Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training

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Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training Janene Rattraya , Elizabeth Riggb,* , Bradley Partridgec, Melissa Taylorb a b c

Caboolture Hospital, McKean Street, Caboolture, Queensland 4510, Australia University of Southern Queensland, School of Nursing and Midwifery, Queensland 4305, Australia Research Development Unit, Caboolture Hospital, McKean Street, Caboolture, Queensland 4510, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 27 March 2019 Received in revised form 5 August 2019 Accepted 5 August 2019 Available online xxx

Background: Australian women seeking a vaginal breech birth report limited access to this option due to resistance from clinicians and strict medical criteria. Limited evidence exists to determine the attitudes, knowledge, experience and perceived confidence of Australian maternity clinicians towards the management of a breech presentation at term. Aim: The aim of this study is to identify experience, knowledge and attitudes of birth suite clinicians’ before and after training, toward term breech presentation and management practices. Methods: A mixed methods research design was used that included a survey tool. A survey of 29 midwives and 11 medical professionals who attended an educational course in breech management (“BABE Becoming a Breech Expert”) was undertaken pre and post BABE training. Results: While participants were experienced in providing maternity services, the results indicated most were inexperienced in facilitating a vaginal breech birth. Prior to training, most participants believed vaginal breech birth had a higher risk of neonatal morbidity and mortality compared to caesarean birth. The prospect of a woman choosing a breech birth outside of medical recommendations made many participants “nervous”. Despite this, support to ensure there was informed decision-making and respect for a woman’s choice was high. Following training, clinician knowledge of assessment of risks for breech birth and intention to discuss breech management options with women increased. Conclusions: Participation in breech management training is beneficial to increasing clinician knowledge and assessment of risk and confidence towards discussing vaginal breech birth management, respect for women’s choice and informed decision-making. © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Keywords: Vaginal breech birth Breech External cephalic version Caesarean section

Statement of significance Problem or issue Little is known about clinician’s experience and attitudes towards facilitating a woman’s request for a vaginal breech birth against medical recommendations. What is already known? The option of a vaginal breech birth is not commonly offered to women who want this choice. The dominant mode of birth for a breech presentation is a caesarean section. What this paper adds

* Corresponding author. E-mail addresses: [email protected] (J. Rattray), [email protected] (E. Rigg), [email protected] (B. Partridge), [email protected] (M. Taylor).

This paper adds insight into how providing clinician’s access to specialised breech birth training increases their knowledge, experience and perceived confidence to facilitate this option. ;1; Introduction In Australia, approximately 4.3% of all babies present in the breech position and of these 87% are born by caesarean section (CS).1 This trend echoes other high and middle-income countries where the dominant management of a breech presentation has been heavily influenced by the recommendations of a randomised control trial known as the Term Breech Trial (TBT).2–4 The TBT recommended that a planned CS was the safest mode of birth for breech presentations instead of a planned vaginal breech birth (VBB).2 This trial was a catalyst for a global increase in rates of CS

http://dx.doi.org/10.1016/j.wombi.2019.08.002 1871-5192/© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002

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for breech presentations despite criticisms and a subsequent call for this recommendation to be reversed.2,5–7 Literature highlights that whilst there are increased risks related to VBB, having a caesarean birth is known to result in increased risks of maternal and neonatal morbidity and complications for subsequent births.8 VBB at term is a viable option that can be achieved safely when careful selection criteria, protocol and experienced clinicians are in attendance.9,10 This has raised questions about the appropriateness of caesarean birth that may not be medically required and attempts are being made globally to reduce this trend.11 In Australia, current CS rates are high at 33% when compared against the Organisation for Economic Coorporation and Development (OECD) rates of 28%.11 The Royal Australian College of Obstetricians and Gynaecologists (RANZCOG) guidelines support a range of breech management options and recommend care be individualised to the woman following consideration of the maternal and neonatal risk factors and the expertise of the birth clinicians.12 However, Australian evidence demonstrates that women who seek a planned VBB typically face difficulty accessing a facility that is both supportive of their birthing choice, and adequately resourced with midwives and/or obstetricians who are experienced and confident in facilitating VBB.13 This is further supported with a decline in rates of a planned VBB over the last 15 years that is thought to have precipitated a reduction in the number of maternity clinicians with experience in facilitating a VBB.14,15 One small Australian study that explored the experiences of obstetricians (n = 5) and midwives (n = 4) involved in the care of women having a VBB at two different hospitals in New South Wales found that clinicians encountered considerable resistance towards facilitating VBB from colleagues.14 This was largely due to inexperience, fear of complications, and the possibility of litigation. Importantly, the study identified that upskilling clinicians and a collaborative approach to care, along with a process, to carefully select women suitable for VBB, could improve access to a VBB for Australian women. Within this context, there is clearly a need to better understand the knowledge and attitudes of Australian maternity clinicians towards the care of women seeking a VBB. There is limited evidence about the attitudes, knowledge, and confidence of maternity clinicians in Australia towards facilitating VBB.12,16 Our research consisted of a cohort of maternity clinicians from one hospital who had chosen to engage in a one-day course known as “Becoming a Breech Expert” or “BABE”.17 The course is designed to increase knowledge, understanding, and confidence in the care of women with a breech presentation late in pregnancy. The course included facilitating conversations to share current evidence with women to promote informed choice. The purpose of this research was to identify the knowledge and attitudes of birth suite clinicians’ before and after the BABE training, toward term breech presentation and management practices. The study was reviewed by The Prince Charles Hospital Human Research Ethics Committee Office and deemed compliant with NHMRC guidance on “Ethical Considerations in Quality Assurance and Evaluation Activities” (HREC/17/QPCH/447).

Methods This was a quantitative study that used a survey tool to collect data. A hard copy of the survey was distributed to participants prior to, and six months post BABE training. The setting was a medium sized, metropolitan public hospital in South-East Queensland, Australia. A participant group was invited from all attendees at the BABE workshop, this included 29 midwives and 11 medical officers working in the birth suite. BABE course attendees were provided with an information sheet about the study and written consent to participate was obtained. Survey items included demographic information from participants including: age; gender; role (midwife/medical officer); years of experience working in the maternity service provision; and, number of VBBs observed and facilitated. Participants answered questions surrounding their training and experience in relation to breech birth including: lectures, supporting a physiological birth using a “hands off the breech” approach; assisted breech manoeuvres with models and/or simulation; ‘on the job’ training or skills development as the opportunity presented within the work environment. The survey explored several categories with clinicians including: level of experience; knowledge and assessment of risks; attitudes towards VBB; confidence and information giving. The pre-course survey utilised the ‘relative’ and ‘absolute contra indicators’ listed in the 2016 RANZCOG guidelines12 on management of breech pregnancies at term to ascertain participant’s attitudes about risks of VBB and identify how their attitudes aligned with the guideline.12 The pre-course survey presented participants with a range of statements to explore their confidence in caring for women having a VBB. This included: the extent to which clinicians inform women with a breech term pregnancy about birthing options; their assessment of the relative risks of maternal and perinatal morbidity and mortality for VBB compared to CS. A Likert scale was used to measure the extent of agreement, and frequency of behaviour for example: Item: “I feel confident in my ability to diagnose a breech pregnancy” [rarely; sometimes; mostly; always] The post-course survey presented the same items again to assess for any changes in confidence, attitudes, assessment of risk, or intentions to change practice (e.g. “If a breech presentation is recognised in labour, I intend to discuss the option of proceeding with VBB”). The survey ended by asking participants for open-ended written responses to the question “How do you feel when a woman wants to have a vaginal breech birth against recommendations?” Analysis Descriptive statistics for all quantitative items were produced using the SPSS software analysis program to ascertain the overall extent of agreement with survey items, and an overall profile of experience amongst the cohort.18 Responses to openended questions were collated and read independently by all authors. Three of the authors then examined the responses for

Table 1 Sample characteristic.

Male Female Mean age in years (range) Mean years of maternity experience (range) Observed more than 5 VBB Facilitated more than 5 VBB

Medical officers (n = 11)

Midwives (n = 29)

Total (n = 40)

4 (36%) 7 (63%) 40.6 (22–70) 12.4 (1–45) 7 (64%) 4 (36%)

1 (3%) 28 (97%) 45.5 (29.70) 16.7 (1–40) 10 (35%) 3 (10%)

5 (13%) 35 (88 %) 44.2 (22–70) 15.5 (1–45) 17 (43%) 7 (18%)

Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002

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major themes and independently wrote a memo style account of their interpretation of the responses. Following this, the research group came together to discuss these memos and reflect as a group. Given that the responses were typically brief there was a large amount of convergence of concepts that emerged. Refinement of the interpretations occurred through further discussion to interrogate the major concepts for countervailing opinions and to detect minority views. The final write up of the open-ended responses was then produced and approved by all authors. Results

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Assessment of potential contraindications for VBB Participants identified a number of factors that were contraindicated for VBB based on the RANZCOG guidelines12 (Table 3). The two most recognised RANZCOG contra-indications by all participants were a cord presentation (93%) and suspected macrosomia (73%). Smaller numbers of participants identified a low fetal weight indicating growth restriction (48%) as a contraindicator for VBB. This number increased significantly in the post BABE course survey (78%), despite this not being listed as a contraindicator for VBB in the RANZCOG guidelines. Few participants regarded extension of the fetal head (35% vs 33% post BABE course) as a contra-indicator to VBB.

Sample characteristics and experience in breech management Confidence in diagnosing and facilitating VBB There were 42 maternity clinicians who attended the BABE course, however, only 40 participated in the study and completed the pre-course survey including: eleven (11) medical officers and twenty-nine (29) midwives. Of the original participant group, thirty-eight (38) participants chose to complete the follow-up survey. This included ten (10) medical officers and twenty-eight (28) midwives. The medical officer cohort included visiting obstetricians, and medical officers (doctors) working in the maternity unit at the Hospital. The midwives were registered with the Australian Health Practitioners Regualtion Agency and working as a midwife in the birth suite. Overall, the sample was experienced in the provision of maternity service however their experience with VBB differed by discipline (Table 1). Thirteen participants had worked in maternity services for greater than 20 years and of these, 3 (2 medical officers, 1 midwife) had facilitated more than 20 VBBs, y8 had facilitated less than 5 VBBs in that time. While midwives were slightly older and had more years of experience than medical officers (16.7 years vs 12.4 years), medical officers had observed (64%) and facilitated (36%) more VBB than midwives (35% and 10% respectfully). A total of 68% of all the participating midwives had never facilitated a VBB. Methods of training for VBB Participants had gained experience facilitating a VBB through a number of different types of training represented in Table 2. The most common training for both midwives and medical officers was with anatomical models (83%); followed by lectures (70%) and then simulation learning (57%). A total of 73% of medical officers gained the majority of their training with VBB whilst practising on the job or with models. A smaller percentage of midwives (37%) gained exposure to training on the job, however, had undertaken more formal instruction than medical officers, with models, lectures and simulation learning. Midwives reported more experience in “assisted breech manoeuvres” than medical officers.

Table 2 Methods of training. Training type

Medical Officers (n = 11)

Midwives (n = 29)

Total (n = 40)

With models Lectures Simulation “Hands off the breech” On the job training Assisted breech manoeuvres

8 5 4 6 8 3

25 (86%) 23 (79%) 19(66%) 14 (48%) 11 (38%) 15 (52%)

33 (83%) 28 (70%) 23 (57%) 20 (50%) 19 (48%) 18 (45%)

(73%) (46%) (36%) (55%) (73%) (27%)

Midwives (83%) were more confident diagnosing a breech presentation than medical officers (55%) and only a minority of participants (30%) said that they were “mostly/always” confident in their ability to conduct a VBB prior to the training (Table 4). This was the case for both medical officers and midwives. This is perhaps unsurprising given that many participants were relatively inexperienced in conducting a VBB. In the post-course survey 64% of participants reported feeling more confident in diagnosing a breech and 95% of participants said they felt more confident in their ability to conduct a VBB. Informing women In the pre-course survey 65% of participants said that if a breech presentation was first recognised during labour they would always discuss the option of proceeding with a VBB. This intention increased to 88% in the post BABE course survey (Table 5). When the woman’s preference was for a planned VBB, 70% of participants in the pre-course survey said they always discussed the benefits and risks of CS birth. In the post course survey this percentage increased to 93%. However, when the woman’s preference was for a planned CS, fewer participants 55% said they discussed the risk and benefits of VBB. Following the BABE course, this percentage increased to 88%. Overall, there was a higher intent to inform women following the BABE course. Attitudes towards risk: comparing VBB and CS Overall the results demonstrated that participants believed a VBB was safer than a CS for the mother and that a CS was safer for the baby in the short term. (Table 6). Medical officers demonstrated a 100% belief that the risk of neonatal death was higher with a VBB compared to a CS with only 52% of midwives sharing this belief. In relation to long-term outcomes for mothers and babies, only one participant in the pre-course survey thought planned CS resulted in better long-term outcomes for mothers compared to a planned VBB. Prior to the BABE course, most participants thought planned VBB resulted in better long term outcomes, however this reduced slightly in the post results from pre 63% to post 57% (Table 6). The remainder of participants felt there was no difference and only 5% thought this was the case for babies. After the BABE course, no participants thought planned CS resulted in better long-term outcomes compared to planned VBB for mothers. However, in the post course results, fewer medical officers indicated a VBB had better long term effects for mothers. This reduced from 55% in the pre survey of 55%, to 36% in the post survey results. No participants believed a VBB had better outcomes for babies compared to CS following the course.

Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002

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Table 3 Indicators considered as contra-indicators for VBB based on RANZCOG recommendations. Pre -BABE Course

Cord presentation Suspected macrosomia Estimated fetal weight <2 kgs Extension of head Complete breech, knees flexed, not below buttocks Frank breech Missing data

Post-BABE Course

Medical officers (n = 11)

Midwives (n = 29)

Total (n = 40)

Medical officers (n = 11)

Midwives (n = 29)

Total (n = 40)

10 (91%) 8 (73%) 5 (45%) 5 (55%) 0 (0%)

27 (93%) 21 (72%) 14 (48%) 9 (31%) 3 (10%)

37 (93%) 29 (73%) 19 (48%) 14 (35%) 3 (8%)

9 7 8 7 0

26 (90%) 28 (97%) 23 (79%) 6 (21%) 1 (3%)

35 (88%) 35 (88%) 31 (78%) 13 (33%) 1 (3%)

1 (9%)

1 (3%)

2 (5%)

0 (0%) 1 (9%)

0 (%) 1 (3%)

0 (0%) 2 (5%)

(82%) (64%) (73%) (64%) (0%)

Table 4 Confidence in dealing with aspects of breech management “most of the time/ always”. Pre -BABE Course Survey item

Medical Officers (n = 11)

Midwives (n = 29)

Total (n = 40)

Confident in ability to diagnose a breech presentation. Confident in ability to conduct a VBB Missing data

6 (55%) 3 (27%) 0 (0%)

24 (83%) 9(31%) 0 (0%)

30 (75%) 12 (30%) 0 (0%)

Table 5 Informing women about VBB and CS. Pre-BABE course

If breech presentation recognised in labour, intention to discuss option to proceed to VBB Intention to inform about risks and benefits of CS if Maternal preference is for a VBB Intention to inform about risks and benefits of VBB Maternal preference is for a CS Missing data

Medical officers (n = 11) 6 (55%) Always Most of time 3 (27%) Sometimes/rarely 2 (18%) 9 (82%) Always Most of time 2 (18%) Sometimes/rarely 0 (0%) 7 (64%) Always Most of time 4 (36%) Sometimes/rarely 9 (0%) 0 (0%)

Post -BABE course Midwives (n = 29)

Totals (n = 40)

20 (69%) 6 (21%) 3 (10%) 19 (66%) 14 (4%) 6 (21%) 15 (52%) 9 (31%) 4 (14%) 0 (0%)

26 (65%) 9 (23%) 5 (3%) 28 (70%) 6 (15%) 6 (15%) 22 (55%) 13 (33%) 4 (10%) 0 (0%)

Medical officers (n = 11) 9 (82%) 1 (9%) 0 (0%) 10 (91%) 0 (0%) 0 (0%) 9 (82%) 1 (9%) 0 (0%) 1 (9%)

Midwives (n = 29) 26 (90%) 2 (7%) 0 (0%) 27 (93%) 1 (3%) 0 (0%) 26 (90%) 2 (7%) 0 (0%) 1 (3%)

Total (n = 40) 35 (88%) 2 (5%) 0(0%) 37 (93%) 1 (3%) 0 (0%) 35 (88%) 3 (8%) 0 (0%) 2 (5%)

Table 6 Clinician’s Views: Comparison of risks between VBB and CS. Pre-BABE course

Maternal death

Maternal morbidity

Neonatal death

Neonatal morbidity

Long term outcomes for mothers

Long-term outcomes for babies

Missing data

VBB has higher risk than CS CS has higher risks than a VBB No difference VBB has higher risk than CS CS has higher risks than a VBB No difference VBB has higher risks than CS CS has higher risks than VBB No difference VBB has higher risks than a CS CS has higher risk than a VBB No difference CS better than VBB VBB better than CS No difference CS better than VBB VBB better than CS No difference

Medical officers (n = 11%) 3 (27%) 4 (36%) 4 (36%) 1 (9%) 7 (64%) 3 (27%) 11 (100%) 0 (0%) 0(0%) 9 (82%) 0 (0%) 2 (18%) 1 (9%) 6 (55%) 4 (36%) 1 (9%) 3 (27%) 7 (66%) 0 (0%)

Post-BABE course Midwives (n = 29) 2 (7%) 22 (76%) 5 (17%) 2 (7%) 22 (76%) 5 (17%) 15 (52%) 4 (14%) 10 (35%) 17 (59%) 4 (14%) 8 (28%) 0 (0%) 19 (66%) 10 (35%) 1 (3%) 7 (24%) 21 (72%) 0 (0%)

Total (n = 40 5 (13%) 26 (65%) 9 (23%) 3 (8%) 29 (73%) 8 (20%) 26 (65%) 4 (10%) 10 (10%) 26 (65%) 4 (10%) 10 (10%) 1 (3%) 25 (63%) 14 (35%) 2 (5%) 10 (25%) 28 (70)% 0 (0%)

Medical officers (n = 11) 2 (18%) 3 (27%) 5 (45%) 1 (9%) 5 (45%) 4 (36%) 9 (82%) 0 (0%) 0 (0%) 2 (18%) 0 (0%) 0 (0%) 0 (0%) 4 (36%) 6 (55%) 0 (0%) 0 (0%) 10 (90%) 1 (9%)

Midwives (n = 29) 1 (3%) 22 (76%) 5 (17%) 1 (3%) 24 (83%) 3 (10%) 20 (69%) 2 (7%) 5 (17%) 27 (93%) 2 (7%) 7 (24%) 0 (0%) 19 (66%) 9 (31%) 8 (28%) 0 (0%) 20(69%) 1 (3%)

Total (n = 40) 3 (8%) 25 (63%) 10 (25%) 2 (5%) 29 (73%) 7 (18%) 29 (73%) 2 (5%) 5 (13%) 29 (73%) 2 (5%) 7 (18%) 0 (0%) 23 (57%) 15 (38%) 8 (20%) 0 (0%) 30 (75%) 2 (5%)

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Open ended questions Nearly all participants (39/40) responded to the open-ended question “How do you feel when a woman wants to have a vaginal breech birth against recommendations?” Responses were brief and typically single sentences, or several short phrases. Despite the brevity of these responses, two over-arching concepts were clear: (1) Clinician nervousness about VBB; but also, (2) A willingness to support a mother and her choice. From the attitude of support, several related themes emerged: (3) An expectation that a woman’s choice must be an “informed choice”; (4) The perceived primacy of giving information about the risks of VBB as part of ensuring the woman makes an informed choice; and (5) Recognition that obstacles might impact her choice (particularly clinician inexperience, or a lack of support from key clinicians). These findings are elaborated below. Clinician nervousness The words “nervous”, “worried”, and “anxious” were used by 15/40 (37.5%) participants to describe their feelings. The underlying reasons reflected insecurity about their inexperience and confidence, concerns about staffing in the organisation, or more specifically the risk of poor outcomes from a VBB, for example: Nervous as I have limited experience (P.6) Anxious! Need a skilled clinician (P.37) Nervous, some anxiety. Worried about potential negative outcomes (P.28). Importantly, many participants who felt nervous or anxious still expressed their support for a woman who chose a VBB against recommendations: Worried and concerned, but willing to work with the mother (P.9) Nervous but will support it (P.31). Willingness to support the mother and her choice Many participants (40%) expressed support for the woman choosing to have a VBB despite recommendations against it, and some described positive feelings of happiness for the woman, for example: Happy she is making her own choices (P.23); Happy to support (P21); Empowered for the woman (P.4). Some specifically identified being “encouraging” and “supportive”, implying their active facilitation of a woman’s choice was more than simply “approving”. Several participants reserved judgement about supporting a VBB “against recommendations” given that they did not have enough information about why it was not recommended; they appeared to want more clarification about the particular risks. Nevertheless, these participants still indicated support for a woman’s “informed choice” to have a VBB against recommendations: Depends on why against recommendation but I strongly believe in support for a woman’s informed choice. (P.26) Indeed, it was common for participants who expressed support for a woman choosing a VBB to insist that this choice was “informed”. Informed choice A number of participants (25%) specifically talked about their willingness to support a woman making an “informed choice” or “informed consent” to a VBB. Respondents were willing to support

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the woman providing they believed the woman’s choice was informed. It was apparent that many participants were supportive of whatever choice a woman might make. Within this, risks were a salient intertwining feature and for many of these participants it was clear they considered an informed choice to be one that was not blind to the risks of having a VBB: As long as woman has informed consent and understands risks/ benefits then I will support her (P.25) If a woman has been well informed of the risks, she has a right to choose. (P.2) Talking about risks There was clear importance placed on ensuring that women take into consideration the “risks” of VBB when making an informed choice. There was almost no mention of the benefits of VBB or the risks of VBB in comparision to other options such as CS. What also emerged was different ways of talking about risks with women. For some participants the important thing was to “give information” to women about the risks, particularly by referring to professional guidelines and other pieces of “evidence”: Have to give evidence based information (P.19); As long as she has received adequate unbiased appropriate information (P.39). Others saw their role in more value-laden terms, for example that women should be “cautioned” about risks. In contrast, other midwives framed this discussion of risks in a facilitative way, for instance: Supportive, encouraging, education about risks (P 15). The phrases “education about risks” and “understand risks/ benefits” were expressed with the suggestion that the midwife was actively facilitating the woman’s understanding of the risks and with the woman being an active participant in the process, more so than simply “giving information” or “cautioning”. Rarely was there mention of asking women about what was important to them; what questions she might have; or trying to understand what the woman’s expectations were. Only one participant said they were: Interested to know her rationale (P 40). Obstacles Some midwives identified organisational obstacles to supporting a woman’s choice for VBB against medical recommendations, including inexperience among the staff: We have not great experience with breech birth here, doesn’t happen often enough for increase in skills (P 1). Other concerns were raised including whether a VBB would impact existing conditions in the birth suite; lack of access to 24-h operating theatre; and, a lack of support from some doctors: Concerned about staffing, some Dr’s supportive, some not (P 28). Discussion In this study we investigated the experience, knowledge and attitudes of clinicians about breech management, VBB and CS. We also explored participant willingness to inform women about care options when a woman presents with a breech presentation at term and seeks a VBB against medical recommendations. The findings indicated that the prospect of a woman opting for a VBB made many midwives and obstetricians nervous. Participants demonstrated a high degree of caution when assessing risk factors

Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002

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that contraindicate recommendations for VBB. Most clinicians were of the view that there was a higher risk of neonatal morbidity and mortality associated with VBB compared to CS birth before undertaking training. Clinician confidence in facilitating all aspects of breech management increased after the BABE training course and participants held a strong view in support of respecting women’s choice to have a VBB. Participants identified potential barriers to enabling choice through organisational policy and hesitation from clinicians in deciphering informed decision making practices of the woman at a time of stress and vulnerability. Barriers also presented from clinicians where the capacity to upskill or maintain the knowledge and skill of VBB in practice was limited. Clinical experience Our findings concur with literature that suggests maternity clinicians have become deskilled in managing VBB, particularly midwives despite it being viewed as a normal birth option for women.13,19–21 While some clinicians had several years’ experience of working in practice the survey data reveals that clinicians were relatively inexperienced with vaginal breech birth. Midwives who had in excess of a decade of experience had facilitated relatively few VBBs. Generally, medical officers had more experience in facilitating a VBB than the midwives. Minimal evidence exists to guide the definition of an ‘experienced’ clinician.22 Research suggests that obstetric and midwifery clinicians exposure to facilitating a VBB has dwindled.23–26 This negatively impacts clinician confidence and preparedness to facilitate a VBB resulting in the risk of intervention more likely to proceed.27 In the TBT, clinicians self-assessed their experience and only a statement provided by their department head confirmed individuals experience.28 Others highlight how experience was traditionally determined by many years of working within maternity service provision29 however, this is not a proven indicator for experience with VBB. Within our cohort there was a diverse range of VBB experience. Of the 13 participants that had worked in maternity services for greater than 20 years, 3 had facilitated more than 20 VBB, and 8 had facilitated less than 5 VBBs in that time. As Sloman et al. reccommended, there should be greater opportunity, particularly for midwives, to be mentored with more experienced practitioners and clinical guidelines should clearly outline the role of the midwife in facilitating VBB in practice.21 This study concurs with our findings in relation to the deskilling and need to provide opportunity for midwives and doctors to be more experienced in VBB. Equally, time in employment does not demonstrate a clinician’s confidence nor desire to support VBB. One Australian study investigated the experience, confidence, and intentions of trainee obstetricians regarding vaginal breech birth delivery upon completion of their speciality training.24 It found that trainee obstetricians experience with VBB increased as they progressed through their years of training however, their confidence levels remained low and with 11% expressing an intention to support VBB as part of their ongoing practice.24 Our findings identified a low level of confidence 30% in conducting a VBB in the pre-course surveys, however following the BABE training this rose to 95%. More recently, the concept of “expertise” has been defined as having an “ongoing function, to generation of comparatively good outcomes, confidence and competence among colleagues”22 (p.207). Walker, Parker and Scamell, suggest that while experience is important, clinical expertise develops as clinicians take on other social roles that support the development of experience for example, roles such as mentoring, specialist and even experise in breech birth.22 Developing expertise within a service requires a commitment from within the service to support individuals who

demonstrate interest in becoming a breech expert, to work within these roles and within a specialist breech birth team.24 The stimulus, interest and support in terms of funding for the BABE training came from the Director of Obstetric services at the study hospital site. The intention was to build a strong culture of support for increased options for women and a centre of excellence with clinicians and midwives working collaboratively and skilled in diagnosing and facilitating a VBB for women which, is encouraging. Evidence demonstrates that a breech presentation can follow a natural physiological process to birth vaginally and unaided,21,30 which is similar for when a baby presents with a cephalic presentation.10,12,31 However, with both of these presentations, there remains potential for complexity to occur, generating the need for skilled assistance to promote positive outcomes. In Australia, it is mandated that health professionals participate in continuing professional development, preferably via simulation training to maintain skills in managing these types of events,32 however this tends to be focused on cephalic presentations. We argue, annual training be inclusive of VBB including physiological breech birth with a ‘hands off the breech’ approach. Literature suggests that minimal handling of the breech fetus during a VBB is recommended to avoid a reflex extension of the arms and head, which can result in further complications during VBB.33 Anecdotally most training tends to focus on active management of the second stage of labour for when there is delay in decent of the fetus during a breech birth.34 Our study found that only 50% of the participants had engaged in “hands off the breech” training prior to undertaking the BABE course. Further, medical officers had more “on the job” training and experience therefore had more opportunities to practice VBB than midwives. Further research into the positioning for VBB between medical officers and midwives and associated birth outcomes would be of interest. Informing women The World Health Organisation, highlights the need for all women to have access to, and receive, respectful care when giving birth to promote positive birth experiences.35 A key aspect to achieving this standard is ensuring women receive unbiased, evidence based information so they can make an informeddecision and then give their consent to care choices offered.36 The timing and way in which clinicians provide information are key to ensuring respectful care experiences and informed decisionmaking by the woman.36 Our data indicates a strong support and respect of the choice of the woman wanting a VBB however recognised that there were often challenges by other staff on duty e.g. doctors, and the organisational policies surrounding safe maternity care, such as the conditions in the birth suite and access to theatre in the case of an emergency. In Australia, the dominant management approach for woman who present with a breech presentation at term is CS, even if the woman has birthed a full term fetus vaginally previously.1 A woman’s expressed desire to have a VBB can frequently be dismissed in favour of institutional and professional preferences.37 Our data indicated that inconsistencies existed in the provision of information to enable women to make an informed choice about the risks and benefits of both VBB and CS. The confidence of both midwives and obstetricians increased after the BABE training course to provide information to support women to make an informed choice about VBB and in preparedness to facilitate VBB. The complexity of ensuring informed choice identified in our data is supported in the literature where clinicians provide information to women who may quickly become embroiled in a complex medicalised culture to seek “permission” for herself to continue with a physiological birthing process.38,39

Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002

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In Australia, maternity service providers espouse to offer informed choice relevant to women’s individual circumstances.40 To support this, clinicians need to ensure they maintain current and up to date information that can be shared with the woman in a factual and non-biased manner to enable true informed choice. Our study supports the need for ongoing training that is inclusive of processes to enable clinicians to discuss and engage women in informed decision making practices. Australian medical guidelines recommend all women with a breech presentation at, or near term should be informed about birth options including VBB or CS.12 Our data demonstrated that not all midwives or obstetricians informed women of all treatment options even though they expressed this was the ideal. This is consistent with research which demonstrates women were given minimal information, and information biased by the personal view of the clinician instead of evidence-based information.38 The post BABE education survey indicated an improvement in intention to engage women about choices relevant to their individual circumstances. There was a connection between recency of education and training, confidence in VBB and the inclusion of information and choices for women. The BABE training course included education for participants on how to counsel women if concerns arise when the women is in labour.17 It also engaged participants in interactive learning to practice the process of counselling women about options for breech management at term. Following the BABE training course, the majority of participants stated they would “always” discuss birth options with women. This demonstrates the importance of this type of training to enable open discussion that can enable women’s choice. A core component of shared decision-making is the provision of unbiased information to women about the risks and benefits of all their health care options.36 However, clinician bias towards treatment options can undermine this and clinician bias is not always overtly conscious nor does it necessarily take the form of exaggerating benefits or downplaying risks.36,41 Elements of this concept are evident in the pre-course survey question which asks participants about risks and benefits of planned caesarean birth versus VBB. For example, when a woman’s preferred option was to have a CS birth, only 55% of clinicians in our survey said that they would ‘always’ inform the woman about the option of VBB. In constrast, when a woman’s preferred option was to have a VBB, 70% of staff stated they would ‘always’ discuss the option of CS. There may be several factors contributing to this difference. One interpretation could be that when the woman’s choice aligns with that of the clinician and the organisational preference, the clinician may see little reason to discuss other options. When preferences do not align, then clinicians may be more motivated to make the woman more aware of the clinician’s preferred option. We did not ask participants to explain their reasons for explaining risk and benefits of one management option over the other, further research is required in this space. Importantly, most participants in our study showed a strong commitment to woman centred approaches for a VBB and respect for the woman’s choices providing her choice was an informed choice that took into account all the risks of VBB. How they planned to determine this was not made clear.

A core component of shared decision-making is the provision of unbiased information to women about the risks and benefits for all their health care options.36,41 Clinicians can inadvertently (be it conscious or not) develop bias towards treatment options due to negative perceptions of risk, safety and fear of litigation which undermines the principal of informed decision making and respectful maternity care.44,45 Kumar-Hazard, highlights how “care providers can violate, disrespect thus discriminate against women’s human rights under the guise of supporting the woman to make an informed decision; for example, by expressing “concern for the fetus or profess to speak on behalf of the fetus when discussing treatment options”37 (p. 52). Findings from our study demonstrated that clinicians were nervous, worried and fearful for the woman and her unborn baby’s safety when they sought a VBB against medical recommendations. This fear related to perceptions of risk and safety in relation to: a belief that there were inadequate numbers of skilled clinicians available within the unit who could support a VBB; the possibility of medical professionals not supporting the woman’s choice; personal perceptions of inadequate knowledge and experience of facilitating a VBB and concern that informed decision-making may not have occurred for the women. Several studies have found that external influences impact practitioners perceptions of risk when caring for women in labour.39,46,47 This includes internal and external factors within maternity service provision in which individual practitioners may have limited control over for example, protocols, guidelines and assigned and assumed responsibility for decision-making. Strict clinical guidelines and protocols can perpetuate and increase the perception that birth is a high risk event.39,46,47 One study that investigated facilitators and barriers to decision-making by midwives during labour, found that despite midwives being experienced in both midwifery and obstetric led models of care, working under strict hospital guidelines caused them to distrust the women’s ability to birth naturally and stimulated them to promote strict adherance to guidelines,46 thereby limiting women’s access to choice during childbirth.

Our study found that clinicans were relatively inexperienced in facilitating a vaginal breech birth at term. While the prospect of a woman opting for a VBB against medical recommendations generated feelings of nervousness and worry in clinicians, strong support for the respect of women who choose to have a VBB remained a priority. Potential barriers to enabling a woman’s choice and access to a VBB include clinicians lack of knowledge and confidence to discuss: all breech birth management options with women; the risks and benefits for VBB and CS; the perception of limited support from medical officers and skilled or experienced clinicians who can facilitate a VBB. Undertaking specialised breech birth training such as the BABE training course can increase clinicians confidence in their ability to discuss all breech management options with women, increase confidence to facilitate a VBB, and increase intention to discuss with women all breech birth management options at the end of pregnancy.

Risk, fear and informed decision-making

Recommendation

Literature highlights how the medical model of birth “encourages women to view birth as inherently risky for both the mother and baby”42 (p. 45). This can increase fears about childbirth among women, but also midwives, medical professionals and policy makers who are driven to mitigate risk to avoid litigation.42,43 Increasing the focus on risk can increase women’s fear about risks and thus reduce women’s ability to trust their bodies to proceed with the normal physiological processes of birth.43,44

The provision of specialised breech birth training and its benefits on a regular basis is recommended to promote change and support of clinicians who can provide more choice for women and increase the availability of skilled clinicians who can facilitate a vaginal breech birth. More research is needed to explore the sustainablity of having breech birth specialist teams and the clinicians reasons for only explaining one management option over another.

Conclusions

Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002

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Limitations The sample size was small and limited to staff from one hospital in Queensland. The data captured is the experience of one BABE education group and not a more widely distributed group of clinicians from a variety of health services or demographic areas. Changes to the wording of the open ended questions asked may have provided greater insight into the experience of participants or the inclusion of a focus group may have enabled more depth of understanding from the participant group. Ethical statement This study was reviewed by The Prince Charles Hospital Human Research Ethics Committee Office. It was deemed compliant with NHMRC guidance on “Ethical Considerations in Quality Assurance and Evaluation Activities” (HREC/17/QPCH/447), on 13th December 2017. Conflict of interest statement We declare that there are no known conflicts of interest to declare for this paper. Funding None declared. Acknowledgments We wish to thank the midwives and medical professionals who participated in this study and who spoke honestly and openly in their responses. References 1. Australian Institute of Health and Welfare (AIHW). Austrlian mothers and babies 2015 in Brief. Canberra: Australia AIHW; 2017. p. 1–62. 2. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356:1375–83. 3. Kotaska A, Menticoglou S, Gagnon R. Vaginal delivery of breech presentation: SOGC clinical practice guideline. J Obstet Gynaecol 2009;31:557–66. 4. Miller S, Ablalos E, Chamillard M, Clapponi A, Colaci D, Comande D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016;388:2176– 92. 5. Deans CL, Zoe Penn Z. Review the case for and against vaginal breech delivery. Obstet Gynaecol 2008;10. 6. MJNC Keirse. Evidence-based childbirth only for breech babies? Birth 2002;29:55–9. 7. Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;195:20–5. 8. Tharaux G, Carmona E, Bouvier-Colle M, Breart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynaecol 2006;108:541–8. 9. Doyle NM, Riggs JW, Ramin SM, Sosa MA, Gilstrap LC. Outcomes of term vaginal breech delivery. Am J Perinatol 2005;22:325–8. 10. Alarab M, Regan C, O’Connell M, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Am Coll Obstet Gynaecol 2004;103. 11. Organisation for Economic Co-operation and Development. Health at a glance 2017. Paris: OECD Indicators; 2017. 12. Royal Australian College of Obstetricians and Gynaeloclgists (RANZCOG). Management of breech presentation at term. Australia: RANZCOG; 2016 p. 13. 13. Homer CSE, Watts NP, Petrovska K, Sjostedt CM, Bisits A. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 2015;15. 14. Catling C, Petrovska K, Watts N, Bisits A, Homer CSE. Barriers and facilitators for vaginal breech births in Australia: clinicians experiences. Women Birth 2015;29:138–43.

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Please cite this article in press as: J. Rattray, et al., Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.002