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.