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Women's and providers’ experiences of breech presentation in Jamaica: A qualitative study
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International Journal of Nursing Studies 44 (2007) 1391–1399 www.elsevier.com/locate/ijnurstu
Women’s and providers’ experiences of breech presentation in Jamaica: A qualitative study Sandra A. Founds Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania 15261, USA Received 20 May 2005; received in revised form 11 July 2006; accepted 13 July 2006
Abstract Background: Most research on breech relates to medical management of the malpresentation. Little is known about women’s or providers’ experiences of breech, an obstetrical complication. Objectives: This study aims to increase the understanding of women’s and providers’ experiences of breech presentation and to understand the effects of context on these experiences. Methods: A qualitative descriptive research was conducted in a rural health district of Jamaica. Nine postpartum women who birthed singleton live born breech infants in the past year and five experienced obstetric care providers consented to participate. Content analysis was conducted with data from one-time interviews, observations, and hand searches of maternity ward delivery logs. Member checking was conducted with successive participants and Jamaican health care providers. Results: Findings included realizing the baby was breech, interpreting what breech meant, reacting to breech presentation, and identifying the impact of breech. Rates of breech births were less than 1%. Conclusions: Symbolic interaction can guide nursing and midwifery education, practice and research of breech presentation. Nurses and midwives can identify and teach women and their significant others about breech and its risks. r 2006 Elsevier Ltd. All rights reserved. Keywords: Breech; Jamaica; Malpresentation; Providers’ experience; Qualitative descriptive women’s experience
What is already known about the topic?
Previous research of breech malpresentation and its
management focused on medical interventions.
clinical practice and research of breech pregnancy care. Symbolic interactionism emerged from the findings as a framework to guide nurses’ and midwives’ practice in helping women to construct meaning and to cope safely with breech.
What this paper adds
Women’s
and providers’ experiences of breech presentation in Jamaica provide a basis for improved
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1. Introduction Breech presentation with the infant’s buttocks down in the maternal pelvis causes concern to nurses, midwives, and physicians who care for pregnant women in every country because breech is considered a malpresentation
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that increases maternal–infant morbidity and mortality (Cunningham et al., 2001; Oxorn, 1986). Cord prolapse below the presenting fetal buttocks antenatally or during labor can lead to fetal hypoxia and asphyxia (Erkkola, 1996; Oxorn, 1986). The after coming fetal head may be trapped in an incompletely dilated cervix, resulting in obstructed labor that can lead to maternal and infant mortality (Ullery, 1967). Obstetric care providers have searched for interventions to avoid these risks. The Term Breech Trial, a large multicenter RCT conducted in 26 countries, found more severe morbidity and mortality for infants whose mothers were randomized to planned vaginal breech birth than those randomized to planned cesarean delivery (Hannah et al., 2000). Since that trial was published, external cephalic version (ECV; manually turning the infant to head down presentation through the mother’s abdomen) and planned cesarean delivery have become preferred management strategies for breech presentation in some countries (American College of Obstetricians and Gynecologists, 2001; Rietberg et al., 2005; Phipps et al., 2003). These interventions, however, pose further risks to women and infants (Coco and Silverman, 1998; Hofmeyr and Kulier, 2005). Few lowerrisk interventions for breech management have been supported by research. The acupuncture technique of moxibustion significantly increased antenatal cephalic version in Chinese primiparas (Cardini and Weixin, 1998), but may not be accessible to all women pregnant with breech presentation. 1.1. Experiences of breech While most research has focused on medical management of breech as an obstetrical complication, little is known about women’s or providers’ experiences of breech. Structured interviews conducted in a Japanese clinic elicited responses to a questionnaire about pregnant women’s attitudes toward ECV and breech delivery (Leung et al., 2000). Recently, Fok et al. (2005) investigated Chinese women’s experience of pain during ECV. Physicians’ reasons for nonparticipation in a trial of preterm breech delivery included concerns about time commitment and workload of consent procedures, adequacy of consent by non-English speaking clients, providers’ skills with breech deliveries, liability, and research design issues (Penn and Steer, 1990). These previous studies focused on experiences of or attitudes toward breech management options rather than subjective experiences of pregnancy complicated by breech malpresentation. Learning about women’s and providers’ experiences of breech may provide better understanding for clinical care and research. The current study was conducted in Jamaica to explore the effect of context on experiences of breech. Women and providers may view the complication differently in a setting where
fewer resources are available for routine ECV or cesarean delivery for malpresentation (Erskine, 2001). The findings presented in this paper were part of a larger study conducted to investigate how experiences of breech presentation might affect participation in research on a lower-risk intervention for breech. The research aims included increasing understanding of women’s and providers’ experiences of breech presentation and examining the context of these experiences in rural Jamaica.
2. Methods 2.1. Design Qualitative descriptive research design provides straightforward information about an event or a service with less emphasis on interpretation or abstraction than other types of qualitative methods (Lincoln and Guba, 1985; Sandelowski, 2000). This qualitative descriptive study included semi-structured interviews, observations, and birth log reviews. I recorded my observations of participants, their friends and families, participants’ environments, and community, clinic and hospital settings where interviews occurred. I hand-searched 3 years of hospital maternity ward birth logs for rates of breech deliveries. 2.2. Setting/entre´e The study occurred in one of the most rural of the 14 Jamaican parishes. Approximately 91,000 people inhabit 286.8 mountainous, shore-lined square miles (Ministry of Health Jamaica, 2002) where fishing and agriculture are the major economic bases for one of the lowest income parishes of the island. In 2001, 67.65% of the school-aged population in the poorest quintile was enrolled in school (Ministry of Health Jamaica Annual Report, 2001). Winding, ill-repaired roads make slowgoing travel. Health personnel often travel by taxi as far as the road will allow, then walk unpaved roads and steep rocky paths to reach rural clients. Some community dwellers live without plumbing, carrying clean water to the house from local standpipes and using pit latrines in their yards. Four health districts comprise one health department in this Jamaican parish. A single campus houses the hospital, public health administration, and housing for medical personnel. The Senior Public Health Nurse administers 17 health centers staffed by 11 public health nurses, 37 community health aids, and four peer educators. One public hospital with 88–118 beds needs 10 doctors, but runs with 4, and 1 or 2 nurses run the 30-bed wards. The Senior Medical Officer of the hospital struggles ‘‘with budget cuts from nothing to cut from’’
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Hospital nurse administrators reported severe nursing shortages as nurses emigrate to Canada, the UK and the US. A few physicians run private practices in the parish. In the previous 9 years, I coordinated an annual crosscultural nursing program from a university in the northeastern US with health care personnel and community members in this Jamaican parish. I am licensed as an RN in Jamaica. Collegial relationships with health care personnel and understanding of the health care system facilitated my contacts with participants for this study. Ethical review systems are rapidly developing in Jamaica, but at that time, no research ethics committee existed locally; therefore, approval to conduct the study was obtained from my university in the US, the Jamaican hospital’s Senior Medical Officer, and the Health District Medical Officer before data collection began. Referrals and independent contacts led to interviews with women and providers. Nurses and midwives connected me with mothers who had recent breech births. Community health workers accompanied me directly to the homes of three women. I requested interviews with midwives and doctors who attended breech deliveries logged in the hospital maternity ward register or who were referred to me because they were regarded as ‘‘experienced’’ by newer obstetric care providers. Verbal consent for interviews and observations was obtained with assurances of anonymity and confidentiality in data analysis and any verbal or written reports. Specific consent for audiotaping was elicited. I was approved by my university’s review board and Jamaican health officers to consent all participants in a consistent verbal format, rather than written, to avoid distancing myself from any participants who may have been illiterate. Interviews occurred in private settings, unless requested otherwise by the participant. Women were interviewed in their homes, their yards, or in postpartum clinics. Women received baby care items as a thank you gift. Providers were interviewed in their offices at the hospital or clinics. 2.3. Sample Purposive sampling conducted in January 2004 recruited nine Jamaican women who birthed singleton live born breech infants at the local community hospital within the year and five obstetric care providers. Primiparous participants were two 18-year-olds and one 34-year-old woman. Six multiparous women participated, ranging from 24 to 38-years-old and each having three–five children. Every woman held and interacted with her baby during our interview. The provider participants were two physicians, two hospital nurse midwives, and a district nurse midwife. An obstetrician had worked in her specialty for 9 years.
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The second physician is a generalist who covers all types of patient’s in hospital. He and the nurse midwives all reported 20 or more years of practice experience. All participants are referred to by pseudonyms. 2.4. Procedures Semi-structured interviews included the following open-ended questions. What was your experience of breech presentation? What were your experiences of interventions for breech? If participants’ answers did not contain details, I probed further, such as, what did you understand that breech meant? Providers were asked what they told women about the diagnosis and management options. Interviews lasted an average of 45–60 min, until the participant offered no new information and I had no more questions for them. Interviews were audiotaped for 11 of 14 participants. One woman and one provider preferred not to be audiotaped. A second woman asked to interview by telephone rather than meeting. Extensive notes were used to record data that were not audiotaped. I wrote field notes after each interview and a reflective journal throughout all phases of the research project. Data were de-indentified and coded by a number assigned to each participant. I stored the participant’s name, contact information and demographic data separately from the data in my locked room in Jamaica and locked office file in the US. I transcribed the interviews; no one else accessed the data. Tapes and participants’ information were destroyed after data analysis was completed. 2.5. Data analysis Content analysis was conducted with data from interviews, field notes, and journal entries written during data collection (Bogdan and Biklen, 2003; Miles and Huberman, 1994). After I transcribed the interviews, I read transcripts to verify accuracy with tape-recorded interviews, reread for overall sense of each interview, and then reread noting initial codes. I used Atlas.ti 5.0 for coding and categorizing codes; the software logs analytic steps. I developed themes from analysis within and between code categories. Verification during analysis and interpretation included discussions of my evolving findings with the Senior Medical Officer, the District Medical Officer, and an academic nurse midwife in Jamaica, January 2005. Discussions occurred with qualitative methods expert advisors and research seminar colleagues in the US.
3. Findings Parallel themes emerged from the women and providers experiences of breech presentation: realizing
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the baby was breech, interpreting what breech meant, reacting to breech presentation, and identifying the impact of breech. 3.1. Women’s experiences of breech presentation 3.1.1. Realizing the baby was breech Women realized the baby was in breech presentation during antenatal appointments or when they were examined in labor. All women reported attending regular antenatal clinic visits and going to the local hospital for their births. All learned about the diagnosis of breech from a nurse midwife or doctor. Some participants experienced physical sensations that led them to suspect that something was different, but they did not realize the sensations were from the baby in breech presentation until the nurse or doctor provided the information. Noreen felt cramps whenever she sat down. Sharon grew suspicious: ‘‘I wasn’t sure if his head was down or not. The feeling I had down here, it wasn’t a head feeling, it feel more like kicking, it didn’t feel like his head was down there at all.’’ Five of nine participants knew before going into labor that the baby had turned to breech presentation. Anna was the only primipara who was aware of breech presentation antenatally because she had a few ultrasounds for fibroids, low-lying placenta and malpresentation, as she was the only participant in the study who received obstetric care in the city 2 hours from her rural home. Four of the six multiparas realized the babies were breech from provider’s information at antenatal appointments. Four women were told that the baby’s head was down at their last antenatal visits, then learned their babies were presenting breech in labor. A multipara explained, ‘‘I did an ultrasound (at) 7 months his head had turned down, but when I went for delivery, his head was up so, he breeched. Born footway.’’ 3.1.2. Interpreting what breech meant The women’s experiences were affected by their interpretation of ‘‘breech.’’ Information about what breech meant came from personal obstetric histories, obstetric care providers, family members, and friends. Understanding what breech meant included interpretations of normalcy, risk, and cultural beliefs. Information from nurses, midwives, and doctors helped women make sense of what breech presentation meant. Women knew breech or ‘‘footway’’ meant, the baby birthing feet and buttocks first rather than head first. They generally understood that breech presentation was not normal during pregnancy, although some women who were not diagnosed until labor were unaware of the meaning of breech until after delivery.
For example, a young primipara had not known what breech meant until the nurse told her after delivery that it was life threatening for the baby. Women understood that breech presentation might require other than usual treatment during delivery. Some of them were told by a nurse that the doctor would have to deliver the baby instead of the midwife. Breech presentation diagnosed antenatally in primiparas meant that cesarean section would be planned for delivery. The older primipara remained scheduled for cesarean because of breech presentation after the issues of her fibroids and low-lying placenta resolved. She was adamant that she did not want a cesarean; even though her doctor told her it was ‘‘a mmmmust!’’ Multiparas interpreted breech relative to their own previous births. Sharon interpreted her experience of vaginal breech birth by comparing it with her two previous deliveries with the baby’s head down, thinking that her breech baby had to be pulled out by the doctor because the baby could not push his way out with his bottom instead of his head. Betty and Anita both had breech births prior to their recent deliveries. Although they acknowledged that breech is not normal, they did not define breech as a problem for themselves in their second breech pregnancies because, their first breech births progressed without problems. People in women’s social networks relayed to the women that breech presentation posed life-threatening risks for mother and baby. Betty heard, ‘‘They said it can cost your life my brother told me that earlier. And I heard lots of people talk about it.’’ Women knew that chances of cesarean increased as Sharon mentioned, ‘‘like most people always talking that it is harmful because mainly you have to get cut.’’ Participants were told by family or friends that babies born ‘‘footway’’ had lots of complications or were ‘‘born dead.’’ Cultural beliefs about breech presentation also came through information from social networks. Participants found the beliefs more or less true in their own experiences. Dorothy reported that she had never heard of breech ‘‘until having it now’’, and offered that ‘‘when they get big (they’re) rude my mother told me, (they’re) rude when (they’re) born breech baby.’’ Rude meant, ‘‘like they cry a lot and give a lot of trouble, and so.’’ Noreen heard that, ‘‘they walk up and down, like when they get big, they always love to walk because they walk home. That is, many people always talking.’’ Anita was told that ‘‘most times, breech babies are born with eczema.’’ 3.1.3. Reacting to breech presentation Women reacted with thoughts, feelings, and actions in response to realizing, and interpreting the fact that their babies were breech before or during labor. Some participants did not think or feel ‘‘any way’’ about the malpresentation, while others were fearful or worried.
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The experience of birthing a breech baby was unremarkable for some, but terrible for others. Most participants were afraid or scared knowing that the baby turned to breech presentation. Realizing the diagnosis and interpreting breech as a life-threatening risk that might require cesarean delivery frightened women. Anna was ‘‘scared after delivery,’’ once she realized that, the difficulties ‘‘getting the baby’s shoulders out could have cost her (baby’s) life.’’ Conversely, Anita ‘‘was never scared’’ about breech. The young primiparas were not afraid because, they didn’t know what ‘‘footway’’ meant until after the babies were born. Karan claimed she would have been afraid during labor, if she knew that breech could be life threatening. A few women reacted about terrible pain that ‘‘vexed’’ them in vaginal breech birth. Compared with her previous cephalic-presenting births. Dorothy exclaimed, ‘‘The third one here was the hottest I thought, I was going to die! So much pain!’’ For Sharon, ‘‘Was terrible, ya know, the pain is much hotter, and so I spit and holler. The pain was hot terrible.’’ Although Anita was easy going about her labor contractions, she reported the baby’s delivery as painful. Women reacted with worries for babies with problems. Dorothy’s daughter was in an incubator immediately postpartum, but the baby’s condition did not delay their discharge from the hospital. What Dorothy understood was that the baby swallowed water during birth, and that ‘‘something bad happened.’’ She thought the baby might have asthma like herself. Yatisha, having been hospitalized for leaking fluid early, felt that ‘‘I wasn’t worrying about the position, I was worrying about if he would live or suffer because he was early.’’ Reactions included behavioral responses to breech presentation. Four women reported prayer as a distinct response, an action separate from what was thought or felt about being pregnant with or delivering a breech baby. Betty cried from fear, and prayed when she was told her first baby turned breech. Dorothy’s description of labor with her breech baby was ‘‘I felt pain like a big knife, andy I said Jesus straight. Yeh and I just put my hand up, so, and just lie down ya know and say ‘Jesus.’y and he stand by and help me. I just lie there, and I make noise and I say ‘Jesus Jesus’ until the doctor come in.’’ Two women labored at home knowing the babies were breech, arriving at the hospital in advanced labor. Betty and Anna both realized their babies were breech antenatally, but spent most of their labors at home. Betty had pains from morning until evening. She arrived at the hospital after 7 pm, and delivered 50 min later. She was pleased that other women on the maternity ward admired how quickly she delivered. Anna was the most
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graphic of the three primiparas about her labor. Although her water broke in the morning, she labored at home doing her hair that day. Her menstrual-like cramps progressed to pains that led her to decide to go to the local hospital in the late afternoon, delivering in the early evening. 3.1.4. Identifying the impact of breech In describing their experiences, the postpartum women identified issues associated with breech presentation that impacted their lives after the babies were born. Participants did not necessarily ascribe causality between breech and its later impact, but mentioned these issues as part of the whole story concerning their experiences of breech presentation. Some babies who had been breech during pregnancy were born with problems that required ongoing medical care. Future reproductive choices may have been affected by the experience of breech presentation. Six women’s babies had problems after birth. Dorothy and Anna’s babies’ problems resolved within a few days after birth, but four babies ills were more chronic or severe. Betty’s clinic nurse knew that the baby appeared to have Down’s syndrome, but stated her role was to refer the mother, and baby to the pediatrician for diagnosis and plan of care; so Betty and her family did not yet know the diagnosis. Yatisha’s baby was diagnosed with ‘‘twisted tripe, part of his tripe was twisted and locked off.’’ They traveled 2 hours to a tertiary center in the city for surgery and follow-up care of his bowel problems. A few women indicated that they would have no more pregnancies after their experiences with breech presentation. Anna was quite emphatic when asked about her next pregnancy. ‘‘No I’m not going to get pregnant again. I want to try all; I’m not going to get pregnant again. No no no no Repeat it No! Scary!’’ 3.2. Obstetric care providers’ experiences of breech presentation 3.2.1. Realizing the baby is breech The five obstetric care providers realized that women’s babies were in breech presentation using clinical assessment skills acquired in training, and practice experience. Three providers who trained in other developing countries before coming to practice in Jamaica found the same protocols between regions, where they trained and practiced. Providers detected breech by palpating the pregnant woman’s abdomen, and they preferred ultrasound to confirm the diagnosis of antenatal breech presentation. Another means of realizing breech was via communication through the health care system.
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Palpations were routinely performed during third trimester antenatal clinic visits, and admission for labor and delivery. Sometimes the diagnosis was difficult to determine, as Nurse Eva explained ‘‘because sometimes they’re not very well-flexed breech, sometimes it’s not readily diagnosed.’’ If a nurse midwife at antenatal clinic determined that the baby was breech, she referred the woman to either high-risk clinic to be assessed by a doctor or directly to ultrasound in late pregnancy. Once breech was identified, it was noted on the woman’s ‘‘docket’’ (chart) and on a blue card that the woman carried with her to communicate between providers at antenatal sites and to the maternity ward staff in the hospital. Ultrasound was not readily accessible because most women in the parish could not afford it. Nurse Yang said ‘‘Usuallyy they take weeks before they go and do the ultrasoundy(it) would cost quite a loty for the ordinary person here. The clinics don’t have an ultrasound machine and they can’t just do it free of charge. They have to go to the private doctors and they payy about 2000 (about $34US) plusythe ultrasound. I think it’s about 2–8 (2800J about $48US)y And not everybody has insurance coveragey some of the placesy don’t take the (insurance)y you have to pay up front and then you’re paid from your insurance, so, maybe that will take some time.’’ The physicians reported that the local hospital had an ultrasound machine for echocardiogram, not suitable for obstetric use, and there was no sonographer. Dr. Talso explained that limited resources required providers to rely on ‘‘clinical knowledge’’ more than ‘‘investigation’’ to deliver medical care in places like Jamaica and the Caribbean. 3.2.2. Interpreting what breech meant Providers interpreted breech presentation as a pregnancy abnormality because the baby is positioned for birthing buttocks first rather than head first, the ‘‘baby is coming by its buttocks.’’ Breech meant increased maternal–infant risks requiring management. Primigravidas with breech known antenatally would be scheduled for cesarean delivery. Providers mentioned that often times, breech presentation could mean underlying congenital pathology. On maternity ward, the midwife admitting the woman in labor palpated to assess the baby’s size, the degree of flexion, the presenting part and stage of labor. Depending on the type of risk factors, the nurse midwives or doctor would manage the birth. If a primipara with undiagnosed breech was admitted in advanced labor, it was too late to perform cesarean section and the
provider managed vaginal breech birth. Nurse Harker described risks in vaginal breech birth. ‘‘You find that it will start coming through and they’ll feel to push, but you have to advise them because you need to wait until because the head is the bigger part that is going to come aftery they’ll have a problem having the head out and they might lose that baby.’’ Providers interpreted the meaning of breech presentation to their patients in order to educate them to work with the labor and delivery process. They acknowledged women’s reactions to the abnormality. ‘‘Well depending on how you tell them too and depending on theiry ability to understand it, they will accept it differently. Some will understand and they just say ‘alright nurse’ or so. Some will feel like (frightened voice) ‘nurse, anything going to happen to the baby?’ and you know, they show fear and all of that, but somey just take it normally.’’ For primiparas, ‘‘sometimes they need more counseling becausey that amount a fear is in their mind. So you know, you have to understand how you talk to them about it and get them prepared fory whatever comes.’’ Regardless of previous birth experiences, ‘‘Women get very scared too if they think that something is wrongy no matter if they have like ten, nine, or seven babies, they all want to know that they have healthy babies.’’ 3.2.3. Reacting to breech presentation Providers’ reactions to breech included thoughts, feelings, and actions in response to the malpresentation. Participants focused on training and practice experiences with breech presentation. During the course of their careers, each provider had delivered a sufficient number of breech babies to become matter of fact in managing the abnormality. As Dr. Talso stated, ‘‘most times it’s bad news ya know in the last trimester,’’ but as Nurse Eva said, ‘‘so I had must to deliver the breech.’’ Routines of management were consistent across providers’ descriptions. All participants had heard of antenatal external cephalic version to turn a breechpresenting baby to head down, but it was not a routine protocol. Primiparas with breech were scheduled for cesarean section if the malpresentation was known antenatally and vaginal breech births were normative for multiparas without other risk factors. Primiparas with undiagnosed breech babies often came into the hospital in advanced labor and delivered vaginally. Providers thought that, ‘‘you have to know the maneuvers and prepare for resuscitation.’’ Nurse Harker best typified reactions providers expressed and reflected hospital staffing patterns:
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‘‘Here by yourself, you have to be doing whatever comes. If it’s anything difficult, theny we call doctor to help usy The more you practice, the more you understand how to maneuver yourself and then it comes like nothingy it’s just deliver a breech normallyy In the early stages, (laughing) I was a bit afraidy to hear about breech, but now, you know, if it comesy you don’t really feel any way nowy When we didn’t havey Dr. ______ mosty emergencies had to go into (city with tertiary center). But we have Dr. ______ aroundy we can call and they do them here, so we don’t have much of the (high risk) transfers now.’’ 3.2.4. Identifying the impact of breech In describing their experiences, providers identified issues related to breech presentation that impact their obstetric practice and maternal–infant health. They brought up low incidence, congenital defects, delivery problems, and cesarean delivery. The physicians reported seeing few women with breech, but they did not have statistics to show trends. Dr. Barnett commented, ‘‘incidence is very low or we’re not detecting it antenatally.’’ I told him my findings from hand searches of 3 recent years’ delivery logs, which showed 1% or less of births were live born singleton breech deliveries (.005, .006, .013 per year). Although breech did not occur often, providers were concerned with avoiding potential morbidity and mortality associated with malpresentation. Risks and benefits for the mother and baby were weighed in the decision for route of delivery. As Nurse Eva put it, ‘‘The breeches are not a hundred percent. Normallyy with breechy the process of labor and how the breech present itself and the manipulation getting it out, ya know, sometimes cause some sort of illness or risk.’’ Yet Dr. Talso recalled ‘‘no complication (or) any mortality’’ from breech during his service there. Another issue associated with breech was congenital defects often seen with babies presenting breech. Dr. Barnett advised women that, ‘‘breech presentation often has underlying pathology. When the baby’s breech you can’t guarantee the outcomeyI explain risks of breech delivery and the chance of malformations.’’ A group of community health workers with years of experience in the district thought breech was not too usual and that many born ‘‘footway’’ had brain problems. One knew of a baby with meningocele who died at 1 year of age. And another knew of a Down’s baby born breech. When cesarean delivery was indicated for breech, more resources for surgery and postoperative hospitalization were required than for vaginal breech birth. Nurse Harker said that women progressing along a
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normal postoperative course would be discharged 3 days post-cesarean, whereas women who delivered vaginally were usually discharged 1–2 days postpartum. Women returned to the unit 1 week after cesarean for suture removal and incision checks by the midwives.
4. Discussion This qualitative descriptive study gathered interviews and observational information from postpartum women and obstetric cares providers about their experiences of breech presentation in a rural parish of Jamaica. Themes that emerged showed each participant realizing the baby was breech, interpreting what breech meant, reacting to breech presentation, and identifying the impact of breech. No known previous study elicited women’s or providers’ experiences of breech from their own perspectives. This study showed that women relied on their midwives or doctors to provide the information that the baby was breech, what breech meant, and what was to be done about the malpresentation. Even women who physically sensed that something had changed did not fully realize that the babies were in breech presentation until informed by their providers. Personal experiences with prior breech pregnancies and information from family and friends further influenced women’s interpretations of what breech meant, which in turn affected women’s reactions to breech. Women’s reactions were affected by understanding of information about breech presentation and by the timing of information received relative to her stage in pregnancy or labor. Women participants expressed a range of responses to breech childbirth between normal for themselves and extreme pain or fear. The study revealed that providers’ experiences of breech stemmed from training and practice. Conforming with a local medical protocol, providers with limited resources relied on clinical assessments more than tests and technological interventions in managing breech presentation (Peabody et al., 1998). The providers’ experiences were consistent with portrayals of Jamaica as a middle-income country where shortages of personnel, equipment, and capital affect health care (Figueroa, 2001; Handa, 2000). In the rural parish where this study occurred, providers’ routines did not include ECV and cesarean delivery was reserved for women and infants at greatest risk because these procedures burden the medical system’s resources (Erskine, 2001; Webster et al., 1992). Thus, providers became experienced in managing vaginal breech birth and understood the importance of educating women about the diagnosis and it is meaning in order to work more expeditiously with delivering the breech baby.
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Although symbolic interactionism was not used as a sensitizing framework for this study, the findings taken together may suggest this theory as a means of understanding women’s and providers’ experiences of breech presentation (Becker, 2003). The process of interpretation and the meaning participants gave there experiences were essential to understanding their behaviors (Bogdan and Biklen, 2003; Miles and Huberman, 1994). The study indicated how interaction mediated construction of meaning about breech presentation for these Jamaican participants. Not only were the providers socialized by their education into the routines of the medical system, but also they perpetuated the medical system by practicing those routines for women with breech presentation during pregnancy (Becker, 2003; Hall, 2003). Providers were instrumental in shaping the women’s experiences of breech, as women required information from the providers for defining and interpreting the meaning of breech. However, women’s experiences were also affected by meanings of breech derived from their own prior personal experiences and the contexts of their Jamaican socio-cultural networks. Providers acknowledged that their ways of telling women about breech influenced women’s reactions. 4.1. Implications and conclusions Nurses, midwives, physicians, childbirth educators, and others in disciplines concerned with helping pregnant women avoid the risks of breech presentation and its management may recognize from their own practice the experiences relayed by the participants in this study. Further research from the woman’s perspective of experiencing breech presentation may propel future research on lower risk interventions to manage this malpresentation. Symbolic interaction is a theory that could guide our education and practice of managing breech presentation. Nurses and midwives can be educated that we are ideally positioned to do palpations to assess breech presentation if it exists antenatally and to promote prevention by teaching women about the definition and risks of breech presentation. We influence women’s understanding of their need for cesarean delivery or for seeking care early in labor with breech. We can help women know that each pregnancy with breech presentation poses discrete risk to themselves and their infants, even if a previous breech pregnancy and birth seemed harmless. Educating significant others in women’s socio-cultural networks may help to reinforce women’s understanding of breech presentation, its risks, and what to do when labor begins. Providers can teach women to understand the meaning and risks of breech presentation to better cope with labor and delivery.
Acknowledgements This research was supported by NINR T32 2 T32 NR007100 06. I thank the participating women and their infants, my Jamaican colleagues, US mentors, Dr. Janet Deatrick, and Dr. Roberta Cricco-Lizza. References American College of Obstetricians and Gynecologists, 2001. ACOG committee opinion no. 265: mode of term singleton breech delivery. Obstetrics & Gynecology 98 (6), 1189–1190. Becker, H.S., 2003. The politics of presentation: goffman and total institutions. Symbolic Interaction 26 (4), 659–669. Bogdan, R.C., Biklen, S.K., 2003. Qualitative research for education: an introduction to theory and methods, fourth ed. Allyn and Bacon, Boston. Cardini, F., Weixin, H., 1998. Moxibustion for correction of breech presentation: a randomized controlled trial. Journal of the American Medical Association 280 (18), 1580–1584. Coco, A.S., Silverman, S.D., 1998. External cephalic version. American Family Physician 58 (3), 731–742. Cunningham, F.G., Gant, N.F., Leveno, K.J., Gilstrap, L.C., Hauth, J.C., Wenstrom, K.D., 2001. Williams Obstetrics, 21st ed. McGraw-Hill, New York. Erkkola, R., 1996. Controversies: selective vaginal delivery for breech presentation. Journal of Perinatal Medicine 24 (6), 553–561. Erskine, J., 2001. Term breech trial. Lancet 357 (9251), 228. Figueroa, J.P., 2001. Health trends in Jamaica. Significant progress and a vision for the 21st century. West Indian Medical Journal 50 (Suppl. 4), 15–22. Fok, W.Y., Chan, L.W., Leung, T.Y., Lau, T.K., 2005. Maternal experience of pain during external cephalic version at term. Acta Obstetricia et Gynecologica Scandinavica 84 (8), 748–751. Hall, P.M., 2003. Interactionism, social organization, and social processes: looking back and moving ahead. Symbolic Interaction 26 (1), 33–55. Handa, S., 2000. The impact of education, income, and mortality on fertility in Jamaica. World Development 28 (1), 173–186. Hannah, M.E., Hannah, W.J., Hewson, S.A., Hodnett, E.D., Saigal, S., Willan, A.R., 2000. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 356 (9239), 1375–1383. Hofmeyr, G.J., Kulier, R., 2005. Cephalic version by postural management for breech presentation. Cochrane Pregnancy and Childbirth Group Cochrane Database of Systematic Reviews 1. Leung, T.Y., Lau, T.K., Lo, K.W., Rogers, M.S., 2000. A survey of pregnant women’s attitude towards breech delivery and external cephalic version. Australian & New Zealand Journal of Obstetrics & Gynaecology 40 (3), 253–259. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage Publications, Beverly Hills. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis: An Expanded Sourcebook. Sage, Thousand Oaks, CA.
ARTICLE IN PRESS S.A. Founds / International Journal of Nursing Studies 44 (2007) 1391–1399 Ministry of Health Jamaica Annual Report 2001. /http:// www.moh.gov.jm/MOHAnnualReport2001.pdfS, accessed February 25, 2006. Ministry of Health Jamaica 2002. /http://www.serha.gov.jm/S accessed February 25, 2006. Oxorn, H., 1986. Oxorn-Foote: Human Labor and Birth, 5th ed. Appleton & Lange, Norwalk, CT. Peabody, J.W., Gertler, P.J., Leibowitz, A., 1998. The policy implications of better structure and process on birth outcomes in Jamaica. Health Policy 43 (1), 1–13. Penn, Z.J., Steer, P.J., 1990. Reasons for declining participation in a prospective randomized trial to determine the optimum mode of delivery of the preterm breech. Controlled Clinical Trials 11 (4), 226–231. Phipps, H., Roberts, C.L., Nassar, N., Raynew-Greenow, C.H., Peat, B., Hutton, E.K., 2003. The management of breech pregnancies in Australia and New Zealand. Australian &
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New Zealand Journal of Obstetrics & Gynaecology 43 (4), 294–297. Rietberg, C.C., Elferink-Stinkens, P.M., Visser, G.H., 2005. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of 35,453 term breech infants. BJOG: An International Journal of Obstetrics & Gynaecology 112 (2), 205. Sandelowski, M., 2000. Focus on research methods. Whatever happened to qualitative description? Research in Nursing & Health 23 (4), 334–340. Ullery, J.C., 1967. Obstetric malpresentations. Hospital Medicine, 22–29. Webster, L.A., Daling, J.R., McFarlane, C., Ashley, D., Warren, C.W., 1992. Prevalence and determinants of caesarean section in Jamaica. Journal of Biosocial Science 24 (4), 515–525.
International Journal of Nursing Studies 44 (2007) 1391–1399 www.elsevier.com/locate/ijnurstu
Women’s and providers’ experiences of breech presentation in Jamaica: A qualitative study Sandra A. Founds Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania 15261, USA Received 20 May 2005; received in revised form 11 July 2006; accepted 13 July 2006
Abstract Background: Most research on breech relates to medical management of the malpresentation. Little is known about women’s or providers’ experiences of breech, an obstetrical complication. Objectives: This study aims to increase the understanding of women’s and providers’ experiences of breech presentation and to understand the effects of context on these experiences. Methods: A qualitative descriptive research was conducted in a rural health district of Jamaica. Nine postpartum women who birthed singleton live born breech infants in the past year and five experienced obstetric care providers consented to participate. Content analysis was conducted with data from one-time interviews, observations, and hand searches of maternity ward delivery logs. Member checking was conducted with successive participants and Jamaican health care providers. Results: Findings included realizing the baby was breech, interpreting what breech meant, reacting to breech presentation, and identifying the impact of breech. Rates of breech births were less than 1%. Conclusions: Symbolic interaction can guide nursing and midwifery education, practice and research of breech presentation. Nurses and midwives can identify and teach women and their significant others about breech and its risks. r 2006 Elsevier Ltd. All rights reserved. Keywords: Breech; Jamaica; Malpresentation; Providers’ experience; Qualitative descriptive women’s experience
What is already known about the topic?
Previous research of breech malpresentation and its
management focused on medical interventions.
clinical practice and research of breech pregnancy care. Symbolic interactionism emerged from the findings as a framework to guide nurses’ and midwives’ practice in helping women to construct meaning and to cope safely with breech.
What this paper adds
Women’s
and providers’ experiences of breech presentation in Jamaica provide a basis for improved
Home address: 2631 Glenchester Road, Wexford, PA
15090, USA. Tel.: +1 413 281 0092; fax: +1 412 624 8521. E-mail address: [email protected].
1. Introduction Breech presentation with the infant’s buttocks down in the maternal pelvis causes concern to nurses, midwives, and physicians who care for pregnant women in every country because breech is considered a malpresentation
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.07.018
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that increases maternal–infant morbidity and mortality (Cunningham et al., 2001; Oxorn, 1986). Cord prolapse below the presenting fetal buttocks antenatally or during labor can lead to fetal hypoxia and asphyxia (Erkkola, 1996; Oxorn, 1986). The after coming fetal head may be trapped in an incompletely dilated cervix, resulting in obstructed labor that can lead to maternal and infant mortality (Ullery, 1967). Obstetric care providers have searched for interventions to avoid these risks. The Term Breech Trial, a large multicenter RCT conducted in 26 countries, found more severe morbidity and mortality for infants whose mothers were randomized to planned vaginal breech birth than those randomized to planned cesarean delivery (Hannah et al., 2000). Since that trial was published, external cephalic version (ECV; manually turning the infant to head down presentation through the mother’s abdomen) and planned cesarean delivery have become preferred management strategies for breech presentation in some countries (American College of Obstetricians and Gynecologists, 2001; Rietberg et al., 2005; Phipps et al., 2003). These interventions, however, pose further risks to women and infants (Coco and Silverman, 1998; Hofmeyr and Kulier, 2005). Few lowerrisk interventions for breech management have been supported by research. The acupuncture technique of moxibustion significantly increased antenatal cephalic version in Chinese primiparas (Cardini and Weixin, 1998), but may not be accessible to all women pregnant with breech presentation. 1.1. Experiences of breech While most research has focused on medical management of breech as an obstetrical complication, little is known about women’s or providers’ experiences of breech. Structured interviews conducted in a Japanese clinic elicited responses to a questionnaire about pregnant women’s attitudes toward ECV and breech delivery (Leung et al., 2000). Recently, Fok et al. (2005) investigated Chinese women’s experience of pain during ECV. Physicians’ reasons for nonparticipation in a trial of preterm breech delivery included concerns about time commitment and workload of consent procedures, adequacy of consent by non-English speaking clients, providers’ skills with breech deliveries, liability, and research design issues (Penn and Steer, 1990). These previous studies focused on experiences of or attitudes toward breech management options rather than subjective experiences of pregnancy complicated by breech malpresentation. Learning about women’s and providers’ experiences of breech may provide better understanding for clinical care and research. The current study was conducted in Jamaica to explore the effect of context on experiences of breech. Women and providers may view the complication differently in a setting where
fewer resources are available for routine ECV or cesarean delivery for malpresentation (Erskine, 2001). The findings presented in this paper were part of a larger study conducted to investigate how experiences of breech presentation might affect participation in research on a lower-risk intervention for breech. The research aims included increasing understanding of women’s and providers’ experiences of breech presentation and examining the context of these experiences in rural Jamaica.
2. Methods 2.1. Design Qualitative descriptive research design provides straightforward information about an event or a service with less emphasis on interpretation or abstraction than other types of qualitative methods (Lincoln and Guba, 1985; Sandelowski, 2000). This qualitative descriptive study included semi-structured interviews, observations, and birth log reviews. I recorded my observations of participants, their friends and families, participants’ environments, and community, clinic and hospital settings where interviews occurred. I hand-searched 3 years of hospital maternity ward birth logs for rates of breech deliveries. 2.2. Setting/entre´e The study occurred in one of the most rural of the 14 Jamaican parishes. Approximately 91,000 people inhabit 286.8 mountainous, shore-lined square miles (Ministry of Health Jamaica, 2002) where fishing and agriculture are the major economic bases for one of the lowest income parishes of the island. In 2001, 67.65% of the school-aged population in the poorest quintile was enrolled in school (Ministry of Health Jamaica Annual Report, 2001). Winding, ill-repaired roads make slowgoing travel. Health personnel often travel by taxi as far as the road will allow, then walk unpaved roads and steep rocky paths to reach rural clients. Some community dwellers live without plumbing, carrying clean water to the house from local standpipes and using pit latrines in their yards. Four health districts comprise one health department in this Jamaican parish. A single campus houses the hospital, public health administration, and housing for medical personnel. The Senior Public Health Nurse administers 17 health centers staffed by 11 public health nurses, 37 community health aids, and four peer educators. One public hospital with 88–118 beds needs 10 doctors, but runs with 4, and 1 or 2 nurses run the 30-bed wards. The Senior Medical Officer of the hospital struggles ‘‘with budget cuts from nothing to cut from’’
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Hospital nurse administrators reported severe nursing shortages as nurses emigrate to Canada, the UK and the US. A few physicians run private practices in the parish. In the previous 9 years, I coordinated an annual crosscultural nursing program from a university in the northeastern US with health care personnel and community members in this Jamaican parish. I am licensed as an RN in Jamaica. Collegial relationships with health care personnel and understanding of the health care system facilitated my contacts with participants for this study. Ethical review systems are rapidly developing in Jamaica, but at that time, no research ethics committee existed locally; therefore, approval to conduct the study was obtained from my university in the US, the Jamaican hospital’s Senior Medical Officer, and the Health District Medical Officer before data collection began. Referrals and independent contacts led to interviews with women and providers. Nurses and midwives connected me with mothers who had recent breech births. Community health workers accompanied me directly to the homes of three women. I requested interviews with midwives and doctors who attended breech deliveries logged in the hospital maternity ward register or who were referred to me because they were regarded as ‘‘experienced’’ by newer obstetric care providers. Verbal consent for interviews and observations was obtained with assurances of anonymity and confidentiality in data analysis and any verbal or written reports. Specific consent for audiotaping was elicited. I was approved by my university’s review board and Jamaican health officers to consent all participants in a consistent verbal format, rather than written, to avoid distancing myself from any participants who may have been illiterate. Interviews occurred in private settings, unless requested otherwise by the participant. Women were interviewed in their homes, their yards, or in postpartum clinics. Women received baby care items as a thank you gift. Providers were interviewed in their offices at the hospital or clinics. 2.3. Sample Purposive sampling conducted in January 2004 recruited nine Jamaican women who birthed singleton live born breech infants at the local community hospital within the year and five obstetric care providers. Primiparous participants were two 18-year-olds and one 34-year-old woman. Six multiparous women participated, ranging from 24 to 38-years-old and each having three–five children. Every woman held and interacted with her baby during our interview. The provider participants were two physicians, two hospital nurse midwives, and a district nurse midwife. An obstetrician had worked in her specialty for 9 years.
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The second physician is a generalist who covers all types of patient’s in hospital. He and the nurse midwives all reported 20 or more years of practice experience. All participants are referred to by pseudonyms. 2.4. Procedures Semi-structured interviews included the following open-ended questions. What was your experience of breech presentation? What were your experiences of interventions for breech? If participants’ answers did not contain details, I probed further, such as, what did you understand that breech meant? Providers were asked what they told women about the diagnosis and management options. Interviews lasted an average of 45–60 min, until the participant offered no new information and I had no more questions for them. Interviews were audiotaped for 11 of 14 participants. One woman and one provider preferred not to be audiotaped. A second woman asked to interview by telephone rather than meeting. Extensive notes were used to record data that were not audiotaped. I wrote field notes after each interview and a reflective journal throughout all phases of the research project. Data were de-indentified and coded by a number assigned to each participant. I stored the participant’s name, contact information and demographic data separately from the data in my locked room in Jamaica and locked office file in the US. I transcribed the interviews; no one else accessed the data. Tapes and participants’ information were destroyed after data analysis was completed. 2.5. Data analysis Content analysis was conducted with data from interviews, field notes, and journal entries written during data collection (Bogdan and Biklen, 2003; Miles and Huberman, 1994). After I transcribed the interviews, I read transcripts to verify accuracy with tape-recorded interviews, reread for overall sense of each interview, and then reread noting initial codes. I used Atlas.ti 5.0 for coding and categorizing codes; the software logs analytic steps. I developed themes from analysis within and between code categories. Verification during analysis and interpretation included discussions of my evolving findings with the Senior Medical Officer, the District Medical Officer, and an academic nurse midwife in Jamaica, January 2005. Discussions occurred with qualitative methods expert advisors and research seminar colleagues in the US.
3. Findings Parallel themes emerged from the women and providers experiences of breech presentation: realizing
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the baby was breech, interpreting what breech meant, reacting to breech presentation, and identifying the impact of breech. 3.1. Women’s experiences of breech presentation 3.1.1. Realizing the baby was breech Women realized the baby was in breech presentation during antenatal appointments or when they were examined in labor. All women reported attending regular antenatal clinic visits and going to the local hospital for their births. All learned about the diagnosis of breech from a nurse midwife or doctor. Some participants experienced physical sensations that led them to suspect that something was different, but they did not realize the sensations were from the baby in breech presentation until the nurse or doctor provided the information. Noreen felt cramps whenever she sat down. Sharon grew suspicious: ‘‘I wasn’t sure if his head was down or not. The feeling I had down here, it wasn’t a head feeling, it feel more like kicking, it didn’t feel like his head was down there at all.’’ Five of nine participants knew before going into labor that the baby had turned to breech presentation. Anna was the only primipara who was aware of breech presentation antenatally because she had a few ultrasounds for fibroids, low-lying placenta and malpresentation, as she was the only participant in the study who received obstetric care in the city 2 hours from her rural home. Four of the six multiparas realized the babies were breech from provider’s information at antenatal appointments. Four women were told that the baby’s head was down at their last antenatal visits, then learned their babies were presenting breech in labor. A multipara explained, ‘‘I did an ultrasound (at) 7 months his head had turned down, but when I went for delivery, his head was up so, he breeched. Born footway.’’ 3.1.2. Interpreting what breech meant The women’s experiences were affected by their interpretation of ‘‘breech.’’ Information about what breech meant came from personal obstetric histories, obstetric care providers, family members, and friends. Understanding what breech meant included interpretations of normalcy, risk, and cultural beliefs. Information from nurses, midwives, and doctors helped women make sense of what breech presentation meant. Women knew breech or ‘‘footway’’ meant, the baby birthing feet and buttocks first rather than head first. They generally understood that breech presentation was not normal during pregnancy, although some women who were not diagnosed until labor were unaware of the meaning of breech until after delivery.
For example, a young primipara had not known what breech meant until the nurse told her after delivery that it was life threatening for the baby. Women understood that breech presentation might require other than usual treatment during delivery. Some of them were told by a nurse that the doctor would have to deliver the baby instead of the midwife. Breech presentation diagnosed antenatally in primiparas meant that cesarean section would be planned for delivery. The older primipara remained scheduled for cesarean because of breech presentation after the issues of her fibroids and low-lying placenta resolved. She was adamant that she did not want a cesarean; even though her doctor told her it was ‘‘a mmmmust!’’ Multiparas interpreted breech relative to their own previous births. Sharon interpreted her experience of vaginal breech birth by comparing it with her two previous deliveries with the baby’s head down, thinking that her breech baby had to be pulled out by the doctor because the baby could not push his way out with his bottom instead of his head. Betty and Anita both had breech births prior to their recent deliveries. Although they acknowledged that breech is not normal, they did not define breech as a problem for themselves in their second breech pregnancies because, their first breech births progressed without problems. People in women’s social networks relayed to the women that breech presentation posed life-threatening risks for mother and baby. Betty heard, ‘‘They said it can cost your life my brother told me that earlier. And I heard lots of people talk about it.’’ Women knew that chances of cesarean increased as Sharon mentioned, ‘‘like most people always talking that it is harmful because mainly you have to get cut.’’ Participants were told by family or friends that babies born ‘‘footway’’ had lots of complications or were ‘‘born dead.’’ Cultural beliefs about breech presentation also came through information from social networks. Participants found the beliefs more or less true in their own experiences. Dorothy reported that she had never heard of breech ‘‘until having it now’’, and offered that ‘‘when they get big (they’re) rude my mother told me, (they’re) rude when (they’re) born breech baby.’’ Rude meant, ‘‘like they cry a lot and give a lot of trouble, and so.’’ Noreen heard that, ‘‘they walk up and down, like when they get big, they always love to walk because they walk home. That is, many people always talking.’’ Anita was told that ‘‘most times, breech babies are born with eczema.’’ 3.1.3. Reacting to breech presentation Women reacted with thoughts, feelings, and actions in response to realizing, and interpreting the fact that their babies were breech before or during labor. Some participants did not think or feel ‘‘any way’’ about the malpresentation, while others were fearful or worried.
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The experience of birthing a breech baby was unremarkable for some, but terrible for others. Most participants were afraid or scared knowing that the baby turned to breech presentation. Realizing the diagnosis and interpreting breech as a life-threatening risk that might require cesarean delivery frightened women. Anna was ‘‘scared after delivery,’’ once she realized that, the difficulties ‘‘getting the baby’s shoulders out could have cost her (baby’s) life.’’ Conversely, Anita ‘‘was never scared’’ about breech. The young primiparas were not afraid because, they didn’t know what ‘‘footway’’ meant until after the babies were born. Karan claimed she would have been afraid during labor, if she knew that breech could be life threatening. A few women reacted about terrible pain that ‘‘vexed’’ them in vaginal breech birth. Compared with her previous cephalic-presenting births. Dorothy exclaimed, ‘‘The third one here was the hottest I thought, I was going to die! So much pain!’’ For Sharon, ‘‘Was terrible, ya know, the pain is much hotter, and so I spit and holler. The pain was hot terrible.’’ Although Anita was easy going about her labor contractions, she reported the baby’s delivery as painful. Women reacted with worries for babies with problems. Dorothy’s daughter was in an incubator immediately postpartum, but the baby’s condition did not delay their discharge from the hospital. What Dorothy understood was that the baby swallowed water during birth, and that ‘‘something bad happened.’’ She thought the baby might have asthma like herself. Yatisha, having been hospitalized for leaking fluid early, felt that ‘‘I wasn’t worrying about the position, I was worrying about if he would live or suffer because he was early.’’ Reactions included behavioral responses to breech presentation. Four women reported prayer as a distinct response, an action separate from what was thought or felt about being pregnant with or delivering a breech baby. Betty cried from fear, and prayed when she was told her first baby turned breech. Dorothy’s description of labor with her breech baby was ‘‘I felt pain like a big knife, andy I said Jesus straight. Yeh and I just put my hand up, so, and just lie down ya know and say ‘Jesus.’y and he stand by and help me. I just lie there, and I make noise and I say ‘Jesus Jesus’ until the doctor come in.’’ Two women labored at home knowing the babies were breech, arriving at the hospital in advanced labor. Betty and Anna both realized their babies were breech antenatally, but spent most of their labors at home. Betty had pains from morning until evening. She arrived at the hospital after 7 pm, and delivered 50 min later. She was pleased that other women on the maternity ward admired how quickly she delivered. Anna was the most
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graphic of the three primiparas about her labor. Although her water broke in the morning, she labored at home doing her hair that day. Her menstrual-like cramps progressed to pains that led her to decide to go to the local hospital in the late afternoon, delivering in the early evening. 3.1.4. Identifying the impact of breech In describing their experiences, the postpartum women identified issues associated with breech presentation that impacted their lives after the babies were born. Participants did not necessarily ascribe causality between breech and its later impact, but mentioned these issues as part of the whole story concerning their experiences of breech presentation. Some babies who had been breech during pregnancy were born with problems that required ongoing medical care. Future reproductive choices may have been affected by the experience of breech presentation. Six women’s babies had problems after birth. Dorothy and Anna’s babies’ problems resolved within a few days after birth, but four babies ills were more chronic or severe. Betty’s clinic nurse knew that the baby appeared to have Down’s syndrome, but stated her role was to refer the mother, and baby to the pediatrician for diagnosis and plan of care; so Betty and her family did not yet know the diagnosis. Yatisha’s baby was diagnosed with ‘‘twisted tripe, part of his tripe was twisted and locked off.’’ They traveled 2 hours to a tertiary center in the city for surgery and follow-up care of his bowel problems. A few women indicated that they would have no more pregnancies after their experiences with breech presentation. Anna was quite emphatic when asked about her next pregnancy. ‘‘No I’m not going to get pregnant again. I want to try all; I’m not going to get pregnant again. No no no no Repeat it No! Scary!’’ 3.2. Obstetric care providers’ experiences of breech presentation 3.2.1. Realizing the baby is breech The five obstetric care providers realized that women’s babies were in breech presentation using clinical assessment skills acquired in training, and practice experience. Three providers who trained in other developing countries before coming to practice in Jamaica found the same protocols between regions, where they trained and practiced. Providers detected breech by palpating the pregnant woman’s abdomen, and they preferred ultrasound to confirm the diagnosis of antenatal breech presentation. Another means of realizing breech was via communication through the health care system.
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Palpations were routinely performed during third trimester antenatal clinic visits, and admission for labor and delivery. Sometimes the diagnosis was difficult to determine, as Nurse Eva explained ‘‘because sometimes they’re not very well-flexed breech, sometimes it’s not readily diagnosed.’’ If a nurse midwife at antenatal clinic determined that the baby was breech, she referred the woman to either high-risk clinic to be assessed by a doctor or directly to ultrasound in late pregnancy. Once breech was identified, it was noted on the woman’s ‘‘docket’’ (chart) and on a blue card that the woman carried with her to communicate between providers at antenatal sites and to the maternity ward staff in the hospital. Ultrasound was not readily accessible because most women in the parish could not afford it. Nurse Yang said ‘‘Usuallyy they take weeks before they go and do the ultrasoundy(it) would cost quite a loty for the ordinary person here. The clinics don’t have an ultrasound machine and they can’t just do it free of charge. They have to go to the private doctors and they payy about 2000 (about $34US) plusythe ultrasound. I think it’s about 2–8 (2800J about $48US)y And not everybody has insurance coveragey some of the placesy don’t take the (insurance)y you have to pay up front and then you’re paid from your insurance, so, maybe that will take some time.’’ The physicians reported that the local hospital had an ultrasound machine for echocardiogram, not suitable for obstetric use, and there was no sonographer. Dr. Talso explained that limited resources required providers to rely on ‘‘clinical knowledge’’ more than ‘‘investigation’’ to deliver medical care in places like Jamaica and the Caribbean. 3.2.2. Interpreting what breech meant Providers interpreted breech presentation as a pregnancy abnormality because the baby is positioned for birthing buttocks first rather than head first, the ‘‘baby is coming by its buttocks.’’ Breech meant increased maternal–infant risks requiring management. Primigravidas with breech known antenatally would be scheduled for cesarean delivery. Providers mentioned that often times, breech presentation could mean underlying congenital pathology. On maternity ward, the midwife admitting the woman in labor palpated to assess the baby’s size, the degree of flexion, the presenting part and stage of labor. Depending on the type of risk factors, the nurse midwives or doctor would manage the birth. If a primipara with undiagnosed breech was admitted in advanced labor, it was too late to perform cesarean section and the
provider managed vaginal breech birth. Nurse Harker described risks in vaginal breech birth. ‘‘You find that it will start coming through and they’ll feel to push, but you have to advise them because you need to wait until because the head is the bigger part that is going to come aftery they’ll have a problem having the head out and they might lose that baby.’’ Providers interpreted the meaning of breech presentation to their patients in order to educate them to work with the labor and delivery process. They acknowledged women’s reactions to the abnormality. ‘‘Well depending on how you tell them too and depending on theiry ability to understand it, they will accept it differently. Some will understand and they just say ‘alright nurse’ or so. Some will feel like (frightened voice) ‘nurse, anything going to happen to the baby?’ and you know, they show fear and all of that, but somey just take it normally.’’ For primiparas, ‘‘sometimes they need more counseling becausey that amount a fear is in their mind. So you know, you have to understand how you talk to them about it and get them prepared fory whatever comes.’’ Regardless of previous birth experiences, ‘‘Women get very scared too if they think that something is wrongy no matter if they have like ten, nine, or seven babies, they all want to know that they have healthy babies.’’ 3.2.3. Reacting to breech presentation Providers’ reactions to breech included thoughts, feelings, and actions in response to the malpresentation. Participants focused on training and practice experiences with breech presentation. During the course of their careers, each provider had delivered a sufficient number of breech babies to become matter of fact in managing the abnormality. As Dr. Talso stated, ‘‘most times it’s bad news ya know in the last trimester,’’ but as Nurse Eva said, ‘‘so I had must to deliver the breech.’’ Routines of management were consistent across providers’ descriptions. All participants had heard of antenatal external cephalic version to turn a breechpresenting baby to head down, but it was not a routine protocol. Primiparas with breech were scheduled for cesarean section if the malpresentation was known antenatally and vaginal breech births were normative for multiparas without other risk factors. Primiparas with undiagnosed breech babies often came into the hospital in advanced labor and delivered vaginally. Providers thought that, ‘‘you have to know the maneuvers and prepare for resuscitation.’’ Nurse Harker best typified reactions providers expressed and reflected hospital staffing patterns:
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‘‘Here by yourself, you have to be doing whatever comes. If it’s anything difficult, theny we call doctor to help usy The more you practice, the more you understand how to maneuver yourself and then it comes like nothingy it’s just deliver a breech normallyy In the early stages, (laughing) I was a bit afraidy to hear about breech, but now, you know, if it comesy you don’t really feel any way nowy When we didn’t havey Dr. ______ mosty emergencies had to go into (city with tertiary center). But we have Dr. ______ aroundy we can call and they do them here, so we don’t have much of the (high risk) transfers now.’’ 3.2.4. Identifying the impact of breech In describing their experiences, providers identified issues related to breech presentation that impact their obstetric practice and maternal–infant health. They brought up low incidence, congenital defects, delivery problems, and cesarean delivery. The physicians reported seeing few women with breech, but they did not have statistics to show trends. Dr. Barnett commented, ‘‘incidence is very low or we’re not detecting it antenatally.’’ I told him my findings from hand searches of 3 recent years’ delivery logs, which showed 1% or less of births were live born singleton breech deliveries (.005, .006, .013 per year). Although breech did not occur often, providers were concerned with avoiding potential morbidity and mortality associated with malpresentation. Risks and benefits for the mother and baby were weighed in the decision for route of delivery. As Nurse Eva put it, ‘‘The breeches are not a hundred percent. Normallyy with breechy the process of labor and how the breech present itself and the manipulation getting it out, ya know, sometimes cause some sort of illness or risk.’’ Yet Dr. Talso recalled ‘‘no complication (or) any mortality’’ from breech during his service there. Another issue associated with breech was congenital defects often seen with babies presenting breech. Dr. Barnett advised women that, ‘‘breech presentation often has underlying pathology. When the baby’s breech you can’t guarantee the outcomeyI explain risks of breech delivery and the chance of malformations.’’ A group of community health workers with years of experience in the district thought breech was not too usual and that many born ‘‘footway’’ had brain problems. One knew of a baby with meningocele who died at 1 year of age. And another knew of a Down’s baby born breech. When cesarean delivery was indicated for breech, more resources for surgery and postoperative hospitalization were required than for vaginal breech birth. Nurse Harker said that women progressing along a
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normal postoperative course would be discharged 3 days post-cesarean, whereas women who delivered vaginally were usually discharged 1–2 days postpartum. Women returned to the unit 1 week after cesarean for suture removal and incision checks by the midwives.
4. Discussion This qualitative descriptive study gathered interviews and observational information from postpartum women and obstetric cares providers about their experiences of breech presentation in a rural parish of Jamaica. Themes that emerged showed each participant realizing the baby was breech, interpreting what breech meant, reacting to breech presentation, and identifying the impact of breech. No known previous study elicited women’s or providers’ experiences of breech from their own perspectives. This study showed that women relied on their midwives or doctors to provide the information that the baby was breech, what breech meant, and what was to be done about the malpresentation. Even women who physically sensed that something had changed did not fully realize that the babies were in breech presentation until informed by their providers. Personal experiences with prior breech pregnancies and information from family and friends further influenced women’s interpretations of what breech meant, which in turn affected women’s reactions to breech. Women’s reactions were affected by understanding of information about breech presentation and by the timing of information received relative to her stage in pregnancy or labor. Women participants expressed a range of responses to breech childbirth between normal for themselves and extreme pain or fear. The study revealed that providers’ experiences of breech stemmed from training and practice. Conforming with a local medical protocol, providers with limited resources relied on clinical assessments more than tests and technological interventions in managing breech presentation (Peabody et al., 1998). The providers’ experiences were consistent with portrayals of Jamaica as a middle-income country where shortages of personnel, equipment, and capital affect health care (Figueroa, 2001; Handa, 2000). In the rural parish where this study occurred, providers’ routines did not include ECV and cesarean delivery was reserved for women and infants at greatest risk because these procedures burden the medical system’s resources (Erskine, 2001; Webster et al., 1992). Thus, providers became experienced in managing vaginal breech birth and understood the importance of educating women about the diagnosis and it is meaning in order to work more expeditiously with delivering the breech baby.
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Although symbolic interactionism was not used as a sensitizing framework for this study, the findings taken together may suggest this theory as a means of understanding women’s and providers’ experiences of breech presentation (Becker, 2003). The process of interpretation and the meaning participants gave there experiences were essential to understanding their behaviors (Bogdan and Biklen, 2003; Miles and Huberman, 1994). The study indicated how interaction mediated construction of meaning about breech presentation for these Jamaican participants. Not only were the providers socialized by their education into the routines of the medical system, but also they perpetuated the medical system by practicing those routines for women with breech presentation during pregnancy (Becker, 2003; Hall, 2003). Providers were instrumental in shaping the women’s experiences of breech, as women required information from the providers for defining and interpreting the meaning of breech. However, women’s experiences were also affected by meanings of breech derived from their own prior personal experiences and the contexts of their Jamaican socio-cultural networks. Providers acknowledged that their ways of telling women about breech influenced women’s reactions. 4.1. Implications and conclusions Nurses, midwives, physicians, childbirth educators, and others in disciplines concerned with helping pregnant women avoid the risks of breech presentation and its management may recognize from their own practice the experiences relayed by the participants in this study. Further research from the woman’s perspective of experiencing breech presentation may propel future research on lower risk interventions to manage this malpresentation. Symbolic interaction is a theory that could guide our education and practice of managing breech presentation. Nurses and midwives can be educated that we are ideally positioned to do palpations to assess breech presentation if it exists antenatally and to promote prevention by teaching women about the definition and risks of breech presentation. We influence women’s understanding of their need for cesarean delivery or for seeking care early in labor with breech. We can help women know that each pregnancy with breech presentation poses discrete risk to themselves and their infants, even if a previous breech pregnancy and birth seemed harmless. Educating significant others in women’s socio-cultural networks may help to reinforce women’s understanding of breech presentation, its risks, and what to do when labor begins. Providers can teach women to understand the meaning and risks of breech presentation to better cope with labor and delivery.
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