Sharing the decision about VBAC: introducing the ARCS-V motivational learning model
Shared decision-making is considered key to influencing women's motivation to choose vaginal birth after caesarean section (VBAC), as when women's self-determination is respected, they are more likely to avoid intervention. However, the shared decision-making conversation can be challenging.
This article introduces the ARCS-V (attention, relevance, confidence, satisfaction, volition), an model for understanding and responding to women's motivation to share the decision about VBAC vs repeat caesarean section. Each of the model's components are introduced, including the psychological basis for managing a shared conversation; capturing and holding women's attention on what they need to learn; matching the learning goals with women's personal goals; building their confidence to achieve their optimal birth; and ensuring they are satisfied with decision-making experience. When these educational conditions are met, women are more likely to use shared decision-making conversations to choose optimally.
The World Health Organization (WHO) (2015a) estimates that in the UK, 24.9−29.1% of births are by caesarean section, despite evidence illustrating that caesarean section rates greater than 10% fail to achieve a reduction in maternal and newborn mortality rates (WHO, 2015b). Additionally, vaginal birth is associated with lower staffing and financial demands; potentially due to reduced need for pharmacological analgesia and longer hospital stays (Royal College of Obstetricians and Gynaecologists (RCOG), 2015; National Institute for Health and Care Excellence (NICE); 2019). Although there has been a focus for more than a decade on reducing unnecessary caesarean section by increasing vaginal birth after caesarean (VBAC) (Emmett et al, 2006), evidence suggests that this public health goal has not yet been realised (Macdonald and Loder, 2015; Miller et al, 2016). In an effort to engage women in the decision-making process, women who are clinically eligible for VBAC are routinely informed that successful VBAC after a single previous caesarean section is estimated at 72–75%, rising to 85–90% for those with a history of a previous vaginal birth, either before or after their caesarean section (RCOG, 2015). Yet despite this statistical evidence, some women's motivation and preference is still focused on a repeat caesarean section. This article introduces practitioners to a motivational systems-and-learning model to guide women through the shared decision-making process. It is proposed that, by providing practitioners with a practical guide to optimising the VBAC vs repeat caesarean section conversation, knowledge of how to promote VBAC through shared decision-making can be improved.
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