Breeching the system: An exploration of women’s experiences in Western Australia and breech birth recommendations

Breech presentation creates division in the consumer and healthcare communities. A number of studies report the use of scare tactics and bullying from clinicians, when women express a preference for vaginal birth after the diagnosis of a breech presenting fetus. Despite evidence showing that vaginal birth of a breech presenting fetus is safe in the presence of an appropriately skilled and experienced clinician, Caesarean Section is the primary mode of birth for breech presenting fetuses, which has resulted in a global lack of accessibility to breech birth experienced practitioners and birth mode options for women. Women planning a vaginal breech birth in a maternity care system, where the occurrence of this phenomenon is rare, face multiple challenges. Little is known of women’s breech pregnancy and birth experiences in Western Australia (WA). A mixed methods study involving semi-structured interviews, a multinational electronic Delphi (e-Delphi) study and clinical practice guideline review was designed to explore breech presentation from the perspective of women in Western Australia, and professionals with knowledge and/or experience of caring for women with a breech presenting fetus. The clinical practice guideline review provides insight into the parameters women with a breech presenting fetus planning a vaginal birth have to work within. For the clinical guideline review, clinical practice guidelines were purposively sought from leading obstetric organisations and reviewed using the International Centre for Allied Health Evidence (iCAHE) appraisal checklist. Key consistencies and inconsistencies between the guidelines were identified. Varying levels of evidence are used to support the recommendations made by professional organisations. The inconsistencies highlighted in the review have the potential to create confusion among clinicians and women and to cause issues related to valid consent, further emphasising the importance of balanced information and universal definitions for variations such as a footling presentation. The women’s aspect of this study illustrates the experiences of some women in WA. Critical theoretical concepts of knowledge and power as described by Michel Foucault, were used to describe power relations noted during clinical interactions between women and their care providers. These findings were consistent with previous reports of coercion and bullying when women’s preferences conflicted with those of their care provider. Also identified were five distinct phases women experienced throughout their breech experience – Reacting, Information, Bargaining, Decision Making and Acceptance - which showed some similarities to the Kübler-Ross model of grief. Combining the Five Stages of Breech and Foucauldian concepts of knowledge and power facilitated the identification of areas in practice which need improvement. Midwives were seen as supportive navigators of a restrictive system. The multinational e-Delphi study explored the panel’s knowledge views and recommendations of care for breech presentation. The main findings of this aspect of the study were the Breech Care Pathway provided in a midwifery-led multidisciplinary continuity of care model, a clinical skills development and maintenance framework and the proposal of a standard definition for a footling breech presentation. Providing woman-centred care in a midwifery – led multidisciplinary continuity of care model has the potential to improve the experiences and health outcomes for women and their babies. While continued improvement is needed, steps are being undertaken, particularly by midwives, to facilitate women’s autonomy and support their birth preferences. This thesis highlights current obstacles faced by women and clinicians in relation to breech presentation in contemporary maternity care. It suggests multiple ways in which this may be achieved and provides pathways and frameworks which may be used to support this process