Expectant parents' preferences for mode of delivery and trade-offs of outcomes for breech presentation

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

OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.

Breech specialist midwives and clinics in the OptiBreech Trial feasibility study: An implementation process evaluation

BACKGROUND

Attendance of skilled and experienced professionals at breech births has been associated with a reduction in adverse perinatal outcomes. We aimed to determine whether United Kingdom National Health Service (NHS) sites could reliably provide attendants with OptiBreech training and/or advanced proficiency (intervention feasibility) and consistent care (fidelity) that meets women's needs (acceptability), with low neonatal admission rates (safety) and recruitment adequate to support a clinical trial (trial feasibility).

METHODS

Mixed methods implementation evaluation was used. Settings were 13 services in England and Wales. Participants were 82 women requesting support for a vaginal breech birth (VBB) at term. Outcomes were descriptively analyzed. Twenty-one women were interviewed, and transcripts were analyzed using the Theoretical Framework of Acceptability. Iterative analysis informed subsequent interviews and the ongoing process of implementation across sites.

RESULTS

Although we initially suggested multidisciplinary teams, actively recruiting Trusts yielded services where VBB care was provided through a dedicated clinic, organized and delivered primarily by a lead midwife who functioned as a specialist. This model achieved 87.5% fidelity with the intervention's goal of ensuring the attendance of OptiBreech-trained professionals. Neonatal outcomes remained stable, with an admission rate of 5.5%. Women reported care from specialist midwives as highly acceptable, but the model is vulnerable without a strategic effort to develop additional proficient team members.

CONCLUSIONS

Dedicated clinics coordinated by specialist midwives appear to be an acceptable and feasible implementation strategy to test the safety and effectiveness of proficient team care for VBB in a clinical trial. Back-up arrangements should be maintained while additional members of the team develop proficiency.

The feasibility of team care for women seeking to plan a vaginal breech birth (OptiBreech 1): an observational implementation feasibility study in preparation for a pilot trial

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 prior to proceeding with a planned pilot randomised controlled trial.

METHODS

Our design was an observational implementation 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), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants included women > 37 weeks pregnant with a breech-presenting foetus, requesting support for a vaginal breech birth following standard counselling, and staff involved in the study. No randomisation occurred in this first stage of feasibility work.

RESULTS

Thirteen National Health Service sites were recruited. A total of 82 women planned births in the study. Sites with a breech specialist midwife recruited at double the rate of sites without (0.90/month, 95% CI 0.64-1.16 vs 0.40, 95% CI 0.12-0.68). 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, 95% CI 0.732-0.958) and by staff who met additional proficiency criteria at 67.5% (27/40, 95% CI 0.509-0.814). Fidelity criteria were more consistently met by staff who also met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82).

CONCLUSIONS

A prospective observational cohort of OptiBreech collaborative care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and strategically develop further proficient members of staff, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility tested. It is funded by the NIHR (NIHR300582).

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

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.

Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS)-an international multi-stakeholder Delphi study: study protocol

BACKGROUND

Women pregnant with a breech-presenting foetus at term are at increased risk of adverse pregnancy outcomes. The most common intervention used to improve neonatal outcomes is planned delivery by caesarean section. But this is not always possible, and some women prefer to plan a vaginal birth. A number of providers have proposed alternative interventions, such as delivery protocols or specialist teams, but heterogeneity in reported outcomes and their measurements prevents meaningful comparisons. The aim of this paper is to present a protocol for a study to develop a Breech Core Outcome Set (Breech-COS) for studies evaluating the effectiveness of interventions to improve outcomes associated with term breech birth.

METHODS

The development of a Breech-COS includes three phases. First, a systematic literature review will be conducted to identify outcomes previously used in effectiveness studies of breech birth at term. A focus group discussion will be conducted with the study's pre-established Patient and Public Involvement (PPI) group, to enable service user perspectives on the results of the literature review to influence the design of the Delphi survey instrument. Second, an international Delphi survey will be conducted to prioritise outcomes for inclusion in the Breech-COS from the point of view of key stakeholders, including perinatal care providers and families who have experienced a term breech pregnancy. Finally, a consensus meeting will be held with stakeholders to ratify the Breech-COS and disseminate findings for application in future effectiveness studies.

DISCUSSION

The expectation is that the Breech-COS will always be collected in all clinical trials, audits of practice and other forms of observation research that concern breech birth at term, along with other outcomes of interest. This will facilitate comparing, contrasting and combining studies with the ultimate goal of improved maternal and neonatal outcomes.

TRIAL REGISTRATION

Core Outcome Measures in Effectiveness Trials (COMET) #1749.

A New Ethical Framework for Assessing the Unique Challenges of Fetal Therapy Trials

New fetal therapies offer important prospects for improving health. However, having to consider both the fetus and the pregnant woman makes the risk-benefit analysis of fetal therapy trials challenging. Regulatory guidance is limited, and proposed ethical frameworks are overly restrictive or permissive. We propose a new ethical framework for fetal therapy research. First, we argue that considering only biomedical benefits fails to capture all relevant interests. Thus, we endorse expanding the considered benefits to include evidence-based psychosocial effects of fetal therapies. Second, we reject the commonly proposed categorical risk and/or benefit thresholds for assessing fetal therapy research (e.g., only for life-threatening conditions). Instead, we propose that the individual risks for the pregnant woman and the fetus should be justified by the benefits for them and the study's social value. Studies that meet this overall proportionality criterion but have mildly unfavorable risk-benefit ratios for pregnant women and/or fetuses may be acceptable.

Risk tolerance in adjuvant and metastatic melanoma settings: a patient perspective study using the threshold technique

Background: Adverse events (e.g., pyrexia) may affect treatment patterns and adherence. This study explored pyrexia risk tolerance among melanoma patients when treatment benefit is unknown versus known. Materials & methods: US respondents with stage III (n = 100) or stage III unresectable/stage IV melanoma (n = 125) chose between hypothetical melanoma treatments, defined by reoccurrence/progression-free survival and pyrexia risk, one resembling standard-of-care and one resembling dabrafenib + trametinib. Respondents chose first when efficacy was unknown and then when efficacy was known; pyrexia risk was varied systematically to define maximum acceptable risk. Results: Maximum acceptable risk of pyrexia was statistically significantly higher when efficacy was known versus unknown in stage III patients (85 vs 34%) and stage III unresectable/stage IV patients (66 vs 57%). Conclusion: Patients accepted higher levels of pyrexia risk when they understood treatment benefit.

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review

BACKGROUND

Medical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback.

METHODS

We searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics).

RESULTS

A total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%.

CONCLUSIONS

Study designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.

Impact of implementation of a breech clinic in a tertiary hospital

BACKGROUND

The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced.

METHODS

This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality.

RESULTS

After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods.

CONCLUSION

The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

Using the Threshold Technique to Elicit Patient Preferences: An Introduction to the Method and an Overview of Existing Empirical Applications

Patient preference information (PPI) is a topic of interest to regulators and industry. One of many known methods for eliciting PPI is the threshold technique (TT). However, empirical studies of the TT differ from each other in many ways and no effort to date has been made to summarize them or the evidence regarding the performance of the method. We sought to describe the TT and summarize the empirical applications of the method. Forty-three studies were reviewed. Most studies estimated the minimum level of benefit required to make a treatment worthwhile, and over half estimated the maximum level of risk patients would accept to achieve a treatment benefit. The evidence demonstrates that the TT can be used to elicit multiple types of thresholds and can be used to explore preference heterogeneity and preference non-linearity. Some evidence suggests that the method may be sensitive to anchoring and shift-framing effects; however, no evidence suggests that the method is more or less sensitive to these potential biases than other stated-preference methods. The TT may be a viable method for eliciting PPI to support regulatory decision-making; however, additional understanding of the performance of this method may be needed. Future research should focus on TT performance compared with other stated-preference methods, the extent to which results predict patient choice, and the ability of the TT to inform individual treatment decisions at the point of healthcare delivery.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

PROBLEM

Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems.

BACKGROUND

Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear.

QUESTION

How do professionals develop competence and expertise in physiological breech birth?

METHODS

Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition.

RESULTS

Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners.

DISCUSSION

The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices.

CONCLUSION

Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.

The art of vaginal breech birth at term on all fours

Despite a shift in clinical practice favouring cesarean section for breech presentation, adequate skills are still needed for a safe vaginal breech birth. This case report illustrates the physiological mechanism of vaginal breech birth. The accompanying pictures are a testimony to the "hands-off" approach and could be used for educational purposes.

Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study

OBJECTIVE

The aim of this study was to evaluate the effect of the increased cesarean rate for term breech presentation on neonatal outcome. We also investigated whether the clinical case selection for vaginal delivery applied by Dutch obstetricians led to an optimization of neonatal outcome, or whether there is still room for improvement in terms of perinatal outcome.

DESIGN

Retrospective cohort.

SETTING

The Netherlands.

POPULATION

Singleton term breech deliveries from 37+0 to 41+6 weeks, excluding fetuses with congenital malformations or antenatal death.

METHOD

We used data from the Dutch national perinatal registry from 1999 up to 2007.

MAIN OUTCOME MEASURES

Perinatal mortality and morbidity.

RESULTS

We studied 58,320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3 0/00 vs. 0.7 0/00;odds ratio 0.51 (95% confidence interval 0.28–0.93)], whereas it remained stable in the planned vaginal birth group [1.7 0/00 vs. 1.6 0/00; odds ratio 0.96(95% confidence interval 0.52–1.76)]. The number of cesareans done to prevent one perinatal death was 338.

CONCLUSIONS

Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies.