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Table 5 Triangulation of qualitative evidence synthesis and quantitative narrative synthesis at summary of findings level

From: Women’s, partners’ and healthcare providers’ views and experiences of assisted vaginal birth: a systematic mixed methods review

  Qualitative evidence synthesis Convergence coding matrix Quantitative narrative synthesis
Barriers and facilitators to AVD Summary of findings Studies Agreement Partial agreement Silence Dissonance Studies Summary of findings
       Prevalence of AVD use in practice  
  0 studies      Bailey 2017 [12] Prevalence of assisted vaginal delivery (Moderate confidence) Included studies indicate low levels of use of instrumental birth, and early default to CS. Lack of equipment and lack of trained staff contribute to this situation. Improved access to the Cochrane database was associated with an increased use of ventouse vs forceps over time in one UK study, but this was not explained by changes in individual staff knowledge attitudes, or access to Cochrane reviews. Views of AVD use in practice
Crosby 2017 [39]
Fauveau 2006 [41]
Healy 1985 [45]
Hewson 1985 [46]
Maaloe 2012 [66]
Ramphul 2012 [50]
Rowlands
Ryding 1998 [55] Schwappach 2004 [58]
Uotila 2005 [61]
Wilson 2002 [64]
  0 Studies      Alexander 2002 [34] Skills (development) in assisted vaginal delivery (Low confidence) Mixed findings about the self-reported skills of obstetricians in determining the need for, seeking a second opinion in, and accuracy of clinical stills for, instrumental delivery. Evidence from one study that more junior doctors report being more likely to default to a CS, and that senior doctors are more aware than junior doctors that they make errors in some relevant clinical judgements. Less than 15% of responding LMICs in one multi-country study reported teaching in AVD, as reported in 2006. In another survey most trainees report correct techniques for assessment prior to instrumental vaginal birth, but that, in practice, this is more difficult where women have insufficient pain relief, or where there is significant fetal caput, or where the practitioner is relatively inexperienced. In one study, Irish trainees were more likely to use AVD than Canadian trainees, but confidence in AVD use did not differ between the two groups. Midwives who were trained in using ventouse in the UK seemed to be confident in its use. Actual skills and competence were not tested in any included studies..
Crosby 2017 [39]
Fauveau 2006 [41]
Garcia 1985 [43] Ramphul Sanchez del Hierro 2014 [57]
Wilson 2002 [64]
       Skills and attitudes  
  0 studies      Crosby 2017 [39] Professional attitudes to the use of assisted vaginal delivery (Low confidence) In one US study undertaken in 1985, the attitude of the director of the obstetric training program was not associated with the rate of forceps performed in their institution. One UK study showed that staff attitude was not a key determinant of a rise in use of ventouse over time. In an Egyptian study, nearly half of all obstetricians attending a conference rejected the use of instrumental birth (49%) with more experienced medical staff being more positive to AVD than more junior staff, and those working in the private sector less positive than those working in the public sector (check with full text. A survey of practitioners in 121 LMICs reported in 2006 indicated that practitioners in about half (48%) of the countries represented reported knowledge, positive attitude, teaching and countrywide use of the method; 15% reported no knowledge and therefore no use in their country. Irish trainees were more likely to use AVD and were more comfortable with its use than Canadian trainees in one study.  
Fauveau 2006 [41]
Healy 1985 [45]
Sanchez del Hierro 2014 [57]
Shaaban 2012 [59]
Wilson 2002 [64]
  0 studies      Al-Mufti 1997 [35] Personal attitudes to mode of birth for oneself/a partner (obstetricians) (Very low confidence) Preference for elective CS amongst UK obstetricians (for them/their partners) was around 16% (15–17%) in both 1997 and 2001. A majority in both time periods would be happy to have an instrumental birth as an alternative for mid-cavity arrest, especially if they could choose the operator. Junior staff in 1997 were more likely than senior staff to choose ventouse than forceps for arrested labour, for both OP and OA positions. Choices were not affected by gender, age, or hospital status. Experiences AVD
Wright 2001 [65]
Coming to know AVD by experience      Experience of the birth
Expectations and preparedness for assisted vaginal delivery - a birth you couldn’t plan for (Low confidence) Women and men reported views of assisted vaginal deliveries as a birth experience that you couldn’t plan for. In some cases, this was because an assisted vaginal delivery had simply not been contemplated, with women’s birth preparations focused elsewhere. While women perceived an absence of information about forceps or ventouse, compared to spontaneous vaginal birth or caesarean section, there was an appreciation of the difficulties surrounding information about assisted vaginal delivery, which not everyone needs to know, and not everyone desires to know. Although assisted vaginal delivery was reported to be a missing component of antenatal preparation, other parents described their own self-imposed limitations on preparation. Hurrell 2006 [26]
Murphy 2003 [23]
     Avasarala 2009 [36] Women’s experiences of assisted vaginal delivery (Low confidence) In all studies where spontaneous physiological birth is included, it scores the highest for a positive experience. In some, elective CS scores almost as highly. Having an unplanned mode of birth (emergency CS or instrumental, especially with an episiotomy, and especially where the intervention is done for delay in labour rather than for acute clinical risk) seems to be associated with less positive reports of childbirth experience for women. In some studies, emergency CS is rated as the least positive of all birth modes, followed by instrumental, with a better experience reported after ventouse than forceps in most, but not all comparisons. In others, instrumental birth with episiotomy is the most distressing, especially after a trial of labour following a previous CS. A few studies note that negative experience is associated with poor pain relief, but in one study women with AVD reported higher levels of pain relief than women with spontaneous birth. Where longer term memories of birth experience are recorded, the differences reported immediately after birth persist (up to 3 years in one study).
Garcia 1985 [43]
Handelzalts 2017 [44]
Hewson 1985 [46]
Hildingsson 2013 [28]
Kjerulff 2018 [47] Maclean 2000 [48] Nolens 2019 [2, 29]
Ranta 1995 [51]
Beliefs about need/indications for assisted vaginal delivery (Low confidence) Some parents described an acceptance of assisted vaginal delivery based on their perception of necessity. In some cases, there was a lack of understanding about what happened, when and why. Some women understood that there had been a problem with either themselves or their baby, which some women viewed as a failure on their part to deliver vaginally. Some women could not remember any explanation from a health professional as to what happened, others could remember being spoken to, but not what it was about. Hurrell 2006 [26]
Murphy 2003 [23]
   
Rijnders 2008 [53]
Salmon 1992 [56] Schwappach 2004 [58] Shorten 2012 [60] Uotila 2005 [61] Waldenstrom 1999 [62]
Reconciling/coping with personal experience of assisted vaginal delivery (Low confidence) Women described finding a context for their birth experience that allowed them to come to terms with it. Conversely some women had difficulties with moving on, describing feels of low mood and low self-worth. Hurrell 2006 [26]     
Wiklund 2008 [63]
Turbulent feelings about the actual experience      
Pain during assisted vaginal delivery (Moderate confidence) For some women, effective pain relief allowed an absence of major concerns about the procedure, and for other women who did experience pain, compassionate support enabled them to work with it. However, some women experienced pain as traumatic and men expressed concerns that their partners would be traumatised. Hurrell 2006 [26]
Sjödin 2018 [30]
Nystedt 2006 [32]
Zwedberg 2015 [31]
   
Frightening and violent experiences during assisted vaginal delivery (Moderate confidence) Some women and men experience AVD as frightening, distressing or violent. Participants use vivid language to describe the sights and sounds of their experience – seeing blood, perceptions of force or violence (words like tearing, ripping, dragging), the baby’s appearance afterward. Participants described the emotional impact of the experience in terms of fear or distress and a few participants relate experiences of dissociation or trying to avoid perceiving/experiencing anything. Hurrell 2006 [26]
Sjödin 2018 [30]
Nystedt 2006 [32]
Zwedberg 2015 [31]
Goldbort 2009 [33]
   
Positive or beneficial reactions during assisted vaginal delivery (Moderate confidence) Women and men reported a range of positive reactions after experiencing an AVD. These included feeling unperturbed by having an AVD, to feeling relief that labour is over, to feelings of joy at the birth of the baby. Men described finding strength to cope with a difficult situation to support their partners. Hurrell 2006 [26]
Zwedberg 2015 [31]
Nystedt 2006 [32]
   
Trust, control and relationships        Living after experiences of AVD
Active participation through collaboration and involvement (Moderate confidence) Both women and men wished to feel part of a team with care providers and to be involved in decision making. Men expressed feelings of being excluded but wishing to be involved. Hurrell 2006 [26]
Zwedberg 2015 [31]
Sjödin 2018 [30]
     Avasarala 2009 [36] Fauveau 2006 [41] Garcia 1985 [43] Ramphul 2012 [50] Renner 2007 [52] Communication, information and consent (Moderate confidence) Some evidence that many women do not have information about the risks and benefits of AVD (plus or minus episiotomy), either antenatally, intrapartum when the procedure is used, or postnatally to explain what happened.
Balancing control and trust (Moderate confidence) The amount of trust that women and men have in their caregivers at the time of an assisted vaginal delivery is linked both to their perceptions of control and to their acceptance of the intervention. Hurrell 2006 [26],
Zwedberg 2015 [31]
Sjödin 2018 [30]
Nystedt 2006 [32]
Goldbort 2009 [33]
    
Uotila 2005 [61]
The need to understand and be understood (Moderate confidence) The quality of communication between caregivers, women and men at the time of an assisted vaginal delivery was key. Women appreciated care in what was said and how it was said. They wanted information and to be listened to as a means to retaining some degree of involvement in something they had little control over. Hurrell 2006 [26]
Zwedberg 2015 [31]
Sjödin 2018 [30]
    
Implications of AVD for future reproductive choices      Impact and consequences of AVD for women and partners
Mixed views about any future pregnancy and delivery (moderate confidence) AVD impacts on women and men views about future pregnancies - In some cases, the experience of an assisted vaginal delivery put women off planning another pregnancy, while for other women and some men, it meant that they had stronger views about a particular birth mode. Some women, and men, described preferring a caesarean for any future birth. Other women, and men, felt bettepared for labour and a future vaal delivery. Hurrell 2006 [26]
Murphy 2003 [23]
Zwedberg 2015 [31]
    Avasarala 2009 [36] Chan 2002 [38] Impact of assisted vaginal delivery (women) (Low confidence) Studies have variously measured postnatal mood, sexual function, desire to have more children, dyspareunia, urinary and bowel problems, postnatal fear of childbirth, pain, haemorrhoids, and backache, Having a spontaneous vaginal birth without instruments or episiotomy seems to result in the most positive outcomes in the short and longer term (though this is not the case for a few variables). Having an unplanned mode of birth may be the strongest predictor of negative outcomes. In some studies, emergency CS is associated with least positive impacts, followed by instrumental (negative outcomes reported for both forceps or ventouse in some studies – others show better outcomes for ventouse than CS in the short and longer term). In others, instrumental birth is the most distressing. Surveys that assessed preference for mode of birth next time indicate that spontaneous VD is preferred by most, with some preferring a planned CS, and most preferring instrumental birth over emergency CS. If an instrumental birth is required, most seem to prefer ventouse over forceps.
Declercq 2008 [40]
Fisher 1997 [42]
Garcia 1985 [43] Handelzalts 2017 [44] Hildingsson 2013 [28]
Nolens 2019 [2, 29]
Nolens 2018 [49] Rowlands 2012 [54] Ryding 1998 [55]
Schwappach 2004 [58]
Uotila 2005 [61] Wiklund 2008 [63]
Belanger-Levesque 2014 [37] Experience of witnessing assisted vaginal delivery (partners) (Low confidence) Witnessing an emergency CS or instrumental birth seems to be associated with less positive reports of childbirth for partners than a spontaneous vaginal birth. Emergency CS seems to be associated with marginally higher scores than instrumental birth, but only two studies measure this comparison. In one study, partners reported having panic attacks during the birth, and a few said they wouldn’t have more children. Some would prefer their partner chose an elective cs next time.
Chan 2002 [38]
Hildingsson 2013 [28]