	we	then	compared	our	codebooks	for	congruency	before	the	transcripts	were	coded	in	their	entirety.	When	compared,	the	two	codebooks	had	conceptual	congruency	indicating	we	identified	similar	phenomena	in	the	transcripts.	However,	the	codebooks	had	different	semantic	approaches	to	labeling	these	phenomena;	one	followed	Charmaz’s	approach	of	using	gerunds	to	describe	action	and	of	explicating	implicit	actions	and	meanings	(SM);(84)	while	the	other	followed	a	pragmatic	approach	that	drew	on	applied,	health	planning	frameworks	(JK).	To	reconcile	the	semantic	differences	between	our	analyses	and	achieve	greater	congruency,	I	merged	the	two	codebooks	following	Charmaz’s	approach	and	coded	a	further	two	transcripts	to	test	the	merged	codebook	for	fit	and	relevance.	Finally,	she	and	I	discussed	the	merged	codebook	and	agreed	that	its	categories	achieved	both	fit	and	relevance;	the	codebook	had	crystallized	participants’	experiences	and	made	implicit	processes	and	structures	visible.(84)			A	research	assistant	skilled	in	qualitative	health	research	analysis	(EW)	and	I	then	independently	coded	the	transcripts.	To	ensure	consistency	in	interpretation	of	the	codebook	and	application	of	its	concepts,	we	coded	a	sample	of	three	transcripts	at	the	outset.	There	was			85	almost	perfect	consistency	between	our	coding	at	this	level.	Coding	was	facilitated	by	use	of	NVivo	analysis	software	(version	11)	for	organization	and	documentation	of	the	transcript	data.	During	the	coding	process,	I	also	returned	to	my	field	notes	to	make	comparisons	between	the	early	analyses	and	theories	I	had	developed	during	my	data	collection,	and	the	analysis	that	developed	from	coding	and	situational	maps.	The	field	notes	sparked	my	memories	of	each	interview	and	the	key	concepts	that	each	participant	focused	on	in	their	story	of	decision-making.								Throughout	the	analysis	I	gave	presentations	to	Fraser	Health	stakeholder	partners,	including	my	clinical	co-investigator	(SK).	These	presentations	described	emerging	findings	and	I	asked	my	knowledge	partners	to	give	“member-checking”	feedback	on	what	the	preliminary	study	findings	meant	to	them	in	their	context	and	experience.	Dissent	was	noted	and	unless	a	factual	error	needed	correcting	the	findings	were	unaltered.	A	full	description	of	integrated	knowledge	translation	activities	can	be	found	in	Chapter	7.	Throughout	my	analysis	and	writing	of	results,	I	also	hand-drew	“situational	maps.”	In	this	grounded	theory	analysis	technique,	the	researcher	draws	visual	representations	to	help	in	analyzing	relations	between	elements	of	the	study	data.(152)	I	illustrated	the	elements	involved	in	decision-making	for	birth	after	caesarean	(people,	organizations,	objects),	drew	the	relationships	between	them,	and	plotted	the	attitudes	and	beliefs	taken	up	by	participants.	In	using	this	analytic	approach	I	aimed	to	make	visible	the	relationships	between	categories	that	were	emerging	in	my	data	and	grapple	with	complexity	and	heterogeneity	in	participants’	narratives.	I	created	individual	maps	for	emerging	categories	that	were	particularly	complex,			86	such	as	women’s	decision-making	process	(a	final	version	of	this	map	is	included	as	Figure	4.1).	This	activity	also	helped	me	to	identify	and	situate	individual	narratives	that	conflicted	with	the	majority	of	participants’	experiences.			3.7 Reliability	and	Validity	Following	Morse’s	definition	of	qualitative	rigour,	verification	strategies	were	pursued	throughout	the	research	process	to	ensure	reliability	and	validity.(164)	Strategies	include	those	listed	above	–	constant	comparison,	keeping	a	data	trail	through	memos,	and	sampling	to	theoretical	sufficiency.	As	well,	following	a	constructivist	standpoint,	I	adopted	a	flexible	and	responsive	approach	to	ensure	that	the	research	question,	method,	and	analytic	techniques	fit	with	the	data	to	guarantee	the	validity	of	the	method.(164)	This	included	bi-weekly	discussions	with	my	supervisory	team	about	categories	emerging	from	data	collection	and	analysis.	I	also	engaged	in	reflexive	strategies	to	check	my	assumptions	about	the	data.	Reflexivity	is	a	core	method	in	qualitative	research	in	which	the	researcher	recursively	considers	how	their	beliefs	and	experiences	influence	the	research	process.(165)	In	this	dissertation,	my	reflexive	strategies	included	engaging	in	a	one-hour	memoing	exercise	prior	to	beginning	coding	of	the	transcripts,	where	I	rapidly	wrote	down	my	assumptions,	biases,	and	key	observations	from	the	data	collection	period.	This	“brain	dump”	activity	aimed	to	help	me	confront	my	preconceived	ideas	and	reflexively	question	my	perspectives	on	the	phenomenon	with	the	aim	of	helping	keep	my	analysis	grounded	in	the	transcripts.				87	I	also	had	“insider	status”	with	each	of	the	stakeholder	population	groups	because	of	my	many	years	of	experience	as	a	labour	and	delivery	doula	and	breastfeeding	counselor,	and	as	an	applied	health	services	research	assistant	in	rural	maternity	care.	I	also	had	longstanding	relationships	with	care	providers	and	decision	maker	stakeholders	through	my	mother,	who	has	practiced	as	a	doula	in	the	greater	Vancouver	region	for	the	past	25	years.	This	combination	of	experiences	provided	me	with	an	understanding	of	the	language	and	cultural	norms	of	maternity	health	services	in	BC.	I	adopted	a	reflexive	approach	to	ensure	that	my	background	and	personal	relationships	did	not	influence	my	data	collection	and	analysis.	In	my	field	notes	and	memoing,	particularly	immediately	after	conducting	an	interview,	I	noted	how	my	beliefs	and	past	experiences	were	similar/dissimilar	to	those	of	participants.			3.8 Developing	a	Theory	Throughout	analysis,	I	took	aims	to	reveal	my	preconceptions	and	assumptions	about	the	phenomenon	–	what	I	had	read,	observed,	and	studied	in	the	past.	I	wrote	reflexive	memos,	discussed	the	analysis	with	my	supervisors,	and	checked	that	each	code	“earned”	its	way	into	the	analysis.(84)	After	writing	the	narrative	of	my	results	(Chapters	4	and	5),	I	had	a	“contextualized	analysis”	that	theorized	connections	between	individual	stakeholders,	local	communities,	and	larger	social	and	organizational	structures.	I	had	identified	processes,	outlined	their	phases,	and	described	them	–	the	“how”	of	decision-making	for	birth	after	caesarean.	I	was	then	encouraged	by	committee	members	(JK,	KC)	to	keep	up	my	“analytic	momentum”	and	push	my	analysis	a	step	further	into	theorizing	why	participants	“construct	meanings	and	actions	in	specific	situations.”(84)	As	Charmaz	explains:			88		“Recall	 that	 Glaser	 (1997,	 1998)	 advises	 you	 to	 begin	 the	 analytic	 process	 by	asking	 ‘What	 is	 this	data	a	study	of?	 (1978:	57).	 If	we	ask	 the	question	at	each	stage	of	the	analytic	process	and	seek	the	most	fundamental	answer	that	fits,	we	might	discover	that	particular	meanings	and	actions	in	our	studied	world	suggest	theoretical	 links	 to	 compelling	 ideas	 that	 had	 not	 occurred	 to	 us.”	 [p.	 138,	emphasis	included]	(84)		I	raised	into	theoretical	concepts	those	categories	that	explained	participants’	attitudes	and	experiences	most	effectively,	provided	an	interpretive	frame	for	the	study,	and	offered	an	abstract	understanding	of	the	relationships	between	categories.	The	method	for	my	theorizing	consisted	of	memoing,	conversation	with	committee	members	and	colleagues,	and	returning	to	the	data	again	and	again	to	consider	which	categories	had	the	most	analytic	weight.			3.9 Theoretical	Matching	An	orthodox	inductive	approach,	as	proposed	by	Glaser,	suggests	that	theory	development	should	be	grounded	only	in	the	data,	emerge	from	the	data,	and	not	be	imposed	using	extant	theories	or	categories.(166)	Another	school	of	thought	proposes	that	theory	can	be	both	grounded	empirically	in	the	data	as	well	as	grounded	theoretically	in	pre-existing	extant	theories.	As	researchers	Goldkuhl	and	Cronholm	write	in	their	methodological	work	on	grounded	theory:			89		“If	 one	 ignores	 existing	 theory,	 there	 is	 a	 risk	 of	 reinventing	 the	 wheel.	 As	researchers	we	often	build	 new	knowledge	on	existing	 knowledge.	An	 isolated	theory	 development	 also	means	 that	 there	 is	 a	 risk	 for	 noncumulative	 theory	development.	We	 believe	 that	 it	 is	 important	 to	 relate	 the	 evolving	 theory	 to	established	research	during	the	process	of	theorizing.	Existing	theory	can	be	used	as	a	building	block	that	supports	the	empirical	data	forming	the	new	emergent	theory.”(167)		Theoretical	matching	may	be	used	to	facilitate	interpretation	of	data,	to	organize	an	analysis,	or	to	structure	the	evolving	theory.(167,168)	I	engaged	in	“theoretical	matching”	by	comparing	my	emerging	concepts	to	existing	empirical	literature	and	theories	that	helped	to	explain	or	contradict	the	patterns	I	was	observing.(86)	The	purpose	of	the	theoretical	matching	was	not	to	test	or	extend	existing	theory,	or	to	generalize	and	decontextualize	my	local	analysis.	Nor	was	the	purpose	to	select	the	“best”	theory	for	understanding	decision-making	for	birth	after	caesarean.	Rather	it	served	to	organize	my	subjective	analysis	of	emerging	concepts	in	a	language	and	conceptual	framework	that	would	further	illuminate	the	behaviours	and	processes	that	support	or	impede	women’s	access	of	informed	choice	for	birth	after	caesarean.	This	follows	Charmaz’s	conceptualization	of	the	purpose	of	theoretical	frameworks	in	grounded	theory:				90	“Researchers	 who	 use	 a	 traditional	 quantitative	 design	 invoke	 an	 established	theory	and	deduce	hypotheses	from	it	before	conducting	their	studies.	For	them,	the	theory	to	use	in	their	theoretical	framework	is	already	there.	In	contrast,	in	a	grounded	theory	study	you	put	your	sensitizing	concepts	and	theoretical	codes	to	 work	 in	 the	 theoretical	 framework.	 These	 concepts	 and	 codes	 locate	 your	manuscript	in	relevant	disciplines	and	discourses.”	[p.	169]	(84)		In	discussion	with	my	supervisory	team	during	the	study	design	phase	and	analysis,	we	considered	different	theoretical	frameworks	that	could	facilitate	this	final	stage	of	analysis.	I	considered	a	range	of	process	models,	determinant	frameworks,	classic	theories,	implementation	theories,	and	evaluation	frameworks	could	help	explain	patterns	in	participants’	narratives.	I	considered	the	Theoretical	Domains	Framework	(169)	and	Behaviour	Change	Wheel,(170)	which	aim	to	explain	the	determinants	(e.g.	barriers	and	enablers)	that	influence	implementation	outcomes.	Conversations	with	colleagues	in	the	School	of	Population	and	Public	Health	led	to	suggestions	of	Behavioural	Contagion	Theory	(171)	and	Normalization	Process	Theory,(172)	which	aim	to	enhance	understanding	of	individual	behaviour.	However,	complex	adaptive	systems	(CAS)	offered	a	lens	through	which	to	understand	my	contextualized	analysis,	and	support	the	specific	argument	I	wished	to	make	about	implementation	processes	for	a	health	services	research	audience.				91	3.10 Ethics	This	study	was	approved	by	the	University	of	British	Columbia	Behavioural	Research	Ethics	Board	(H15-00319),	Fraser	Health	Research	Ethics	Board	(FHREB	2015-032),	and	Northern	Health	Research	Review	Committee	(RRC	H	2015-001).		 			92	Chapter	4: Seeking	Control	in	the	Midst	of	Uncertainty:	Women’s	Experiences	of	Choosing	Mode	of	Delivery	after	Caesarean	This	chapter	focuses	on	findings	from	my	analysis	of	women’s	narratives.	I	describe	my	grounded	theory	of	seeking	control	in	the	midst	of	uncertainty.		4.1 Description	of	the	Sample	Five	hospital	sites	met	the	study	criteria:	three	in	rural	northern	BC	and	two	in	southwestern	BC.	Participants	included:	a)	women	who	had	had	a	recent	primary	caesarean	(n=8);	b)	women	who	were	pregnant	with	a	second	child	and	planning	a	birth	after	caesarean	(n=7);	and	c)	women	who	had	given	birth	after	caesarean	(n=8),	half	who	had	planned	a	VBAC	and	half	who	gave	birth	by	planned	elective	repeat	caesarean.	Among	the	15	women	who	had	had	a	recent	primary	caesarean	or	were	pregnant	again,	their	preferences	were	represented	equally:	five	expressed	a	preference	for	planned	VBAC,	five	for	planned	repeat	caesarean,	and	five	were	uncertain.	Of	the	eight	participants	who	were	considering	mode	of	birth	after	two	caesareans,	three	preferred	VBAC	and	five	preferred	repeat	caesarean,	consistent	with	their	preferences	for	their	first	birth	after	caesarean.	One	was	uncertain.	All	participants	lived	with	a	partner	and	the	majority	were	born	in	Canada,	had	a	college	diploma	or	university	degree,	and	were	between	the	ages	of	30	and	39.	Three	women	were	Aboriginal,	one	South	Asian,	and	the	remainder	were	Caucasian.	Table	4.1	provides	a	description	of	participant	characteristics,	while	Table	4.2	provides	information	on	each	participant’s	childbirth	histories.		 			93	Table	4.1	Demographic	Characteristics	of	Women			Characteristic	 N	(%)	Region	 	Rural	 16	(69.6)	Urban	 7	(30.4)	Ethnicity	 	Aboriginal	 3	(13.0)	Asian	 0	(0.0)	Caucasian	 19	(82.6)	South	Asian	 1	(4.3)	Age	 	<	20	years	 0	(0.0)	20-29	years	 5	(21.7)	30-39	years	 16	(69.5)	>	40	years	or	more	 2	(8.7)	Living	with	a	partner	 	Yes	 23	(100.0)	No	 0	(0.0)	Annual	household	revenue	 	<	$35,000	 1	(4.3)	$35,000-$70,000	 8	(34.8)	>$70,000	 14	(60.9)	Highest	level	of	education	received	 	Graduated	high	school	 1	(4.3)	College	or	Technical/Trade	 7	(30.4)	University	degree	 15	(65.2)					94		Table	4.2	Childbirth	Histories	of	Participants	Woman	 Previous	births	 Induction	 Indication	for	caesarean	 Past	delivery	preference	Current/future	delivery	preference	Primary	provider	Region	 Mental	Health*	001	 1)	Planned	CS	2)	ERCS	--	 Breech		Maternal	request	Vaginal	CS	CS	 Midwife	 Urban	 --	002	 1)	Unplanned	CS	 Yes	 Failure	to	progress	 Vaginal		 VBAC	 Midwife	 Urban	 Anxiety	003	 1)	Unplanned	CS	2)	Pregnant	No	 Failure	to	progress		Vaginal	 Uncertain	 Midwife	 Urban	 Anxiety	005	 1)	Unplanned	CS	2)	ERCS	3)	Pregnant	Yes	 Failed	induction	Recommended	(“small	pelvis”)	Vaginal	CS		CS	 Family	physician	Urban	 --	006	 1)	Planned	CS		2)	Pregnant	--	 Placenta	previa		CS	 CS	 Family	physician	Urban	 --	007	 1)	Unplanned	CS	2)	Pregnant	No	 Dystocia		Vaginal	 VBAC	 Midwife	 Rural	 Depression	010	 1)	Unplanned	CS	2)	CS	during	VBAC	No	No	Dystocia	Fetal	distress	Vaginal	VBAC	Uncertain	 Midwife	 Urban	 Depression	024	 1)	Planned	CS		No	 Breech		CS		CS	 Family	physician	Rural	 --	025	 1)	Unplanned	CS	 No	 Failure	to	progress	 Vaginal	 VBAC		 Midwife	 Rural	 --	028	 1)	Unplanned	CS	 No	 Dystocia		Vaginal	 VBAC	 Family	physician	Rural	 Depression	029	 1)	Unplanned	CS	 No	 Failure	to	progress	 Vaginal	 CS	 Midwife	 Rural	 --	030	 1)	Unplanned	CS	 No	 Dystocia		Vaginal		Uncertain	 Family	physician	Rural	 --	031	 1)	Unplanned	CS	 Yes	 Failed	induction	 Vaginal	 CS	 Family	physician	Rural	 --			95	Woman	 Previous	births	 Induction	 Indication	for	caesarean	 Past	delivery	preference	Current/future	delivery	preference	Primary	provider	Region	 Mental	Health*	034	 1)	Unplanned	CS	2)	Pregnant	No	 Failure	to	progress	 Vaginal	 Uncertain	 Family	physician	Rural	 Anxiety	035	 1)	Unplanned	CS	2)	VBAC	3)	Pregnant	No	 Fetal	distress		Vaginal	VBAC		VBAC	 OB	 Rural	 --	036	 1)	Unplanned	CS	2)	Pregnant	No	 Failure	to	progress		Vaginal	 VBAC	 GPESS	 Rural	 --	037	 1)	Unplanned	CS		No	 Failure	to	progress	 Vaginal	 Uncertain	 GPESS	 Rural	 --	039	 1)	Planned	CS	2)	Pregnant	--	 Breech		CS	 Uncertain	 OB/GPESS	 Rural	 --	040	 1)	Unplanned	CS	2)	VBAC	3)	VBAC	Yes	 Failure	to	progress	 Vaginal	Home	VBAC	Home	VBAC	Home	VBAC	 OB/Midwife	 Rural	 Depression	045	 1)	Unplanned	CS	2)	Pregnant	No	 Failure	to	progress/Malposition		Vaginal	 VBAC	 OB/GPESS	 Rural	 --	048	 1)	Unplanned	CS	2)	ERCS	3)	Pregnant	No	 Failure	to	progress	Maternal	request		Vaginal	CS	CS	 OB/FP	 Rural	 Depression	049	 1)	Unplanned	CS	2)	VBAC	No	 Failure	to	progress		Vaginal	VBAC	VBAC	 OB/Family	physician	Rural	 Depression	054	 1)	Unplanned	CS	2)	ERCS	3)	Pregnant	No	 Fetal	distress	Recommended	(“big	baby”)	Vaginal	Uncertain	CS	 Midwife	 Urban	 --	*Self-reported	postpartum	mental	health	state	after	primary	caesarean	CS:	Caesarean;	ERCS:	Elective	repeat	caesarean;	GPESS:	General	practitioner	with	enhanced	surgical	skills		 			96		Analysis	revealed	few	differences	between	the	experiences	and	attitudes	of	women	who	lived	in	rural	communities,	compared	to	their	urban	counterparts.	Some	rural	women	lived	one	to	two	hours	from	the	hospital	facility	and	had	the	option	of	giving	birth	in	a	different	community	where	care	providers	expressed	less	support	for	planned	VBAC.	These	participants	traveled	to	one	of	the	study	communities	to	secure	a	planned	VBAC.	Rural	women	also	had	less	access	to	midwifery	care.	I	did	not	observe	any	differences	in	decision-making	by	income	level	or	education,	however	this	may	reflect	my	small,	relatively	homogenous	sample.	Also,	for	this	study	I	did	not	aim	to	explore	the	intersection	of	socio-cultural	differences	and	decision-making.		4.2 Results	Analysis	of	participants’	narratives	revealed	that	women’s	experience	of	decision-making	for	birth	after	caesarean	was	a	process	of	“seeking	control	in	the	midst	of	uncertainty.”	Women	sought	control	through	their	decision-making	process,	which	was	organized	around	six	conceptual	phases:	reflecting	on	their	birth,	clarifying	their	values,	becoming	informed,	considering	the	feasibility	of	options,	deliberating	with	the	care	team,	and	making	an	actual	choice.	These	key	themes	are	presented	in	Table	4.3.						97	Table	4.3	Themes	and	Subthemes	Emerging	from	Women’s	Narratives		Core	Theme	 Subtheme	Seeking	control	in	the	midst	of	uncertainty	 Reflecting	on	their	birth	Clarifying	their	values	Becoming	informed	Considering	the	feasibility	of	options		Deliberating	with	the	care	team	Making	an	actual	choice			Figure	4.1	illustrates	these	subthemes.	The	phases	of	women’s	decision-making	(“Process”)	corresponded	with	different	events	in	women’s	childbearing	years	(“Event”),	and	were	influenced	by	external	factors	(“Context”).	The	figure	was	developed	based	on	analysis	of	findings	from	my	analysis	of	women’s	interviews	and	then	compared	with	an	existing	conceptual	framework	on	“interprofessional	shared	decision-making”	developed	by	Légaré	and	colleagues.(52)	As	described	in	Chapter	3,	comparing	my	emerging	theory	with	existing	extant	concepts	helped	to	explain	or	contradict	the	patterns	I	was	observing.	Comparison	with	Légaré’s	framework	also	helped	to	organize	my	subjective	analysis	of	women’s	attitudes	and	experiences	using	conceptual	terms	and	an	organizing	framework	that	further	illuminated	decision-making	behaviours	and	processes.	 In	the	following	sections,	I	provide	a	qualitative	analysis	of	women’s	birth	after	caesarean	attitudes	and	experiences	in	each	phase	of	their	decision-making	process,	within	the	overarching	theme	of	seeking	control	in	the	midst	of	uncertainty.			 			98	Figure	4.1	A	Conceptual	Map	of	Women’s	Decision-Making				 			99	4.2.1 Seeking	Control	in	the	Midst	of	Uncertainty	Women	who	had	an	unplanned	caesarean	during	first	or	second	stage	labour	(n=19)	typically	felt	a	loss	of	control	during	their	births	due	to	overwhelming	labour	hormones,	labour	interventions,	or	unexpected	events	that	precipitated	a	caesarean.	Those	participants	who	had	an	unplanned	caesarean	described	the	moments	in	their	birth	where	they	experienced	feeling	“out	of	control,”	or	“losing	control.”	This	referred	to	losing	control	over	their	body	and/or	losing	control	over	their	decision-making	autonomy.	As	one	urban	mother	described,		“You’re	 in	 control	 giving	 birth	 to	 a	 certain	 degree	 and	 then	 having	 to	 have	emergency	 C-section,	 you	 feel	 out	 of	 control.	 Especially	 like,	 with	 the	 epidural	 I	could	 feel	 [pushing],	and	 I	didn’t	know	I	was	going	to	be	able	to	do	that.	No	one	told	me	 I	 thought	 I	would’ve	 been	numb	 from	 the	waist	 down.	 But	 then	 I	 had	a	spinal	for	the	c-section	and	I	did	not	like	that	feeling.	Obviously	I	know	that	I	wasn’t	going	to	be	able	to	feel	[the	obstetrician]	cutting	me	open.	It	happened	so	fast	too,	so	 it	was	 like,	you	have	 to	surrender	control	and	you	have	 to	 trust	whoever	your	care	providers	are.”	(010)		Making	the	decision	for	birth	after	caesarean	was	a	process	of	seeking	and	regaining	control	over	their	birth	experience.	Some	participants	described	this	as	seeking	control	over	decision-making	authority,	which	was	connected	to	their	sense	of	self,	identity,	and	autonomy.	As	one	women	articulated	regarding	her	choice	for	planned	VBAC:			100		“I	want	to	be	that	active	participant.	 I	don’t	want	to	be	the	bystander	 in	my	own	delivery.	I	have	no	interest	in,	I’m	not	the--	(Laugh)	My	best	friend	needs	to	be	the	center	of	attention	and	I	don’t	need	to	be	the	centre	of	attention,	but	I	don’t	want	to	be	the	person	it’s	happening	to.	I	almost	felt	like	a	victim,	Right?	Like,	you	know	like	things	happen	that	you	can’t	control.	 I	don’t	 like	to	use	the	word	victim	and	I	don’t	mean	 to	 offend	 people	 who	 are	 you	 know,	 victims	 of	 crime	 and	 stuff.	 It’s	obviously	a	different	matter,	but	when	you’re	put	in	these	situations,	your	choice	is	taken	 away.	 You	 know?	 And	 I	 feel	 that,	 yeah,	 so	 to	 regain	 my	 choice	 and	 my	(Pause)	I	guess	my	standing	as	a	mom,	to	reclaim	that	[through	VBAC],	as	weird	as	that	sounds.”	(002)		Women	described	how	they	engaged	in	strategies	to	ensure	control	as	an	active	participant	in	decision-making,	such	as	communicating	their	delivery	preferences	clearly	to	a	partner	or	doula,	printing	out	a	“birth	plan”	for	their	care	team.	Others	sought	midwifery	care,	which	they	perceived	to	be	more	supportive	of	women’s	choices.	Some	women	who	planned	VBAC	struggled	to	cope	with	the	uncertainty	of	the	outcome	of	labour.		Participants	extended	this	concept	of	control	to	include	both	control	in	the	decision-making	experience	and	the	childbirth	experience	too.	One	woman	described	the	importance	to	her	of	having	control	over	the	feeling	of	her	delivery	because	her	previous	unplanned			101	caesarean	had	triggered	postpartum	depression	and	anxiety.	She	described	her	process	of	planning	a	repeat	caesarean	as	a	strategy	of	seeking	control	and	avoiding	uncertainty:		“I	need	to	plan	this	[next	birth]	so	that	it	helps	me	keep	this	[anxiety]	in	control.	So,	that	was	a	deciding	factor	too	I	think.	Going	into	having	a	VBAC	would	be	giving	up	that	 control	 that	 I	 was	 working	 for	 to	 keep	 the	 postpartum	 [depression	 and	anxiety]	away	so	that	added	to	it	too.	That	was	like	no,	I	am	going	to	plan	this	c-section	and	then	I	am	going	to	plan	my	doctors	around	it	…	Being	able	to	control	the	 c-section	 and	 being	 awake	 for	 it	 and	 not	 having	 such	 a	 rush,	 like	 things	happening	 so	 fast.	 Because	 once	 they	 actually	 go	 to	 the	 c-section	 part,	 once	 I	actually	got	 into	 surgery,	 it	was	 so	hectic	 right?	With	 this	 [repeat	 caesarean]	 it’s	calm.	 Everyone’s	 happy.	 Everyone	 knows	 what	 to	 expect.	 You	 come	 in,	 and	everyone	is	greeting	you,	and	so,	it	helped	a	lot.”	(048)		4.2.2 Reflecting	on	the	Prior	Birth	Experience		Each	participant’s	first	birth	experience	was	the	single	most	influential	factor	in	informing	her	preferences	for	birth	after	caesarean.	Women	who	had	an	unplanned	caesarean	described	a	first	birth	experience	characterized	by	losing	control	of	their	expected	birth	process,	becoming	emotionally	and	physically	depleted,	and	experiencing	“failure.”	Some	described	this	as	a	sense	of	social	failure	in	the	eyes	of	their	friends	and	peers	at	not	experiencing	vaginal	birth	as	a	“female	right	of	passage”	(024),	while	others	expressed	a	sense	of	personal	failure	at	not	having			102	achieved	their	desired	birth	in	spite	of	their	education	and	planning.	In	contrast,	the	four	women	who	had	elective	caesareans	for	their	first	child,	for	breech	presentation	(n=3)	and	placenta	previa	(n=1),	characterized	their	caesarean	deliveries	as	friendly,	predictable,	and	calm.	All	feared	the	uncertainty	of	a	vaginal	delivery	and	consequently	leaned	toward	repeating	the	caesarean	experience.	However,	one	participant	who	had	a	caesarean	for	breech	presentation	in	a	rural	community	described	the	caesarean	itself	as	a	negative	experience:			“I	just	remember	being	on	that	table	and	everything	is	bared,	like	‘we’re	going	to	put	a	catheter	in	you	now’	and	you	just	feel	so,	so	vulnerable.	Your	arms	are	tied	up	to	the	sides,	your	legs	are	splayed,	and	you	can’t	see	anything	…	I	didn’t	really	get	to	see	her	right	after	other	than	the	quick	peek	over	the	curtain.	 I	was	really	upset	about	that,	but	you	know	what	can	I	do	really?”	(024)			 For	all	participants	the	most	negative	attribute	of	their	caesarean	experience	was	being	immediately	separated	from	their	newborn	for	at	least	one	hour	following	delivery.	This	period	lasted	longer	and	was	more	disorienting	for	women	who	received	general	anaesthesia.	Women	described	that	they	felt	anxious,	abandoned	by	their	nurses,	and	confused	about	the	location	and	wellbeing	of	their	newborn.	This	was	especially	challenging	for	participants	in	one	urban	hospital	site	who	were	told	that	local	policy	was	to	keep	moms	and	babies	roomed	together	post-surgery.	Many	reported	that	the	loss	of	this	first	hour	with	their	first	baby	had	far-reaching	effects	on	their	ability	to	breastfeed	and	bond.	One	participant	who	was	planning	a	VBAC	felt			103	that	her	primary	caesarean	made	her	feel	detached	from	her	daughter:	“The	bonding.	I	really	feel	like	I	missed	out	on	that.	That’s	hard	to	talk	to	anyone	about	…	[Cries]	I	lots	of	time	feel	she	is	not	my	baby.	I	love	her	but	I	felt	like	she	was	a	stranger	when	she	came	out	[Cries]	and	it	took	months	before	I	felt	like	I	got	to	know	her”	(028).	Nine	women	described	experiencing	postpartum	depression	and/or	anxiety	and	expressed	that	their	mental	health	issues	began	with	the	emotional	trauma	of	being	separated	from	their	baby	in	the	immediate	postpartum.	For	many,	this	anxiety	was	directly	related	to	being	separated	from	her	baby	post-caesarean:	“They	told	me	she	was	fine,	but	who	knew?	I	didn’t	because	I	was	in	the	post-op	recovery	room	between	two	people	who	were	fighting	for	life.	I	was	just	paralyzed	on	the	bed	…	You’re	completely	helpless	physically,	emotionally.	You’re	locked	away	in	a	room	somewhere	away	from	your	baby.	It’s	absolutely	horrific	[Laughs].	The	worst	part	is	definitely	that	recovery”	(002).		Reflecting	on	their	birth	experience	was	a	way	for	women	to	clarify	what	mattered	most	to	them,	to	figure	out	the	gaps	in	their	knowledge	of	childbirth	options,	and	to	determine	what	information	and	resources	they	needed	to	fill	in	those	gaps.	During	their	inter-pregnancy	interval,	women	consolidated	and	integrated	new	information	and	experiences	with	the	memory	of	their	first	births.	As	such,	each	woman’s	primary	caesarean	section	experience	was	the	baseline	reference	point	for	her	decision-making	process	for	future	deliveries.				104	4.2.3 Clarifying	Values		Participants	in	this	study	entered	their	first	pregnancy	with	opinions	about	the	desirability	of	the	different	characteristics	of	vaginal	and	caesarean	birth.	These	opinions	changed	after	having	a	primary	caesarean.	Throughout	her	inter-pregnancy	interval	each	woman	engaged	in	a	process	of	“values	clarification”	where	she	considered	the	extent	to	which	the	positive	and	negative	characteristics	of	vaginal	and	caesarean	birth	were	personally	important	to	her.(173)	In	ideal	circumstances,	values	clarification	should	take	place	after	a	patient	is	fully	informed	of	her	options.	However,	participants	in	this	study	considered	the	importance	of	birth	attributes	throughout	their	inter-pregnancy	interval	based	on	their	experiential	knoweldge,	typically	before	seeking	or	receiving	evidence	from	other	sources.	Consequently,	women’s	values	were	often	based	on	incomplete,	poor	quality,	or	incorrect	information	about	mode	of	delivery	after	caesarean.	In	clarifying	their	values,	many	participants	began	by	assigning	importance	to	different	attributes	of	mode	of	delivery.	Each	woman	described	a	different	set	of	attributes	as	being	most	important	to	her,	and	included	maximizing	their	and	their	baby’s	health,	discovering	their	baby’s	sex,	experiencing	skin	to	skin	bonding	in	the	immediate	postpartum,	maintaining	the	strength	of	their	core	and	perineal	floor,	feeling	cared	for	and	respected	by	one’s	care	providers,	having	a	quicker	recovery,	and	avoiding	emotional	trauma.	They	then	estimated	their	likelihood	of	experiencing	that	characteristic	in	a	vaginal	versus	caesarean	birth.	Finally,	participants	described	the	“trade-offs”	they	were	willing	to	make,	recognizing	that	the	decision	for	mode	of	delivery	was	complex,	based	on	many	variables,	and	they	would	have	to	give	up			105	something	in	order	to	achieve	their	desired	birth.	For	most	participants,	their	actual	mode	of	delivery	was	less	important	than	experiencing	certain	attributes	and	outcomes	of	her	labour	and	delivery.	The	clinical	risks	and	benefits	of	childbirth	were	less	prominent	in	women’s	narratives	than	were	social	and	personal	aspects	of	their	experience.	Women	emphasized	that	“of	course”	they	wanted	a	healthy	baby	above	all	else,	which	they	felt	an	elective	repeat	caesarean	would	guarantee	(although	this	is	not	in	fact	the	case).	This	meant	making	a	trade-off	and	losing	the	attributes	of	a	vaginal	delivery	that	were	also	of	importance.	As	one	expressed:	“Ultimately,	the	safety	totally	outweighs	my	experience,	but	telling	[that	to]	my	brain	and	my	emotions	is	another	thing”	(010).	Some	participants	said	they	would	have	no	qualms	about	choosing	elective	repeat	caesarean	to	maximize	the	health	of	their	baby	if	it	was	“family-centred”	and	included	the	characteristics	they	desired	from	a	vaginal	delivery:	immediate	and	uninterrupted	skin-to-skin	bonding	in	the	OR,	no	separation	during	postpartum	recovery,	dim	lighting,	music	of	their	choice,	discovering	the	sex	of	the	baby	with	their	partner,	and	in	one	case,	manually	colonizing	the	baby	with	the	mother’s	vaginal	microbiota.	As	one	rural	woman	expressed:	“The	biggest	thing	is	skin	to	skin	after,	immediate	skin	to	skin	in	the	OR.	It’s	extremely	hard	to	get	here	…	I	think	that	would	be	the	number	one	huge	thing	for	me	to	try	and	get	that	love	feeling	right	after	birth”	(007).	This	participant	was	willing	to	accept	trade	offs,	including	the	increased	risk	of	uterine	rupture,	in	order	to	maximize	her	chances	of	experiencing	skin-to-skin	bonding	after	a	vaginal	birth.				106	Women’s	access	to	resources	and	social	support	also	influenced	their	values	clarification.	Participants	who	lived	far	from	their	immediate	families	and	had	limited	local	social	support	expressed	that	recovering	from	caesarean	surgery,	including	not	being	able	to	lift	their	toddler	for	six	weeks,	was	a	particularly	key	attribute.	This	motivated	many	to	plan	a	VBAC	in	order	to	have	a	short	recovery,	while	others	opted	for	a	repeat	caesarean	so	that	they	could	schedule	postpartum	assistance	from	family	and	friends.	The	impact	of	surgical	recovery	on	their	family	was	information	shared	by	other	experienced	mothers,	not	care	providers.	Similarly,	in	communities	where	the	local	hospital	provided	intermittent	access	to	post-surgical	rooming	together	for	mother	and	baby,	participants	emphasized	the	importance	of	staying	in	the	same	room	as	their	baby	in	the	immediate	postpartum.	Participants	were	afraid	of	getting	their	hopes	up	in	case	the	service	was	unavailable	during	the	date	of	their	birth	after	caesarean.	Two	women	were	considering	planning	birth	at	a	nearby	tertiary	centre	where	they	believed	rooming	together	to	be	a	consistent	service.		4.2.4 Becoming	Informed		As	women	reflected	on	their	birth	experience	and	gained	clarity	about	the	attributes	and	outcomes	that	they	valued	most,	they	began	to	seek	out	information	to	fill	in	their	knowledge	gaps.	This	process	began	in	the	early	postpartum	and	continued	into	women’s	inter-pregnancy	interval	and	subsequent	pregnancy.					107	4.2.4.1 “De-briefing”	No	participant	who	had	an	intrapartum	caesarean	felt	she	had	a	full	understanding	of	why	it	occurred.	Participants	described	multiple	opportunities	for	“de-briefing”	their	birth	experience	with	their	care	team:	during	their	in-hospital	postpartum	stay,	at	newborn	wellness	check-ups,	and	at	their	6-week	post-operative	clinic	visit.	However	most	did	not	have	a	satisfactory	conversation	with	a	care	provider.	One	participant	described	an	exchange	with	her	obstetrician	at	her	6-week	post-operative	check-up:			“I	 asked,	 ‘Was	 this	 like	 a	 freak	 thing	 or	 was	 it	 something	 wrong	 with	 me	anatomically,	and	what	are	my	chances	for	a	VBAC?’	He	looked	at	my	chart,	and	he	says,	‘It	says	persistent	OP	[occiput	posterior].’	And	it	lead	me	to	believe	that	he	didn’t	 remember.	 I	 mean	 6	 weeks	 later,	 how	 many	 c-sections	 have	 you	 done	between	than	and	now?	I	understand	that,	but	for	me	it	was	like,	‘that’s	my	birth	story	that	you	just	summed	up	in	persistent	OP.’	I	wanted	more	information	than	that.	Then	that’s	when	he	said,	‘the	rates	[of	successful	VBAC]	are	60	to	70%	and	probably	less	in	your	case.’”	(025)		Three	women	who	were	particularly	dissatisfied	with	the	limited	information	shared	by	their	care	team	chose	to	review	their	patient	chart.	A	number	of	women	who	received	risk	information	from	their	care	provider	felt	the	outcomes	of	planned	caesarean	were	predictable	while	those	for	planned	VBAC	were	too	uncertain:	“It	was	all	pretty	like,	‘Well,	maybe	it	[VBAC]			108	will	work,	maybe	it	won’t”	(001).	To	avoid	the	ambiguity	of	a	planned	VBAC,	this	participant	formed	an	early	preference	for	repeat	caesarean.		4.2.4.2 Seeking	Knowledge	Between	pregnancies,	participants	actively	sought	knowledge	on	birth	after	caesarean	from	peers	and	family,	books,	and	the	Internet.	They	primarily	Googled	information	and	landed	at	sites	including	Babycenter,	WebMD,	Huffington	Post,	and	Motherisk.	Women	searched	primarily	for	statistics	on	clinical	risks	and	benefits	of	the	attributes	of	VBAC	and	repeat	caesarean	that	were	important	to	them.	This	information	gathering	helped	women	gain	confidence	in	their	preferred	mode	of	delivery.	For	instance,	one	woman	researched	information	on	optimal	fetal	positioning,	because	she	felt	her	primary	caesarean	was	related	to	baby’s	poor	position,	and	on	risks	of	planned	VBAC,	to	counterbalance	the	poor	information	provided	by	family	and	friends:	“I	had	people	telling	me,	‘how	dare	I	even	consider	having	a	VBAC	because	it	could	kill	my	child.’”	(049)		4.2.4.3 Experiential	Knowledge	Women	also	sought	out	information	in	the	form	of	lived	experiences	and	birth	stories	shared	by	others.	Experiential	knowledge	helped	women	to	gain	certainty	with	their	choice	and	was	a	therapeutic	process	for	the	eight	women	who	experienced	postpartum	depression	and	anxiety.	One	of	these	woman	collected	dozens	of	quotes	about	birth	“wounds”	and	“scars”	from	Pinterest,	a	social	media	website	that	allows	users	to	share	images	and	videos.	Another	took	up			109	amateur	birth	photography	to	witness	natural	deliveries.	One	woman	became	a	member	of	the	International	Caesarean	Awareness	Network	(ICAN)	to	connect	with	others	who	had	experienced	caesarean	“trauma.”	Many	participants	felt	they	would	be	“judged”	for	having	had	a	caesarean	and	were	selective	in	revealing	their	mode	of	delivery	only	to	women	who	they	expected	would	empathize	with	their	experience.	For	most	women,	the	act	of	engaging	in	this	research	interview	was	part	of	that	therapeutic	process	and	many	expressed	hope	that	members	of	the	health	care	system	would	learn	of	their	experiences	as	a	result.		4.2.5 Feasibility	of	Options	All	women	were	certain	that	a	planned	elective	caesarean	would	be	accessible,	if	they	chose	it,	but	a	number	of	participants	who	had	unplanned	primary	caesareans	questioned	whether	their	original	care	team	and	hospital	environment	were	motivated	enough	to	support	vaginal	birth.	Some	felt	it	would	be	challenging	to	secure	skin-to-skin	bonding	in	the	immediate	postpartum,	based	on	their	experience	with	the	post-operative	policies	at	their	hospital.	Other	participants	learned	from	research	on	the	Internet	and	birth	stories,	not	their	care	providers,	that	they	might	have	limited	access	to	the	operating	room	in	the	event	that	they	might	need	an	emergent	caesarean.	As	one	rural	woman	who	preferred	a	repeat	caesarean	described:			“I	know	a	friend	of	mine,	when	she	was	considering	a	VBAC	the	doctor	had	told	her	not	to	...	I	don’t	think	he	tried	to	scare	her	but	just	said,	‘If	your	uterus	ruptured	we	have	two	minutes	to	get	you	to	surgery	to	stop	the	bleeding	before	you	bleed	out.			110	And	we	don’t	keep	a	surgeon	at	the	hospital	24	hours	a	day.’	…	That	was	one	of	her	deciding	factors	to	do	a	repeat	c-section.”	(048)		These	access	factors	motivated	some	women	to	seek	midwifery	care,	which	they	felt	would	increase	their	chances	of	having	the	vaginal	birth	they	desired.	One	rural	woman	who	was	particularly	motivated	to	have	a	home	birth	after	caesarean	relocated	south	at	the	end	of	her	pregnancy	to	receive	care	from	a	lay	birth	attendant,	not	a	registered	midwife.	Two	participants	traveled	1-2	hours	from	outlying	communities	to	give	birth	at	the	study	site	that	had	a	reputation	for	supporting	planned	VBAC	and	vaginal	twin	delivery.				 	4.2.6 Deliberating	with	the	Care	Team	Although	most	of	the	women’s	decision-making	occurred	while	they	were	not	patients,	they	did	deliberate	with	care	providers	at	two	time	points	–	immediately	before	or	after	their	primary	caesarean,	and	during	their	subsequent	pregnancy.	For	the	women	who	had	planned	caesareans	for	their	first	births,	they	were	told	briefly	before	their	caesarean	if	VBAC	would	be	an	option	in	future.			4.2.6.1 Physician	Care	Discussions	with	physicians	were	brief	and	remembered	as	a	one-way	information	exchange.	After	their	first	caesarean,	all	participants	were	counselled	to	wait	18-24	months	before	becoming	pregnant	again.	In	a	later	discussion,	either	at	the	6	week	check-up	or	in	their			111	subsequent	pregnancy,	the	physician	shared	a	quick	heuristic	or	“pitch”	about	clinical	options,	risks,	and	benefits,	tailored	to	the	woman’s	individual	patient	history.	Although	participants	had	the	opportunity	to	ask	their	physician	questions,	many	described	feeling	rushed.	Others	were	hesitant	to	share	sensitive	personal	information,	or	feared	that	by	asking	too	many	questions	they	would	be	perceived	as	a	“resistant	patient”	(049).	As	a	result	of	having	a	limited	voice	in	the	clinical	encounter,	few	women	told	their	physician	about	the	attributes	of	mode	of	delivery	that	were	most	important	to	them.		 Women	remembered	the	“gist”	of	statements	that	care	providers	gave	them	(e.g.	the	risk	of	uterine	rupture	is	“very	low”	or	“very	rare”),	and	a	few	could	recall	the	risk	estimates	or	percentages	they	were	given.	Participants	often	described	information	and	risk	statistics	provided	by	physicians	that	were	inconsistent	with	evidence-based	care.	For	instance,	one	woman	was	diagnosed	with	a	small	pelvis	after	“failure	to	progress”	in	her	first	labour:	“‘The	baby	can’t	fit	through.	You	can’t	ever	deliver	naturally,’	they	were	telling	me	…	‘Miracles	have	happened,’	they	said	[Laughs],	‘but	your	pelvis	is	too	narrow	…	This	[caesarean]	is	the	only	way	we’re	going	to	get	the	baby	out’”	(005).	Like	many	participants,	she	felt	that	she	had	no	options	for	mode	of	delivery	after	two	caesareans:	“If	you	have	two	[caesareans],	it’s	just	a	given	that	you’re	going	to	have	a	third.	That’s	the	information	I’ve	gotten	from	other	moms	and	medical	professionals,	my	doctor,	the	fertility	[clinic],	and	then	the	OBGYN”	(005).	Care	providers	recommended	repeat	caesareans	to	three	other	participants	for	the	following	reasons:	1)	“tearing	and	bulging”	of	the	uterus,	2)	advanced	maternal	age,	and	3)	suspected	fetal	macrosomia.	Although	these	conditions	are	not	contraindications	to	planned			112	VBAC	according	to	national	clinical	practice	guidelines	(13),	participants	expressed	that	there	was	no	deliberation	involved.	In	each	case,	the	care	provider	made	a	persuasive	recommendation	for	elective	repeat	caesarean,	presented	VBAC	as	an	alternative	but	unsafe	option,	and	the	participant	consequently	felt	that	she	did	not	have	a	choice	in	the	decision-making	process.	One	woman	recalled	having	such	a	conversation	with	a	care	provider	in	the	days	following	her	primary	caesarean:			“I	said,	 ‘What	happens	 if	we	want	to	have	another?’	And	he	said,	 ‘Well	you’re	45.	You	 probably	 shouldn’t	 have	 any	more.’	 And	 I’m	 like,	 ‘I	 understand	 that,	 but	 my	husband	would	really	like	a	boy.	We’d	like	two	kids.’	…	‘Well	you’d	probably	have	to	have	another	c-section	and	you’ll	have	all	these	other	risks.’	And	I’m	like,	‘So	you’re	not	really	listening	to	me	here.	You’re	just	looking	at	age,	you’re	looking	at	height,	and	you’re	just	going	[snaps	fingers]	off	the	bat,	this	is	what	we’ll	do.’”	(031).		In	one	rural	community	where	vaginal	birth	rates	were	significantly	higher	than	the	provincial	average,	women	found	that	physicians	presented	planned	VBAC	as	the	default	option.	One	participant	who	was	pregnant	with	twins	described	having	limited	information	exchange	and	no	deliberation:	“I	went	in	and	because	[my	pregnancies]	were	so	far	between,	I	figured	it	was	safe	for	me	to	do	it	naturally.	They	just	kept	checking	throughout	the	pregnancy	...	[The	obstetrician]	didn’t	really	give	a	lot	of	information,	just	that	I	was	able	to	have	them	vaginally	and	they	didn’t	think	a	caesarean	would	be	necessary”	(035).	While	the			113	recommendation	of	VBAC	was	consistent	with	evidence-based	guidelines,	the	participant	was	not	supported	to	make	a	shared	choice	based	on	her	informed	preferences.			4.2.6.2 Midwifery	Care	Midwifery	clients	experienced	an	informed	choice	process	in	which	power	was	distributed	evenly	and	deliberation	was	spread	out	over	multiple	long	appointments.	However	a	number	wished	their	midwife	had	played	a	greater	role	in	decision-making.	Midwives	provided	more	opportunities	for	deliberation	about	mode	of	delivery	in	comparison	to	physicians,	but	delegated	decision-making	authority	to	women,	which	left	midwifery	clients	feeling	anxious	about	the	weight	of	that	responsibility.	Midwifery	and	family	physician	patients	were	referred	to	an	obstetrician	around	the	36th	week	of	their	pregnancy	for	an	informed	consent	consultation.	All	but	one	participant	had	solidified	a	choice	for	mode	of	birth	by	the	third	trimester	and	the	risk	and	benefit	“pitch”	provided	by	consultants	caused	many	to	be	uncertain	about	their	impending	delivery.	The	one	participant	who	was	undecided	felt	the	consultant	obstetrician	pressured	her	to	make	a	choice	during	the	visit.	She	regretted	signing	consent	for	a	repeat	caesarean	without	first	deliberating	with	her	midwives	and	husband	(054).	The	consent	form	was	unique	to	one	hospital	site,	while	women	in	other	settings	describing	having	a	verbal	discussion	only,	with	no	accompanying	consent	form	for	mode	of	delivery.	Another	participant	under	midwifery	care	in	an	urban	community	expressed	how	the	consult	involved	biased	presentation	of	the	risks	of	mode	of	delivery.	She	described	the	encounter	as	unnecessary	and	irritating:			114		“[The	obstetrician]	shared	statistics	about	real	realities	of	VBACs	and	uterus	rupture	and	all	these	different	scary	things.	I	was	kind	of	just	numb	to	being	there.	I	didn’t	really	take	it	all	in.	I	didn’t	want	to	be	swayed	one	way	or	another	and	wasn’t	about	to	 schedule	 a	 C-section.	 And,	 like	 ‘there’s	 that	 risk	 [of	 rupture]	 without	 having	 a	VBAC	right?’	And	he	was	like	‘well	of	course	there	is.’	And	I’m	like,	‘Ok,	well,	why	am	I	here?’	I	felt,	I	don’t	need	the	negative,	the	fear	…	[I	felt]	irritated.	Yeah.	I	knew	that	if	there	was	a	real	risk	they	would	tell	me.	There	was	risk	in	everything,	so	I	felt	like	it	was	an	unnecessary	appointment.”	(010)		4.2.6.3 Actual	Choice	Women	spoke	about	the	difference	between	their	preference	for	mode	of	delivery	and	their	actual	choice.	Many	women	expressed	that	they	did	not	begin	trying	to	get	pregnant	again	until	they	felt	confident	in	their	preference	for	VBAC	or	repeat	caesarean	and	were	ready	to	make	an	actual	choice.	For	some	this	was	easy,	reflecting	an	early	confidence	in	their	preference:	“I	made	up	my	mind	before	I	even	started	trying	[to	get	pregnant	again],	because	I’m	a	planner.	I	didn’t	really	talk	about	my	options	with	my	provider	before	I	made	my	decision.	I	never,	ever	at	all	discussed	just	signing	up	for	a	repeat	caesarean”	(007).	Others	struggled	with	uncertain	and	contradictory	preferences.	One	found	it	took	a	long	time	to	become	confident	in	making	an	actual	choice	for	repeat	caesarean:	“It	wasn’t	a	light	decision.	This	was	months	in	the	making.	Lots	of	discussion”	(005).				115	Of	the	23	participants,	only	six	(26%)	were	uncertain	of	their	preference	for	mode	of	delivery	after	caesarean.	Two	had	recently	had	an	unplanned	primary	caesarean,	three	were	pregnant	after	their	primary	caesarean,	and	one	woman	had	recently	had	a	planned	VBAC	that	had	resulted	in	an	emergent	caesarean	for	fetal	distress.	They	felt	that	they	had	time	to	consider	their	options	and	were	not	ready	to	make	a	choice	yet.	One	woman	who	had	recently	had	her	primary	caesarean	expressed	that	she	had	a	strong	preference	for	a	planned	VBAC	but	was	unsure	of	what	she	would	plan	in	a	future	pregnancy;	she	wanted	information	on	whether	or	not	she	would	be	separated	from	her	baby	again	after	a	planned	or	unplanned	caesarean	(030).	Another	participant	described	being	uncertain	of	her	preference	for	planned	VBAC	because	she	had	a	disproportionately	large	fear	about	the	relatively	small	risk	of	uterine	rupture:			“For	me,	even	knowing	 that	 there’s	a	 risk	 is	worrisome	 for	me.	 I,	 for	example,	 like	flying.	I	used	to	have	to	take	prescription	medication	to	fly,	because	I	was	so	anxious	about	the	plane	crashing.	Well,	 there’s	not	a	big	risk	of	the	plane	crashing,	there’s	more	of	a	risk	of	getting	in	a	car	accident.	But	no	matter	what	people	told	me	or	the	information	that	I	could	read,	there’s	still	that	risk.	I’m	not	sure,	I	think	a	plane	crash	is	such	a	traumatic	experience,	that	that’s	why	it	plays	so	much	on	my	mind.	Same	with,	you	know,	delivering	a	baby.	Bleeding	out	and	dying	is	traumatic,	right?	Even	though	there’s	a	small	risk,	it’s	still,	for	some	reason,	something	I	focus	on.”	(003)				116	For	many	participants	who	were	certain	of	their	preference,	it	was	challenging	to	make	an	actual	choice	because	of	the	difficult	trade-offs	involved	in	the	decision.	For	one	participant,	choosing	a	repeat	caesarean	meant	giving	up	the	social	identity	she	dreamed	of	having	through	a	vaginal	birth:		“I	was	making	a	decision	 that	my	children	were	going	 to	be	born	by	caesarean.	 It	was	 like	 the	closing	of	a	door	 to	 that.	And	saying,	 ‘Okay,	 I’m	not	going	 to	be	 that	person,’	that	I	always	thought	maybe	I	would	be	…	The	person	who	is	lucky	enough	[Laugh]	to	have	that	beautiful	moment	where	your	child	comes	out	and	you	see	 it	and	it	lays	on	you	and	it’s	right	there.	[Cries]	I	didn't	get	that.	So	deciding	that	I	was	willing	to	let	go	of	that	dream	was	challenging.”	(054)		Participants	were	aware	of	how	care	provider	preferences,	resource	constraints,	and	input	from	trusted	friends	and	family	all	influenced	their	decision-making	process.	However,	most	felt	that	the	actual	choice	for	mode	of	delivery	was	ultimately	theirs	alone.	While	they	felt	that	being	the	final	decision	maker	was	appropriate,	women	wanted	more	support	from	their	care	team	when	making	their	decision:	“It	feels	like	a	lot	to	kind	of	be	the	one	making	the	decision	all	by	yourself”	(001).	In	addition	to	deliberating	with	care	providers,	all	women	spoke	with	their	partner	and	most	with	another	trusted	individual,	such	as	a	family	member	or	friend.	These	discussions	focused	primarily	on	the	logistics	of	caring	for	both	a	toddler	and	newborn	in	the	postpartum,	and	strategies	to	mitigate	postpartum	depression	and	anxiety.	Most	women	found			117	that	discussion	provided	comfort	and	support,	but	being	the	sole	decision	maker	was	stressful	for	many	women.	They	wished	their	partner	had	taken	some	shared	responsibility	in	the	choice	for	birth	after	caesarean.	Regardless	of	the	actual	choice	women	made,	many	expressed	that	being	an	active	partner	in	the	decision-making	process	was	the	key	to	being	satisfied	with	their	birth	experience:		“If	things	had	ended	up	the	same	with	my	son	and	ended	up	with	a	c-section,	I	think	if	I	had	felt	more	empowered	in	the	process	and	not	just	felt	like	I	had	been	dragged	along	and	not	felt	like	I	didn’t	have	alternatives	and	not	felt	like	they	were	treating	me	like	I	was	being	difficult	when	I	didn’t	agree	with	them,	that	I	would	have	felt	a	lot	more	comfortable	with	what	happened.”	(049)		This	woman’s	response	was	provided	at	the	end	of	the	her	interview,	after	being	asked	the	closing	question,	“If	you	could	wave	a	magic	wand	and	change	the	health	system,	what	would	it	look	like	for	women	who	are	giving	birth	after	caesarean?”		Responses	to	the	question	were	diverse	but	all	involved	strategies	for	helping	women	to	choose	a	birth	experience	that	is	congruent	with	their	personal	values	and	preferences.	These	strategies	included	suggestions	for	improving	health	services,	such	as	at-home	support	for	socially	isolated	women	in	the	first	six	weeks	of	postpartum	recovery	(001)	and	increasing	the	number	of	midwives	in	the	health	care	system	(007).	Participants	also	desired	more	information	about	their	options	for	mode	of	delivery.	One	woman	wished	to	receive	this			118	information	from	peers,	such	as	through	a	support	group	where	women	share	their	birth	stories	(044).	Others	wanted	more	individualized	information	exchange	with	physicians,	particularly	about	their	personal	health	goals,	“where	you	could	talk	about	what	your	priorities	are”	(001).	Women	desired	that	information	be	provided	“ahead	of	time”	so	that	they	could	have	the	opportunity	to	process	the	new	knowledge	and	prepare	questions	before	clinic	appointments	(005).	On	their	own,	pamphlets	and	materials	written	for	the	general	population	were	considered	“impersonal”	(025)	and	were	not	perceived	to	be	useful	for	making	a	decision.	Rather,	each	woman	desired	specific	information	on	the	attributes	and	outcomes	of	the	birth	experience	that	were	most	important	to	her.	Participants	accessed	this	information	from	midwives,	peers,	and	the	Internet,	but	many	also	wanted	individualized	information	from	a	consultant	obstetrician	who	was	familiar	with	her	obstetric	history	(029).	Others	emphasized	that	they	wanted	more	information	about	the	reasons	for	their	primary	caesarean	and	to	have	been	asked	by	care	providers	about	their	mental	wellbeing	after	an	unplanned	caesarean	experience	(049).	To	curb	the	potential	for	experiencing	a	sense	of	“failure”	after	a	primary	caesarean,	participants	suggested	that	women	receive	education	about	caesarean	section	in	prenatal	classes	for	primiparous	women	(024).	Many	also	focused	on	the	caesarean	experience	itself	and	suggested	ways	for	making	non-emergent	caesarean	more	family-centred	through	immediate	skin-to-skin	in	the	OR,	dim	lights,	a	warmer	room	temperature,	and	uninterrupted	contact	between	mother	and	newborn	in	the	immediate	hours	of	postpartum	recovery.					119	4.3 Conclusion	This	qualitative	analysis	of	women’s	narratives	revealed	that	the	decision-making	process	for	birth	after	caesarean	is	a	complex	and	challenging	experience	characterized	by	seeking	control	over	their	birth	in	the	midst	of	uncertain	outcomes.	Key	findings	include	the	insight	that	participants’	decision-making	process	began	during	the	inter-pregnancy	interval	when	participants’	contact	with	the	health	care	system	was	limited.	Notably,	women’s	decision-making	process	was	fairly	rational.	They	first	reflected	on	their	caesarean	experience	and	their	perceived	reasons	for	the	caesarean,	relying	primarily	on	their	experiential	knowledge	to	make	sense	of	their	birth	and	form	a	preference	for	future	deliveries.	Participants	buttressed	this	knowledge	with	information	about	options	for	mode	of	delivery	from	peers	and	the	Internet,	which	was	often	not	evidence-based	and	may	have	been	due	in	part	to	the	perceived	inadequacy	of	clinical	explanations.	They	then	considered	the	attributes	of	birth	that	were	most	important	to	them	and	the	trade	offs	they	would	have	to	make	in	order	to	have	their	desired	next	birth	experience.	For	participants	in	this	study	who	had	had	an	unplanned	primary	caesarean,	their	values	were	influenced	by	the	emotional	impact	of	their	labour	and	caesarean	delivery.	For	many	this	experience	was	marked	by	a	sense	of	trauma	due	to	unanticipated	events	in	labour	that	led	to	an	unplanned	caesarean,	and	due	to	being	separated	from	their	newborn	during	immediate	postpartum	surgical	recovery.			My	findings	include	a	conceptual	model	that	describes	women’s	decision-making	process	when	choosing	mode	of	birth	after	a	previous	caesarean:	reflecting	on	their	birth,	clarifying	their	values,	becoming	informed,	considering	the	feasibility	of	options,	deliberating			120	with	the	care	team,	and	making	an	actual	choice.	Women’s	preferences	were	heavily	influenced	by	their	first	caesarean	experience,	which	for	many	was	unplanned.	Each	woman	considered	different	process	attributes	and	outcomes	in	their	decision-making,	and	these	included	a	diverse	array	of	clinical,	psychological,	social,	and	environmental	factors.	In	order	to	achieve	their	primary	goal	of	having	a	healthy	baby,	many	women	felt	they	had	to	make	trade	offs	between	their	desire	for	a	vaginal	birth	and	their	belief	that	an	elective	caesarean	would	be	safest	for	their	baby.	In	the	next	chapter,	I	describe	the	findings	of	my	analysis	of	care	provider	and	decision	makers’	narratives.			 			121	Chapter	5: Supporting	Women	to	Make	a	Choice:	Care	Providers’	and	Decision	Makers’	Perspectives	on	Barriers	to	Access	of	Health	Services	for	Birth	after	a	Previous	Caesarean			5.1 Description	of	the	Sample	Care	provider	participants	included	midwives	(n=4),	obstetricians	(n=4),	family	physicians	(n=3),	general	practitioners	with	caesarean	section	skills	(n=3),	nurses	(n=7)	and	one	anaesthetist.	Decision	makers	included	hospital	administrators	(n=5),	regional	decision	makers	(n=4),	and	provincial	policy	makers	(n=4).	Ten	decision	makers	had	a	history	of	clinical	perinatal	practice,	which	allowed	them	to	speak	from	their	experiences	as	both	a	care	provider	and	a	decision	maker.	Participants	in	each	region	had	closeknit,	collegial	relationships,	particularly	in	the	rural	communities.	In	order	to	protect	participant	anonymity	I	have	opted	not	to	provide	a	table	describing	each	participant’s	characteristics.		5.2 Results	Analysis	of	care	provider	and	decision	makers’	narratives	revealed	that	their	attitudes	and	experiences	were	characterized	by	the	core	theme	of	“supporting	women	to	make	a	choice.”	Three	additional	themes	illuminated	the	barriers	and	facilitators	to	care	providers’	perceived	ability	to	support	women	to	make	a	choice:	being	an	“information	provider,”	listening	to	the	woman’s	voice,	and	“making	it	work”	in	the	midst	of	limited	access	to	services	(see	Table	5.1).	Care	providers’	narratives	revealed	the	characteristics	of	clinical	decision-making	while	decision			122	makers	highlighted	the	influence	of	health	service	resources	and	policy	on	the	context	of	that	decision-making.		Table	5.1	Themes	and	Subthemes	Emerging	from	Care	Provider	and	Decision	Maker	Narratives		Core	Theme	 Theme	 Subtheme	Supporting	women	to	make	a	choice	Being	an	‘information	provider’	 • Timing	the	discussion	• Giving	a	‘pitch’	• Describing	‘real	world	consequences’	Listening	to	the	woman’s	voice	 • Recognizing	that	women	‘experience	failure’	• ‘Debriefing’	a	woman’s	birth	experience	• Creating	a	safe	space	for	sharing	‘Making	it	work’	in	the	midst	of	limited	access	to	services	• Making	safe	choices		• Coping	with	policy	constraints	• Working	as	a	team				 			123	5.2.1 Supporting	Women	to	Make	a	Choice	Care	providers	indicated	that	their	role	in	the	decision-making	process	was	to	“support”	women	and	their	families	in	making	their	own	informed	choices.	However,	these	participants	revealed	that	informed	choice	discussions	were	often	persuasive.	Care	providers	expressed	that,	on	balance,	planned	VBAC	is	the	optimal	mode	of	delivery	for	healthy	women	with	a	previous	caesarean.	Citing	their	clinical	practice	guidelines,(13)	they	commonly	counseled	women	to	choose	VBAC	and	assessed	women’s	willingness	and	motivation	to	attempt	a	vaginal	birth:	“I	rarely	give	women	the	choice	of,	‘Do	you	want	a	VBAC	or	a	c-section?’	I	kind	of	say,	‘this	is	the	way	to	go.	Try	a	VBAC,’	and	‘where	do	you	sit	on	the	spectrum	of	tolerance	[in	labour]?’”	(Midwife/Decision	Maker,	055).	Care	providers	recommended	elective	repeat	caesarean	when	they	believed	that	an	individual	woman	had	risk	factors	that	would	decrease	her	chance	of	a	healthy	planned	VBAC,	such	as	a	potentially	large	baby	(suspected	macrosomia).		The	intent	of	care	providers’	persuasion	appeared	not	to	be	to	bias	women’s	decision-making	or	compromise	autonomy.	As	one	remarked,	“I	rarely	do	push	my	opinion	if	I	feel	the	decision	has	been	made	before	coming	to	see	me”	(Urban	family	physician,	016).	Rather,	care	providers	believed	they	were	providing	information	that	would	help	women	make	the	healthiest	choices	possible	at	both	an	individual	and	population	level,	but	based	on	the	care	providers’	own	interpretation	of	the	evidence	and	their	personal	values.	There	were	no	differences	between	midwives	and	physicians	with	regard	to	this	theme,	and	all	care	provider	participants	described	their	role	as	that	of	information	providers	to	support	their	patients’	autonomous	decisions.				124		5.2.2 Being	an	“Information	Provider”	5.2.2.1 Timing	the	Discussion	Analysis	of	interviews	revealed	that	mode	of	delivery	discussions	between	care	providers	and	women	occurred	at	multiple	stages	during	the	childbearing	journey	and	with	range	of	professionals.	A	woman	could	learn	from	her	surgeon	during	a	post-operative	check-up	if	she	was	eligible	for	planned	VBAC,	or	discuss	options	with	a	hospital	nurse	or	her	midwife	in	the	first	six	weeks	postpartum.	In	a	woman’s	subsequent	pregnancy,	she	may	visit	a	maternity	care	provider	or	a	general	practitioner	(who	does	not	practice	maternity	care)	during	the	first	20	weeks,	during	which	discussions	about	mode	of	delivery	risks	and	benefits	could	surface.	Participants	perceived	this	to	be	a	barrier	to	decision-making	as	generalist	practitioners	who	are	not	actively	involved	in	intrapartum	care	may	not	be	up-to-date	with	the	evidence	on	the	safety	of	planned	VBAC	compared	to	those	in	active	maternity	care	practice.	However,	primary	maternity	care	providers	felt	there	was	enough	time	over	the	course	of	multiple	antenatal	visits	to	provide	women	with	accurate	information	about	mode	of	delivery.	Discussions	about	mode	of	delivery	primarily	occurred	during	the	woman’s	subsequent	pregnancy	and	focused	on	the	clinical	and	procedural	risks	and	benefits	that	care	providers	felt	were	important	to	disclose	for	“informed	consent.”	Discussions	rarely	included	a	comprehensive	discussion	of	health	services	and	social	risks	that	may	be	pertinent	to	decision-making.	This	discussion	frequently	included	both	the	primary	maternity	care	provider	and	a	consultant	obstetrician,	however	the	purpose	of	the	obstetric	consult	varied	widely.	In	two			125	large	sites,	care	providers	generally	only	referred	women	with	risk	factors	for	a	consult	at	25-30	weeks	gestation.	In	contrast,	one	urban	site	routinely	referred	all	women	for	a	routine	“informed	consent”	consult.	This	was	the	only	included	study	site	that	required	signing	of	a	consent	form	for	either	planned	VBAC	or	elective	repeat	caesarean.	In	two	small	rural	sites,	all	women	had	a	“risk	screening”	obstetric	consult	in	the	first	trimester	to	identify	those	who	were	eligible	for	local	birth	and	those	who	needed	a	higher	level	of	care.	This	approach	was	perceived	to	“tighten”	standards	of	care	and	prevent	unnecessary	caesareans	for	otherwise	healthy	women.	In	all	communities,	midwives	might	send	women	who	were	uncertain	about	their	choice	for	an	obstetric	consult,	in	the	belief	that	obstetricians	carried	more	authority	and	would	increase	women’s	confidence	in	choosing	planned	VBAC.	In	each	of	these	cases,	risk/benefit	discussions	were	a	confirmatory	exercise	to	ensure	that	the	woman	could	give	informed	consent	for	mode	of	delivery,	had	confidence	in	their	decision,	and/or	received	the	appropriate	level	of	care	for	their	risk	profile.	Notably,	participants	observed	that	women	enter	their	pregnancy	with	a	preference	for	mode	of	delivery	and	most	solidify	their	choice	before	the	third	trimester.	These	examples	illustrate	the	variation	in	participants’	timing	of	the	risk/benefit	discussion	and	the	function	of	conversations	at	different	stages	of	the	woman’s	care	pathway.	One	participant	added	that,	to	support	true	informed	decision-making,	women	would	benefit	from	iterative	discussions	beginning	after	the	primary	caesarean	until	her	next	birth:				126	“I	think	you	need	to	start	educating	people	now	if	they’ve	just	had	their	primary	section	 for	 whatever	 reason.	 By	 the	 time	 you	 hit	 that	 second	 pregnancy,	 you	often	 have	made	 up	 your	 [mind].	 I	 think	women	 come	 in	with	 a	 pretty	 strong	sense	 of	what	 they’d	 like	 to	 do	 [for	 birth	 after	 caesarean].	 By	 then,	 over	 time,	they’ve	 taken	 their	 [first	 birth]	 experience	 and	 what	 they’ve	 understood	 what	happened	and	all	 those	things	have	had	time	to	sort	of	become	‘true’	as	to	the	events.	And	maybe	some	clarification	needs	to	happen	about	what	happened	[in	their	first	birth].”	(Urban	family	physician,	015)		However,	a	number	of	participants	illustrated	that	some	lack	awareness	of	the	challenges	women	may	face	in	making	informed	choices	for	birth	after	caesarean.	In	the	two	small	rural	communities,	where	there	were	no	midwives,	physicians’	attitudes	toward	vaginal	birth	were	overwhelmingly	positive	and	they	perceived	planned	VBAC	to	be	the	norm.	As	one	participant	expressed:	“Not	to	say	it’s	a	non-issue,	but	I	was	a	wee	bit	surprised	of	your	[research]	subject.	It’s	just	a	thing	we	don’t	think	about	too	much	these	days,	about	a	VBAC”	(Rural	family	physician,	041).	In	other	rural	and	urban	communities,	some	participants	felt	the	repeat	caesarean	section	rate	was	appropriate	for	their	patient	population	and	that	suggesting	otherwise	questioned	their	clinical	judgment.					127	5.2.2.2 Giving	a	“Pitch”	Participants	provided	examples	of	a	typical	discussion	they	might	have	with	a	woman	about	options	for	mode	of	birth	after	caesarean.	Most	physicians	opened	the	discussion	by	first	asking	women	about	their	preference	for	mode	of	delivery,	and	then	responded	in	their	role	as	an	information	provider	by	giving	a	standard	“pitch”	on	the	medical	and	procedural	risks	and	benefits	of	the	woman’s	preferred	mode	of	delivery.	For	planned	VBAC,	this	consisted	primarily	of	giving	women	a	verbal	description	of	the	absolute	risk	of	uterine	rupture	(“1	in	200”	[Participants	016,	051,	056])	and	the	likelihood	of	an	average	woman	experiencing	a	vaginal	delivery	as	planned	(“70-80%”	[Participants	004,	016]).	Participants	gave	accurate	statistics	for	these	two	risk	estimates1	and	rarely	cited	inaccurate	risk	information.	One	participant	inaccurately	suggested	that	a	woman’s	“risk	of	section	is	coming	up	on	50	percent”	if	induced	at	41	weeks	gestation	(Participant	011).		Apart	from	stating	the	two	numeric	risk	estimates	(absolute	risk	of	uterine	rupture,	likelihood	of	vaginal	delivery),	care	providers	typically	presented	risks	in	narrative	form.	They	rarely	communicated	the	comparative	risks	associated	with	caesarean	section.	They	also	focused	their	discussion	on	the	potential	harms,	rather	than	benefits,	of	mode	of	delivery.	Some	referred	women	to	additional,	local	resources	including	the	SOGC	clinical	practice	                                                1	In	a	large	meta-analysis	of	the	published	literature	on	VBAC	(1966-2009)	the	rate	of	uterine	rupture	for	all	women	with	a	prior	caesarean	(regardless	of	route	of	delivery)	was	0.3%	(95%	CI	0.2-0.4)	and	the	risk	was	significantly	increased	with	planned	VBAC	(0.47%)	versus	elective	repeat	caesarean	(0.026%).(54)				128	guidelines,	the	Power	to	Push	campaign	website	(www.powertopush.ca),	or	an	Optimal	Birth	BC	information	brochure	(www.optimalbirthbc.ca).		 Participants	spoke	interchangeably	about	“informed	consent”	and	“informed	choice.”	In	the	model	of	midwifery	care,	“informed	choice”	is	a	principle	enshrined	in	their	scope	of	practice	that	refers	to	women’s	right	to	be	the	primary	decision-maker,	while	the	midwife	is	responsible	for	facilitating	“the	ongoing	exchange	of	current	knowledge	in	a	non-authoritarian	and	co-operative	manner.”(174)	Most	participants	described	supporting	such	an	“informed	choice”	model,	where	the	care	provider	communicates	information	to	the	woman	on	her	options	and	the	woman	makes	an	autonomous	decision	after	deliberation.	No	participant	used	the	terms	“shared	decision”	or	“shared	decision-making”	in	their	interview,	but	most	described	engaging	in	some	components	of	a	shared	decision-making	process,	in	which	the	care	provider	shared	information	on	options,	the	woman	shared	information	on	her	preferences,	and	after	mutual	deliberation	the	woman	and	primary	care	provider	both	participated	in	making	a	mode	of	delivery	decision.(175)	Other	individuals	may	be	involved	in	the	shared	decision,	participants	emphasized,	including	a	partner	and/or	consultant	obstetrician.	These	narratives	highlighted	that	while	birth	after	caesarean	was	a	preference	sensitive	decision	that	rested	with	the	woman,	care	providers	may	move	fluidly	from	an	informed	choice	to	a	shared	decision-making	dialogue.	The	model	they	adopted	depended	on	their	perception	of	the	woman’s	information	needs,	her	likelihood	of	having	a	successful	vaginal	birth,	and	whether	it	was	time	to	engage	in	deliberation.								129	5.2.2.3 Describing	“Real	World	Consequences”	Despite	describing	numerous	opportunities	for	information	exchange	with	women,	urban	participants	felt	that	women	were	not	receiving	information	on	health	services	risks	(legal	and	operational)	of	planned	VBAC,	which	many	described	as	the	“real	world	consequences”	of	not	having	access	to	the	operating	room	for	an	immediate	caesarean	if	needed.	Care	providers	in	the	small	rural	communities	expressed	that	they	routinely	communicated	the	risks	of	limited	local	resources	to	all	women,	regardless	of	caesarean	history.	Some	urban	participants	had	been	exposed	to	two	recent	events	in	the	region:	a	series	of	malpractice	lawsuits	related	to	decision-making	for	caesarean,	and	a	panel	presentation	on	informed	consent	at	a	medical	conference.	These	participants	emphasized	their	legal	responsibilities	in	decision-making	for	birth	after	caesarean	and	perceived	that	they	must	disclose	the	potential	harms	and	consequences	of	planned	VBAC	and	the	resources	available.	As	one	expressed:		“All	 the	obstetricians	 in	 [the	region]	need	to	be	very,	very	clear	about	the	fact	that	if	there	is	an	urgent,	emergent	need	to	rescue	mom	and/or	baby	during	a	labour	and	delivery,	and	especially	related	to	VBAC,	the	obstetrician	is	obligated	to	share	[the	risks]	with	their	patient.	So,	I	think	that	up	until	now,	that	has	not	been	 part	 of	 the	 discussion.	 So	 I	 think	 there	 is	 a	 new	 awareness	 among	 our	obstetricians	 particularly	 related	 to	 the	need	 for	 really	 clear	 language	around	what	resources	are	available	at	each	site.”	(Regional	decision	maker,	017)				130	Although	care	providers	were	aware	of	the	fear	this	might	cause	women,	they	felt	legally	responsible	for	disclosing	the	consequences	of	delayed	access	to	caesarean,	including	potential	harm	to	the	baby.	Notably,	the	few	participants	who	had	experienced	a	mother	or	baby’s	death	or	injury	from	VBAC,	all	obstetricians	with	experience	in	high-volume	practice	settings,	did	not	feel	that	it	had	affected	their	willingness	to	attend	such	births,	because	they	believed	such	outcomes	were	rare.	Instead,	they	expressed	that	they	adjusted	their	practice	and	adopted	an	air	of	heightened	awareness	around	VBAC	labours,	monitoring	closely	for	signs	of	uterine	rupture.	These	participants	did	not	suggest	that	they	were	more	likely	to	offer	repeat	caesarean	as	a	result	of	these	past	experiences,	however	many	other	participants	noted	examples	of	their	colleagues	(non-participants)	who	had	become	more	risk-averse	after	experiencing	a	poor	outcome	from	a	uterine	rupture.	One	participant	remarked	on	the	practice	of	nurses	in	one	community	who	had	witnessed	an	adverse	outcome	from	a	planned	VBAC:	“I	have	a	couple	of	nurses	that	are	really	hesitant	and	feel	really	anxious	about	VBACs	and	they	will	not	leave	the	room	unless	they	have	coverage	of	someone	else	going	in	there.	It’s	not	necessarily	a	bad	thing	but	I	think	some	of	the	patients	feel	like	they	are	being	hovered	over.”	(Rural	hospital	decision	maker,	042)		5.2.3 Listening	to	the	Woman’s	Voice	5.2.3.1 Recognizing	that	Women	Experience	“Failure”	Participants	also	revealed	how	care	providers	made	efforts	to	listen	to	the	woman’s	voice	in	decision-making.	This	theme	was	underpinned	by	participants’	belief	that	the	decision	for	birth			131	after	caesarean	is	an	emotional	choice	that	is	shaped	by	women’s	experience	of	their	first	caesarean	and	the	stories	they	hear	from	the	Internet	and	peers.	Female	participants	in	particular	spoke	passionately	about	the	lifelong	impact	of	a	woman’s	birth	on	her	identity	as	a	mother,	and	some	described	their	own	experience	of	giving	birth	by	caesarean	or	planned	VBAC.	These	participants	revealed	that	in	decision-making	for	mode	of	delivery	a	healthy	baby	is	the	most	important	factor,	but	it	is	not	the	only	thing	that	matters.		Participants	observed	that	women	with	an	unplanned	caesarean	commonly	experience	a	sense	of	“failure”	and	“fear	of	labour.”	The	first	birth	experience	directly	impacted	women’s	reproductive	choices,	as	one	commented:		“If	 you	 looked	 at	 it	 from	 the	woman's	 perspective,	 she	might	 say,	 ‘Oh,	 I	 can't	 go	through	 another	 long	 labour	 like	 I	 did	 last	 time	 and	 end	 up	 a	 C-section.’	 I	 think	certainly	 there's	 that	 psychological	 impact	 too,	 like,	 ‘Oh,	 I'm	 going	 to	 fail	 again.’”	(Hospital	decision	maker,	012)		In	the	urban	region,	care	providers	also	spoke	with	empathy	and	frustration	about	routine	practices	for	separating	the	mother	and	newborn	for	the	first	one	to	two	hours	in	post-caesarean	recovery,	which	they	felt	compounded	the	trauma	of	an	unplanned	caesarean.		Paradoxically,	although	all	participants	believed	that	the	first	birth	had	a	profound	effect	on	women’s	choices	for	the	next	delivery,	few	physicians	asked	women	about	their	first	birth	experience.	Instead,	as	described	above,	their	discussions	about	mode	of	delivery	after			132	caesarean	focused	on	clinical	and	procedural	risks	and	benefits.	Further,	only	the	midwifery	participants	and	one	community-based	nurse	spoke	about	treating	fear	of	birth	through	strategies	other	than	prophylactic	repeat	caesarean.	These	included	higher	levels	of	labour	pain	medication,	counselling	from	a	mental	health	professional	or	social	worker,	seeking	midwifery	care,	or	building	a	trusting	relationship	with	a	single	maternity	care	provider	rather	than	a	larger	on-call	group.		5.2.3.2 “Debriefing”	a	Woman’s	Birth	Experience	Midwives	often	began	their	first	antenatal	visit,	typically	one	hour	in	length,	with	a	“debriefing”	conversation	about	the	woman’s	first	birth	experience.	They	felt	that	many	women	sought	midwifery	care	after	caesarean	to	maximize	their	chances	of	having	a	planned	VBAC.	By	beginning	their	dialogue	with	women’s	experience,	midwives	felt	better	able	to	tailor	a	comprehensive	risk/benefit	discussion	to	the	things	that	were	central	to	their	decision,	such	as	how	postpartum	recovery	from	a	caesarean	would	restrict	a	woman’s	ability	to	carry	her	older	child,	or	how	labour	might	trigger	post-traumatic	stress	or	anxiety.	Consultant	obstetricians	in	the	small	rural	communities	held	a	similar	conversation	in	their	first	trimester	“risk	screening”	appointment	with	women,	which	could	also	last	one	hour	and	often	included	discussion	of	social	risks	(emotional,	cultural,	financial)	of	mode	of	delivery.		5.2.3.3 Creating	a	Safe	Space	for	Sharing	Participants	who	had	practiced	as	a	public	health	nurse	or	midwife	in	a	community	setting			133	observed	that	women	would	share	different	information	depending	on	their	environment.	One	decision	maker	reflected	that	in	her	previous	role	as	a	public	health	nurse	she	would	make	repeated	home	visits	to	new	mothers.	Being	in	their	own	homes	allowed	women	to	share	highly	personal	and	emotional	stories	of	failure	and	redemption	related	to	birth	and	breastfeeding	(Rural	nurse	/	Hospital	decision	maker,	038).	Midwives	similarly	observed	that	women	are	not	as	willing	to	open	up	and	share	personal	stories	in	a	medical	environment,	such	as	a	hospital	room,	or	over	the	phone.	This	highlights	how	physical	environment	influences	the	content	of	discussions	about	mode	of	delivery	and	may	constrain	women’s	ability	to	integrate	her	first	birth	experience	into	the	informed	choice	process.			5.2.4 “Making	it	Work”	in	the	Midst	of	Limited	Access	to	Services	Care	providers	and	decision	makers	in	the	three	large	communities	had	strong	patient	safety	and	medico-legal	concerns	about	being	able	to	access	an	operating	room	(OR)	in	a	timely	fashion	if	a	uterine	rupture	was	suspected.	These	concerns	were	due	to	a	lack	of	dedicated	obstetric	ORs,	competing	access	with	other	surgical	specialties	to	existing	ORs,	and	lack	of	in-house,	24/7	anaesthesia.	A	dedicated	maternity	OR	and	24/7	in-house	anaesthesia	are	not	health	system	requirements	for	planned	VBAC	in	Canada	(13)	and	at	the	time	of	the	study	all	five	study	communities	offered	planned	VBAC.	However	participants	in	the	three	large	communities	emphasized	that	existing	obstetrical	surgical	services	did	not	match	population	need,	creating	unsafe	conditions	for	access	to	non-elective	caesareans.	In	all	settings,	participants	described	“making	it	work”	with	limited	resources.	One	strategy	in	the	large	sites			134	was	to	page	the	anesthetist	away	from	another	patient	whose	surgery	was	in	progress.	The	anaesthetist	would	stabilize	the	patient,	leave	them	under	the	observation	of	a	nurse,	and	attend	the	caesarean	in	another	OR.		Urban	regional	managers	expressed	that	women’s	health	tends	to	be	a	low	priority	in	health	service	priority	setting,	particularly	in	this	era	of	fiscal	restraint,	and	were	pessimistic	about	receiving	funding	to	support	an	appropriate	level	of	surgical	services	for	their	patient	population.	Care	providers	and	decision	makers	in	these	larger	sites	described	how	other	surgical	specialists	act	as	gatekeepers	to	the	operating	room	and	control	its	access:			“The	people	that	have	the	decision-making	power	over	the	operating	room	are	not	the	obstetric	group,	so	it	is	the	surgical	program.	I'll	just	be	very	honest.	When	you	get	very	powerful	surgeons,	such	as	an	orthopaedic	surgeon	or	a	physician	that's	doing	cataract	surgeries	and	that	sort	of	thing,	and	they	really	own	it.	 I	don't	see	them	as	really	giving	up	any	of	that	time	or	space.”	(Hospital	decision	maker,	012)		These	issues	of	competing	access	influenced	clinical	decision-making.	Care	providers	felt	more	comfortable	with	managing	planned	VBAC	deliveries	on	days	with	easier	access	to	the	operating	room	(e.g.	when	fewer	elective	surgeries	were	scheduled).	In	contrast,	when	access	to	the	operating	room	was	limited,	they	felt	that	planned	VBAC	incurred	greater	risks.	As	described	above,	care	providers	communicated	these	risks	to	their	maternity	patients:				135	“We	just	usually	say	that	we	have	only	one	operating	room	after	3,	4	p.m.	There's	one	anaesthetist.	If	there's	one	acute	surgical	case,	the	OR	could	be	occupied	and	access	could	be	limited	for	a	certain	number	of	hours.	I	think	that	also	goes	into	a	more	 elective	 section	 decisions	 rather	 than	 VBACs.	 I	 know	 that,	 of	 course,	 the	surgeons	who	 sign	 the	 consent,	 especially	 those	who	 sign	 for	 VBAC,	 spend	more	time	 talking	 about	 possible	 operating	 room	 access	 and	 anaesthetist	 availability	and	so	on.”	(Urban	family	physician,	016)			Patient	safety	concerns	about	limited	surgical	resources	did	not	emerge	from	analysis	of	interviews	from	participants	in	the	two	small	rural	sites.	They	expressed	confidence	in	their	current	access	to	surgical	services,	experience	in	working	with	limited	resources,	and	no	professional	competition	with	other	surgical	specialties	for	access	to	the	operating	room.	All	three	rural	sites	described	“making	it	work”	by	communicating	with	the	anaesthetist	and	OR	team	when	a	woman	began	labour	with	a	planned	VBAC,	particularly	if	they	were	off-site.	This	suggests	that	small	rural	communities	were	better	equipped	to	provide	the	option	of	planned	VBAC	than	their	urban	counterparts	due	to	a	combination	of	care	provider	characteristics,	risk	screening	protocols,	and	interprofessional	communication.		The	College	of	Midwives	of	British	Columbia	supports	planned	home	birth	after	caesarean	(HBAC)	(176)	however	attitudes	toward	this	service	varied	by	midwife.	The	two	rural	midwives	supported	women’s	informed	choice	of	HBAC	and	felt	supported	by	local	obstetricians	in	providing	that	service.	One	urban	midwife	chose	not	to	offer	HBAC	due	to	personal	beliefs	that			136	it	is	safest	to	plan	VBAC	in	hospital,	while	the	second	expressed	that	offering	HBAC	could	threaten	her	practice’s	positive	relationships	with	obstetricians,	who	provide	their	hospital	admitting	privileges:	“We	both	prefer	hospital	VBACs,	just	because	we	don’t	know	what	the	obstetricians	are	going	to	say	to	us	and	we	want	to	keep	our	privileges,	right?”	(Urban	midwife,	004).	Midwives’	narratives	indicate	that	interprofessional	relationships	with	obstetricians	and	fear	of	losing	one’s	hospital	privileges,	along	with	concerns	about	patient	safety,	may	limit	women’s	access	to	options	for	place	of	birth.			5.3 Conclusion	Results	of	this	qualitative	analysis	indicate	that	care	providers	and	decision	makers	believe	women	have	the	right	to	make	autonomous,	informed	choices	between	options	for	mode	of	delivery	after	caesarean.	Interviews	revealed	that	health	system	characteristics	may	influence	women’s	decision-making,	including	access	to	surgical	and	anaesthesia	health	services;	care	providers’	attitudes	toward	the	risks	of	planned	VBAC;	the	quality	and	type	of	risk	information	shared	in	informed	choice	discussions;	and	the	timing	of	those	discussions	in	the	care	pathway.	Disclosing	clinical	risk	is	important	and	necessary	from	an	informed	consent	perspective,	but	may	not	help	women	consider	the	comprehensive	health	services	and	social	risks	pertinent	to	their	choices	for	mode	of	delivery.	In	the	next	chapter,	I	synthesize	the	findings	of	my	analysis	of	women’s,	care	providers’,	and	decision	makers’	narratives.	 			137	Chapter	6: Patient,	Care	Provider,	and	Decision	Makers’	Perceptions	of	Barriers	to	Implementation	of	Shared	Decision-Making	for	Birth	after	Caesarean:	A	Complex	Adaptive	Systems	Perspective		6.1 Introduction	The	objective	of	this	chapter	is	to	explore	the	factors	that	influence	the	implementation	of	SDM	in	routine	practice	for	birth	after	caesarean,	where	implementation	refers	to	“the	process	of	putting	to	use	or	integrating	evidence-based	interventions	within	a	setting.”(4)	I	explore	participant	narratives	–	patients,	care	providers,	and	decision	makers	–	through	the	lens	of	complex	adaptive	systems	(CAS),	an	explanatory	theory	that	helps	to	understand	health	service	implementation	processes	and	challenges	at	a	behavioural	and	organizational	level.(1,60,177)	A	CAS	is	a	collection	of	individuals	“with	freedom	to	act	in	ways	that	are	not	always	totally	predictable,	and	whose	actions	are	interconnected	so	that	one	agent's	actions	changes	the	context	for	other	agents.”(1)	CAS	is	a	fitting	framework	for	understanding	how	contextual	factors	and	relationships	at	micro,	meso,	and	macro	levels	of	the	healthcare	system	influence	decision-making	for	mode	of	delivery	decision-making	and	implementation	of	SDM.	CAS	has	been	previously	used	as	the	theoretical	foundation	of	research	investigating	implementation	of	interventions	for	Type	II	diabetes,(178,179)	congestive	heart	failure,(180)	physical	rehabilitation,(181)	and	elder	care	services.(182)	Nieuwenhuijze	and	colleagues	(183)	recently	developed	a	comprehensive	taxonomy	of	key	complexity	theory	characteristics,	which	may	be	used	a	framework	for	understanding	system	behaviour	in	maternity	care.	These	studies			138	speak	to	the	interest	of	researchers	and	decision	makers	to	use	CAS	theory	in	implementation	for	health	services	broadly,	and	maternity	care	in	particular.	However	researchers	and	health	service	decision	makers	struggle	to	translate	the	dense	concepts	of	complexity	and	complex	adaptive	theory	for	real-world	health	systems	and	practice.(183)	This	chapter	builds	on	the	results	of	my	grounded	theory	analysis	of	participants’	attitudes	toward	and	experiences	with	decision-making	for	birth	after	caesarean.	In	Chapters	4	and	5	I	explored	the	micro,	meso,	and	macro	levels	of	decision-making	for	birth	after	caesarean.	I	explored	participants’	attitudes	toward	and	experiences	with	the	component	parts	of	SDM:	exchanging	information	about	the	decision,	listening	to	women’s	preferences,	including	those	preferences	in	the	decision,	and	the	role	of	the	woman	and	care	provider(s)	in	decision-making	for	birth	after	caesarean.	Thus,	my	interviews	explored	participants’	perceptions	of	SDM	implementation	barriers	and	enablers,	as	well	as	the	broader	context	in	which	birth	after	caesarean	decision-making	takes	place.	The	findings	from	my	grounded	theory	analysis	identified	two	overarching	themes	and	relevant	subthemes:	1. Women	seek	control	in	the	midst	of	uncertainty	and	form	an	early	preference	for	their	next	birth.	2. Care	providers	and	decision	makers	see	their	role	as	information	providers	and	support	women	to	make	the	choice	for	birth	after	caesarean.	In	supporting	SDM	for	birth	after	caesarean,	decision	makers	and	care	providers	“make	it	work”	in	the	midst	of	limited	access	to	services.				139	These	themes	provided	insights	into	the	various	factors	that	may	influence	women’s	decision-making	for	birth	after	caesarean.		In	this	chapter,	I	build	on	these	findings	using	the	lens	of	CAS	theory	to	consider,	how	does	a	complex	adaptive	system	perspective	of	decision-making	for	birth	after	caesarean	help	to	understand	and	explain	implementation	of	SDM?	I	explore	the	system	characteristics	and	processes	that	influence	implementation	of	SDM	for	birth	after	caesarean	in	the	context	of	this	study,	including	the	relationships	between	barriers	and	enablers,	and	how	these	differ	between	different	clinical	settings,	health	professional	groups,	and	geographic	areas.	This	chapter	informs	Chapter	7	on	integrated	knowledge	translation,	where	I	consider	how	locally-derived	knowledge	on	decision-making	for	birth	after	caesarean	may	be	used	to	support	care	providers	and	policy	makers	in	implementing	SDM	for	birth	after	caesarean.		6.2 Background	In	Elwyn’s	book	exploring	case	studies	of	implementation	of	SDM,	he	suggests	that	the	challenge	of	implementing	SDM	between	patients	and	clinicians	may	be	a	symptom	of	broader	systems	influences:			“Might	it	be	that	we	should	investigate	why	professionals	behave	the	way	they	do?	 What	 drives	 so	 many	 to	 spend	 so	 little	 time	 explaining	 treatments	 to	patients?	Why	so	little	curiosity	about	individual	preferences?	Professionals	do			140	not	go	to	work	to	do	a	bad	job,	so	what	is	it	about	the	surrounding	systems	that	make	it	so	difficult	to	become	patient-centred?”(148)			However,	the	‘surrounding	systems’	involved	in	implementation	of	SDM	have	received	little	attention	in	the	literature	to	date.	Rather,	two	highly	cited	reviews	have	revealed	that	the	literature	has	focused	primarily	on	discrete	barriers	and	facilitators	to	implementation	from	the	perspectives	of	the	two	actors	involved	in	SDM	encounters	–	patients	and	health	care	professionals.		Légaré	et	al	conducted	a	systematic	review	of	38	studies	on	health	professionals’	perceptions	of	barriers	and	facilitators	to	SDM.(147)	Their	findings	were	organized	into	a	taxonomy	of	barriers	and	facilitators.	The	most	cited	barriers	to	health	professionals’	uptake	of	SDM	were	time	constraints	such	as	short	clinic	visits,	and	lack	of	appropriateness	of	SDM	for	their	patient	population	or	clinical	situation,	respectively.(147)	These	findings	illustrate	that	more	attention	needs	to	be	paid	to	how	stakeholders	feel	about	SDM	interventions	before	developing	or	implementing	them	in	routine	practice.	Similar	findings	were	observed	in	Légaré	et	al’s	validation	of	the	Interprofessional	Shared	Decision-Making	framework	(IP-SDM),	a	conceptual	model	for	SDM	in	primary	care	developed	in	Canada.(184)	In	addition	to	the	above	barriers,	an	imbalance	of	power	among	health	professionals,	practicing	in	silos,	disagreement	about	roles	and	responsibilities,	and	costs	of	implementation	(an	organization	barrier)	were	cited	frequently.	Reported	facilitators	pointed	to	the	need	for	interprofessional	collaboration	and	organizational	support	to	integrate	IP-SDM	into	existing	practice.(184)			141	Joseph-Williams	et	al	observed	in	their	systematic	review	of	44	studies	on	patient-reported	barriers	and	facilitators	to	SDM	that	the	“patient”	role	and	power	imbalances	in	the	“doctor-patient”	relationship	lead	to	lack	of	patient	involvement	in	decision-making.(185)	They	organized	their	findings	in	a	taxonomy	of	individual-level	barriers	and	facilitators,	but	highlighted	that	patient	(micro)	level	factors	are	intertwined	with	barriers	at	the	levels	of	the	organization	(meso)	and	health	policy	and	culture	(macro).		These	different	facets	of	the	health	care	system	and	the	relationships	between	them	need	to	be	explored	in	order	to	create	knowledge	that	responds	to	differences	in,	as	Bowen	and	Graham	describe,	“culture	of	decision	making,	type	of	decisions,	importance	of	contexts,	timelines	for	decisions,	and	types	of	evidence	considered	credible.”(40)	The	systematic	reviews	prepared	by	Légaré	and	Joseph-Williams	provide	important	insights	into	the	potential	challenges	that	health	care	providers	and	patients	may	encounter	when	attempting	to	engage	in	SDM,	based	on	findings	primarily	from	qualitative	studies.	However,	it	is	unclear	whether	these	frameworks	consider	the	range	and	context	of	implementation	of	SDM	for	birth	after	caesarean	since	few	studies	on	the	subject	have	concerned	maternity	care	and	none	included	stakeholders	other	than	health	care	professionals	and	patients.	Implementation	researcher	Per	Nilsen	posits	in	a	systematic	review	of	knowledge	translation	theories	that	a	complexity	perspective	may	be	necessary	to	understand	the	relationships	between	discrete	barriers	and	facilitators:	“there	could	be	synergistic	effects	such	that	two	seemingly	minor	barriers	constitute	an	important	obstacle	to	successful	outcomes	if	they	interact.”(7)				142	6.2	The	Conceptual	Lens	Charmaz	cautions	that	“the	constant	comparative	method	in	grounded	theory	does	not	end	with	completion	of	your	data	analysis.”(84)	In	a	grounded	theory	study	a	conceptual	model	or	theoretical	framework	“emerges	from	your	analysis	and	argument	about	it”	and	serves	to	“inform	a	specific	argument	in	a	particular	piece	of	work.”(84)	Focusing	on	a	single	argument,	the	conceptual	model	helps	to	explicate	your	logic	and	directions,	explains	the	significance	of	your	original	concepts,	and	should	fit	the	disciplinary	audience	for	which	you	write.	In	studies	of	implementation,	conceptual	models	should	be	used	with	caution	as	“theory	may	serve	as	blinders,”(7)	restricting	the	problem	to	an	existing	framework	with	predetermined	barriers	and	facilitators,	preventing	researchers	from	seeing	problems	with	a	fresh	perspective.(186)		Previous	investigations	have	used	various	theories	to	understand	how	individual	and	organizational	behaviours	may	facilitate	implementation	of	SDM.	Desroches	et	al.	surveyed	dieticians’	beliefs	about	SDM	using	the	Theory	of	Planned	Behaviour,(187)	a	theory	that	posits	that	a	set	of	beliefs	determine	an	individual’s	intention	to	engage	in	a	given	behavior,	and	links	the	individual’s	intentions	and	context	to	the	actual	behavior	they	undertake.(188)	Frosch	et	al	suggested	use	of	the	Integrative	Model	of	Behaviour	in	developing	and	evaluating	patient	decision	aids,(189)	which	theorizes	that	an	individual’s	intention	to	take	up	a	behaviour	depends	on	their	attitudes	toward	how	favourable	the	behaviour	may	be,	perceived	norms	(e.g.	social	pressure),	and	self-efficacy.(190)	A	multidisciplinary	team	in	the	UK	evaluated	a	complex	SDM	intervention	for	patients,	care	teams,	and	decision	makers	using	Normalization	Process	Theory,	which	seeks	to	explain	how	interventions	and	behaviours	are	routinized	in	everyday			143	practice.(172)	This	last	study	illuminated	the	importance	of	care	providers	having	a	coherent	view	of	their	role	and	purpose,	engaging	in	developing	and	delivering	SDM	interventions,	and	feeling	that	the	intervention	matches	existing	skill	sets	and	organizational	priorities.(191)	However,	behaviour	change	theories	and	taxonomies	that	deconstruct	the	health	care	system	into	pre-defined	theoretical	or	empirical	categories	may	limit	the	scope	of	a	problem	to	the	behaviour	of	individuals	and	overlook	the	role	of	environment,	organizational	context,	and	relationships	between	different	stakeholders.(7)		In	health	services	and	implementation	research,	dominant	theoretical	frameworks	are	built	on	the	premise	that	systems	may	be	improved	by	external	forces	and	that	organizational	barriers	may	be	solved	through	more	collection	of	data,	the	application	of	rigorous	and	sophisticated	analyses,	and	rational	solutions.(192)	This	presumes	that	big,	complex	problems	(such	as	how	to	implement	SDM	or	how	to	support	women’s	choices	for	birth	after	caesarean)	can	be	rendered	into	smaller,	simple	ones.	Deconstructing	approaches	may	work	with	‘complicated’	systems	such	as	cars	or	computers,	which	consist	of	a	vast	number	of	components,	but	each	part	can	be	broken	down	and	described	individually.	However	deconstructing	systems	that	are	‘complex,’	such	as	the	brain,	immune	system,	or	a	healthcare	team,	prove	frustrating,	as	the	interaction	between	the	system	and	its	environment	is	such	that	the	system	as	a	whole	cannot	be	understood	simply	by	analyzing	its	component	parts.(193)		The	paradigm	of	complex	adaptive	systems	(CAS)	retains	complexity	by	shifting	the	focus	of	analysis	from	“foreground”	to	“background”	(194)	–	from	individual	SDM	elements	to	their	context,	the	interaction	between	those	elements,	and	how	they	self-organize.(192)	It			144	“challenges	the	positivistic	framework	that	dominates	health	service	research—a	confident	assumption	that	there	is	one	correct	organizational	solution	towards	which	research	will	inevitably	converge.”(192)	In	decision-making,	complexity	science	can	help	explain	how	an	array	of	factors	influence	individuals	to	make	unexpected,	seemingly	irrational,	and	potentially	dangerous	health	choices.(195)	Complex	systems	exhibit	a	number	of	common	characteristics	that	can	be	used	to	understand	decision-making	behaviour	and	the	factors	that	influence	implementation	of	SDM	(see	Table	6.1).			 			145	Table	6.1	Characteristics	of	Complex	Adaptive	Systems		Attractors*	 Attractor	patterns	provide	a	simple	understanding	of	what	seems	to	be	complex	behavior.	They	are	ordered	states	in	the	midst	of	chaos.	Simple	rules	 Agents	respond	to	their	environment	by	acting	on	internalized	rules,	such	as	instinct	or	heuristics.	These	rules	may	look	illogical	to	another	agent.			Interconnectivity	 The	complex	system	consists	of	agents	that	interact	in	dynamic	ways.	The	system	is	more	than	the	sum	of	its	parts.	Interconnectivity	is	apparent	when	the	system	self-organizes	in	creative	ways	in	response	to	change.	Co-evolution	 Each	agent	and	system	is	nested	in	other	systems,	all	co-evolving	together	and	interacting.	Self-organization	 The	complex	system	inherently	self-organizes	through	simple,	locally	applied	rules	of	behavior.	Innovation	can	emerge	from	within;	it	does	not	need	to	be	imposed.	Emergence	 The	complex	system	emerges/develops	over	time,	adapting	in	response	to	internal	and	external	factors.	Non-linearity	 The	behaviour	of	the	complex	system	is	inherently	non-linear.	Seemingly	small	triggers	can	lead	to	huge	outcomes.	Unpredictability	 The	behaviour	of	the	complex	system	is	inherently	unpredictable	because	its	elements	change	over	time	and	it	is	sensitive	to	small	triggers.	Feedback	loops	 Positive	and	negative	interactions	feedback	to	people	in	the	system.	The	system	is	connected	from	past	to	future.	Initial	conditions	 The	history	of	the	system	is	its	initial	conditions.	It	is	an	attractor	that	influences	how	the	system	behaves,	evolves,	and	responds	to	change.	Open	boundaries	The	boundaries	of	the	system	are	not	well	defined.	Membership	in	the	system	can	change	and	agents	can	be	part	of	multiple	systems	at	once.	*List	of	characteristics	adapted	from	Nieuwenhuijze	et	al	(183)		 			146		6.3 Discussion	In	the	following	section	I	discuss	my	qualitative	findings	through	the	lens	of	complex	adaptive	systems	theory.	I	begin	with	“case	examples”	of	implementation	of	SDM	for	birth	after	caesarean,	drawing	from	two	participant	narratives.	The	case	examples	illustrate	factors	that	influence	implementation	of	SDM	for	birth	after	caesarean	from	the	perspective	of	a)	a	rural	woman	under	family	physician	care	whose	first	caesarean	was	due	to	perceived	failure	to	progress	(Participant	030)	and	b)	an	urban	family	maternity	care	practice,	which	draws	on	composite	interviews	(Participants	013,	016,	020).	These	are	examples	are	not	meant	to	be	representative	of	all	women’s	and	physicians’	experiences.	Rather	they	were	selected	for	illustrating	the	multidimensional	array	of	system	factors	that	may	influence	a	stakeholder’s	decision-making	for	birth	after	caesarean.	After	providing	these	case	examples,	I	then	organize	my	discussion	around	characteristics	of	a	complex	adaptive	system.			 			147		CASE	EXAMPLE	1:	“Hannah,”	Participant	030		Hannah	was	36	when	she	became	pregnant	with	her	first	child.	She	describes	that	her	labour	resulted	in	an	unplanned	caesarean	for	“failure	to	progress,”	yet	she	had	always	had	a	feeling	that	she	would	end	up	with	a	caesarean.	She	felt	disappointed	at	the	loss	of	her	planned	natural	birth	and	felt	that	she	must	not	be	“strong	enough”	to	have	a	vaginal	delivery.	One	month	after	her	birth,	her	family	physician	told	her	she	could	plan	a	VBAC	in	future	but	recommended	that	she	plan	an	elective	repeat	caesarean.	If	Hannah	has	more	children,	she	thinks	she	will	feel	“more	in	control”	if	she	plans	an	elective	caesarean.	At	the	same	time,	she	strongly	desires	to	have	a	vaginal	delivery	to	experience	immediate,	uninterrupted	bonding:	“You’re	supposed	to	be	able	to	have	your	baby	go	through	the	birth	canal	and	pick	her	up	and	hold	her	on	your	own	chest.”	Hannah	cries	as	she	considers	the	difficult	trade	offs	between	her	options	for	mode	of	delivery.		In	her	first	year	of	motherhood	Hannah	goes	over	her	first	birth	and	speaks	frequently	with	a	close	friend	who	also	had	an	unplanned	caesarean.	These	conversations	give	her	comfort	and	make	her	feel	less	alone.	She	has	a	lot	of	difficulty	breastfeeding,	which	she	attributes	to	her	caesarean.	She	and	her	husband	have	no	immediate	family	in	town	to	assist	with	childcare.	This	crystallizes	her	preference	for	repeat	caesarean	so	that	her	family	can	plan	their	visit	around	her	birth	date.	She	feels	sadness	about	this	choice	because	it	closes	the	door	on	her	chance	to	have	a	vaginal	birth.			One	attractor	pattern	in	Hannah’s	behavior	may	involve	social	relationships.	Her	toddler’s	need	for	childcare	and	her	parents’	need	to	plan	their	travel	lead	to	her	preference	for	repeat	caesarean.	These	considerations	emerge	before	any	future	pregnancies,	and	are	based	on	her	personal	experiences.	Other	attractor	patterns	may	be	Hannah’s	desire	for	control	after	having	an	unplanned	caesarean,	and	for	immediate	bonding	with	her	newborn	after	delivery.	Her			148	attitudes	toward	birth	are	influenced	by	her	physician’s	recommendation	for	repeat	caesarean	and	social	norms	about	how	women	are	“supposed”	to	give	birth.			Hannah	struggles	to	make	a	choice	that	matches	her	values	and	her	family’s	needs.	Due	to	the	early	timing	of	her	preference	for	elective	repeat	caesarean	and	recommendation	from	her	physician,	future	SDM	activities	may	have	little	influence	on	her	choice.				CASE	EXAMPLE	2:	“Urban	family	practice,”	Participant	016		Family	physicians	in	an	urban	maternity	care	practice	believe	that	women	should	be	supported	to	make	their	own	informed	choices	for	birth	after	caesarean,	as	both	planned	VBAC	and	repeat	caesarean	are	safe	options.	In	comparison	to	similar-sized	hospitals,	the	family	practice’s	local	hospital	has	high	rates	of	repeat	caesarean	for	healthy	low-risk	patients.	The	physicians	feel	this	is	due	to	patient	request.	When	women	have	their	first	visit	in	their	pregnancy	after	caesarean,	they	typically	express	a	preference	for	elective	caesarean	because	it	is	“convenient”	and	would	prevent	them	from	repeating	the	“trauma”	of	a	labour	that	leads	to	an	unplanned	caesarean.	The	physicians	also	feel	these	choices	are	influenced	by	birth	stories	circulated	on	the	Internet.		The	physicians	all	practice	informed	choice	decision-making	where	the	woman	makes	a	final	decision:	“I	try	to	go	with	what	woman	wants,	and	give	her	information	and	refer	her	to	an	OB.”	It	is	the	practice	group’s	policy	to	refer	all	patients	with	a	previous	caesarean	to	an	obstetrician	at	25-30	weeks	for	an	informed	choice	discussion.	In	this	consult	the	woman	makes	a	final	decision	after	hearing	again	the	medical	risks	and	benefits	and	signing	a	consent	form	for	mode	of	delivery.			Both	the	family	physicians	and	the	obstetrician	explain	to	patients	if	there	is	an	emergency	during	a	VBAC	labour	there	might	be	a	delay	in	getting	access	to	a	caesarean	and	the	potential			149	consequences	for	mother	and	baby	would	be	catastrophic.	Although	nearby	hospitals	may	have	more	surgical	resources	to	support	planned	VBAC,	the	family	physicians	do	not	like	to	send	their	patients	away.		The	attractor	patterns	in	the	family	practice	group’s	behavior	may	be	the	desire	to	support	women’s	informed	choice	and	mitigate	patient	safety	concerns	related	to	limited	local	access	to	caesarean.	These	interviews	reveal	that	their	safety	concerns	stem	from	local	nursing	and	anesthesia	staff	shortages	and	competing	access	with	other	specialties	to	the	operating	room.	Interviews	with	other	participants,	including	health	service	decision	makers,	further	uncover	that	these	access	challenges	began	upstream	with	a	limited	budget	and	strategic	policy	priorities	that	did	not	include	maternity	care.	Also,	recent	malpractice	suits	related	to	decision-making	for	caesarean	have	been	covered	in	the	local	media.	This	has	caused	physicians	throughout	the	urban	region	to	discuss	the	risks	of	limited	access	to	surgery	during	informed	consent	for	birth	after	caesarean.		Through	these	two	case	examples,	I	aim	to	widen	the	focus	from	the	“foreground”	of	patient,	provider,	and	decision	maker	experiences	to	the	“background”	of	the	phenomenon	and	provide	insights	into	relationships	between	actors	in	the	decision-making	context	and	the	blurry	boundaries	between	the	clinical	(micro)	level,	organization	(meso)	level,	and	policy	(macro)	levels	of	the	healthcare	system.	The	overall	pattern	that	emerges	provides	a	simple	understanding	of	what	seems	to	be	complex	behaviour.(1)	What	may	appear	to	be	resistance	to	change	or	irrational	decision-making	may	actually	be	behavior	that	follows	a	natural	“attractor”	pattern	in	the	broader	system.(60,193)	These	patterns	explain	why	some	women	who	value	and	prefer	vaginal	delivery	choose	to	plan	elective	repeat	caesarean	or	why	decision			150	makers	committed	to	supporting	women’s	access	to	planned	VBAC	may	simultaneously	feel	that	it	is	an	unsafe	option.		6.3.1 Attractor	Patterns		Although	the	complex	system	is	unpredictable,	there	is	often	an	overall	pattern	and	it	is	possible	to	anticipate	the	consequences	of	certain	responses.(177)	Attractor	patterns	are	ordered	states	in	the	midst	of	chaos	and	provide	a	simple	understanding	of	what	seems	to	be	complex	behavior.(1)	Positive	and	negative	feedback	intrinsic	to	the	system	leads	to	patterns	of	behaviour,	such	as	a	routine	informed	consent	process	for	birth	after	caesarean	or	relying	on	friends	and	the	Internet	for	birth-related	information.(196)	Thus	although	the	system	is	flexible	and	dynamic,	the	individuals	within	it	act	within	a	slightly	defined	range	of	behaviour.(183)	The	attractor	patterns	in	these	two	case	examples	suggest	that	seemingly	irrational	decisions	made	by	patients	and	care	providers	can	be	explained	by	simple	motivated	behaviour	influenced	by	their	context	and	relationships.	Why	did	Hannah	choose	an	elective	repeat	caesarean	that	she	personally	did	not	want?	Why	did	the	family	practice	group	provide	biased	risk	information	to	their	patients?	Each	was	responding	to	the	elements	of	their	surrounding	system	and	the	intricate	relationships	between	those	elements.		Looking	at	these	attractor	patterns	and	the	behaviour	they	induce	reveals	that	the	care	provider	in	case	example	2	was	not	resistant	to	supporting	women’s	choice	of	birth	after	caesarean;	rather	in	their	attempt	to	support	women	to	make	choices	based	on	full	information	they	counseled	women	about	real	world	patient	safety	and	litigation	concerns.	To	return	to	the			151	core	themes	from	analysis	of	care	provider	and	decision	makers’	narratives,	they	were	“making	it	work”	in	the	context	of	limited	resources.	In	case	example	1,	Hannah’s	social	system	and	family	responsibilities	drove	her	decision-making,	and	through	her	choice	she	sought	control	in	the	midst	of	uncertainty.	Hannah’s	story	illustrates	the	role	of	social	relationships	as	an	attractor	in	her	decision-making	for	birth	after	caesarean.	She	began	her	preference	formation	soon	after	her	first	caesarean,	outside	of	the	healthcare	system	as	she	was	no	longer	a	patient.	Within	her	social	sphere	she	came	in	contact	with	individuals	whose	information	and	experiences	were	relevant	to	the	attributes	of	mode	of	delivery	that	were	most	important	to	her	individual	decision	–	regaining	control	of	her	agency,	experiencing	a	vaginal	delivery,	and	having	local	family	support.			6.3.2 Simple	Rules	The	attributes	of	importance	to	Hannah	can	also	be	viewed	as	“simple	rules”	in	the	system	at	the	patient	level:	“internalised	principles	or	values	that	drive	a	common	direction	of	travel	among	the	people	in	a	complex	system.”(183)	Conversely,	the	simple	rules	that	motivated	the	behaviour	of	the	family	practice	group	in	case	example	2	were	related	to	“making	it	work”	in	the	midst	of	limited	resources,	which	was	a	core	theme	that	emerged	from	my	grounded	theory	analysis	of	care	provider	and	policy	maker	narratives.	The	simple	rules	that	guided	the	family	practice	group’s	behaviour	reflected	their	values	of	supporting	women	to	make	a	choice,	promoting	patient	safety,	and	avoiding	litigation.			152	In	a	complex	adaptive	system,	seemingly	irrational	behaviour	can	be	further	explained	by	drawing	on	complementary	theory	on	cognitive	heuristics,	simple	rules	for	how	individuals	make	decisions	when	faced	with	competing	options.(1)	A	common	heuristic,	loss	aversion,	helps	to	further	explain	the	attractor	patterns	in	decision-making	for	birth	after	caesarean.	Loss	aversion	explains	how	individuals	prefer	avoiding	losses	to	acquiring	comparable	gains.(197).	For	the	family	physician	case	example,	when	they	considered	the	outcomes	of	a	planned	VBAC,	the	risk	of	morbidity	and	mortality	resulting	from	a	rare	uterine	rupture	loomed	larger	than	the	likelihood	of	having	a	healthy	vaginal	delivery.	For	Hannah,	the	risk	of	experiencing	a	traumatic	repeat	caesarean	during	a	planned	VBAC	loomed	larger	than	the	likelihood	that	she	would	have	a	successful	VBAC	as	planned.	This	heuristic	led	Hannah	and	the	family	practice	group	to	avoid	these	rare	potential	losses	by	opting	for	the	mode	of	delivery	they	perceived	to	be	safest	and	most	predictable	based	on	the	outcomes	of	childbirth	they	most	valued	–	feeling	in	control	and	a	healthy	mother	and	baby,	respectively.			6.3.3 Interconnectivity	and	Co-Evolution	These	patterns	also	illustrate	that,	when	making	a	choice	for	birth	after	caesarean,	there	are	multiple	interconnected	systems	that	influence	the	decision-making	process	between	a	care	provider	and	patient.	Patients	and	care	providers	are	nested	in	other	systems,	all	of	which	co-evolve	together	and	interact.	A	patient	like	Hannah	may	respond	to	the	social	influence	of	her	parents,	children,	friends,	and	strangers	on	the	Internet.	Care	providers	such	as	those	in	the	family	practice	group	adjust	their	behaviour	to	cope	with	internal	demands	coming	from	within			153	the	healthcare	system	from	nurses,	anaesthetists,	other	surgical	specialists,	and	physician	peers.	Their	behaviour	also	responds	to	dynamic	interaction	with	the	external	public	sphere	created	by	lawyers,	government	policy	makers,	and	the	media.	Interconnectivity	appears	when	a	system	or	group	self-organizes	or	adopts	creative	changes,	such	as	a	physician	practice	having	increased	repeat	caesarean	rates.	This	self-organizing	activity	is	the	group’s	response	to	dynamic	interaction	with	different	agents.	It	is	not	planned	and,	“if	asked,	no	one	in	the	group	can	explain	exactly	how	they	came	about.”(183)		6.3.4 Self-Organization	and	Emergence	Such	interaction	of	individuals	at	a	micro	level	occurs	without	internal	or	external	direction,	rather	it	emerges	spontaneously	and	allows	the	system	to	adapt	and	self-organize	in	response	to	barriers	and	challenges.	Self-organization	is	a	“process	in	which	people	mutually	adjust	their	behaviour	to	cope	with	changing	internal	and	external	demands.”(183)	This	leads	to	emergence,	which	is	a	pattern	of	behaviour	that	analysis	of	the	component	parts	of	the	system	could	not	have	predicted.(192)			 Hannah’s	diachronic	decision-making	process	illustrates	emergent	behaviour	at	a	micro	level.	She	strongly	desires	to	have	a	vaginal	birth,	yet	her	conflicting	desire	to	have	control	over	her	labour	and	delivery	leads	her	to	prefer	a	planned	repeat	caesarean.	External	influences	from	family	do	not	compel	her	to	make	this	decision,	but	her	values	and	the	interconnectivity	of	her	social	and	healthcare	contexts	reinforce	her	choice	for	a	caesarean.	Within	case	example	2,	the	family	practice	group	illustrates	emergence	and	self-organization	at	a	meso	level	in	their			154	clinical	counseling	and	subsequent	high	rates	of	repeat	caesarean.	Negative	feedback	from	other	overlapping	systems	(e.g.	policy	makers,	the	media,	the	legal	system,	other	clinical	specialties)	causes	them	to	adapt	their	behaviour	not	from	a	top-down	approach	or	“hierarchical	demands,”(183)	but	rather	in	response	to	patient	safety	concerns	about	access	to	the	operating	room.	Looking	at	the	component	parts	of	the	system	does	not	reveal	this	pattern	of	behaviour.	It	is	visible	only	by	looking	at	the	relationships	between	those	components.		Although	not	discussed	in	these	case	examples,	it	is	helpful	to	consider	how	negative	feedback	can	lead	to	emergent	behaviour	that	promotes	patient-centred	care.	In	this	study,	small	rural	communities	expressed	innovative	variation.	Physicians	in	two	small	rural	communities	met	the	challenge	of	limited	access	to	resources	by	creating	practice	groups	involving	all	primary	maternity	care	providers	in	each	community.	They	also	increased	the	communication	between	physicians	and	on-call	surgical	staff	when	a	woman	was	in	labour	with	a	planned	VBAC	(see	Chapter	5).	Pooling	resources	and	increasing	interprofessional	communication	were	innovations	that	appeared	to	flourish	in	these	isolated	rural	communities.	The	system	self	organized	in	response	to	interaction	of	diverse	local	agents,	not	from	external	design.	However,	in	the	case	of	the	rural	communities,	the	emergent	behaviour	led	to	health	service	conditions	that	supported	women’s	informed	choice	of	both	modes	of	delivery.		6.3.5 Non-linearity	and	Unpredictability	In	a	complex	adaptive	system,	“interactions	usually	have	a	fairly	short	range,	i.e.	information	is	received	primarily	from	immediate	neighbours.	Long-range	interaction	is	not	impossible,	but			155	practical	constraints	usually	force	this	consideration	…	As	a	result,	the	influence	gets	modulated	along	the	way.	It	can	be	enhanced,	suppressed	or	altered	in	a	number	of	ways.”(193)	Further	adding	to	the	complexity,	these	interactions	are	non-linear,	unpredictable,	and	small	causes	can	have	very	large	effects.(1)	Effects	are	non-linear	and	interact	with	other	elements	in	the	environment.	The	example	of	the	family	practice	group’s	behaviour	succinctly	illustrates	this	interconnectivity	and	the	dynamic	effect	of	short-range	interactions.	Recent	malpractice	suits	related	to	decision-making	for	caesarean	occurred	in	the	local	area.	These	events	were	reported	in	the	media,	which	drew	the	public’s	attention	and	required	a	response	from	health	service	decision	makers	who	were	aware	of	local	nursing	and	anaesthesia	shortages	and	competing	access	with	other	specialties	to	the	operating	room.	These	staff	shortages	were	the	result	of	budget	constraint	at	a	systems	level,	which	in	turn	resulted	from	allocating	resources	to	areas	other	than	maternity	care.	These	events	were	fed	back	to	individual	care	providers	who	spontaneously	adjusted	their	behaviour	for	decision-making	for	birth	after	caesarean	in	response	to	changing	internal	and	external	demands.	This	interconnectivity	represents	a	feedback	loop,	“in	which	the	positive	and/or	negative	effects	of	a	particular	action	or	change	are	fed	back	to	the	people	in	the	network.	This	feedback	affects	the	way	these	people	behave	in	the	future,	also	in	the	connection	with	one	another.”(183)	There	is	also	a	temporal	component	to	feedback	loops,	as	explained	below.				156	6.3.6 Feedback	Loops	and	Initial	Conditions		“Complex	systems	have	a	history,”	Cilliers	writes,	“Not	only	do	they	evolve	through	time,	but	their	past	is	co-responsible	for	their	present	behaviour.	Any	analysis	of	a	complex	system	that	ignores	the	dimension	of	time	is	incomplete,	or	at	most	a	synchronic	snapshot	of	a	diachronic	process.”(193)	The	element	of	time	in	the	process	of	decision-making	is	often	underrepresented.	The	decision-making	process	is	typically	conceptualized	as	one	that	begins	when	a	health	professional	introduces	the	decision	to	be	made	and	ends	with	the	choice	being	implemented.(50,175,184)		In	decision-making	for	mode	of	birth	after	caesarean,	women’s	decision-making	may	not	begin	with	a	care	provider	introducing	the	decision.	As	in	Hannah’s	case,	a	woman	likely	has	knowledge	that	there	are	two	options	–	planned	VBAC	or	elective	repeat	caesarean	–	and	her	decision	evolves	over	time.	This	is	illustrated	in	the	conceptual	map	of	women’s	decision-making	for	birth	after	caesarean	presented	in	Chapter	4	(Figure	4.1).	Women	who	have	an	unplanned	caesarean	go	over	and	over	the	trauma	of	the	first	birth	in	a	cyclical	fashion.	In	women’s	reproductive	decision-making	from	pregnancy	to	pregnancy,	the	decision	for	the	first	mode	of	delivery	influences	the	decision	for	the	next	birth	and	the	next	and	so	on.	Following	the	case	example	of	Hannah,	going	over	the	trauma	of	the	first	birth	was	part	of	her	process	of	seeking	control	in	the	midst	of	uncertainty	and,	ultimately,	forming	a	preference	for	mode	of	delivery.		Moving	up	from	the	individual	level	to	look	at	feedback	loops	on	a	larger	system	scale,	trends	in	policy	for	birth	after	caesarean	may	be	explained	by	this	concept.	In	the	mid-1990s			157	with	the	publication	of	a	landmark	study	of	6,138	Nova	Scotia	women	with	a	previous	caesarean,	which	suggested	that	the	rate	of	uterine	rupture	and	consequent	morbidity	associated	with	VBAC	was	higher	than	previously	thought,(114)	planned	VBAC	became	less	common	in	the	medical	profession.(54)	However	in	response	to	rising	repeat	caesarean	rates	and	evidence	that	it	was	escalating	to	unsafe	levels,(59)	there	was	another	change	in	practice	patterns	and	care	providers	began	to	increasingly	promote	planned	VBAC	as	a	safe	option.	In	one	community	involved	in	this	study,	a	care	provider	participant	described	this	ebb	and	flow	of	attitudes	toward	planned	VBAC	as	a	“swinging	pendulum,”	another	metaphor	for	the	feedback	loop	construct.	The	history	of	decreasing	rates	of	planned	VBAC	may	be	seen	as	the	initial	conditions	for	the	complex	system.	History	and	research	evidence	function	as	attractor	patterns	influencing	whether	the	system	will	change	or	not.	Thus	each	swing	of	the	pendulum	back	to	a	trend	of	elective	repeat	caesarean	is	new	but	not	unfamiliar.			6.3.7 Open	Boundaries	The	boundaries	of	the	complex	system	are	difficult	to	determine	and	often	depend	on	the	perspective	of	the	viewer	rather	than	some	intrinsic	property	of	the	system.(192)	Thus	when	I	invoke	the	term	“healthcare	system,”	I	refer	to	a	collection	of	people,	identities,	actions,	and	ideas	that	are	part	of	several	systems	at	the	same	time.	The	social	and	professional	interactions	in	the	case	examples	illustrate	how	information	and	interactions	cross	over	from	different	environments,	such	as	a	patient’s	social	network,	policy	directives	from	the	Ministry,	or	lawsuits	in	a	courthouse.	At	a	meso	level	of	the	system,	in	order	to	access	the	OR	in	the	event	of	a	STAT			158	or	emergent	caesarean,	obstetricians	must	negotiate	with	surgeons	in	other	clinical	specialties	who	may	be	using	the	space,	the	anaesthetist	who	is	paged	at	home	during	the	middle	of	the	night,	and	an	increasingly	understaffed	rotation	of	on-call	surgical	nurses.	At	a	micro	level,	the	individuals	in	the	case	examples	are	part	of	multiple	systems	at	the	same	time	that	are	formal	(e.g.	a	maternity	practice	group)	and	informal	(e.g.	an	online	social	community).	In	the	context	of	these	overlapping	systems	of	influence,	the	boundaries	of	the	healthcare	system,	and	the	walls	of	the	antenatal	clinic	room,	become	fuzzy.		6.4 Conclusion	In	this	chapter	I	have	explored	how	a	complex	adaptive	system	(CAS)	perspective	of	decision-making	for	birth	after	caesarean	helps	to	explain	the	context	that	may	influence	implementation	of	SDM	for	birth	after	caesarean.	Applying	complexity	theory	illustrates	that	the	evidence-to-action	gap	cannot	be	understood	by	decomposing	the	problem	into	individual	barriers,	facilitators,	and	outcomes.	Yet	barriers	and	facilitators	to	implementation	are	often	assessed	individually.		The	phenomenon	of	decision-making	after	a	previous	caesarean	emphasizes	the	importance	of	understanding	how	patterns	evolve	within	systems,	how	these	systems	self-organize,	and	the	interaction	between	system	elements.	Current	perspectives	in	the	shared	decision-making	literature	embrace	this	perspective	that	individual	micro-level	decisions	take	place	in	a	broader	context	that	includes	the	meso/macro	influence	of	environment,	social			159	norms,	organizational	routines,	and	social	structures.(184)	However	the	role	of	relationships	between	these	contextual	factors	has	not	been	previously	reported.			 In	this	chapter,	I	have	expanded	my	focus	from	the	foreground	of	patients’	and	health	care	professionals’	perceived	barriers	and	facilitators	to	implementation	of	SDM,	to	the	background	interactions	and	attractors	that	influence	the	SDM	context	for	birth	after	caesarean.	Participants’	experiences	emphasize	the	need	for	shared	understanding	of	the	oft	invisible	factors	and	actors	that	influence	choices	for	mode	of	delivery.	This	principle	of	shared	understanding	is	important	at	different	levels	of	the	health	care	system	–	at	the	individual	level	where	women	go	over	the	trauma	of	the	first	birth	to	gain	personal	understanding;	at	the	clinical	level	in	an	SDM	dialogue	between	the	woman,	her	family,	and	her	care	team;	and	at	an	organizational	level	where	communication	creates	mutual	understanding	of	system	constraints	and	provides	an	opportunity	to	co-create	and	share	knowledge.	Notably,	financial	incentives	did	not	emerge	as	an	attractor	pattern	for	care	provider	behaviour	in	this	study.	Previous	literature	has	observed	that	care	providers	may	find	it	personally	convenient	and	financially	lucrative	to	plan	elective	repeat	caesarean	and	promote	it	with	their	patients	(31,100).	This	may	be	because	all	care	providers	in	this	sample	received	a	similar	fee	for	service	regardless	of	whether	they	attended	a	labour	or	a	caesarean.	Similarly,	care	providers	felt	motivated	to	engage	with	patients	in	iterative	discussions	about	birth	after	caesarean	options,	negating	the	need	to	consider	incentive	strategies	to	encourage	implementation	of	SDM.	A	key	strategy	for	supporting	change	in	a	complex	system	has	been	outlined	by	Jordan	et	al	in	a	theoretical	debate	piece	on	the	role	of	conversation	in	health	care	interventions:			160		“In	the	language	of	complex	adaptive	systems	theory,	one	might	say	that	meaning	emerges	from	the	self-organization	of	diverse	and	responsive	agents.	The	meaning	created	 through	 dialogue	 varies	 greatly	 in	 its	 novelty,	 ranging	 from	 the	reinforcement	 of	 old	 beliefs	 or	 strengthening	 existing	 relationships	 and	 power	structures	to	completely	 innovative	 ideas	existing	 in	the	mind	of	neither	 individual	prior	to	the	conversation.	Through	conversation,	focus	of	this	meaning	is	narrowed	or	broadened	and	options	are	selected,	clarified,	 reduced,	added	or	created.	Such	meaning-making	may	be	especially	important	during	intervention	attempts.”(198)		In	the	following	chapter	I	draw	on	the	concept	of	the	complex	adaptive	system,	and	the	strategies	of	shared	understanding	and	local	collaboration,	to	discuss	the	integrated	knowledge	translation	strategy	that	supported	this	dissertation.	This	included	using	tools	–	a	policy	brief	and	policy	dialogues	–	for	knowledge	exchange	with	decision	maker	and	care	provider	stakeholders	to	build	meaningful	social	relationships	and	shared	understanding.	These	strategies	aim	to	facilitate	the	implementation	of	patient-centred	care	and	SDM	for	birth	after	caesarean	in	one	of	the	study	settings,	the	Fraser	Health	Authority.		 			161	Chapter	7: Knowledge	Exchange	to	Implement	Shared	Decision-Making:	A	Case	Example	of	Partnering	with	Stakeholders	to	Optimize	Services	for	Birth	after	Caesarean		7.1 Introduction	As	discussed	in	the	previous	chapters,	analysis	of	my	findings	on	women’s,	care	providers’,	and	decision	makers’	attitudes	and	experiences	with	decision-making	for	birth	after	caesarean	illustrates	that	bridging	the	gap	between	knowledge	and	action	is	a	complex,	nonlinear,	process.	Focusing	on	implementation	of	SDM	practices	in	particular,	I	have	argued	that	knowledge	translation	(KT)	efforts	may	be	modulated	by	stakeholders’	attitudes	and	experiences	and	the	complex	context	in	which	births	after	caesarean	occur.	I	also	have	highlighted	that	different	forms	of	knowledge	inform	decision-making	–	women’s	experiential	knowledge	of	birth,	care	providers’	and	organizations’	knowledge	of	best	clinical	practices	from	the	scientific	literature,	and	decision	makers’	knowledge	of	how	that	literature	fits	(or	not)	in	real	world	health	service	settings.	In	exploring	what	SDM	implementation	strategies	might	work	for	birth	after	caesarean	in	the	context	of	British	Columbia,	I	thus	began	by	asking	not	which	implementation	strategies	are	most	effective,	but	rather,	what	attitudes,	experiences,	and	contextual	factors	might	influence	implementation.	Returning	to	an	argument	I	made	in	the	Introduction,	in	an	integrated	knowledge	translation	(iKT)	research	process,	different	forms	of	“knowledge”	are	legitimate.	I	have	sought	to	explore	the	different,	often	competing,	forms	of	knowledge	that	influence	decision-making			162	for	birth	after	caesarean	in	British	Columbia,	in	order	to	understand	how	to	adapt	the	scientific	evidence	on	SDM	for	this	local	context.	In	Chapter	6	I	observed	that	implementation	of	SDM	for	birth	after	caesarean	may	be	facilitated	by	dialogue	with	stakeholders.		Building	on	that	analysis,	the	aim	of	this	chapter	is	to	describe	how	I	drew	on	the	principle	of	dialogue	to	co-produce	my	research	findings	in	partnership	with	stakeholders.	I	adopt	the	position	that	the	knowledge	to	action	gap	for	birth	after	caesarean	stems	from	problems	with	“knowledge	exchange”	rather	than	from	issues	with	creating	knowledge	tools	or	transferring	knowledge	into	policy	and	practice.	I	describe	how	I	applied	the	knowledge	exchange	strategies	of	dialogue	and	local	collaboration	throughout	the	research	process.	In	this	chapter,	I	hope	to	provide	an	illustrative	example	of	KT	in	practice,	which	may	prove	useful	to	researchers	and	stakeholders	grappling	with	how	to	address	knowledge	to	action	gaps.			7.1.1 Structure	of	the	Chapter	In	the	following	sections	of	the	chapter,	I	provide	a	case	example	of	the	KT	process	that	emerged	in	this	dissertation.	Through	this	rich	description,	I	hope	to	add	to	the	literature	on	KT	practice	and	demonstrate	how	researchers	and	stakeholders	may	collaborate	in	clinical	and	health	services	research.			7.2 Methods	The	objective	of	my	iKT	approach	was	to	produce	research	findings	that	were	more	likely	to	be	relevant	to	and	used	by	stakeholders	in	British	Columbia.	Through	partnership	with	my	clinical			163	co-investigator	in	Fraser	Health	Authority,	in	particular,	I	sought	to	ensure	co-ownership	of	knowledge	and	shared	responsibility	to	facilitate	sustainable	change	in	practice	and	policy	beyond	the	timeline	of	the	dissertation.			7.2.1 Terminology	In	an	international	study	involving	interviews	with	key	informants	from	33	agencies	involved	in	knowledge	translation,	Tetroe	et	al.	identified	29	terms	used	by	experts	to	describe	knowledge	translation.(199)	Clarifying	my	definition	of	“knowledge	translation”	and	related	terms	locates	my	study	in	relation	to	the	existing	literature	on	KT.	In	the	following	sections	I	revisit	my	definition	of	iKT,	which	I	first	presented	in	the	Introduction	(Chapter	1).	I	then	define	how	I	use	the	terms	“knowledge”	and	“stakeholders,”	before	describing	my	use	of	the	concept	of	“knowledge	exchange.”			7.2.1.1 Integrated	Knowledge	Translation	(iKT)	iKT	or	“engaged	scholarship”	highlights	the	role	of	engaging	stakeholders	throughout	the	research	process.(3)	Doing	so	aims	to	“produce	research	findings	that	are	more	likely	to	be	directly	relevant	to	and	used	by	knowledge	users.”(9)	iKT	activities	aim	to	create	a	sense	of	shared	ownership	over	research,	on	the	premise	that	by	doing	so	stakeholders	will	be	more	likely	to	accept	research	on	implementation	of	SDM	and	create	sustained	changes	in	clinical	practice	and	policy.(21,22)	Using	iKT	processes	and	partnered	research	to	achieve	particular	objectives	focuses	researchers	and	stakeholders	on	the	same	page	to	create	shared	meaning,			164	identify	facilitators	and	barriers	to	the	process	of	evidence	implementation,	and	co-create	empirical	evidence	to	support	health	service	planning.	As	a	result,	the	partnership	process	itself	is	instrumental	in	implementing	sustainable	change.(58)		The	outcomes	of	an	iKT	research	process	ideally	include	knowledge	that	extends	beyond	scientific	research	evidence.	As	described	above	and	in	the	Introduction,	partnered	research	may	produce	evidence	in	context,	including	an	understanding	of	the	feasibility	of	implementation,	stakeholder	relationships,	and	policy	priorities	within	different	jurisdictions	of	the	healthcare	system,	and	the	complex	relationships	between	these	factors.	Throughout	this	dissertation	I	have	argued	that	there	is	a	gap	between	best	practices	for	birth	after	caesarean	(shared	decision-making;	reducing	medically	unnecessary	repeat	caesareans)	and	the	successful	implementation	of	those	practices.	I	argue	that	in	order	to	bridge	this	knoweldge	to	action	gap	it	is	necessary	to	develop	strategies	in	partnership	with	stakeholders	based	on	both	the	scientific	evidence	and	the	health	services	and	policy	context	in	which	decision-making	takes	place.			7.2.1.2 Stakeholders	In	this	study,	I	draw	from	the	traditions	of	participatory	and	community	action	research	(200,201)	to	define	“stakeholders”	as	individuals	and	organizations	involved	in	receiving,	providing,	or	planning	care	for	birth	after	caesarean,	including	patients,	care	providers,	and	health	service	decision	makers.	Stakeholders	in	this	study	are	those	who	may	be	affected	by	decisions	for	birth	after	caesarean,	or	whose	behaviours	and	actions	may	have	an	effect	on			165	efforts	to	support	SDM	for	birth	after	caesarean.	There	may	be	stakeholders	who	benefit	from	SDM	for	birth	after	caesarean	and	those	who	feel	a	negative	impact.	For	instance,	implementation	of	a	patient	decision	aid	(PtDA)	for	mode	of	delivery	could	have	a	positive	impact	on	women	in	hospital	settings	where	both	planned	VBAC	and	elective	caesarean	are	available,	but	create	confusion	or	disappointment	for	women	in	settings	without	resources	to	support	both	options.	Stakeholders	may	include	individuals	in	highly	visible	positions	of	influence,	such	as	a	hospital	Head	of	Obstetrics	or	a	Director	in	the	Ministry	of	Health	who	sets	policy	and	practice	recommendations.	However,	front	line	staff	members	may	be	equally	important	as	they	are	the	individuals	who	are	expected	to	use	healthcare	innovations	in	routine	practice.	I	use	the	term	“knowledge	partners”	to	describe	the	stakeholders	who	actively	engaged	in	the	study	as	participants,	expert	informants,	or	research	collaborators.		“Stakeholder”	and	“knowledge	partner”	differ	from	the	more	conventional	term	“knowledge	user,”	which	is	used	in	the	KT	literature	to	describe	the	non-researcher	individuals	included	as	members	of	research	teams.	CIHR	defines	a	knowledge	user	as	“an	individual	who	is	likely	to	be	able	to	use	research	results	to	make	informed	decisions	about	health	policies,	programs	and/or	practices,”	and	may	include	“a	practitioner,	a	policy	maker,	an	educator,	a	decision	maker,	a	health	care	administrator,	a	community	leader	or	an	individual	in	a	health	charity,	patient	group,	private	sector	organization	or	media	outlet.”(200,201)	However	the	term	“knowledge	user”	suggests	a	unidirectional	research	process,	where	researchers	create	knowledge	and	individuals	in	policy	and	practice	“use”	that	knowledge.		Drawing	from	the	work	of	knowledge	translation	researcher	Vicky	Ward	and			166	colleagues,(8)	I	envision	the	relationship	between	researchers	and	key	individuals	to	be	complex	and	nonlinear,	where	there	is	mutual	exchange	of	knowledge	resulting	in	mutual	learning	(a	process	commonly	termed	“knowledge	exchange,”	which	I	explain	further	below).	I	was	particularly	interested	in	partnering	with	stakeholders	whose	voices	are	not	typically	included	in	maternity	care	policy,	namely	patients,	patient	advocates,	and	individuals	in	rural	communities.	I	chose	to	work	specifically	with	patients	and	rural	communities	based	on	my	previous	experience	supporting	community-based	rural	maternity	care	research	as	a	Knowledge	Translation	Manager	with	the	Centre	for	Rural	Health	Research	from	2007-2012.	My	prior	knowledge	of	rural	health	and	patient	preferences	in	maternity	care	provided	me	with	a	foundation	for	engaging	in	genuine	relationships	with	patient	and	rural	stakeholders.	I	also	had	pre-existing	relationships	with	rural	researchers,	administrators,	and	care	providers	who	could	act	as	“gatekeepers”	to	study	communities.			7.2.1.3 Knowledge	Exchange	Knowledge	exchange	is	a	useful	concept	for	understanding	the	complex,	nonlinear	process	of	engaging	in	iKT	activities.	Following	Ward’s	empirically	derived	conceptual	framework	on	this	concept,	I	define	knowledge	exchange	as	“a	fluid,	dynamic	process	involving	the	proliferation	and	reinvention	of	ideas	drawn	from	many	different	sources	via	an	interactive,	interpretive	process.”(8)	For	instance,	in	a	knowledge	exchange	paradigm,	defining	a	research	problem	is	not	a	single	action	that	occurs	at	the	beginning	of	the	research	process,	rather	it	is	a	process	of	defining,	refining,	and	trialling	a	problem	and	allowing	it	to	evolve	over	time.	This	concept	also			167	adopts	an	expansive,	egalitarian	definition	of	“knowledge”	that	includes	ideas	drawn	from	many	different	sources	via	interaction.	Social	relationships,	professional	identities,	shared	attitudes,	personal	experience,	and	norms	are	forms	of	knowledge	that	influence	KT,	making	it	a	social	and	political	process,	rather	than	just	an	individual	or	behavioural	one.	To	facilitate	effective	KT,	it	is	thus	necessary	to	explore	the	context	of	the	knowledge	to	action	problem	and	“focus	beyond	individual	behaviour	or	specific	organisational	characteristics	as	barriers	to	knowledge	exchange.”	(8)	Understanding	how	knowledge	exchange	works	in	different	contexts	can	inform	the	development	and	implementation	of	SDM	approaches	that	suit	the	needs	of	specific	environments	and	populations.		Notably,	the	principles	of	knowledge	exchange	can	be	applied	at	different	levels	of	the	health	care	system,	beyond	the	health	services	or	policy	context.	At	the	clinical	level	knowledge	exchange	occurs	through	SDM,	where	the	patient	and	care	provider	exchange	knowledge	to	create	a	shared	understanding	of	both	the	patient’s	and	care	provider’s	perspectives	on	a	healthcare	decision.	This	is	why	SDM	interventions	for	patients	are	commonly	termed	“patient-mediated	knowledge	translation.”(202)	In	the	next	section	I	describe	how	I	operationalized	these	terms	in	my	study	and	outline	the	specific	steps	in	my	process.	Rather	than	adopt	a	rule-bound	approach	and	adhere	to	the	mechanisms	of	a	particular	method,(153)	I	adopted	the	stance	that	KT	is	messy	and	complex	and	requires	different	tools	for	different	stakeholders	and	settings.	Consequently,	while	my	approach	was	guided	loosely	by	an	established	KT	framework	(the	KTA	cycle),	I	was	pragmatic	and	employed	different	KT	techniques	at	each	stage	of	the	research	process	that	fit	my	specific			168	objectives.	iKT	functioned	as	the	overarching	conceptual	approach	for	my	activities	with	stakeholders,	while	the	concept	of	knowledge	exchange	guided	our	interactions	and	mutual	learning.		7.2.2 Design	The	overarching	framework	for	my	KT	process	was	Graham	et	al’s	Knowledge-to-Action	(KTA)	cycle	(see	Figure	7.1).(20)	iKT	and	knowledge	exchange	provided	a	set	of	concepts	and	principles	for	engaging	with	stakeholders,	while	the	KTA	cycle	provided	a	flexible	“map”	for	the	knowledge	to	action	process.	The	KTA	cycle	is	a	widely	used	framework	that	was	developed	by	researchers	within	the	Canadian	Institutes	of	Health	Research	following	a	review	of	31	planned	action	theories.(10)	The	KTA	cycle	is	consistent	with	a	systems	perspective	to	implementation	research,	that	is,	it	illustrates	the	co-evolution	of	knowledge	in	research	and	clinical	practice,	and	feedback	loops	in	the	system	from	past	to	future.		In	their	foundational	publication	on	the	KTA	cycle,	Graham	et	al.	emphasized	that	the	KT	process	is	“complex	and	dynamic,”	and	the	boundaries	between	knowledge	creation,	knowledge	application,	and	their	ideal	phases	are	“fluid	and	permeable.	The	action	phases	may	occur	sequentially	or	simultaneously,	and	the	knowledge	phases	may	influence	the	action	phases.”(20)	In	my	study,	I	operationalized	the	KTA	cycle	as	a	framework	that	identifies	what	the	key	stages	were	in	my	KT	process,	while	the	concepts	of	iKT	and	knowledge	exchange	offered	a	perspective	on	who	should	be	engaged	in	both	the	“Knowledge	Creation”	phase	(e.g.	the	funnel)	and	the	“Action	Cycle”	and	how	they	might	engage.			169		Figure	7.1	Knowledge-to-Action	Cycle	Adapted	from	Graham	et	al.	(20).	Reprinted	with	permission	from	Wolter	Kluwer	Health,	Inc.						 			170	For	each	phase	in	the	KTA	cycle,	I	partnered	with	my	committee,	a	clinical	co-investigator,	patient	advocates,	and	key	stakeholder	partners	to	identify	our	iKT	objectives	and	select	problem-focused	methods.	Table	7.1	outlines	the	steps	in	our	KT	process	in	rough	chronology,	including:	the	phase	of	the	KTA	cycle,	the	iKT	objective,	the	intended	stakeholder	group,	and	the	activity/output.	To	maximize	the	potential	for	uptake	of	the	research,	at	each	stage	of	the	research	I	sought	to	partner	with	the	intended	stakeholder	group	as	a	partner	in	the	process.	For	instance	in	“Identifying	the	problem”	I	cast	a	wide	net	and	sought	to	partner	with	as	many	different	stakeholder	groups	as	possible	to	ensure	that	different,	even	competing,	perspectives	were	captured.	Later	in	the	“Develop	knowledge	products”	stage	of	the	cycle,	I	narrowed	my	focus	and	targeted	health	service	decision	makers	as	the	core	intended	stakeholder	group.	During	that	time,	I	partnered	closely	with	the	Optimal	Birth	Fraser	Health	task	force	to	determine	the	scope,	medium,	and	audience	for	my	research	findings.	The	final	column	in	the	table	denotes	which	stage	of	the	KTA	cycle	the	activities	fell	under	and	illustrates	that	we	fluctuated	between	“Knowledge	Creation”	and	the	“Action	Cycle”	to	ensure	that	we	were	producing	knowledge	that	met	the	needs	of	users	in	our	local	study	contexts.	For	instance,	I	created	knowledge	each	time	I	returned	to	the	literature	review	to	synthesize	more	literature	in	response	to	problems	and	questions	that	developed	from	data	collection,	analysis,	or	through	dialogue	with	research	partners.	I	also	developed	new	knowledge	products	in	collaboration	with	my	research	partners	(policy	brief;	presentation	for	care	providers)	to	support	knowledge	exchange.	Thus	the	“knowledge”	we	co-created	comprised	syntheses	of	the	existing	scientific	literature,	perspectives	and	theory	from	my			171	original	qualitative	study,	and	research	partners’	understanding	of	how	that	evidence	fit	in	their	context.					172	Table	7.1	Integrated	Knowledge	Translation	Framework	PHASE	 OBJECTIVE	 STAKEHOLDERS	 ACTIVITY	 STAGE	1) Identify	problem	/	Identify,	review	and	select	knowledge	Define	and	refine	the	knowledge	to	action	problem		Ministry	of	Health	directors	involved	in	women’s	health,	regional	health	authorities,	key	informants	Critical	review	of	policy	documents;	identified	key	stakeholder	groups/individuals	and	their	relationships;	conducted	informal	policy	dialogues	with	stakeholders	to	determine	the	scope	of	the	problem	Action	cycle	2) Knowledge	inquiry	and	synthesis	Review	the	evidence	on:	a)	Implementation	of	SDM	in	maternity	care,	b)	Attitudes	and	experiences	with	decision-making	for	birth	after	caesarean	--	 Literature	review	was	conducted	for	the	dissertation	Knowledge	creation	3) Assess	barriers	and	enablers	to	knowledge	use	Determine	barriers	and	enablers	to	women’s	choice	of	birth	after	caesarean;	explore	attitudes	toward	and	experiences	with	decision-making	for	birth	after	caesarean	All	stakeholders:	Women,	care	providers,	decision	makers	Qualitative	research	was	conducted	involving	in-depth	interviews	with	all	stakeholder	groups;	key	themes,	barriers,	and	enablers	were	identified	Action	cycle	4) Develop	knowledge	products	Translate	the	dissertation	into	a	policy	brief	Health	service	decision	makers	Developed	policy/practice	recommendations	to	facilitate	women’s	birth	after	caesarean	Knowledge	creation	5) Adapt	knowledge	to	local	context	Pilot	test	policy	brief	recommendations		 Health	service	decision	makers		(In	progress)	Policy/practice	recommendations	were	pilot	tested	with	stakeholders	through	iterative	face-to-face	meetings;	action	items	were	created	for	different	settings	and	stakeholders		Action	cycle	6) Select,	tailor,	and	implement	intervention	Select,	tailor,	and	implement	interventions	for	patients,	care	providers,	hospitals,	and	policy	to	support	SDM	for	birth	after	caesarean	All	stakeholders	 In	planning	 Knowledge	Creation/	Action	cycle	7) Monitor,	evaluate	knowledge	use	Process	and	outcome	evaluation	of	the	implementation	All	stakeholders	 In	planning	 Action	cycle	8) Sustain	knowledge	use	Develop	a	community	of	practice	 All	stakeholders	 Tacit	knowledge	about	the	problem	and	solutions	was	exchanged;	researcher-stakeholder	alliances	were	formed	and/or	strengthened	Action	cycle			173	7.3 Results	In	the	following	sections	I	describe	how	I	engaged	in	KT	for	this	study.	I	begin	by	describing	how	stakeholders	were	involved	as	active	partners	in	the	planning,	data	collection,	and	interpretation	of	the	Birth	after	Caesarean	study.	First,	I	summarize	the	KTA	gap	I	sought	to	address	and	how	previous	research	has	approached	this	issue	as	a	“knowledge	transfer”	problem.	I	then	describe	how	I	approached	the	KTA	gap	as	an	issue	of	“knowledge	exchange.”	I	then	provide	a	pragmatic	overview	of	my	iKT	framework	and	the	objectives,	stakeholders,	activities,	and	outputs	that	corresponded	with	each	phase	of	the	research.	In	illustrating	my	iKT	process,	I	draw	on	preexisting	frameworks:	Graham	et	al’s	Knowledge	to	Action	(KTA)	cycle	(20)	and	Lavis	et	al’s	SUPPORT	tools	for	evidence-informed	policymaking.(203)	I	highlight	how	knowledge	partners	and	I	vacillated	between	the	“Knowledge	Creation”	and	“Action	Cycle”	stages	of	the	KTA	cycle	in	order	to	produce	relevant	research.	Finally,	I	offer	a	discussion	of	the	next	steps	for	this	program	of	research.		7.3.1 Identifying	the	Problem	At	the	outset	of	the	study,	I	sought	“to	create	a	reliable,	comprehensive	and	shared	understanding	of	the	issue	and	care	needed	to	address	it.”(58)	Issue	identification	and	clarification	for	this	study	emerged	in	collaboration	with	patient	advocates,	care	providers,	and	decision-making	stakeholders	through	two	activities:	1)	critical	review	of	policy	documents,	and	2)	informal	“policy	dialogues.”	Lavis	argues	that	research	and	policymaking	processes	are	often	distinct	and	asynchronous	processes	making	it	unlikely	that	relevant	research	will	be	conducted			174	at	the	exact	moment	a	policy	window	opens.(204)	This	again	reflects	a	complex	adaptive	system	perspective	whereby	the	research	and	policymaking	systems	co-evolve	together.	They	are	interconnected,	although	the	production	of	knowledge	between	the	two	systems	is	non-linear.	Unpredictable	changes	in	the	system	can	cause	research	and	policy	agendas	to	align	in	opportune	ways.	Paying	attention	to	the	attractor	patterns	in	each	system	–	what	is	on	the	policy	agenda;	what	research	areas	are	funders	prioritizing;	what	social	values	are	funders	and	policy	makers	prioritizing	–	may	help	to	align	this	process	in	a	“purposefully	linked”	way.		This	is	the	goal	in	iKT	research,	to	purposefully	link	the	policy	and	research	processes	together	(see	Figure	7.2,	scenario	C),	whereby	researchers	and	stakeholders	engage	in	mutual	influence	and	learning	through	knowledge	exchange,	and	co-produce	knowledge	that	addresses	problems	in	policy	and	practice,	as	well	as	in	patients’	lives,	in	a	timeframe	that	meets	the	stakeholders’	needs	and	facilitates	evidence-informed	policymaking.	One	strategy	for	supporting	this	process	with	policy	makers,	Lavis	and	colleagues	argue,	is	through	“policy	dialogues,”	which	they	conceptualize	as	interactive	knowledge-sharing	activities	that:		1) Address	a	high	priority	issue,		2) Provide	opportunities	to	discuss	the	problem,	potential	solutions,	and	implementation	considerations,	3) Are	preceded	by	policy	documents	and	discussion	about	the	full	range	of	factors	that	can	influence	the	policymaking	process,		4) Ensure	fair	representation	of	all	stakeholders,		5) Remain	open-ended,	and	produce	outputs	and	activities	that	support	action.(205)			175	Figure	7.2	Research,	Policy-Making,	and	Knowledge	Translation	Processes	Adapted	from	Lavis	(204).	Reprinted	with	permission	from	Wolter	Kluwer	Health,	Inc.					The	“high	priority	issue”	for	our	iKT	process	emerged	in	2014	with	the	publication	of	new	strategic	and	operational	policies	for	the	BC	Ministry	of	Health,	Setting	Priorities	for	the	B.C.	Health	System.(206)	Priority	#1	was	“Provide	patient-centred	care,”	and	the	Ministry	produced	supporting	policy	documents	specifically	on	patient-centred	cared	(The	British			176	Columbia	Patient	Centred-Care	Framework)(57)	and	three	clinical	priority	areas:	surgical	services,(207)	rural	health	services,(208)	and	primary	and	community	care.(209)	These	documents	emphasized	that	strategies	to	implement	patient-centred	care	would	include	incorporating	patient	values	into	care	plans,	information	sharing,	and	patient	engagement	in	decision-making,(57)	which	clearly	aligns	with	SDM.	These	high-profile	policy	shifts	within	the	Ministry	of	Health	were	an	opportune	policy	moment	unlinked	to	our	ongoing	research	on	optimizing	women’s	access	to	maternity	services	(Figure	7.2,	scenario	A).	I	critically	reviewed	these	policy	documents	and	then	met	with	stakeholders	to	define	and	refine	the	policy	issue	from	their	perspectives.	The	key	knowledge	partner	involved	at	this	stage	was	Optimal	Birth	Fraser	Health	(formerly	Fraser	Health	Caesarean	Task	Force),	a	multidisciplinary	group	of	health	service	decision	makers,	family	physicians,	midwives,	nurses,	and	obstetricians	affiliated	with	Fraser	Health,	one	of	five	regional	health	authorities	in	the	province.	The	task	force	had	been	mandated	to	address	rising	rates	of	caesarean	section,	but	from	the	perspectives	of	patient	safety	and	quality	of	care.	The	task	force	had	convened	just	as	the	Ministry	of	Health	priorities	were	being	published	and	did	not	explicitly	include	a	mandate	to	promote	patient-centred	care	at	that	point.	My	senior	supervisor	(PJ)	had	a	longstanding	history	of	actively	partnering	with	Fraser	Health	to	address	pressing	clinical	problems	through	co-production	of	local	audit	and	feedback	data.	This	relationship	allowed	us	to	form	a	strategic	alliance	to	understand	the	issue	of	SDM	for	birth	after	caesarean	and	access	to	health	service	resources	in	Fraser	Health.	Thus	2013-14	produced	policy	moments	germane	to	our	research	interests	in	1)	patient-centred	care			177	and	2)	access	to	the	health	services	that	support	women’s	choice	of	mode	of	delivery	after	caesarean.	One	limitation	of	Lavis’s	approach	to	policy	dialogues	is	that	by	identifying	a	high	priority	policy	issue	at	the	outset	of	the	process,	that	issue	and	form	of	knowledge	may	be	privileged	above	other	priorities	–	such	as	those	perceived	by	patients	or	evidenced	in	the	research	literature.	To	avoid	normatively	reinforcing	a	policy	agenda,	I	attempted	to	bring	these	different	and	somewhat	competing	forms	of	knowledge	together	at	the	outset.	I	met	and	discussed	the	subject	of	birth	after	caesarean	with	patient	advocates	who	provided	doula	care	to	childbearing	women	with	a	history	of	caesarean	in	the	Greater	Vancouver	region.	These	conversations	provided	opportunities	for	me	to	involve	patient	advocates	in	an	early	stage	of	the	research	process,	test	research	and	interview	guide	questions	with	them,	and	ensure	that	my	approach	was	grounded	in	women’s	perceived	needs.		I	also	engaged	in	dialogue	with	key	informants	to	understand	the	perspectives	of	care	providers	and	decision	makers	in	other	regional	health	authorities.	I	sought	a	legal	perspective	from	a	lawyer	who	had	represented	families	in	high	profile	cases	of	obstetric	malpractice.	I	also	spoke	with	care	providers	at	BC	Women’s	Hospital,	the	largest	maternity	facility	in	western	Canada,	who	had	tried	to	implement	SDM	for	birth	after	caesarean	in	recent	years.	Throughout,	I	also	had	informal	discussions	with	childbirth	advocates	across	British	Columbia,	including	doulas,	public	health	nurses,	and	community-based	workers	affiliated	with	the	BC	Association	for	Pregnancy	Outreach	Programs,	a	provincial	network	that	provides	support	and	education	to	vulnerable	women	in	the	childbearing	year.			178	At	the	outset	of	the	research	process,	dialogue	was	initiated	primarily	by	Dr.	Janssen	and	myself,	reflecting	“push”	KT	strategies	of	dissemination	and	diffusion	to	inform	knowledge	users	about	the	research,	gain	their	feedback,	and	encourage	their	participation.	However,	over	time	the	number	and	scope	of	knowledge	users	engaged	in	the	project	grew,	leading	to	an	increasing	amount	of	“pull”	requests	from	care	providers	and	decision	makers	for	information	on	the	program	of	research,	how	to	get	involved,	and	what	the	findings	might	mean	for	birth	after	caesarean	in	their	local	context.		 Rather	than	adopt	a	formal	approach	to	policy	dialogues	as	suggested	by	Lavis	and	colleagues,	our	approach	was	opportunistic,	pragmatic,	reflected	our	real-world	relationships,	and	included	both	formal	and	informal	discussions	with	Optimal	Birth	Fraser	Health	members.	Throughout	I	was	mindful	of	Lavis	and	colleagues’	key	considerations	for	a	policy	dialogue	process	(203),	which	in	our	case	example	included:		1) Addressing	a	high	priority	issue	(patient-centred	care;	the	rising	repeat	caesarean	rate);		2) Taking	opportunities	through	monthly	in-person	meetings	with	Optimal	Birth	Fraser	Health	to	discuss	the	problem,	co-develop	the	Birth	after	Caesarean	research	study,	and	discuss	potential	policy	and	practice	actions	resulting	from	the	research	findings;	3) Discussing	the	Ministry	of	Health’s	and	regional	Health	Authorities’	strategic	policy	priorities	and	the	diverse	factors	that	influence	policy	and	practice;	and		4) Ensuring	fair	representation	of	all	stakeholders,	by	seeking	out	and	discussing	the	dissertation	and	policy	issue	with	key	informants	outside	of	Optimal	Birth	Fraser	Health,	including	patients	and	patient	advocates;				179	5) Remaining	open-ended	to	different	viewpoints	and	sources	of	knowledge.			These	informal	policy	dialogues	were	nested	within	Optimal	Birth	Fraser	Health	meetings,	where	I	was	an	invited	guest	with	a	predefined	amount	of	time	to	engage	in	discussion	about	the	evolving	study	design.	As	an	invited	doctoral	student,	it	was	not	within	my	purview	to	involve	patient	advocates	or	other	stakeholders	in	these	meetings,	so	to	assure	fair	representation	I	took	time	in	each	meeting	to	update	the	group	of	care	providers	and	decision	makers	on	the	perspectives	of	patients	advocates,	rural	stakeholders,	and	provincial	decision	makers.	I	encountered	few	challenges	while	engaging	in	the	policy	dialogues,	primarily	due	to	the	enthusiasm	of	this	group	of	decision	makers	and	interest	in	my	research	process.		Through	these	informal	policy	dialogues	we	discovered	that	women’s	eligibility	for	planned	VBAC	varied	widely	from	hospital	to	hospital.	We	reviewed	rates	of	planned	VBAC	by	hospital	around	the	province,	as	well,	and	observed	similar	geographic	variation	in	rate	of	planned	VBAC	that	could	not	be	explained	by	clinical	or	demographic	conditions.	We	also	learned	that	nurses,	although	not	primary	maternity	care	providers,	may	discuss	birth	after	caesarean	options	with	women	at	different	time	points	in	their	childbearing	journey	and	may	play	an	understudied	role	in	the	decision-making	process.	Finally,	stakeholders	suggested	through	the	dialogues	that	limited	access	to	operating	room	and	anaesthesia	services	influenced	care	providers’	willingness	to	support	planned	VBAC	in	urban	settings.	They	were	interested	to	know	how	some	small	rural	services	in	the	province	were	able	to	provide	women	safe	access	to	the	option	of	VBAC	in	the	face	of	limited	surgical	resources.				180	Over	the	course	of	approximately	six	months,	I	collaborated	with	my	supervisory	committee,	clinical	co-investigator,	and	Optimal	Birth	Fraser	Health	to	define	and	refine	the	issue	into	two	questions	that	were	meaningful	to	clinical	practice:	Why	do	our	patients	choose	repeat	caesareans	and	what	can	our	care	teams	do	to	support	patients	to	attempt	VBAC	births?		However,	recognizing	that	decision	makers,	clinicians,	and	researchers	do	not	ask	the	same	questions,(210)	I	further	distilled	these	into	a	series	of	researchable	questions	to	identify	barriers	and	enablers	to	women’s	choice	of	birth	after	caesarean	from	the	perspective	of	all	key	stakeholders:		1) What	are	women’s	attitudes	toward	and	experiences	with	choosing	mode	of	delivery	after	caesarean	in	British	Columbia?	2) What	are	care	providers’	attitudes	toward	and	experiences	with	providing	care	for	women	considering	mode	of	delivery	after	caesarean	in	British	Columbia?		3) What	are	decision	makers’	experiences	with	planning	services	for	birth	after	caesarean	in	British	Columbia?	The	methodology	for	exploring	these	three	research	questions	(Chapter	3)	was	collaboratively	designed	with	Optimal	Birth	Fraser	Health.	After	data	collection	and	qualitative	analysis	(Chapters	4-6),	the	results	were	interpreted	in	collaboration	with	these	knowledge	users	so	that	they	could	assess	the	applicability	and	transferability	of	the	results	to	comparable	settings.					181	7.3.2 Engaging	in	Knowledge	Inquiry	and	Synthesis	This	stage	of	the	KTA	cycle	involves	the	methodologically	rigorous	synthesis	of	studies	or	information	relevant	to	the	research	question	to	make	sense	of	all	relevant	knowledge	on	the	subject.(20)	As	with	defining	the	problem,	writing	the	literature	review	was	an	iterative	process.	I	outline	in	Chapter	3	how	I	delved	into	new	literature	as	new	theoretical	insights	emerged	from	my	qualitative	data	collection	and	analysis.	Writing	the	literature	review	began	at	the	outset	of	my	doctoral	program	of	research	to	provide	an	understanding	of	the	existing	published	research	on	decision-making	for	birth	after	caesarean.	I	explored	the	published	literature	on	women’s,	care	providers’,	and	organizational	attitudes	and	experiences	toward	decision-making	for	birth	after	caesarean,	as	well	as	research	on	implementation	of	SDM	for	birth	after	caesarean.	As	my	research	questions	evolved	through	knowledge	exchange	with	stakeholders,	I	continued	to	search	and	analyze	the	extant	literature,	and	returned	the	findings	of	those	later	syntheses	to	my	research	partners.	For	instance,	after	contacting	the	Ministry	of	Health	to	request	an	interview	for	my	study,	they	in	turn	requested	that	I	provide	them	some	evidence	on	planned	VBAC	and	shared	decision-making.	I	updated	my	early	literature	review	and	packaged	it	as	a	formal	evidence	synthesis,	which	the	Ministry	has	since	used	to	inform	their	forthcoming	Women’s	Health	Strategy.	Similarly,	during	data	collection	and	analysis	I	identified	new	avenues	of	inquiry	and	added	to	the	review	to	set	the	stage	for	how	my	grounded	theory	answers	those	questions.	As	I	explained	in	Chapter	3,	this	flexible,	adaptive	approach	is	encouraged	in	KT	research	to	understand	the	mechanisms	and	circumstances	that	underpin	implementation	of	complex	interventions	such	as	SDM.(87)			182		7.3.3 Assessing	Barriers	and	Enablers	to	Knowledge	Use	The	first	round	of	my	qualitative	analysis	resulted	in	an	emerging	theory	of	the	processes	that	women,	care	providers,	and	decision	makers	undertake	with	regard	to	decision-making	for	birth	after	caesarean:	Women	seek	control	in	the	midst	of	uncertainty;	Care	providers	and	decision	makers	support	women	to	make	the	choice	for	birth	after	caesarean	and	“make	it	work”	in	the	midst	of	limited	access	to	services.	In	the	second	round	of	my	analysis,	I	aimed	to	explain	the	significance	of	these	original	concepts	for	an	audience	of	implementation	and	health	service	researchers.	Using	the	lens	of	complex	adaptive	systems	(CAS)	theory	I	described	how	an	array	of	factors	influence	individuals	to	engage	in	seemingly	irrational	decision-making	behaviour	and	how	their	behaviour	may	be	adapted	to	support	evidence-based	practices.	This	analysis	revealed	the	complex,	interwoven	contextual	factors	that	pose	challenges	to	SDM	for	birth	after	caesarean.	These	included	women’s	experience	of	birth	trauma,	their	early	and	recurrent	preference	formation	for	mode	of	delivery,	and	limited	access	to	the	surgical	and	anaesthesia	services	that	support	the	option	of	planned	VBAC.		By	engaging	in	these	analyses	I	further	identified	the	contextual	factors	that	influence	SDM	for	birth	after	caesarean	and	identified	that	the	problem	was	one	of	knowledge	exchange	rather	than	knowledge	transfer.	The	issue	at	hand	with	regard	to	birth	after	caesarean	was	not	only	barriers	and	facilitators	in	discrete	parts	of	the	healthcare	system,	but	also	the	interplay	between	those	factors	and	between	different	systems	(e.g.	temporal,	legal,	environmental,	and	interprofessional).	It	was	clear	that	change	needed	to	be	made	within	and	between	different			183	levels	of	the	healthcare	system	in	order	to	support	SDM	for	birth	after	caesarean.	For	instance,	an	important	antecedent	to	implementation	of	SDM	was	having	both	options	of	mode	of	delivery	available	for	women.	However,	in	Fraser	Health,	care	providers	and	decision	makers	felt	that	to	make	continuous	safe	access	to	VBAC	possible,	health	service	decision	makers	would	need	to	increase	funding	to	increase	levels	of	anaesthesia	service	and	decrease	competing	access	with	other	specialties	to	the	OR.	The	small	rural	communities	in	this	study	had	fewer	resources,	yet	this	was	not	a	barrier	to	SDM	for	birth	after	caesarean	in	the	north.	Consequently	Fraser	Health	stakeholders	also	wished	to	know	more	about	the	model	of	care	in	the	north	and	particularly	how	the	rural	towns	provided	planned	VBAC	without	in-house	anaesthesia.		My	analysis	illustrated	the	need	to	add	strategies	to	our	iKT	process	that	would	encourage	knowledge	exchange	through	dialogue	among	the	clinicians	who	provide	services	for	birth	after	caesarean	and	the	health	service	decision	makers	who	plan	surgical	and	anaesthesia	services,	and	between	Northern	and	Fraser	Health.	Different	stakeholder	communities	needed	different	knowledge	and	interventions	to	address	SDM	for	birth	after	caesarean,	reflecting	differences	in	their	environment,	relationships,	and	attitudes.	In	the	following	sections	I	describe	how	I	encouraged	such	dialogue	through	multiple	strategies	–	by	nurturing	a	community	of	practice,	and	by	creating	and	discussing	a	policy	brief	with	stakeholders.		Although	outside	the	scope	of	this	dissertation,	I	also	am	working	with	members	of	the	research	team	(PJ,	SK)	to	secure	funding	for	a	consortium	on	normal	birth	–	a	knowledge	exchange	meeting	planned	for	November	2016	where	we	will	bring	together	stakeholders	from			184	around	the	province	and	where	discussion	will	include	different	models	of	service	to	support	planned	VBAC.	This	meeting	will	include	participation	from	key	stakeholders	from	each	of	my	study	communities	in	order	to	respond	to	Northern	and	Fraser	Health	participants’	interest	in	learning	from	each	other.		7.3.4 Developing	Knowledge	Products	After	identifying	the	problem,	conducting	a	literature	review,	and	engaging	with	knowledge	users	to	co-produce	knowledge	on	the	barriers	and	enablers	to	evidence-based	practice	for	birth	after	caesarean,	we	had	co-developed	local	evidence	that	addressed	Optimal	Birth	Fraser	Health’s	first	question:	Why	do	our	patients	choose	repeat	caesareans?	We	then	turned	to	their	second	question	regarding	actionable	next	steps:	What	can	our	care	teams	do	to	support	patients	to	attempt	VBAC	births?	This	phase	of	the	KTA	cycle	involved	working	with	local	evidence	on	birth	after	caesarean	decision-making	that	emerged	from	analysis	of	participants’	narratives	in	Northern	and	Fraser	health	authorities,	considering	how	these	findings	compared	to	the	previous	literature	and	might	be	transferable	to	comparable	settings,	and	focusing	on	what	solutions	might	work	at	the	patient,	clinical,	and	organizational	levels	to	promote	sustainable,	evidence-based	practices	for	birth	after	caesarean.		Knowledge	products	are	practical	tools	that	present	knowledge	in	clear	and	concise	formats	and	provide	explicit	recommendations	or	guidance	for	different	stakeholder	audiences.(20)	The	aim	of	knowledge	products	is	to	influence	stakeholders’	behaviour	or	actions	and	meet	their	information	needs,	in	order	to	bridge	specific	knowledge	to	action			185	gaps.(20)	Research	syntheses,	clinical	practice	guidelines,	patient	decision	aids	(PtDA),	policy	briefs,	and	social	marketing	toolkits	are	all	examples	of	knowledge	products.	In	keeping	with	my	overarching	goal	of	facilitating	knowledge	exchange	in	this	research	process,	my	knowledge	product	goal	was	to	develop	tools	that	would	generate	dialogue	with	stakeholders	and	support	particular	behaviours.		Based	on	recommendations	from	my	research	partners	on	what	modalities	work	best	for	care	provider	stakeholders	around	British	Columbia,	I	chose	to	develop	a	research	presentation	that	provides	an	overview	of	the	study,	my	findings,	and	actionable	recommendations.	I	focused	on	those	actions	that	are	relevant	to	clinical	practice	in	different	settings	depending	on	where	I	give	the	presentation	(e.g.	my	rural	study	communities,	larger	teaching	hospitals,	different	provinces).	I	am	in	the	process	of	giving	this	presentation	to	knowledge	partners	in	each	of	my	study	communities.	For	childbearing	women,	I	will	develop,	evaluate,	and	implement	a	PtDA.	The	PtDA	will	be	developed	in	future	in	partnership	with	Fraser	Health	Authority	as	part	of	our	continued	research	partnership.	Finally,	for	health	service	decision	makers,	I	discussed	different	knowledge	product	options	with	Optimal	Birth	Fraser	Health	and	with	my	committee.	Their	recommendations	and	the	consensus	from	the	literature	was	that	the	most	impactful	approach	would	be	for	me	to	create	a	policy	brief	that	summarized	the	research	and	put	the	findings	in	context	for	health	service	decision	makers.	Most	importantly,	we	agreed	that	I	should	actively	disseminate	the	policy	brief	through	face-to-face	meetings.	The	policy	brief	has	been	developed	and	used	in	knowledge	exchange	activities	to			186	date,	as	I	outline	below,	while	the	research	presentation	and	PtDA	knowledge	products	are	still	in	progress.			7.3.4.1 Developing	a	Policy	Brief	Together	with	Optimal	Birth	Fraser	Health,	we	translated	the	research	findings	into	a	policy	brief	that	systematically	highlights	what	is	known	and	not	known	about	choosing	birth	after	caesarean	in	British	Columbia,	options	for	addressing	barriers,	and	potential	enabling	strategies	to	implement	best	practices	in	SDM	(see	Appendix	C).		Drawing	from	Lavis	and	colleagues,	I	consider	policy	briefs	to	be	a	form	of	“evidence	packaging”	–	rapidly	produced	summaries	that	address	decision	makers’	needs	for	timely	knowledge	on	a	priority	issues,	present	knowledge	on	an	underlying	knowledge	to	action	problem,	describe	how	to	address	the	problem,	and	offer	key	implementation	considerations.(211)	Policy	briefs	help	decision	makers	access	research	findings	that	are	tailored	to	their	decision-making	needs	and	may	help	bridge	the	gap	between	knowledge	and	action.(212)	There	is	limited	evidence	on	which	policy	brief	format	is	most	usable	to	audiences.	The	Canadian	Health	Services	Research	Foundation	(CHSRF)	1:3:25	template	of	a	1	page	structured	abstract,	3	page	executive	summary,	and	25	page	report	provides	increasing	detail	with	each	iteration.(211)	This	template	is	widely-recommended,	however	the	effectiveness	of	this	format	for	impacting	policy	is	unclear	due	to	its	limited	evaluation.(213)	A	more	compressed	approach	is	that	of	research	summaries,	two-page	documents	written	for	non-academic	audiences	that	engage	plain	language	writing	and	design	principles.	This	alternative			187	format	may	be	better	suited	for	providing	an	introduction	to	a	research	study,	however	its	effectiveness	is	again	unclear.(214)		For	this	policy	brief,	I	began	with	the	research	summary	format	and	then	engaged	in	iterative	rounds	of	collaborative	feedback	and	redesign	with	my	supervisory	committee,	my	clinical	co-investigator,	and	Optimal	Birth	Fraser	Health	to	“package”	the	knowledge	from	the	Birth	after	Caesarean	study	in	a	format	that	would	suit	the	needs	of	a	range	of	health	service	decision	makers	in	BC.	This	echoed	Lavis	and	colleagues	recommendation	that	at	least	one	policy	maker,	one	stakeholder,	and	one	researcher	should	review	a	policy	brief	for	its	scientific	quality	and	system	relevance.(211)	I	also	invited	two	patient	advocates	to	review	the	policy	brief	to	ensure	that	I	had	represented	women’s	stories	effectively.	One	of	the	patient	advocates	suggested	I	include	a	richer	description	of	women’s	birth	after	caesarean	decision-making	experiences,	so	I	included	quotes	from	participants	in	sidebars.		In	the	policy	brief,	I	emphasized	the	importance	of	addressing	barriers	and	facilitators	at	different	levels	of	the	healthcare	system	and	provided	recommendations	at	the	patient	(micro),	care	provider	(meso),	and	health	planning	and	policy	(macro)	levels.	The	recommendations	are	relevant	for	the	study	regions	and	individual	communities	included,	but	may	be	transferable	to	similar	settings.	The	recommendations	aim	to	support	patient	decision-making	(Recommendations	1-5)	and	clinicians	and	health	services	(Recommendations	6-7).	I	illustrate	that	an	intervention	at	one	level	of	the	system	will	have	downstream	effects,	and	that	recommendations	take	place	in	the	context	of	complex	environment	and	relationships.	The	recommendations	include:			188		1. Develop	standardized	regional	and/or	hospital-specific	protocols	that	support	care	providers	to	engage	in	shared	decision-making	for	birth	after	caesarean	beginning	before	hospital	discharge,	and	continuing	in	clinic	visits	during	the	first	6	weeks	postpartum.	Shared	decision-making	includes	discussion	of	risks	and	benefits,	actively	listening	to	the	woman’s	expression	of	her	values,	helping	the	woman	understand	what	factors	of	the	decision	matter	most	to	her,	and	making	a	decision	together.	2. Create	consistent,	evidence-based	provincial	and/or	national	resources	to	support	shared	decision-making	and	legal	consent	for	mode	of	birth	after	caesarean.	Resources	should	include	accurate	risk	estimates,	information	on	the	medical,	personal,	and	social	attributes	of	the	decision,	including	mental	health	concerns,	and	describe	the	available	resources	and	time	required	to	attend	an	obstetric	emergency.	3. Support	clinicians	to	“debrief”	with	women	about	their	primary	caesarean	experience	beginning	in	the	first	6	weeks	postpartum,	and	continuing	in	the	first	trimester	of	the	subsequent	pregnancy.	This	dialogue	may	include	answering	women’s	questions,	establishing	their	eligibility	for	planned	VBAC	based	on	SOGC	clinical	practice	guidelines,	encouraging	eligible	women	to	consider	VBAC	for	future	pregnancies,	and	reviewing	the	antenatal	chart	and	operative	report	with	the	woman.	4. Identify	the	need	for	and	provide	mental	health	support	services	to	women	who	experience	an	unplanned	caesarean	to	mitigate	the	effect	of	birth	trauma	on	future	reproductive	choices.			189	5. Implement	continuous	skin-to-skin	contact	after	caesarean	and	family-centred	post-surgical	recovery	practices.	6. Address	concerns	about	limited	access	to	obstetric,	anaesthetic,	and	pediatric	services	and	increase	these	resources	where	appropriate.	This	may	include	pooling	resources	to	provide	dedicated	24/7	in-house	obstetric	anaesthesia	and	a	dedicated	obstetric	OR	where	population	size	and	demographics	warrant	this	level	of	service.	7. Make	planned	VBAC	a	provincial	facility-level	maternal	indicator	and	set	facility	targets.	Additionally	monitor	and	evaluate	indicators	for	VBAC	eligibility,	planned	VBAC,	and	actual	mode	of	delivery	after	caesarean.			7.3.4.2 Using	the	Policy	Brief	to	Catalyze	Dialogue	Continuing	with	the	theme	that	KTA	gaps	may	be	a	result	of	knowledge	exchange,	rather	than	knowledge	transfer,	problems,	I	chose	not	to	passively	disseminate	the	policy	brief	to	stakeholders.	Rather	I	first	emailed	the	policy	brief	to	knowledge	partners	for	their	review	and	then	scheduled	face-to-face	meetings	with	each	person	or	organization	so	that	we	could	sit	together	and	use	the	policy	brief	as	a	tool	to	guide	our	discussion	about	what	the	research	meant	in	different	settings	around	the	province.	This	also	allowed	me	to	engage	in	further	mutual	learning	and	ensure	that	audiences	understood	the	difference	between	the	paradigms	of	informed	choice,	informed	consent,	and	shared	decision-making,	as	confusion	about	these	concepts	was	a	finding	from	care	provider	and	decision	maker	narratives	(Chapter	5).	The	rationale	for	adopting	an	active	rather	than	passive	approach	to	dissemination	is	based	on	the			190	body	of	evidence	demonstrating	that	passive	dissemination	of	materials	alone	may	fail	to	change	practice	because	of	a	stakeholder’s	disagreement	with	the	content	of	materials,	personal	characteristics	of	stakeholders,	and	logistic	or	financial	barriers	to	implementation.(41,215)		Dialogues	were	held	with	Optimal	Birth	Fraser	Health,	Department	Heads	of	Obstetrics	in	the	Fraser	Health	region,	directors	in	the	Ministry	of	Health	and	Perinatal	Services	BC,	and	multidisciplinary	groups	of	clinicians	and	hospital	managers	in	each	study	site.	This	included	planning	significant	travel	around	the	province	to	ensure	that	I	was	present	in	person.	Continuing	an	open	dialogue	with	stakeholders	aimed	to	bring	the	static	document	to	life	and	co-produce	shared	knowledge	about	the	problem	and	potential	solutions	that	fit	the	needs	of	a	range	of	different	knowledge	users,	from	individual	clinicians	in	small	rural	communities	who	support	women	at	the	point	of	care,	to	executives	responsible	for	provincial	priority	setting.	By	engaging	in	this	dialogue,	stakeholders	and	I	were	also	able	to	consider	the	transferability	of	the	qualitative	findings	to	other	settings,	how	the	findings	compared	to	the	published	literature,	and	how	stakeholders	felt	about	the	study	findings	as	birth	after	caesarean	is	an	emotionally	and	politically	charged	topic.		Stakeholders’	feelings	about	the	study	findings	varied	depending	on	their	attitudes	and	experiences.	While	the	majority	agreed	with	the	results	and	expressed	interest	in	partnering	on	next	steps,	not	all	received	the	research	findings	and	policy	brief	in	a	positive	light.	One	knowledge	exchange	meeting,	in	particular,	revealed	that	there	was	historical	tension	between	one	group	of	institutional	decision	makers	and	individual	care	providers.	The	decision	makers			191	reacted	strongly	to	one	of	the	recommendations	in	the	policy	brief,	claiming	that	it	must	reflect	the	biased	remarks	of	this	particular	group	of	care	providers.	They	consequently	questioned	the	validity	of	the	study.	Although	the	policy	brief	indicated	that	this	particular	recommendation	stemmed	from	a	key	theme	observed	in	three	of	the	five	study	communities,	the	decision	makers	opposed	it	based	on	their	attitudes	and	beliefs	toward	birth,	which	clearly	differed	from	those	of	the	care	provider	group.	This	particular	meeting	was	an	illustrative	example	of	how	knowledge	exchange	can	involve	a	collision	of	different	perspectives	and	reveal	new	factors	that	influence	the	research	to	action	process.	As	knowledge	translation	researcher	Ward	noted,	“knowledge	exchange	is	a	social	and	political	rather	than	behavioural	phenomenon	which	involves	professional	identities	and	norms	in	addition	to	individual	beliefs.	These	norms	can	be	the	source	of	resistance	to	particular	forms	of	knowledge	exchange	where	the	latter	is	perceived	as	a	threatening	or	destabilising	influence.”(8)	In	contrast,	in	most	face-to-face	meetings	I	observed	that	physicians	were	particularly	interested	in	the	key	finding	that	women	form	a	preference	for	mode	of	delivery	soon	after	their	primary	caesarean,	before	being	fully	informed	of	their	options	and	the	clinical	risks	and	benefits.	Physicians	identified	the	six-week	post-caesarean	check	up	as	an	important	opportunity	to	begin	SDM	for	future	deliveries.	Health	service	decision	makers	expressed	interest	in	addressing	patient	safety	and	litigation	concerns	about	access	to	the	operating	room.	This	led	to	discussions	about	the	potential	of	PtDAs	to	act	as	both	a	SDM	tool	and	a	step	in	the	informed	consent	process	to	give	women	full	information	about	resources	available	while	still	promoting	VBAC	as	a	reasonable	and	safe	option.	Care	providers	in	one	rural	community			192	additionally	suggested	that	SDM	could	be	supported	in	their	setting	by	different	members	of	the	interprofessional	primary	maternity	care	team	they	were	working	to	establish,	including	nurses,	peer	support	workers,	physicians,	and	allied	health	professionals.	As	intended,	the	policy	brief	drew	stakeholders’	attention	to	the	evidence,	allowed	us	to	discuss	the	research	in	their	local	context,	and	led	to	co-production	of	ideas	for	actionable	next	steps	to	implement	SDM	while	addressing	barriers	at	the	patient,	clinician,	and	organization	levels.			7.3.5 Adapting	Knowledge	to	Local	Context	This	phase	of	the	KTA	cycle	is	still	in	progress	and	will	continue	beyond	the	scope	of	my	doctoral	studies.	In	adapting	knowledge	to	local	context,	knowledge	translation	researchers	Graham	et	al.	mean	“the	process	individuals	or	groups	go	through	as	they	make	decisions	about	the	value,	usefulness,	and	appropriateness	of	particular	knowledge	to	their	setting	and	circumstances.	It	also	encompasses	those	activities	that	they	may	engage	in	to	tailor	or	customize	the	knowledge	to	their	particular	situation.”(20)	Regarding	activities,	I	engaged	in	knowledge	exchange	to	customize	and	contextualize	the	knowledge	from	this	study	for	the	setting	and	circumstances	of	different	decision	maker	stakeholders.		Specifically,	in	my	policy	brief	I	sought	to	clarify	the	issue,	provide	local	evidence,	and	offer	broad	recommendations	for	different	stakeholder	groups	who	serve	patients,	care	providers,	decision	makers,	and	government	in	different	settings	around	the	province.	To	allow	the	recommendations	to	be	tailored	to	different	decision	makers’	settings,	I	did	not	suggest	concrete,	actionable	solutions	for	stakeholders,	rather	I	sought	to	co-develop	solutions	with			193	stakeholders	through	dialogue	to	ensure	that	any	recommended	actions	would	be	useful	and	usable	to	the	individuals	and	organizations	who	would	be	engaging	in	them.	This	follows	Ward	et	al’s	empirical	study	of	knowledge	exchange,	which	involved	observational	and	interview	data	investigating	the	nature	of	knowledge	translation	in	three	clinical	practice	settings	in	the	UK.(8)	The	authors	observed	that	“healthcare	delivery	and	organisation	is	characterised	by	uncertainty	and	there	are	often	no	clear	answers	to	the	challenges	which	need	to	be	faced.	The	knowledge	which	is	needed	to	solve	problems	and	bring	about	changes	is	likely	to	be	distributed	throughout	organisations	and	to	come	from	many	different	sources.”(8)		In	Fraser	Health	Authority,	for	instance,	there	was	a	great	deal	of	interest	in	Recommendation	2	on	SDM	tool	development	and	Recommendation	6	on	access	to	surgical	services.	In	response,	I	compiled	evidence	syntheses	on	effective	strategies	to	address	these	two	subjects	and	gave	the	stakeholders	a	presentation	on	options	for	actionable	next	steps.	Fraser	Health	care	provider	and	decision	maker	stakeholders	indicated	that,	to	act	on	the	recommendations,	we	would	benefit	from	engaging	with	hospitals	in	the	region	beyond	my	two	study	sites	and	with	the	regional	OB	department	heads.	This	knowledge	exchange	was	unexpected	and	led	to	identification	of	individuals	across	the	system	who	would	need	to	be	involved	in	change.				7.3.6 Selecting,	Tailoring,	and	Implementing	Interventions	This	stage	of	the	KTA	cycle	is	concerned	with	working	with	stakeholders	to	select,	tailor,	and	implement	interventions	that	respond	to	identified	barriers	for	specific	groups.	While	outside			194	the	scope	of	this	dissertation,	I	am	in	the	early	stages	of	co-developing	two	interventions	that	respond	to	the	recommendations	of	interest	to	Fraser	Health.	These	include	a	multifaceted	SDM	intervention	involving	a	PtDA	for	mode	of	birth	after	caesarean,	and	a	knowledge	exchange	event	for	Fraser	and	Northern	Health	communities	to	learn	how	rural	sites	manage	planned	VBAC	with	limited	access	to	surgical	services.		7.3.7 Monitoring	and	Evaluating	Knowledge	Use	In	future,	I	will	participate	in	monitoring	and	evaluating	the	implementation	interventions	that	result	from	the	knowledge	co-produced	through	this	dissertation	in	my	role	as	a	postdoctoral	research	fellow.			7.3.8 Sustaining	the	Project	through	a	Community	of	Practice	There	were	a	number	of	intended	and	unintended	consequences	of	the	iKT	process	that	set	the	stage	for	a	long-term	researcher-partner	collaboration.	In	the	KTA	cycle,	“sustaining	knowledge	use”	typically	occurs	at	the	end	of	the	Action	Cycle,	after	knowledge	has	been	created,	implemented,	and	monitored.	However	in	an	iKT	approach,	researchers	and	stakeholders	work	from	day	one	to	form	relationships	and	think	creatively	about	ways	to	sustain	those	relationships	and	the	co-production	of	knowledge	in	the	face	of	limited	time	and	resources.(3,40)	In	their	commentary	on	iKT,	which	they	describe	as	a	critical	“second	look”	at	the	framework,	Kothari	and	Wathen	draw	on	the	“two	communities”	theory,	which	posits	that	researchers	and	policy	stakeholders	come	from	distinct	worlds	and	value-systems.	They	posit			195	that	iKT	facilitates	close	interactions	between	researchers	and	policy	stakeholders	during	knowledge	production	and	application	to	create	a	bridge	between	their	two	distinct	worlds.(216)	This	reflects	a	complex	adaptive	systems	perspective	that	different	systems	co-evolve	and	interact.	The	resulting	researcher-stakeholder	alliance	“makes	space	for	an	additional,	‘value-added,’	communal	perspective”	or	“community	of	practice”	characterized	by	facilitating	the	development	of	a	shared	language,	common	stories,	and	a	joint	understanding	of	the	problem	at	hand.(216)	Building	on	the	assumption	that	meaningful	relationships	with	stakeholders	might	catalyze	and	sustain	knowledge	co-production,	I	endeavored	to	develop	a	holistic	understanding	of	the	problem	of	birth	after	caesarean	from	different	stakeholder	perspectives,	and	to	understand	what	SDM	meant	in	different	contexts	and	in	the	day-to-day	realities	of	clinicians	and	decision	makers.		Through	the	dialogues	with	Fraser	Health	care	providers	and	decision	makers,	I	developed	a	better	understanding	of	the	complexity	of	the	decision-making	environment	for	maternal	health	services	and	the	competing	priorities	facing	health	service	managers,	in	particular	the	important	role	of	regional	strategic	plans	and,	upstream,	Ministry	policy	in	determining	who	and	what	gets	funded.	This	perspective	allowed	me	to	better	understand	what	might	motivate	different	stakeholder	groups	to	adopt	evidence-based	practices	for	birth	after	caesarean.	Sitting	at	the	table	with	Optimal	Birth	Fraser	Health	members	(which	included	midwives,	physicians,	hospital	managers,	and	regional	decision	makers)	at	their	monthly	meeting	also	gave	me	a	better	understanding	of	what	vocabulary	to	use	when	communicating	with	different	health	care	professionals	to	create	shared	understanding.	To	ensure	the			196	relevance	of	the	research	process	to	Optimal	Birth	Fraser	Health,	I	also	gave	regular	presentations	on	preliminary	research	findings.	This	allowed	for	mutual	learning	–	I	gave	the	knowledge	users	snapshots	of	my	research	in	an	effort	to	keep	them	engaged	in	the	study,	and	they	provided	context	and	insights	on	the	patterns	I	was	observing.	Observing	relationships	between	the	different	stakeholder	groups	and	individuals	also	gave	me	insight	into	who	worked	together	well,	who	held	power,	and	what	their	motivations	were.	This	allowed	me	to	identify	individuals	who	could	facilitate	introductions	with	hard-to-reach	participant	groups,	such	as	busy	obstetricians	and	members	of	the	Ministry	of	Health.	My	clinical	co-investigator,	for	instance,	provided	me	an	introduction	to	a	regional	decision	maker,	who	then	introduced	me	to	a	provincial	decision	maker.	This	“snowball	sampling”	approach	is	a	common	method	for	participant	recruitment	in	qualitative	research,	but	it	also	allowed	me	to	map	out	stakeholder	relationships	and,	in	turn,	for	stakeholders	to	see	who	was	entrusting	me	to	be	involved	in	their	policy	planning	process.	As	a	result	of	these	relationships,	I	was	sought	out	by	the	BC	Ministry	of	Health	to	provide	an	evidence	review	on	VBAC	midway	through	my	data	collection,	and	by	the	Ontario	Provincial	Council	for	Maternal	and	Child	Health	to	provide	expert	guidance	on	their	VBAC	quality	standards	project.	The	six	months	of	relationship	building,	information	sharing,	and	mutual	learning	laid	the	foundation	for	a	meaningful	researcher-stakeholder	alliance	that	helped	to	sustain	the	dissertation	study	and	open	up	new	opportunities	to	co-produce	knowledge	with	stakeholders	in	Fraser	Health.				197	7.4 Discussion	Following	an	iKT	strategy	for	bridging	the	knowledge	to	action	gap	and	Graham’s	KTA	cycle	for	knowledge	translation	in	healthcare,	I	approached	the	problem	of	implementing	SDM	for	birth	after	caesarean	as	an	issue	of	knowledge	exchange,	rather	than	knowledge	transfer.	The	KTA	cycle	was	dynamic,	easy	to	operationalize,	and	allowed	for	knowledge	partners	and	I	to	move	between	the	“Knowledge	Creation”	and	“Action	Cycle”	sections	of	the	framework	in	a	nonlinear	fashion	as	needed.	Although	the	KTA	cycle	was	limited	in	that	it	provided	no	guidance	on	how	to	engage	with	stakeholders,	it	provided	enough	flexibility	to	allow	me	to	draw	on	actionable	concepts	and	principles	from	other	frameworks,	including	iKT	and	knowledge	exchange.	My	qualitative	analysis	illustrated	how	“transferring”	evidence-based	SDM	tools	and	skills	to	knowledge	users	may	not	be	effective	unless	important	antecedents	are	addressed.	Namely,	women	begin	to	form	their	preference	for	birth	after	caesarean	before	their	subsequent	pregnancy,	based	on	non-medical	factors	and	knowledge	from	their	primary	caesarean,	peers,	and	the	Internet.	This	indicates	the	need	to	create	SDM	tools	(knowledge	products)	that	address	the	real	world	context	of	how	women	make	decisions	for	birth	after	caesarean.	At	a	care	provider	and	health	system	level	the	key	antecedent	to	SDM	for	birth	after	caesarean	was	having	both	options	of	mode	of	delivery	available	to	women.	In	urban	Fraser	Health,	access	was	limited	due	to	resources	constraints	in	anaesthesia	and	surgical	services,	while	in	Northern	Health	these	factors	did	not	influence	decision-making	in	small	rural	communities.	This	indicates	the	need	to	address	these	inequities	in	access	at	a	policy	level,	otherwise	implementation	of	SDM	in	routine	practice	will	be	ineffective	in	some	setting	where	women	do			198	not	have	equal	access	to	both	options	of	mode	of	delivery.		In	order	to	address	these	systemic	factors,	my	focus	for	the	iKT	relationships	in	this	dissertation	was	primarily	with	care	providers	and	decision	makers	in	Fraser	Health	Authority	and	the	Ministry	of	Health,	who	were	the	“lightning	rods”	positioned	to	catalyze	significant	change	at	a	systems	level.	At	a	patient	level,	I	partnered	with	patient	advocates,	engaged	women	through	the	qualitative	interviews,	and	I	shared	their	narratives	with	care	provider	and	decision	maker	stakeholders.	Different	iKT	objectives	with	patients	will	be	necessary	at	a	later	stage	of	the	KTA	cycle.	Although	patients	were	not	active	partners	at	the	decision-making	table,	there	will	continue	to	be	patient	advocates	involved	in	future	stages	of	the	development	of	tailored	interventions	to	support	implementation	of	SDM.	For	this	dissertation,	the	evolving	iKT	process	illustrated	that	it	was	necessary	to	partner	actively	with	stakeholders	in	the	meso	and	macro	levels	of	the	healthcare	system,	before	any	micro	level	patient	change	could	take	place.	The	iKT	process,	coupled	with	the	rich	findings	from	qualitative	analysis	of	stakeholder	interviews,	indicated	that	a	number	of	knowledge	exchange	strategies	could	support	implementation	of	SDM	across	different	levels	of	the	healthcare	system.	Care	providers	would	benefit	from	health	system	and	resource	support	for	birth	after	caesarean,	as	well	as	information	about	gaps	in	current	care	and	the	impact	of	these	gaps	on	women’s	experience	and	decision-making.	These	actions	would	be	an	important	precursor	to	offering	women	both	options	of	mode	of	delivery	after	caesarean.	It	was	also	clear	that	women	needed	better	information,	timed	earlier.	This	included	information	on	non-medical	attributes	of	the	decision,	and	an	opportunity	to	debrief	with	care	providers	to	promote	knowledge	exchange	at	the			199	clinical	level	around	what	happened	in	the	primary	caesarean.	A	debriefing	visit	at	the	6	week	postpartum	mark	and	a	patient	decision	aid	were	identified	through	literature	review	and	dialogue	with	stakeholders	as	tools	that	could	facilitate	patient	level	behaviour	change	around	becoming	informed.	Decision	makers	at	hospital,	regional,	and	provincial	levels	also	needed	to	learn	about	the	relationships	between	SDM	barriers	at	different	levels	of	the	system,	including	the	influence	of	different	models	of	care,	the	factors	that	inform	women’s	preferences,	and	the	profound	impact	of	resource	shortage	issues	on	access	to	VBAC.		A	number	of	ethical	considerations	emerged	as	part	of	the	iKT	process	that	warrant	consideration	for	future	research.	As	discussed	in	Chapter	3,	informed	consent	took	place	with	individual	research	participants,	and	many	participants	were	also	knowledge	partners	who	collaborated	in	the	research	process.	During	the	research	design	stage	of	the	study,	knowledge	partners	and	I	had	opportunities	to	negotiate	the	type	of	identifiers	I	would	include	in	my	iKT	activities	and	outputs.	We	agreed	that	I	would	de-identify	interview	data	and	change	details	where	necessary	to	minimize	the	potential	for	personal	or	professional	harm,	particularly	if	participants	spoke	negatively	about	their	health	service	environment.	At	the	level	of	the	study	site,	all	participants	consented	to	have	their	community	named	in	iKT	outputs.	Participants	were	in	fact	eager	to	learn	about	examples	of	health	service	success	stories	in	other	named	communities	and	did	not	perceive	that	identifying	information	at	the	community	level	would	lead	to	potential	harm.	Rather	participants	were	eager	to	share	their	challenges	and	pitfalls	because	it	could	lead	to	benefits	including	attention	from	the	Ministry	of	Health	and	ideas	for	health	service	solutions	from	peers	in	other	communities.	These	perspectives	may	not	be			200	shared	in	other	health	service	environments	and	future	research	should	consider	the	ethical	implications	of	identifying	study	communities	in	iKT	outputs.			The	next	steps	in	bridging	this	knowledge	to	action	gap	involve	continuing	to	partner	with	Fraser	and	Northern	Health	to	select,	tailor,	and	implement	interventions	for	patients,	care	providers,	hospitals,	and	policy	to	support	SDM	for	birth	after	caesarean.	We	will	conduct	an	evaluation	of	our	iKT	activities	before	embarking	on	this	next	phase	of	the	study.	The	indicators	included	in	our	iKT	evaluation	plan	will	assess	the	iKT	process,	reach	and	engagement,	usefulness,	use,	collaboration,	and	capacity	building.	Data	will	be	collected	by	a	survey	I	will	co-develop	with	Fraser	Health	research	partners	and	it	will	be	offered	to	all	who	participated	in	the	study,	as	well	as	research	partners	who	participated	in	iKT	activities.	Evaluation	findings	will	be	useful	for	designing	our	future	iKT	strategies	for	engaging	and	collaborating	with	different	stakeholders.	Following	implementation	of	interventions	for	patients,	care	providers,	hospitals,	and	policy	to	support	SDM	for	birth	after	caesarean,	we	will	monitor,	evaluate,	and	sustain	knowledge	use	through	iterative	process	and	outcome	evaluation,	and	nurture	a	community	of	practice.	This	work	of	the	KTA	cycle	(Table	7.1)	extends	beyond	the	scope	of	the	dissertation	and	will	be	the	focus	of	future	research.	I	will	also	continue	the	iKT	process	to	understand	transferability.	Through	iterative	informal	policy	dialogues	with	stakeholders	throughout	the	system,	I	am	seeking	to	understand:	What	do	the	findings	from	this	single	study	mean	in	different	populations?	Is	the	evidence	transferable	to	other	hospitals	and	patient	populations?					201	7.5 Conclusion	In	order	to	break	down	the	siloes	between	academia	and	the	healthcare	system,	it	is	necessary	to	abandon	the	traditional	knowledge	transfer	paradigm	and	move	toward	knowledge	exchange	and	the	co-production	of	knowledge.	This	chapter	offered	a	practical	example	of	how	knowledge	users	were	engaged	in	my	dissertation	process	–	identifying	the	problem,	sustaining	knowledge	use,	and	developing	knowledge	products.	In	the	following	chapter	I	discuss	the	findings	of	this	dissertation	in	relation	to	the	existing	literature	and	opportunities	for	future	research.					 			202	Chapter	8: Discussion	and	Conclusion	8.1 Overview	In	this	dissertation	I	offer	important	insights	regarding	the	nature	of	decision-making	for	birth	after	caesarean	and	the	contextual	factors	that	influence	implementation	of	SDM	for	this	decision	in	five	BC	communities.	The	knowledge	to	action	gap	for	birth	after	caesarean	is	an	issue	of	knowledge	exchange.	Women	make	the	choice	for	mode	of	delivery	before	their	subsequent	pregnancy,	based	on	knowledge	from	their	personal	experience,	social	relationships,	and	the	Internet.	Care	providers	have	a	poor	understanding	of	the	attributes	of	mode	of	delivery	that	matter	most	to	women,	which	vary	by	individual	but	generally	include	the	desire	to	have	uninterrupted	bonding	with	their	newborn	in	the	immediate	postpartum.	This	demonstrates	a	clear	knowledge	exchange	gap	at	the	clinical	level	between	women	and	their	care	providers.	Health	service	decision	makers	provide	insights	into	a	range	of	factors	that	extend	beyond	the	patient-provider	dyad.	These	health	service	factors	include	concerns	regarding	access	to	anaesthesia	and	operating	room	resources.	In	the	small	rural	communities,	where	resources	were	limited	but	not	a	patient	safety	concern,	primary	maternity	practices	led	by	obstetrician	champions	promoted	SDM	and	normal	vaginal	birth.	Given	the	empirically	and	theoretically	derived	findings	in	this	dissertation,	there	are	a	number	of	important	implications	for	implementation	of	SDM.	The	dissertation	findings	are	particularly	salient	to	policy	makers	seeking	to	reduce	unnecessary	caesareans	and	implement	patient-centred	care.						203	8.2 Summary	of	Findings	8.2.1 Women’s	Narratives	Chapter	4,	Seeking	Control	in	the	Midst	of	Uncertainty:	Women’s	Experiences	of	Choosing	Mode	of	Delivery	after	Caesarean,	provided	insights	into	BC	women’s	decision-making	attitudes	and	experiences.	The	core	of	theme	of	“seeking	control	in	the	midst	of	uncertainty”	captured	women’s	experience	of	losing	control	of	their	choice	of	mode	of	delivery	in	their	first	birth.	Participants	who	had	an	unplanned	caesarean	in	particular	described	the	moments	in	their	birth	where	they	experienced	feeling	“out	of	control”	or	“losing	control”	over	their	decision-making	authority,	their	body,	and	their	desired	childbirth	experience.	Making	the	decision	for	birth	after	caesarean	was	a	process	of	seeking	and	regaining	control	over	their	sense	of	self,	identity,	and	autonomy.	Findings	also	highlighted	the	importance	of	considering	the	synergistic	relationship	between	different	factors	that	influence	women’s	choice	of	mode	of	delivery,	including	the	timing	of	women’s	preference	formation	for	mode	of	birth	after	caesarean,	the	role	of	social	birth	stories	and	risk	information	in	shaping	those	preferences,	and	the	availability	of	options,	which	depended	on	their	care	provider’s	scope	of	practice	and	geographic	location.	To	help	women	make	informed	shared	decisions	for	mode	of	delivery	after	caesarean,	clinical	teams,	hospital	environments,	and	policy	makers	must	recognize	that	the	locus	of	decision-making	happens	between	pregnancies.	Previous	intervention	studies	on	women’s	decision-making	for	birth	after	caesarean	have	focused	on	timing	interventions	during	pregnancy,	after	eligibility	has	been	assessed.	Shorten	et	al.	conducted	a	subanalysis	of	212	women’s	preferences	for	mode	of	delivery	using	data	from	a	Australian	randomized	controlled			204	trial	evaluating	a	patient	decision	aid	for	mode	of	delivery	after	caesarean.(217)	Women	were	surveyed	prior	to	any	exposure	to	a	decision	aid,	first	in	early	pregnancy	(12-18	weeks	gestation)	and	again	in	mid-pregnancy	(28	weeks	gestation),	and	analysis	sought	to	determine	if	women’s	preferences	changed	or	remained	stable	during	that	interval.	At	12-18	weeks	gestation,	82%	of	women	expressed	a	preference	for	mode	of	delivery,	119	for	planned	VBAC	(56.1%)	and	55	for	elective	repeat	caesarean	(25.9%),	while	38	were	unsure	(17.9%).	Over	the	course	of	approximately	one	trimester	of	pregnancy,	the	rate	of	women	who	were	unsure	of	which	mode	of	delivery	they	preferred	rose	to	25%	(n=53)	at	28	weeks	gestation.	The	authors	found	a	significantly	higher	rate	of	preferences	for	elective	repeat	caesarean	among	women	who	gave	birth	in	a	setting	with	high	repeat	caesarean	section	rates,	and	among	women	who	had	high	scores	for	postpartum	depression	and	anxiety.	The	authors	suggested	that	interventions	to	support	women’s	choice	of	birth	after	caesarean	should	be	administered	prior	to	28	weeks	gestation,	while	women’s	preferences	are	still	in	flux.		While	the	ideal	timing	of	interventions	for	women	choosing	mode	of	birth	after	caesarean	has	not	been	established	(80),	findings	from	our	present	study	indicate	that	women	would	benefit	from	decision	support	as	early	as	the	immediate	postpartum	following	a	primary	caesarean.	For	some	participants	forming	a	preference	for	mode	of	delivery	and	gaining	confidence	in	that	choice	was	a	necessary	step	before	becoming	pregnant	again.	Such	early	timing	would	be	a	patient-centred	approach	that	reflects	when	women	actually	began	the	decision-making	process	and	would	support	women	to	become	informed	about	their	options	first	prior	to	choosing	which	option	best	matches	their	values.	It	is	important	that	patients	have			205	quality	evidence	about	the	potential	benefits	and	harms	of	health	care	options	before	considering	the	attributes	that	matter	most	to	them,	otherwise	they	may	rely	on	information	that	is	incomplete,	inaccurate,	biased,	or	not	pertinent	to	their	clinical	situation.(62,173)		These	findings	also	provide	insight	into	the	type	and	quality	of	information	that	women	used	to	make	their	decisions	for	mode	of	birth	after	caesarean.	Participants	felt	that	the	clinical	information	they	received	from	care	providers,	and	the	decision	support	tools	that	translated	information	for	decisions,	were	inadequate.	A	number	of	women	desired	retrospective	information	on	their	primary	caesarean	and	the	relationship,	if	any,	to	their	options	for	birth	after	caesarean.	What	were	the	indications	for	their	first	surgery?	Would	those	indications	recur	in	their	next	labour	and	delivery?	Could	they	have	had	a	vaginal	birth	if	other	actions	had	been	taken?	Without	such	information,	they	drew	on	experiential	knowledge	from	their	caesarean	experience,	their	perceived	reasons	for	the	caesarean,	and	information	from	peers	and	the	Internet	to	choose	mode	of	delivery.	This	is	consistent	with	previous	qualitative	studies	involving	postpartum	interviews	with	women	who	gave	birth	after	caesarean	in	northern	England	which	found	that,	in	the	absence	of	accurate,	trustworthy,	and	complete	information	from	their	care	provider,	women	rely	heavily	on	knowledge	from	their	previous	birth	experience(s),	which	are	frequently	characterized	by	feelings	of	unhappiness,	regret,	and	blame,	as	well	as	fears	of	being	physically	incapable	of	having	a	vaginal	birth.(25,28)	While	socially	shared	stories	from	friends	and	family	provided	comfort	for	those	participants	who	struggled	to	come	to	terms	with	their	unplanned	caesarean	delivery,	personal	stories	about	choosing	birth	after	caesarean	may	bias	individuals’	decisions	by	using	value-laden	terms	to			206	describe	less	favoured	options	and	by	presenting	values	and	trade	offs	that	are	most	important	to	the	narrator.(218)	Women	in	this	study	had	questions	about	birth	after	caesarean	that	reflected	their	personal	values,	previous	birth	experiences,	and	social	relationships.	Consequently	they	sought	information	that	was	tailored	to	their	specific	information	needs	and	were	dissatisfied	with	the	one-size-fits-all	“pitch”	on	clinical	risks	and	benefits	of	mode	of	delivery	that	care	providers	typically	provided.	This	indicates	the	need	for	individualized	decision-making	for	birth	after	caesarean,	where	the	care	provider	takes	time	to	learn	what	matters	most	to	the	woman	and	discuss	her	medical	goals	(e.g.	avoiding	postpartum	depression)	and	social	goals	(e.g.	having	family	present	for	support	during	postpartum	recovery).	In	this	study,	women’s	attitudes	toward	birth	after	caesarean	reflected	their	preferences	for	mode	of	delivery.	Among	the	15	women	who	had	had	a	recent	primary	caesarean	or	were	pregnant	again,	their	preferences	were	split	equally.	Five	expressed	a	preference	for	planned	VBAC,	which	reflected	their	motivation	to	experience	outcomes	associated	with	a	vaginal	birth	(e.g.	avoiding	separation	from	baby,	experiencing	a	vaginal	birth	as	a	social	“rite	of	passage”	into	motherhood).	Five	preferred	planned	repeat	caesarean,	again	as	a	strategy	to	secure	their	desired	birth	outcomes	(e.g.	having	predictability	and	control	over	the	birth	experience,	having	a	set	due	date	to	allow	for	planning	childcare	for	other	children),	and	five	were	uncertain	but	leaning	toward	planned	VBAC.	Of	the	eight	participants	who	were	considering	mode	of	birth	after	two	caesareans,	three	preferred	VBAC	and	four	preferred	repeat	caesarean,	consistent	with	their	preferences	for	their	first	birth	after	caesarean,	while			207	one	was	uncertain	because	her	first	planned	VBAC	had	resulted	in	an	emergent	caesarean.	These	“clusters”	of	women’s	preferences	reflect	previous	findings	in	the	qualitative	literature.	Black	et	al	recently	completed	a	meta-ethnographic	synthesis	of	20	papers	reporting	the	views	of	507	women	from	four	countries.(90)	Three	clusters	of	women	were	identified	in	the	literature,	based	on	their	preference	for	mode	of	delivery.	Women	who	confidently	sought	VBAC	were	influenced	by	a	long-standing	anticipation	of	vaginal	birth.	Those	who	sought	repeat	caesarean	were	influenced	by	their	previous	birth	experiences	and	encouragement	from	family,	friends,	and	health	professionals	who	recommended	repeat	caesarean.	Women	who	did	not	have	a	firm	preference	were	open	to	information,	were	influenced	by	professional	guidance,	and	put	effort	into	weighing	the	attributes	of	their	birth	options	to	assess	net	benefit.	I	observed	similar	findings	with	regard	to	women	who	were	uncertain	or	undecided	about	their	preference.	However,	in	this	study	women	who	sought	VBAC	or	repeat	caesarean	were	influenced	by	different	factors.	All	were	influenced	by	positive	and	negative	encouragement	from	family,	friends,	and	health	professionals,	as	well	as	from	reading	information	from	strangers	on	the	Internet.	All	but	two	women	expressed	a	long-standing	anticipation	of	vaginal	birth.	Additional	contextual	factors	worked	synergistically	to	influence	women’s	preferences	and	their	birth	planning.	For	instance,	women	who	had	family	in	town	to	provide	support	during	postpartum	recovery	found	it	easier	to	manage	the	uncertainty	of	their	delivery	date	and	the	outcome	of	a	planned	VBAC.					208	In	considering	the	attributes	of	planned	VBAC	versus	elective	repeat	caesarean,	participants	struggled	to	make	trade	offs	between	maximizing	the	wellbeing	of	their	baby	and	achieving	the	psychosocial	attributes	of	childbirth	that	they	also	valued.	These	findings	are	consistent	with	previous	qualitative	studies	of	women’s	decision-making	for	birth	after	caesarean	in	Australia	(66)	and	the	United	Kingdom	(67),	which	indicated	that	women	experience	a	tension	between	their	desire	to	maximize	well-being	for	their	baby,	based	on	the	perception	that	elective	caesarean	was	safest	for	neonates,	and	to	have	a	vaginal	birth,	which	they	felt	was	best	for	themselves.	This	finding	also	echoes	McClain’s	early	qualitative	work	on	decision-making	for	mode	of	delivery	after	caesarean,	which	found	that	women	equally	weight	their	social	goals	and	perceived	clinical	risks,	and	that	both	social	and	clinical	concerns	were	central	to	women’s	choice.(91)	Conventional	perspectives	on	decision-making	for	mode	of	birth	after	caesarean	involve	consideration	of	the	clinical	risks	and	benefits	of	delivery	options	–	planned	VBAC	or	planned	elective	repeat	caesarean.(52)	However,	how	patients	and	care	providers	conceptualize	“risks	and	benefits”	may	vary	depending	on	their	attitudes	and	beliefs.	This	study	and	previous	research	illustrate	that,	for	women,	“risk”	in	pregnancy	is	multidimensional.	For	instance,	women	described	the	risk	of	emergent	repeat	caesarean	as	both	emotional	(e.g.	experiencing	loss	of	control	and	subsequent	emotional	trauma)	and	clinical	(e.g.	potential	adverse	outcomes).		However	clinicians	tend	to	use	a	narrow	definition	and	focus	on	the	clinical	procedural	risks	of	mode	of	delivery,	such	as	you	have	“a	30%	chance	of	having	a	CS”	during	an	attempted	VBAC.(27)	The	way	risk	information	is	framed	may	influence	pregnant	women	to	avoid	healthcare	choices	they	perceive	as	“risky,”	and	care			209	providers	should	be	thoughtful	in	how	they	present	risk	information.	Bayrampour,	Heaman,	Duncan,	and	Tough	investigated	the	predictors	of	pregnancy	risk	perceptions	in	a	convenience	sample	of	nulliparous	women	in	their	third	trimester	in	Winnipeg	(n	=	159).(107)	They	observed	that	anxiety	was	the	strongest	predictor	accounting	for	30%	of	risk	perception	and	its	effect	was	most	prominent	in	older	women.	In	my	study,	9	women	(39%)	self-reported	having	postpartum	depression	or	anxiety	following	their	primary	caesarean,	and	this	influenced	their	bonding	with	their	baby	and	decision-making	for	future	delivery.	It	is	important	to	identify	and	support	these	women	early	in	their	postpartum	experience.	This	challenge	in	making	trade-offs	is	an	issue	for	many	other	diseases	and	contexts,	and	is	not	novel	to	maternity	care,	thus	these	findings	may	be	relevant	for	other	clinical	decisions.	When	participants	in	this	study	considered	the	outcomes	of	a	planned	VBAC,	the	small	likelihood	of	having	an	intrapartum	or	emergent	caesarean	loomed	larger	than	the	high	likelihood	of	experiencing	a	vaginal	delivery	as	planned.	This	“loss	aversion”	(197)	led	some	participants	to	express	uncertainty	about	their	preference	for	planned	VBAC.	Participants	also	experienced	differences	in	risk	framing	between	midwives	and	physicians,	which	may	have	been	related	to	variation	in	professional	attitudes	(103)	as	well	as	geographic	differences	in	access	to	resources	for	caesarean	section	and	postoperative	recovery.(121)	A	Canadian	survey	on	the	attitudes	of	different	care	provider	groups	conducted	by	Klein	et	al	found	that	obstetricians,	family	physicians,	and	midwives	as	groups	have	varying	attitudes	toward	safety	in	childbirth,	with	obstetricians	favouring	elective	repeat	caesarean	section	for	women	with	a	previous	uterine	scar.(70)	The	variation	in	risk	framing	experienced	by	women	indicates	the			210	need	for	further	research	into	care	provider	groups’	attitudes	toward	birth	after	caesarean,	and	how	they	frame	the	risks	and	benefits	of	mode	of	delivery,	as	these	attitudes	may	influence	how	they	approach	decision-making	for	birth	after	caesarean.		8.2.2 Care	Provider	and	Decision	Makers’	Narratives	Chapter	5,	Do	Women	Have	a	Choice?	Care	Providers’	and	Decision	Makers’	Perspectives	on	Barriers	to	Access	of	Health	Services	for	Birth	after	a	Previous	Caesarean,	highlight	the	influence	of	care	provider	and	health	system	factors	on	women’s	decision-making	for	birth	after	caesarean.	This	is	the	first	study	conducted	in	Canada,	or	a	country	with	similar	health	services,	exploring	decision	makers’	attitudes	toward	and	experience	with	planning	services	and	policy	for	birth	after	caesarean.	It	is	difficult	to	compare	the	findings	of	this	chapter	with	the	existing	literature	due	to	the	limited	number	of	qualitative	studies	on	care	provider	attitudes	toward	decision-making	for	birth	after	caesarean	(26,31,32,100),	none	of	which	took	place	in	the	Canadian	context,	and	only	one	study	from	Nicaragua	that	included	decision	makers’	perspectives.(100)	Bryant	et	al.’s	Australian	qualitative	research	with	care	providers	observed	similar	beliefs	on	informed	choice	decision-making:	that	women	are	entitled	to	make	autonomous	decisions	about	mode	of	birth	after	caesarean,	that	the	role	of	the	care	provider	is	to	provide	guidance	and	information	support,	and	that	care	providers	have	the	prerogative	to	use	the	discussion	of	“risk	factors”	to	limit	women’s	choices.(26)	Like	their	Australian	counterparts,	participants	in	our	Canadian	sample	did	not	distinguish	between	informed	choice	and	informed	consent	as	two	separate	processes,	often	using	the	terms	interchangeably.(26)			211	Informed	choice	is	a	model	of	decision-making	in	which	the	care	provider	gives	information	on	clinical	risks	and	benefits	to	the	patient,	who	then	makes	a	decision	on	their	own.	Informed	consent	may	be	the	output	of	this	decision-making;	it	is	the	principle	that	patients	have	the	right	to	be	informed	of	their	options,	to	agree	voluntarily	to	a	healthcare	decision,	and	that	decision	should	respect	the	wishes	of	the	patient.	Importantly,	informed	choice	decision-making	may	not	include	the	wishes	of	the	patient,	because	the	information	exchange	is	unidirectional	from	care	provider	to	patient.	Informed	choice	thus	does	not	provide	an	opportunity	for	care	providers	to	gain	a	fulsome	understanding	of	the	patient’s	wishes.	Unlike	in	previous	qualitative	studies,(26,31,100)	participants	in	this	research	unanimously	expressed	that	they	were	aware	of	current	clinical	practice	guidelines	for	VBAC	and	agreed	with	the	evidence	on	the	safety	of	planned	VBAC.	However,	participants’	awareness	of	the	evidence	does	not	indicate	that	they	used	the	guidelines	in	actual	practice,	a	behaviour	that	this	study	was	not	able	to	explore.	To	the	best	of	our	knowledge,	this	is	the	first	Canadian	study	to	illustrate	a	relationship	between	litigation	concerns	and	decision-making	for	mode	of	delivery	after	caesarean.	Importantly,	no	participant	felt	that	fear	of	litigation	would	cause	their	hospital	to	ban	planned	VBAC	and	concerns	were	minimal	in	the	rural	settings	that	had	no	in-house	obstetric	anesthesia.	This	differs	from	findings	in	the	US,	where	VBAC	services	have	been	suspended	in	some	facilities	to	minimize	the	risk	of	being	sued,	even	in	sites	with	24/7	in-house	obstetric	anesthesia.(31,37,119)	This	may	be	due	to	differences	in	the	two	countries’	medical			212	malpractice	systems	and/or	language	in	their	clinical	practice	guidelines	regarding	access	to	obstetric	anesthesia.		The	Canadian	SOGC	guidelines	define	timely	access	from	“decision-to-incision”	as	approximately	30	minutes	and	they	do	not	require	surgical	staff	to	be	on	site.(13)	In	contrast,	ACOG	states	“that	resources	for	emergency	cesarean	delivery	should	be	‘immediately	available.’”(111)	This	“immediately	available”	clause	has	been	identified	as	a	key	reason	for	escalating	rates	of	repeat	caesarean	in	the	US.	A	2012	survey	of	all	California	maternity	hospitals	(n=243)	determined	that	availability	of	24/7	anesthesia	coverage	was	a	predictor	of	VBAC	services.(37)	Among	hospitals	that	stopped	providing	VBAC	services	in	the	previous	ten	years,	the	most	commonly	cited	reasons	were	lack	of	immediate	available	anesthesia	(70.7%)	or	obstetrician	(54.5%),	ACOG	guidelines	(48.5%),	and/or	hospital	protocols	(44.4%).(37)	In	spite	of	these	trends,	the	strength	of	evidence	is	weak	regarding	the	appropriate	response	time	from	indication	of	uterine	rupture	to	caesarean	section.	The	best	available	literature	consists	of	two	case	series	conducted	in	tertiary	hospitals	with	in-house	anaesthesia	and	obstetrics,	which	showed	no	significant	association	between	response	time	and	perinatal	outcomes.(219,220)	There	is	no	evidence	from	settings	with	off-site	surgical	teams.	Given	the	influence	of	surgical	and	anaesthesia	services	on	care	provider	attitudes	and	malpractice	concerns,	there	is	a	pressing	need	for	high	quality	research	on	the	safety	of	planned	VBAC	in	settings	with	in-house	vs.	off-site	surgical	teams.		Previous	studies	have	observed	that	care	providers	may	find	it	personally	convenient	and	financially	lucrative	to	plan	elective	repeat	caesarean	and	promote	it	with	their	patients			213	(31,100),	however	this	did	not	emerge	as	a	theme	in	the	study.	This	is	likely	because	Canadian	obstetricians,	family	physicians,	and	midwives	receive	a	similar	fee	for	service	regardless	of	whether	they	attend	a	labour	or	a	caesarean.	This	financial	context,	where	there	is	no	monetary	incentive	to	perform	a	caesarean,	is	similar	to	that	observed	in	California	health	management	organizations	where	physicians	are	salaried	or	receive	a	flat	rate	regardless	of	mode	of	delivery.	(19,132,133)	Previous	literature	has	identified	time	as	a	barrier	to	exchanging	information	and	engaging	in	shared	decision-making,(42)	however	time	constraints	were	not	perceived	to	be	a	barrier	for	birth	after	caesarean	decisions	due	to	the	number	of	visits	that	occur	in	a	woman’s	childbearing	pathway.	Similarly,	care	providers	felt	motivated	to	engage	with	patients	in	iterative	discussions	about	birth	after	caesarean	options.	Nonetheless	care	providers	faced	a	number	of	challenges	when	counseling	women	about	choosing	mode	of	delivery.	These	included	communicating	the	health	services	(clinical,	legal,	operational)	risks	and	real-world	consequences	of	uterine	rupture	without	discouraging	the	woman	from	considering	planned	VBAC;	ensuring	the	woman	receives	accurate	and	consistent	information	as	she	meets	different	care	providers	during	her	childbearing	journey;	and	identifying	women	who	experienced	a	traumatic	first	birth	and	providing	them	with	appropriate	support.	Findings	also	highlighted	that	care	providers	did	not	routinely	discuss	the	non-medical	features	of	the	decision	that	may	be	important	to	the	woman,	such	as	fear	of	labour,	caring	for	older	children,	or	a	desire	to	experience	a	vaginal	delivery	after	a	previous	“failed”	attempt.	Findings	from	international	narrative	reviews	of	qualitative	studies	on	women’s	experiences	of	choosing	mode	of	delivery	indicate	that	women’s	preferences	for	birth			214	after	caesarean	are	highly	individual,	depend	on	both	medical	and	non-medical	factors,	and	largely	depend	on	their	first	birth	experience.(24,221)	Care	providers	could	benefit	from	strategies	to	help	their	patients	clarify	and	communicate	which	outcomes	are	most	important	to	them,	and	incorporate	those	considerations	into	the	decision-making	process.		A	number	of	recent	publications	have	commented	on	the	potential	of	shared	decision-making	(SDM)	for	maternity	care	in	general	(30,222)	and	birth	after	caesarean	in	particular.(223)	Drawing	on	Légaré	et	al’s	model,	the	steps	in	SDM	for	birth	after	caesarean	would	include	the	following:	the	woman	and	her	care	provider	consider	the	best	available	evidence	on	the	clinical	risks	and	benefits	of	planned	VBAC	vs.	elective	repeat	caesarean	and	highlight	areas	where	knowledge	is	uncertain;	take	time	to	consider	the	woman’s	values	and	both	the	medical	and	non-medical	outcomes	that	are	most	important	to	her;	reach	a	consensus	about	mode	of	delivery,	including	input	from	other	members	of	the	care	team	and	family	as	appropriate;	and	have	shared	responsibility	for	the	decision.(184)	SDM	has	the	potential	to	enhance	informed	consent	for	preference-sensitive	choices	like	birth	after	caesarean,	as	failing	to	diagnose	patient	preferences	may	put	care	providers	at	higher	risk	of	litigation.(105)	Unlike	informed	consent	for	mode	of	delivery,	which	typically	occurs	in	the	third	trimester	of	the	next	pregnancy,	SDM	may	begin	as	early	as	the	postpartum	period	following	the	woman’s	primary	caesarean	to	reflect	the	actual	timing	of	when	women	begin	deliberation	and	preference	formation.	Importantly,	analysis	of	narratives	revealed	that	care	providers	engaged	in	components	of	SDM,	with	midwives	and	rural	consultant	obstetricians	illustrating	the	most			215	examples	of	listening	to	and	incorporating	women’s	knowledge	and	preferences	in	decision-making.	However	there	is	room	for	improvement.			8.2.3 Complex	Adaptive	Systems	Analysis	Chapter	6,	Patient,	Care	Provider,	and	Decision	Makers’	Perceptions	of	Barriers	to	Implementation	of	Shared	Decision-Making	for	Birth	after	Caesarean:	A	Complex	Adaptive	Systems	Perspective,	synthesized	the	findings	of	participants’	narratives	to	provide	a	holistic	picture	of	the	context	that	influences	decision-making	for	patients,	care	providers,	and	decision	makers	in	five	BC	communities.	By	using	a	novel	conceptual	framework,	complex	adaptive	systems	theory,	I	provided	a	rich	description	of	how	decision-making	for	birth	after	caesarean	is	influenced	by	a	complex	array	of	factors	and	the	relationships	between	them.	I	demonstrated	how	use	of	CAS	theory	helps	to	understand	challenges	to	implementation	of	SDM.	This	understanding	can	assist	in	the	development	of	SDM	tools	and	interventions	that	are	tailored	to	the	context	in	which	they	are	used,	increasing	their	likelihood	of	successful	implementation.	Women’s	experience	of	birth	trauma	and	early	preference	formation	for	mode	of	delivery,	were	unexpected	and	novel	barriers	to	SDM.	Decision	makers	in	this	study	expressed	attitudes	and	experiences	consistent	with	those	of	care	providers	interviewed,	yet	their	perspective	illuminated	the	relationships	and	interactions	between	these	micro,	meso,	and	macro	levels	of	the	complex	system.	For	instance,	care	provider	participants	in	larger	hospitals	had	patient	safety	concerns	about	access	to	caesarean	section	in	the	event	of	a	uterine	rupture.	The	reasons	for	these	shortages	emerged	through	interviews	with	health	service	decision			216	makers,	who	provided	descriptions	of	local	nursing	and	anaesthesia	shortages	and	competing	access	to	the	operating	room	with	other	specialties.	Health	service	decision	makers	also	revealed	that	the	access	challenges	began	upstream	with	a	limited	budget	and	strategic	policy	priorities	that	did	not	include	maternity	care.	In	one	region,	recent	malpractice	suits	related	to	decision-making	for	caesarean	had	been	covered	in	the	local	media.	This	encouraged	physicians	in	the	region	to	discuss	the	health	services	risks	of	limited	access	to	surgery	during	informed	consent	for	birth	after	caesarean.		Two	previous	systematic	reviews	have	explored	the	knowledge	to	action	gap	from	the	perspectives	of	health	care	professionals	(147)	and	patients.(185)	Légaré	et	al’s	systematic	review	of	38	studies	exploring	health	professionals’	perceptions	of	barriers	and	facilitators	to	SDM	determined	that	the	most	frequently	perceived	barriers	were	time	constraints	(e.g.	short	clinic	visits)	and	perceptions	that	SDM	was	not	applicable	to	the	characteristics	of	the	patient	population	or	the	clinical	situation.(147)	SDM	was	facilitated	primarily	by	the	motivation	of	health	professionals,	and	the	belief	that	SDM	would	lead	to	better	patient	outcomes	and	improved	health	care	processes.(147)	Six	of	the	38	studies	were	conducted	in	Canada	and	one	study,	conducted	in	Wales,	was	on	decision-making	in	maternity	care.		Similar	enablers	to	SDM	for	birth	after	caesarean	were	present	in	participants’	narratives	for	this	thesis.	On	the	whole,	care	providers	were	motivated	to	provide	women	information,	listen	to	their	preferences,	and	support	them	to	make	a	choice.	These	narratives	were	most	common	amongst	the	individual	obstetricians	who	held	long	‘informed	consent’	appointments	in	the	third	trimester	and	in	narratives	from	midwives	across	all	settings.			217	Midwives	in	particular	expressed	the	belief	that	the	attributes	of	SDM	led	to	better	outcomes	and	health	processes	for	women	choosing	mode	of	birth	after	caesarean	decision-making.		Surprisingly,	none	of	the	key	barriers	observed	in	Légaré	et	al’s	review	emerged	in	care	providers’	narratives	in	this	study.	Care	providers	perceived	that	time	constraints	were	not	a	barrier	to	SDM.	While	individual	clinic	visits	may	be	short,	participants	felt	that	there	were	enough	appointments	over	the	course	of	pregnancy	in	which	to	engage	in	SDM.	All	providers	felt	that	SDM	was	ideal	for	maternity	patients	considering	birth	after	caesarean	and	that	most	patients	expected	to	be	highly	involved	in	the	decision	if	not	solely	responsible	for	it.	A	number	of	participants	mentioned	that	they	sometimes	observe	that	new	immigrants	from	different	cultural	backgrounds	express	surprise	and	dis