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.