Experiences, Beliefs, and Values Influencing Midwives' Attitudes Toward the Use of Childbirth Interventions.

INTRODUCTION: Intervention rates in perinatal care vary between and within countries, without populations' characteristics as a full explanation. Research suggests that one factor in this variation might be the attitudes of perinatal health care providers. Systematic knowledge on the background of midwives' attitudes and how this influences the use of interventions is limited. The study aim was to to explore experiences, beliefs, and values that influence midwives' attitudes toward interventions in perinatal care. METHODS: A qualitative study using in-depth interviews with primary care midwives (n = 20) in the Netherlands. The interviews were performed in June 2019 and combined a narrative approach with a semistructured interview guide. Inductive content analysis was applied. RESULTS: We identified 2 main themes: attitudes toward interventions and influences on midwives' attitudes. The midwives in our study described their attitudes toward interventions as oriented to either wait and see or check and control. Care based on wait and see displayed a more supportive style of behavior, and care based on check and control appeared to display a more directive style of behavior. In the theme of influences on midwives' attitudes, 3 subthemes emerged: experiences in collaboration, trust and fear, and woman-centeredness. DISCUSSION: Midwives with a wait and see attitude seem to have a more restricted approach toward interventions compared with midwives with a check and control attitude. Midwives need to be aware how their experiences, beliefs, and values shape their attitudes toward use of interventions. This awareness could be a first step toward the reduction of unwarranted interventions.

Implementation of client versus care-provider strategies to improve external cephalic version rates: a cluster randomized controlled trial.

OBJECTIVE: To determine the effectiveness of a client or care-provider strategy to improve the implementation of external cephalic version. DESIGN: Cluster randomized controlled trial. SETTING: Twenty-five clusters; hospitals and their referring midwifery practices randomly selected in the Netherlands. POPULATION: Singleton breech presentation from 32 weeks of gestation onwards. METHODS: We randomized clusters to a client strategy (written information leaflets and decision aid), a care-provider strategy (1-day counseling course focused on knowledge and counseling skills), a combined client and care-provider strategy and care-as-usual strategy. We performed an intention-to-treat analysis. MAIN OUTCOME MEASURES: Rate of external cephalic version in various strategies. Secondary outcomes were the percentage of women counseled and opting for a version attempt. RESULTS: The overall implementation rate of external cephalic version was 72% (1169 of 1613 eligible clients) with a range between clusters of 8-95%. Neither the client strategy (OR 0.8, 95% CI 0.4-1.5) nor the care-provider strategy (OR 1.2, 95% CI 0.6-2.3) showed significant improvements. Results were comparable when we limited the analysis to those women who were actually offered intervention (OR 0.6, 95% CI 0.3-1.4 and OR 2.0, 95% CI 0.7-4.5). CONCLUSIONS: Neither a client nor a care-provider strategy improved the external cephalic version implementation rate for breech presentation, neither with regard to the number of version attempts offered nor the number of women accepting the procedure.

Implementation of external cephalic version in the Netherlands: a retrospective cohort study.

BACKGROUND: External cephalic version (ECV) reduces the rate of elective cesarean sections as a result of breech presentation. Several studies have shown that not all eligible women undergo an ECV attempt. The aim of this study was to evaluate the implementation of ECV in the Netherlands and to explain variation in implementation rates with hospital characteristics and individual factors. METHODS: We invited 40 hospitals to participate in this retrospective cohort study. We reviewed hospital charts for all singleton breech deliveries from 36 weeks' gestation and onwards between January 2008 and December 2009. We documented whether an ECV attempt was performed, reasons for not performing an attempt, mode of delivery, and hospital characteristics. RESULTS: We included 4,770 women from 36 hospitals. ECV was performed in 2,443 women (62.2% of eligible women, range 8.2-83.6% in different hospitals). Implementation rates were higher in teaching hospitals, hospitals with special office hours for ECV, larger obstetric units, and hospitals located in larger cities. Suboptimal implementation was mainly caused by health care providers who did not offer ECV. CONCLUSION: ECV implementation rates vary widely among hospitals. Suboptimal implementation is mostly caused by the care provider not offering the treatment and secondly due to women not opting for the offered attempt. A prerequisite for designing a proper implementation strategy is a detailed understanding of the exact reasons for not offering and not opting for ECV.

Facilitators and barriers to external cephalic version for breech presentation at term among health care providers in the Netherlands: a quantitative analysis.

OBJECTIVE: guidelines recommend that external cephalic version (ECV) should be offered to all women with a fetus in breech presentation at term. However, only 50-60% of the women receive an ECV attempt. We explored the determinants (barriers and facilitators) affecting the uptake of the guidelines among gynaecologists and midwives in the Netherlands. DESIGN: national online survey. SETTING: the Netherlands. PARTICIPANTS: gynaecologists and midwives. MEASUREMENTS: in the online survey, we identified the determinants that positively or negatively influenced the professionals׳ adherence to three key recommendations in the guidelines: (a) counselling, (b) advising for ECV, (c) arranging an ECV. Determinants were identified in a previously performed qualitative study and were categorised into five underlying constructs; attitude towards ECV, professional obligation, outcome expectations, self-efficacy and preconditions for successful ECV. We performed a multivariate analysis to assess the importance of the different constructs for adherence to the guideline. FINDINGS: 364 professionals responded to the survey. Adherence varied: 84% counselled, 73% advised, and 82% arranged an ECV for (almost) all their clients. Although 90% of respondents considered ECV to be an effective treatment for preventing caesarean childbirths, only 30% agreed that 'every client should undergo ECV'. Self-efficacy (perceived skills) was the most important determinant influencing adherence. KEY CONCLUSIONS: self-efficacy appears to be the most significant determinant for counselling, advising and arranging an ECV. IMPLICATIONS FOR PRACTICE: to improve adherence to the guidelines on ECV we must improve self-efficacy.

Implementation of the external cephalic version in breech delivery. Dutch national implementation study of external cephalic version.

BACKGROUND: Breech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV) is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG). Implementation of ECV does not exceed 50 to 60% and probably less.We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling. METHOD/DESIGN: The ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV.The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured. DISCUSSION: This study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term. TRIAL REGISTRATION: Dutch Trial Register (NTR): 1878.