Implementation strategy, recruitment rates and fidelity
Between February 2021 and December 2021, 54 women requested to plan a vaginal breech birth across 10 sites. Recruitment rates varied significantly between sites, ranging from 1 – 20 women, and study set-up times were heavily impacted COVID-19 pressures (Table 1: OptiBreech Recruitment 2021). The three highest recruiting sites (A,B,C) each had a breech lead midwife who was formally enabled to lead the service as part of her role and enabled to work flexibly to attend the majority of breech births that occurred in these settings. Two of these had a dedicated specialist clinic (A,C), and the third (B) attracted a high number of externally booked women who self-referred for breech specialist care, including from site F.
Three additional sites had midwives informally functioning as specialists (D,E,G). These midwives were enabled to work flexibly to support breech births and counsel women referred to them, but it was not formally part of their job description. Sites C & G were the only sites to clearly identify a multi-disciplinary team as originally suggested, but in practice, all of the births were attended by the breech lead midwife or another midwife in the OptiBreech team. Only one of the midwives reported receiving on-call payments for planned breech births, but all were paid bank hours for time spent at breech births, which also provided clinical negligence insurance cover.
In three of the four sites that only recruited 1 participant, none of these features were operational; the breech lead midwife was on-call for the birth at the fourth. At one site, management actively prohibited the breech lead midwife and obstetrician from attending breech births outside of their regularly scheduled hours.
The breech lead midwives described themselves as fulfilling a number of roles that reflect their operation as specialists within the service, including counselling and clinic co-ordination, communicating plans, attending breech births, supporting less experienced team members, providing training, and leading service development. Interviews with the women indicated that these roles were understood by the recipients of the service, who referred to them as ‘specialists’ or ‘consultants.’
Mode of birth, fidelity and basic feasibility safety outcomes are reported in Table 2: OptiBreech 2021 Fidelity and Safety Outcomes. We originally aimed to ensure >90% of births were attended by someone who fulfilled proficiency criteria, but this was an unrealistic short-term goal given low levels of baseline experience in most centres. Following early discussion with sites, this was modified to >90% of births attended by someone who had completed the OptiBreech training, and this was achieved. Due to the unpredictability of spontaneous labour, some births were attended by on-call obstetric staff. Both neonatal admissions occurred following births where someone meeting the full proficiency criteria was present, so were not attributable to failure to provide proficient attendants.