Previous caesarean sections (CS) account for a significant proportion of the high rates of repeat caesarean section (RCS) reported in high income countries [1–3]. While vaginal birth after caesarean (VBAC) is a safe intervention [4], there has been a dramatic decline in VBAC because of concerns about uterine rupture and perinatal death [5]. This is despite evidence that the rates of uterine rupture and perinatal death are relatively low [4]. According to findings from a systematic review of 203 studies, once a woman has experienced a CS, she has a baseline risk for uterine rupture in subsequent pregnancies that is estimated at 3 per 1000 [4]. For women choosing VBAC in a subsequent pregnancy, this baseline risk increases to 4.7 per 1000, compared with 0.3 per 1000 for women choosing RCS. Of concern, however, is that RCS is associated with an increased risk of adverse maternal and neonatal outcomes [6], and has a major economic impact on health care [7].

Several factors influence women’s decision-making regarding birth mode. Historically, it has been reported that, associated with the notion of “once a caesarean, always a caesarean”, obstetricians recommended RCS to women who had had a previous CS [8]. Higher preference for CS has been reported in women with previous CS [9]. While perceptions of safety were a common reason for caesarean section by maternal request (CSMR) without medical indication [10], evidence demonstrates inconsistent findings in maternal and neonatal risks [11]. Caesarean sections by maternal request (CSMR) were associated with higher rates of infection and length of hospital stay and neonatal respiratory morbidity, compared to planned vaginal birth [11]. Knowledge about birth options influences a woman’s ability to make decisions regarding mode of birth. In a survey to explore how information women received in pregnancy affected their childbirth preferences, all (n = 34) women who chose a VBAC felt involved in the decision-making, while almost 20% (n = 28) of women who underwent a RCS reported not being involved in decision-making [12]. Women also use relevant information from previous birthing experiences to inform a birth decision [13]. According to findings of a qualitative study, 13 Australian women who had a VBAC reported that their previous caesarean experience was unacceptable to them and resulted in an unexpected extended recovery. These experiences reinforced their desire for a subsequent vaginal birth [14]. Fear of birth was related to previous negative birth experience [15]. Additionally, social context has been found to increase women’s fears of birth, such as ‘fear of the unknown’, ‘horror stories’ and ‘general fear for the well-being of the baby’ [16]. In some countries, hospitals restrict access to VBAC based on the capabilities of the service and limitations of VBAC guidelines [17, 18].

Taiwan has high RCS rates [19]. In 2015, a total of 216,229 babies were born in Taiwan; 35.67% (n = 77,144) of babies were born by CS; that is, more than one in three women delivered by CS. Of all births, RCS accounted for 14.16% (n = 30,622) [19]. High RCS rates are associated with extremely low rates of practicing midwives in Taiwan. In 2016, of all births, 99.89% (n = 215,983) of babies were delivered by obstetricians while 0.06% (n = 126) of babies were born with midwives’ assistance [19]. Between 1951 and 1971, a midwife was the main health professional to assist women during birth. With cultural vicissitudes and the concomitant rise of medicalisation within health services, numerous organisations adopted obstetrician-provided maternal care in Taiwan [20], similar to North America. Obstetricians are the primary providers of prenatal care for most childbearing women. An obstetrician is present for the birth, and nurses provide intrapartum and postnatal care [21]. As a result of the high CS rates, the Taiwan government reconsidered the role of midwives [22]. Midwifery education was recommenced and the midwifery qualification was advanced to undergraduate level in 1996 and then to a graduate level in 2000 [22].

Previous CS is ranked as the top reason for RCS in Taiwan [23]. While increasing VBAC is an efficient way to lower CS rates in Taiwan [24], the prevalence of VBAC was less than 0.37% (n = 806) in 2016 [19]. Although studies from high income countries have indicated that women’s choice of RCS was related to: individual preferences [9]; safety [25]; insufficient information about various modes of birth [12–14]; health professionals’ advice [26] and limitations of guideline and policy [18], these findings may not explain the phenomenon of extremely low VBAC rates in Taiwan. In particular, Taiwan has a different social context from high income countries. Studies conducted in high income countries have focussed on either health professionals’ views or women’s perspectives, but little is known about how cultural context and practice patterns influence women’s decisions. More importantly, a number of quantitative studies have been conducted to examine factors related to CS in Taiwan [27–30]. However, qualitative research to explore decision-making regarding mode of birth in Taiwanese women who have had a previous CS, has not been undertaken. To redress this gap, the present study aimed to explore Taiwanese women’s decision-making processes and the influences on their mode of birth following a previous CS.

A qualitative approach was used to elicit Taiwanese women’s decision-making processes and the influences on their mode of birth following a previous CS. Women’s decision-making was identified using multiple data collection methods, including in-depth interviews, observations and field notes. In particular, this study used in-depth interviews to capture individual participants’ viewpoints.

The Theory of Planned Behaviour (TPB) was used to assist in the interpretation of the findings. Specifically, the TPB framework assisted in discerning the reasons underpinning women’s decisions and also assisted to understand women’s actions regarding mode of birth. The TPB includes three psychometric determinants influencing human behavioural intentions [40]. These determinants are attitudes towards a behaviour, subjective norms and perceived behavioural control [41]. Taiwanese women’s decisions were influenced by internal and external factors. Internal or personal factors related to an evaluation of mode of birth were reflected in the ‘attitudes toward behaviour’ construct of the TPB (Fig. 2). In this study, women who evaluated vaginal birth in a positive light were more willing to attempt VBAC. Conversely, women who had a negative attitude towards VBAC selected RCS. This finding is consistent with previous studies [14, 42].

Subjective norms include external factors influencing women’s decision making such as obstetricians’ recommendations, the experiences of significant others and health insurance. In this study, obstetricians’ recommendations and the experiences of significant others (female families or friends) played an important role in women’s decision-making. Obstetricians have been described as a major factor in driving the CS rate upward [10]. Research has shown that hospital physicians were the most frequent information providers; however, they provided women with information about procedural issues rather than possible health risks and benefits [43, 44]. In the present study, unbalanced explanations regarding the risk of uterine rupture potentially affected women in making decisions in favour of RCS. This finding corroborates findings of a recent Australian study [45]. Australian women who chose RCS reported that VBAC was the most risky option, based on the information they received from hospital obstetricians [45]. In addition, some pregnant women in the study complied with obstetricians’ recommendation to opt for RCS because they found it difficult to oppose obstetricians’ opinions. Medical recommendations, especially during the birth, were experienced as powerful and difficult for women to oppose [45]. Power and a knowledge imbalance, as well as trusting relationships with obstetricians continue to reinforce this momentum. Positive benefits of midwife led care indicate the recommencement of midwifery practice in Taiwan to optimise maternal care [46–49].

Perceived behavioural control is related to women’s intention to participate in decision-making. Self-efficacy is a key concept of perceived behavioural control [40]. Four constructs in our findings are related to women’s self-efficacy, including previous birth experience, current pregnancy situation, concern about the risks of vaginal birth and impact of the internet. In this study, women who had a high sense of self-efficacy were more willing to attempt VBAC. Several studies have demonstrated that previous experiences influenced decision-making in women who had had a previous CS and these experiences have been found to affect women’s subsequent birth choice [16, 50–53]. In the present study, Taiwanese women who had a positive experience selected the same mode of birth as their previous birth, while women who had a negative experience chose a different mode of birth. These findings are similar to those of a recent study, in which 85% of women who had an RCS stated they would make the same choice again, compared to 70.1% for the planned VBAC group [53]. In this study, most women lacked confidence to have VBAC because of their previous negative experience of induction. This finding is supported by findings of another Taiwanese study [54]. According to Kuan [54], Taiwanese women who were aiming to birth vaginally but had to have a CS were aware of medical intervention practices and they requested CS out of fear of “suffering twice”. Kuan argued that Taiwanese women requested a CS for their first birth because hospitals enforce a significant amount of medical intervention [54]. Because of concern about the risks of vaginal birth, some women considered RCS as the safest method for mother and baby based on medical perspectives; they were therefore unwilling to attempt VBAC. However, this assumption has been based on a misunderstanding of the risks and benefits of VBAC [55]. In fact, several previous studies have shown that women who have had a previous CS lacked knowledge about the benefits and risks regarding the various birth options [12, 56, 57]. Internet has been found to play an important role for women in searching for information regarding mode of birth [44, 58]. Due to a lack of leaflets, booklets and newsletters regarding VBAC in organisations, Taiwanese women sought help from other women on the internet. However, a lack of comprehensive information and inaccurate information on the internet contributed to study participants’ decision to avoid an attempt of VBAC. The findings of the present study in relation to use of the internet for information were consistent with those of a recent Swedish study [58]. This highlights the need for high quality information provision if the misconceptions are to be corrected.

For geographical convenience, data were collected in a large private medical centre rather than in a public hospital or a clinic in Taiwan. Therefore, the findings may not be transferable to all pregnant women in Taiwan. Women were interviewed in a waiting room while awaiting their consultation, the location and time constraints may have limited their ability to fully share their stories. In spite of these limitations, the findings that emerged from participants’ interviews were meaningful and offered greater depth than a survey would have produced. Additionally, this study comprised of interviews with prenatal and postnatal women which was helpful in capturing their actual thinking regarding mode of birth from different perspectives. Observation of women-obstetrician dyads during consultations enabled examination of the actual interactions between obstetricians and pregnant women, thereby providing a deeper understanding of the information sharing and decision-making process than would not have been obtained through the individual interviews alone.

The health and wellbeing of mother and baby were the major concern for women deciding on a mode of birth after a previous CS. Influenced by internal and external factors, women’s interactions with obstetricians regarding mode of birth choices varied from complying with obstetricians’ recommendations to shared communication styles. In the present study, if women participated passively in the decision-making process regarding their birth choices, their choices were primarily guided by risk reduction of uterine rupture. They were particularly influenced by obstetricians’ recommendations in early pregnancy. By contrast, women who actively participated in decision-making regarding their birth choices were guided by a previous experience of vaginal birth. These women discussed with obstetricians their intention to attempt VBAC and were actively involved in the decision-making.

All women have the right to be informed of alternative options of birth. Internal factors, in particular, establishing a supportive birth environment such as Next Birth after Caesarean (NBAC) clinics is helpful in facilitating women’s confidence in VBAC. Routine provision of explanations by obstetricians regarding risks associated with alternative birth options, in addition to financial coverage for RCS from National Health Insurance, would assist women’s decision-making. Establishment of a website of decision aids to provide women with reliable information about birthing options may also assist women’s decision-making. Finally, midwife-led models of care for information provision may hold promise for reducing risks of birth in Taiwan.