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The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section.
This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women’s experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback.
A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals’ knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time.
Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete.
The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature.
DERR1-10.2196/23514
Birth of any kind, vaginal or cesarean section (CS), is not without risk [
Women come to decisions about birth mode through a complex interplay among their own preferences, social influences, clinicians’ views and experiences, and health system support [
Media representations of breech birth tend to emphasize the risks of a vaginal birth and focus on the relative safety of CS, which contributes to the societal perception of VBB as a dangerous option [
However, with the growing international concern regarding the escalating rate of cesarean birth and its potential consequences for childbearing women and their current and possible future children [
An integrated care pathway (ICP) is a formalized document which outlines the ideal pathway of care for people experiencing a particular health phenomenon and has been broadly used across aspects of health care [
Database searches exposed reference to existing breech-specific ICPs; however, one could neither be found in the Australian context nor were the authors able to obtain a copy of an existing breech-specific ICP. An ICP for breech presentation has the potential to reduce unnecessary intervention and streamline care including timely referral and intervention and aid in promoting nonbiased counseling.
Owing to the potential benefits of ICP, the results of this study will be used to guide the development of an ICP for women diagnosed with a breech presentation close to or at term (ie, approximately 35-40 weeks of gestation) to support the delivery of high-quality, evidence-based care. The development of a breech-specific ICP for women in Western Australia will be achieved through the amalgamation of expert opinion (ie, consensus reached in the electronic Delphi [e-Delphi] study), consumer feedback (ie, based on results from interviews exploring women’s experiences of breech birth), and the incorporation of breech care guidelines [
The primary questions this research aimed to answer were the following:
What barriers and facilitators do women experiencing breech presentation close to or at term experience in Western Australia?
What optimal pathway of care is recommended for women with a breech presentation between 36 and 42 weeks?
In the context of research, a
Mixed methods research has been employed in health care research for decades [
Curran et al [
Semistructured interviews with women who had experienced a live breech birth between 36 and 42 weeks of gestation within the past 5 years of their recruitment to the study
An e-Delphi study with professionals having knowledge or experience of caring for women experiencing breech presentation
A review of current clinical guidelines
Once the data have been analyzed and the ICP is formulated, the recommendations for the care for women with a breech presentation, as determined by the panel, will be compared with local [
The aim of this aspect of the study was to provide insights and understanding into what women in Western Australia who are diagnosed with a breech presentation experience in order to highlight the areas of care that may need improvement.
A preapproved graphic was circulated on social media sites such as Twitter and Facebook by the lead author in December 2018 as a means of generating awareness and interest in the study. The posts received 125
Interviews were conducted and audiorecorded by the lead author. The interviews took place in a location according to the women’s preferences—mainly in their homes or a neutral setting such as a local café. Women were also offered the option of a telephone or video call if it was difficult to schedule a date for a face-to-face meeting to take place.
The audio files generated by the interviews were transcribed by the lead author. Conversation not pertinent to the aims of the study were briefly summarized and filler words such as “umm,” “ahh,” and “like” were removed and were otherwise transcribed verbatim. Transcript analysis was guided by Critical Theoretical concepts to identify and describe the potential barriers, constraints, and facilitators faced by women experiencing breech presentation at the end of their pregnancy.
Critical Theory has its foundations in the Marxist tradition, which focuses on the emancipation of the working class from oppression by bourgeoisie society [
The Delphi technique was originally developed as a way for military experts to forecast the effect of advancing technologies on warfare but has since been employed across many disciplines as a way of reaching consensus regarding matters of import [
Consensus is established through consecutive questionnaires, termed
Questions for the first round were guided by a previous study relating to breech presentation [
As breech care and birth are niche areas of interest compared with other health phenomena, a minimum of 10 professionals with in-depth knowledge of or experience in caring for women with breech presentation was desired for this study. The following inclusion criteria were set for the e-Delphi study: participants were required to be aged 18 years or above; have the ability to speak and read English; and have experience in supporting or caring for women during pregnancy, particularly those experiencing breech presentation. This study aims to capture a panel whose members had varying experiences of caring for women with breech presentation as experience is contextual; therefore, no predetermined years of experience was placed, a mix of convenience, purposive, and snowball sampling was used. Preapproved social media posts outlining the aim of the study and the contact details of the lead author were circulated on Twitter and Facebook groups such as the Coalition for Breech Birth and the Breech Birth Network for convenience sampling; and to the public to generate the interest of potential participants, encouraging them to make contact if they were interested in participating. All those who responded identified themselves as professionals who met the aforementioned selection criteria. This was verified throughout the processing of the data obtained from round 1. Recruitment took place between November 2018 and August 2019. The aforementioned posts were circulated numerous times. Participants were also encouraged to pass the study information to any of their colleagues who they believed might be interested in participating (ie, snowball recruitment). Recent breech literature was also reviewed as a means of identifying potential participants (ie, purposive sample). A minimum of 2 emails or direct messages through social media were sent to the participants identified through the literature.
Current guidelines on breech management and care will be purposively selected from national and professional organizations in the United States, Canada, the United Kingdom, Europe, Australia, and New Zealand for review to aid in answering the second research question (ie, What optimal pathway of care is recommended for women with a breech presentation between 36 and 42 weeks?). The authors propose using the clinical practice guideline appraisal tool International Centre for Allied Health Evidence Guideline Quality Checklist to evaluate each guideline. This tool has been validated and was deemed best suited because of its ability to efficiently and effectively review the quality of clinical practice guidelines [
Permission to undertake this study was granted by the University Human Research Ethics Committee (project number 19566). All participants in this study were provided with an information sheet outlining the scope of the respective studies, the contact details of the research team, and the phone number for a helpline in the event that they experienced any emotional discomfort when recalling their experiences.
Women who met the inclusion criteria and were willing to participate in a semistructured interview were required to sign a consent form before participating. Women were advised that they would be able to withdraw from the study at any time before the completion of their interview. Confidentiality of the women was maintained through the deidentification of all transcripts by using codes based on the women’s birth modes (ie, VBB1 or CS10) and the storage of sensitive documents and data in a secure location only accessible to the research team.
Participants of the e-Delphi study were required to indicate their consent to participate by answering a
All data were stored on the web in Qualtrics, which is password protected and only accessible to the research team, and all data were deidentified, if necessary, for consecutive rounds.
In the interviews, women described their experiences of breech presentation from their diagnosis until after birth. The data generated from the interviews with women will be examined utilizing Critical Theoretical concepts to identify and describe the potential barriers, constraints, and facilitators faced by women experiencing breech presentation near term. This aspect of the study will provide insights into what women in Western Australia experience when diagnosed with a breech presentation near term, providing context and possibly the justification for the development of the breech-specific ICP. By applying the Critical Theoretical framework, the authors hope to explore and examine the unique issues faced by women who are diagnosed with breech presentation at the end of their pregnancy to make recommendations for change to bring about a more woman-centered approach to breech care in Western Australia.
Round 1 comprised demographic and open-ended questions. The responses from this round were evaluated, coded, categorized, and amalgamated where possible to formulate statements for the following 2 rounds using the participants’ own words by the lead author. These statements were then sent to the rest of the research team along with the raw data from round 1 for review. Feedback from the research team was incorporated, and the statements were refined and rechecked before distribution to the panelists. A similar process took place during each round based on the panelist comments made in each round and feedback from the research team members.
Statements were evaluated primarily using a 5-point Likert scale, in which responses ranged from strongly agree to strongly disagree. Owing to human error during the construction of round 2 in Qualtrics, a few statements were evaluated using a 7-point Likert scale. Regardless, if the predetermined level of consensus of 70% or more of the panelists agreeing (responses ranging from somewhat agree to strongly agree) or disagreeing (responses ranging from somewhat disagree to strongly disagree) with the presented statements was reached, consensus was deemed to be met in the third and final round.
In-depth data analysis and review of consensus statements will be combined with an exploration of the women’s experiences of breech birth in Western Australia analyzed using Critical Theoretical concepts and current clinical guidelines to aid the formulation of an ICP for breech presentation. A process adapted from the work of Curran et al [
Integrated care pathway process. e-Delphi: electronic Delphi; ICP: integrated care pathway.
Critical approaches emphasize the importance of researcher reflexivity [
Methods of ensuring the validity of the findings included transcript verification by participants and peer checking of the themes, concepts, and statements derived from the data from both research methods. Women who participated in the semistructured interviews were provided with a copy of their interview transcript and offered the opportunity to verify its contents based on their recollections of the interview. The resultant transcripts were also reviewed by and compared with the audio files by the coauthors to assess the accuracy of transcription. Corrections included typographical errors and 1 change in gestational age at diagnosis of breech presentation based on the woman’s recall.
Peer checking of the themes, concepts, and statements derived from each data set by the lead author was accomplished through reflective discussion and review of field notes and e-Delphi responses by the coauthors. Adaptations were made if deemed necessary based on corroborative and constructive feedback.
Using a pragmatic, mixed methods approach to answer the original research questions has allowed the collection of qualitative and quantitative data to provide a comprehensive examination of differing aspects of breech presentation in Western Australia and various continents around the world. The results will be used to guide the formulation of practice recommendations and a breech-specific ICP that will incorporate multidisciplinary collaboration with consumer and key stakeholder input and the integration of evidence on a local and international level.
The women’s experiences explored in this study will provide insights and understanding into what some women in Western Australia have undergone throughout their breech pregnancy and birth experience and will aid in formulating recommendations to promote a more woman-focused approach to breech care and management. It is the author’s hope that a breech-specific ICP for Western Australia will facilitate this process.
An ICP for breech presentation alongside a specialty breech service has the potential to promote a more women-focused approach to breech care in Western Australia, reduce the rate of CS for breech presentation, and aid data collection for practice review and quality improvement [
An advantage of mixed methods research includes a more comprehensive understanding of the phenomenon in focus instead of a singular point of view by incorporating qualitative and quantitative data and different theoretical perspectives [
Interviews were chosen for their ability to explore and describe issues from the perspective of the participants [
The advantages of the Delphi method include achieving consensus without disregarding the minority, flexibility to adapt the protocol to suit the needs of the project, cost-effectiveness if done on the web, connectivity to geographically dispersed participants, and reduction of the influence of dominant personalities on others’ responses [
This paper describes the design of a mixed method study which will amalgamate expert opinion (consensus reached in the e-Delphi study), consumer feedback (based on the results from interviews exploring women’s experiences of breech birth and the review of exisiting breech birth guidelines [
cesarean section
external cephalic version
integrated care pathway
vaginal breech birth
Although no funding was received for this study, the lead author received fee support from the Australian Government Research Training Program.
None declared.