What are women’s experiences of seeking to plan a vaginal breech birth? A systematic review and qualitative meta-synthesis

Abstract

Background: Guidelines for breech management at term emphasise choice and informed decision-making. Despite this, the choice of vaginal breech birth (VBB), is not always available or accessible. We aimed to describe the experiences of women seeking a VBB as reported in primary research and to offer strategies for improving this experience that are grounded in evidence. Methods: We conducted a systematic review and qualitative meta-synthesis of the results, using grounded theory analysis methods (PROSPERO registration CRD42021262380), with literature published between January 2000 and February 2022. Seven databases were searched. Our review included literature about women with breech presentation, who sought a planned or unplanned VBB. Studies considering only experiences of alternative management (e.g. caesarean, external cephalic version), and those investigating healthcare workers’ experiences were excluded. Covidence systematic review software was used for screening and quality assessment. Qualitative data were extracted using NVivo software (20.5.0). Data were analysed through an iterative process based on constant comparison methods, with an iterative and reflexive code generation process. Codes were then arranged into ‘categories of experience’, which gave rise to over-arching themes. Results: Our review included 19 studies. We present one overarching theory: ‘Women who wish to plan a vaginal breech birth seek connected autonomy’. Our schematic, depicting this theory, includes seven main categories of experience: paternalistic healthcare; emotional turmoil; judgement and self-doubt; mother vs society: refusing to conform; isolated but united by breech; welcomed direction; and supported self-determination and self-efficacy. Conclusions: Women seeking to plan a VBB feel vulnerable and wish to connect with capable and confident healthcare providers. To meet their needs, services should be designed so that they can connect with clinicians who are willing and able to support their autonomy. Services should also seek to limit their exposure to disrespectful and judgemental interactions with healthcare providers.

OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort

“…This was consistent with the demand observed within the OptiBreech care pathway, yet no women planned a VBB when randomised to standard care. Multiple systematic reviews have suggested women encounter barriers to accessing support for a VBB within standard care, and that this option is only acceptable if the birth is likely to be attended by supportive and appropriately trained professionals [10,11] This is also consistent with qualitative work involving women receiving OptiBreech care [1] and feedback from our PPIE group. In the qualitative study, women reported numerous examples of coercive counselling to dissuade them from attempting a VBB [1].…”

“…Two and one member of the research team were service users with lived experience of planning a VBB. Additional service users with lived experience of planning a VBB participated as members of the research team during qualitative work to refine the OptiBreech care pathway intervention [1,11] and consensus work to identify and prioritise outcome measures [16,17]. Service users influenced the design of the trial in multiple ways.…”

“…There is sufficient evidence to conclude that current standard care is unacceptable to women who wish to plan a VBB and that clinicians frequently lack sufficient training and/or equipoise [10,11]. The available evidence indicates that the OptiBreech care pathway is acceptable to women wishing to plan a VBB because it resolves many of the barriers inherent in standard care [1].…”

“…Current United Kingdom (UK) National Health Service (NHS) recommendations for management of breech presentation at term are to offer external cephalic version (ECV) to turn the baby head-down, and if this fails to offer a pre-labour caesarean birth (CB) [7]. Although guidelines also support the choice of vaginal breech birth (VBB) [7][8][9], women find it difficult to access support for a planned VBB within current standard care, and this is in part due to very low overall clinical experience levels [10,11]. Little is known about the potential demand for planned VBB within a multi-disciplinary collaborative care model with skilled support in labour and what the outcomes might be if this were introduced nationally.…”

“…The aim of this pilot trial was to determine the feasibility of conducting a randomised trial nested within a cohort study comparing OptiBreech collaborative care with standard care for women with a breech pregnancy at term. Patient and Public Involvement and Engagement (PPIE) work aimed to ensure the study's design and interpretation were influenced by women who have lived experience of planning or attempting to plan a VBB because previous research indicated this population was least well served within current NHS standard care [1,[10][11][12] (S1 Checklist).…”