The OptiBreech Care Pathway: evaluating the feasibility and acceptability of team care for women seeking to plan a vaginal breech birth (OptiBreech 1) – a mixed methods implementation feasibility study

Abstract

Background OptiBreech Care is a care pathway for breech presentation at term, including where chosen, physiological breech birth attended by professionals with advanced training and/or proficiency. We aimed to assess the feasibility of implementing OptiBreech team care to test it in trial-within-a-cohort study. Methods Our design was a mixed methods trial feasibility assessment across England and Wales, January 2021 – June 2022. Our objectives were to determine whether Trusts could provide attendants with advanced training (implementation feasibility), who deliver protocol-consistent care (fidelity), in a way acceptable to women and staff (acceptability), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants were women > 37 weeks pregnant with a breech-presenting fetus, requesting support for a vaginal breech birth following standard counselling, and the staff involved in the study. No randomisation occurred in this first stage of feasibility work. Results Thirteen National Health Service sites recruited. A total of 82 women planned births on the study, and 21 staff were interviewed. Sites with a breech specialist midwife and/or dedicated clinic recruited 1 woman/month, while sites without recruited an average of 2 women every 3 months. Referrals into the study came from midwives (46%), obstetricians (34%) and women themselves (20%). Vaginal births were attended by staff with OptiBreech training at 87.5% (35/40) and by staff who met stricter proficiency criteria at 67.5% (27/40). Fidelity criteria were met more consistently by staff who met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82); these outcomes compare well with previous breech research. Women found the model of care highly acceptable compared to standard care, and staff providing care generally found the OptiBreech model acceptable. However, staffing shortages throughout the pandemic and persistent negative views of vaginal breech birth outside the teams created challenges. Conclusions A large prospective observational cohort of OptiBreech Care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and develop further proficient members of staff strategically, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility-tested. Funded by the NIHR (300582).

Authors’ reply

“…Across three studies, one serious adverse neonatal outcome has been reported (0.5%). [3][4][5] This is very near to the rate of adverse outcomes observed among low-risk women planning cephalic (head-first) births in the UK. Neonatal admission rates have been below 5%, similar to rates for all term births in the UK.…”

“…The complex intervention being tested, OptiBreech collaborative care, has been built up from over a decade's worth of research into howin the current conditions you describepractitioners acquire VBB skill and experience. [3][4][5] As you say, the conditions that (arguably) enabled this in the past are now non-existent. Different times call for different thinking and different strategies.…”

“…In a pilot trial, comparing OptiBreech care with standard care, more women planned a VBB within OptiBreech care (23.5% vs 0%), marginally more women planned an elective CB without an ECV attempt (20.6% vs 15.2%), and neonatal outcomes were better. 5 Providing genuine choice does mean providing all choices without prejudice.…”