Interviews with women
Analysis of our interviews with women revealed three pivotal needs for
breech care in late pregnancy. Meeting these needs made care acceptable
to women and led to higher recruitment rates. These were: balanced
information, access to skilled breech birth care, and shared
responsibility. We have included exemplary quotes in a supplementary
table, available online (Supplementary Table: Exemplary Quotes).
At the beginning of their breech care, women needed ‘balanced
information.’ Clear, unbiased counselling about their options enabled
them to make informed decisions, which in turn gave them a sense of
self-efficacy and control over the situation. They valued being fully
informed about both potential risks and potential benefits of VBB. Women
consistently described the information they received from specialists as
balanced, detailed and delivered in ways that met their needs.
This contrasted with the way they described counselling from other
professionals, which they often experienced as biased. Having a
caesarean section was presented as a completely safe option with no
risks, which they knew not to be true. This conflicted with their
values, undermined their trust in their care team and sometimes created
conflict between women and their partners. They also described
attempting to access information about their options online as
difficult, time consuming and laborious, with little information
available about VBB, even on NHS and Trust websites. This led women to
express ethical concerns that counselling and publicly available
information did not always reflect the fact that they had a choice about
how to give birth to their baby.
In sites with routine referral to a breech specialist clinic and/or
midwives, women experienced less conflicting information. Women
particularly valued the breech midwives’ ability to describe
complications and their resolution. They interpreted this as a
reflection of the midwives’ skill and experience, which they perceived
could contribute to their and their baby’s safety. Detailed counselling
instilled confidence not only in the midwife but also in themselves.
However, though women all reported receiving information about potential
risks, some reported feeling doubt that the risk could apply to them.
‘Access to skilled breech birth care’ also affected women’s ability to
plan a VBB when they wanted to. They understood the importance of skill
and experience in making VBB as safe as possible and therefore perceived
that this was only a reasonable option if skilled professionals were
available. Participants found it convenient to access care when referred
during their routine care. They expressed reassurance that there was a
good chance the breech specialist midwife would be at the birth, and
that a plan would be in place if not. Women who were referred to
dedicated clinics valued the input of consultant obstetricians who also
appeared knowledgeable and confident about VBB.
On the other hand, for some women, trust and confidence in specialist
breech care was centred solely around the breech specialist midwife. In
one instance, when the woman was not reassured that the specialist could
attend her birth, she chose to change her plan to an ELCS instead. The
focus on the breech specialist midwife rather than a team was especially
apparent when women felt that not all staff appeared to be both aware of
the service and/or supportive of its purpose. There was evidence that
even within units with a specialist clinic and formal role in place, the
service was not fully embedded.
Some women who had no access to skilled breech care locally transferred
their care to an OptiBreech hospital; some even moved their place of
residence. Accessing specialist care was sometimes associated with
opportunity costs such as time off work, financial costs, travelling
long distances to the hospital, additional trips and a lack of antenatal
continuity they would have received in local care. However, many were
happy to make the increased effort because they had chosen to plan a
VBB, and they could not access skilled care in hospitals close to their
home. Women expressed concern that the situation raised equity of access
issues, and perhaps other women who lacked similar resources would not
be able to give birth the way they wanted.
Finally, women who planned a VBB benefitted from ‘shared responsibility’
with their care team. Prior to accessing supportive care, women often
felt a significant emotional burden. They felt alone to bear the
responsibility of any potential adverse events. They also reported that
other people in their lives, including professionals, family and
friends, expressed judgement of their birth choices and suggested that
they were perhaps being irresponsible. This led to feelings of guilt and
selfishness.
For many, transferring care to the OptiBreech team meant developing a
relationship with an experienced breech midwife who supported the
women’s choices, which lightened this emotional burden. Women perceived
the specialist midwives as taking responsibility for cultivating a
safe-as-possible service, including accurate counselling about
complications, spending time on-call to attend births and training other
members of the team. Some women focused on the breech specialist midwife
in contrast to other members of the team, in whom they did not have
confidence. But others perceived that provision of a specialist service
reflected a shared commitment to skill development within the wider
team, which they were prepared to trust, while they understood that not
all members of the team had the same level of experience.