Decision making about breech presentation :exploring women's experiences and developing decision support

Abstract

Breech presentation affects 3-4% of women pregnant with a single baby after 37 weeks of pregnancy. These women face two key decisions: firstly, whether or not to attempt to turn their baby by external cephalic version (ECV). Secondly, if they decide not to attempt this, or it is unsuccessful, then they need to decide how to give birth to their baby, either by planned caesarean section (CS) or vaginal breech birth (VBB). This thesis explores the process of decision making about breech presentation from both women’s and health professionals’ perspectives and documents the development of a patient decision aid (PDA), consisting of an animated film and website, for women facing these decisions in the future. In this qualitative study, data were collected using observed consultations, semi-structured interviews, with both women and professionals, and user-centred design workshops. Thirty nine women and 30 health professionals were respondents. Data were analysed using constant comparison. The results show that the diagnosis of breech presentation often comes late in pregnancy and begins with uncertainty, partly because many professionals are reluctant to provide information about options until the diagnosis is confirmed by ultrasound examination. Professionals are concerned about causing unnecessary anxiety to women who do not have a breech presentation confirmed, but such an approach fails to take account of women’s clear preference for information as soon as the possibility of breech presentation is raised. Women report researching options online and amongst their social contacts, as they strongly value experiential accounts. However they may struggle to find trustworthy information from these sources as they are frequently told horror stories. Women may also be directively counselled by professionals who have a clear preference for attempting ECV. In response to these themes, a PDA was developed which is freely available to women and includes a website summarising the evidence about the different options. In relation to decision making, women described five key values: wanting to keep their baby safe; wanting to experience a natural birth and to breastfeed; preferring to avoid surgery; needing to be able to care for other children; and wanting to have control. Postnatally, they shared vivid accounts of their experiences of ECV and birth, which were used to inform the script for the animated film that aims to provide the experiential information women wanted and also help them to explore their own values about decision making.