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Improving management of breech presentation at term
Rosman, A.N.
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Rosman, A. N. (2014). Improving management of breech presentation at term
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Download date: 15 Jun 2017
7
Facilitators and barriers to external cephalic version for
breechpresentation at term among health care providers in
the Netherlands: A quantitative analysis
Ageeth N. Rosman
Floortje Vlemmix
Antje Beuckens
Marlies E. Rijnders
Brent C. Opmeer
Ben Willem J. Mol
Marjolein Kok
Margot A.H. Fleuren
MIDWIFERY. 2014 MAR;30(3):E145-50
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Chapter 7 Facilitators and barriers to external cephalic version
ABSTRACT
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 gynecologists and midwives in the Netherlands.
Design National online survey.
Setting the Netherlands.
Participants Gynecologists 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 practiceTo improve adherence to the guidelines on ECV we
must improve self-efficacy.
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Chapter 7 Facilitators and barriers to external cephalic version
INTRODUCTION
Clinical problem
Breech presentation occurs in 3–4% of term pregnancies, corresponding to
7450 women annually in the Netherlands. The Term Breech Trial, which compared planned vaginal childbirth to planned caesarean childbirth, showed a
significant reduction in poor neonatal outcome and mortality.1 The results
of this study had a major impact on the management of the term breech
childbirth. The overall caesarean childbirth rate for breech presentation in
the Netherlands increased from 50% to 80%.2 This change was accompanied
by a substantial decrease in perinatal mortality of breech pregnancies from
0.38% to 0.18% (OR 0.53; 95%CI 0.33–0.83) and neonatal trauma (OR 0.26;
95%CI 0.14–0.50).3
The increased number of caesarean sections (CS) has disadvantages as well:
caesarean childbirths are associated with increased maternal morbidity, longer hospital admission and consequences for future pregnancies (increased
risk of abnormal placental implantation, uterine rupture and, as an ultimate
consequence of these complications, fetal death). External cephalic version
(ECV) is a safe obstetrical intervention that has been proven to reduce the
number of breech presentations at birth and therefore reduction of the number of caesarean childbirths.4 ECV is worldwide recommended in obstetrical
guidelines as the first treatment of choice in case of breech presentation at
term, with reported success rates of 40–50%.5
The Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for
Obstetrics and Gynaecology (NVOG) published evidence-based guidelines
on the management of women with a fetus in breech position.6,7 According
to these guidelines ECV should be advised to all eligible women with a fetus
in breech position at 36 weeks and onwards. The three key recommendations in the guidelines are: (1) to counsel all women with a fetus in breech
presentation. This means supplying information and taking the woman’s and
her partners perspective into account so they are able to make an informed
choice; (2) advising an ECV and (3) arranging an ECV; either by performing
ECV or referring to a colleague who is experienced in performing ECV.
Irrespective of these guidelines, not all women are offered an ECV. An inventory survey among all hospitals in the Netherlands in 2007 reported that
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Chapter 7 Facilitators and barriers to external cephalic version
5% of the gynaecologic practices did not perform nor referred for ECV at
all, even though women with breech presentations were referred to these
hospitals as well.8 A prospective cohort study in the Netherlands reported
that 26% of women with a fetus in breech presentation did not undergo ECV;
in 48% of these cases, the obstetrician decided not to perform ECV, 37% of
women declined a version attempt, and 15% gave birth before the version
was performed.9 This means that a substantial proportion of clients are not
receiving the intended care in a way that they benefit from the guidelines.
As a result, these women will have a breech presentation at birth and most
of them will have a caesarean childbirth with all its consequences. As there is
sound evidence supporting an ECV in case of breech presentation, it is clear
that the problem relates to implementation.
Framework of implementation research
One of the main problems with the introduction of guidelines in the health
care system is that professionals do not ‘automatically’ use the guidelines as
intended by the developers. 10,11 A detailed understanding of the factors, or
so-called determinants, that facilitate or impede the innovation process is a
prerequisite for designing an innovation strategy that is adapted to the several critical determinants, in order to achieve real change.12,13 The framework
used in the present study represents the main stages in innovation processes
and related categories of determinants. Each of the four main stages in innovation processes (dissemination, adoption, implementation, and continuation) can be seen as points at which, potentially, the desired change may not
occur. The transition from one stage to the next can be affected by various
determinants. This framework is more extensively discussed elsewhere.12
To identify potential determinants for (non)adherence to the guidelines on
breech presentation, focus group interviews were conducted with midwives
and gynaecologists.14 This resulted in a list of 43 potential determinants, that
was further reduced to a shortlist of key determinants, as recognised by implementation experts.12
The aim of this study was to quantify the determinants (facilitators as well
as barriers) midwives and gynaecologists perceive in adhering to the three
key recommendations in the Dutch ECV guidelines: (a) counselling all eligible
women for ECV, (b) advising positively and (c) arranging an ECV.
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Chapter 7 Facilitators and barriers to external cephalic version
METHODS
Setting
In the Netherlands, obstetric care is organised in regions. A region contains
a hospital and several surrounding midwifery practices who initially refer to
this hospital. In total, there are 97 hospitals and thus regions, and 503 midwifery practices in the Netherlands.
Study design
The study was designed as a survey among gynaecologists and midwives.
As both professions are organised differently, we had a different approach
for each. All 1,217 gynaecologists and residents were sent an invitation by
e-mail to participate in the online questionnaire. It was not possible to limit
the invitations to obstetrical oriented gynaecologists. However, the majority of gynaecologists in the Netherlands are actively involved in obstetrics.
There is no mass e-mail listing for midwives, thus a random sample of addresses of 300 midwifery practices were sent an invitation to participate in
the online questionnaire. To avoid missing data in the online questionnaire,
the questionnaire could not be finished when there were missing answers. If
participants wished to explain their answers in detail, they could do so at the
end of the questionnaire.
The general outline of the questionnaire was derived from the qualitative
determinant analyses.14 Table 2 shows the variables that were measured.
First, the potentially relevant determinants of adherence to the three key
recommendations were measured: attitude towards EVC (10 items); professional obligation (eight items); outcome expectations (four items); self-efficacy (four items) and preconditions for successful ECV (15 items). Professional obligation refers to the degree to which the guideline recommendations
fit in with the tasks for which the user feels responsible when doing his/
her work .15 Self-efficacy refers to the perceived competence of users with
respect to intended behaviour.16,17
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Chapter 7 Facilitators and barriers to external cephalic version
Table Ia. Characteristics of respondents; gynaecologists Number of respondents Gynecologists Residents Unknown Subspecialty of gynaecologists Perinatology Uro-­‐gynaecology Fertility Oncology General gynaecologist Unknown Setting Teaching Hospital Other Training in ECV During residency During work as gynaecologist Training of NVOG Other Experience with ECV ECV performed at least once in the past year Gynecologists (%) 298 203 (68) 69 (23) 26 (9) 75 (37) 28 (14) 28 (14) 12 (6) 57 (28) 3 (1) 270 (91) 28 (9) 137 (68) 15 (7) 15 (7) 35 (17) 255 (85) Outcome expectations refer to the user’s perceived probability of achieving
the client objectives as intended by the guidelines.15 For all items, 5-point Likert scales were used, ranging from ‘totally agree’ to ‘totally disagree’, except
for self-efficacy (4-point scale, ranging from ‘feeling totally able to perform’
to ‘feeling totally unable to perform’). The self-reported level of adherence
was measured at the level of the three key recommendations in the guidelines (adherence to counsel, advising, and arranging ECV). The respondents
were asked to indicate, for each key recommendation, for how many patients they had implemented the activity (7-point Likert scale, ranging from
‘none’ to ‘all’). These three adherence items were used as outcome measures of our analyses. Finally, relevant background variables were assessed,
such as type of respondent (consultant gynaecologist/obstetrics, resident,
and midwife), type of hospital or practice, and experience with ECV (Table 1).
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Chapter 7 Facilitators and barriers to external cephalic version
Table Ib. Characteristics of respondents; midwives Number of respondents Type of practice Solo practice Group practice Temporary helper Specialist in ECV Experience with ECV ECV performed at least once in the past year Midwives (%) 66 8 (12) 54 (82) 4 (6) 3 (5) 11 (17) Data analyses
The items were a priori organised as to reflect clinically plausible constructs
related to ECV. We used principal components analyses (PCA) to identify statistical constructs of items based on the inter-item correlations. Items contributing <0.50 to the construct were considered not to contribute to the
construct and were therefore removed. A Cronbach's alpha of more than
0.70 indicates good reliability.18 If these statistical constructs were found to
be consistent with the clinical constructs or otherwise show good clinical
face validity, their scale properties were assessed and improved using reliability analysis (internal consistency, inter-item correlation) of the items for
each construct. Otherwise the original constructs were used for subsequent
scale construction.
For each construct, a summary score reflecting respondents' ratings on that
construct was obtained with principal components analysis (PCA). PCA is a
way of identifying patterns in data, and expressing the data in such a way as
to highlight their similarities and differences. As patterns in data can be hard
to find in data of high dimension, PCA is a powerful tool for analysing data.
We explored the extent to which these constructs – the determinants – were
associated with the three adherence outcomes. First we took for each construct separately (univariate analyses), and subsequently explaining the outcomes by taking those constructs with a p-value below 0.10 from the univariate model, all into account (multivariable way) to assess their combined
association with the outcomes.
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Chapter 7 Facilitators and barriers to external cephalic version
Table II: Adherence and determinants in adhering to the ECV guideline in daily practice 1
A. Attitude towards ECV 1.
Every client* should be counselled 2.
During counselling should be explained that ECV is the best choice for the client 3.
Every client should undergo ECV 4.
Uterus relaxants increase the success rate of ECV 5.
Uterus relaxants should be offered to all clients 6.
Clinical experience of the professional is leading in the decision to offer a client an ECV ECV is a good treatment to increase the number of cephalic presentation at birth 7.
8.
Every client with a failed ECV should be offered a second attempt 9.
ECV is a good treatment to decrease the number of caesarean sections due to breech presentation 10. Knowledge of guidelines on ECV improves counselling 1
B. Task orientation 11. It is my responsibility to counsel every client 12. It is my responsibility to convince every client to opt for ECV 13. It is my responsibility to refer to the professional with the highest success rate in the region 14. It is my responsibility to take care of an unambiguous policy within my hospital / practice 15. It is my responsibility to take care of an unambiguous policy within my region 16. It is my responsibility to discuss reasoning when colleagues do not offer ECV 17. It is the task of gynaecologists to decide on contra indications of ECV 18. It is the task of special trained midwives to decide on contra indications of ECV 1
C. Outcome expectations 19. Clients are more content if ECV is always offered 20. Counselling increases the number of clients opting for ECV 21. An unambiguous policy increases the number of ECV attempts 22. Performing ECV leads to more cephalic presentations at birth 1
D. Preconditions of successful ECV 23. Counselling should contain information on breech birth; vaginal vs. caesarean section. 24. ECV is safe in an out of hospital setting, under precondition of good agreements with the hospital in case of complications 25. To improve quality of care, ECV should be performed in specialized centres. 26. Registration of ECV in a the nationwide obstetric database is necessary for a good evaluation 27. To offer all clients ECV, compromises on reference between midwives and gynaecologists is essential 28. Special finance is necessary for counselling 29. 10 ECV attempts per year are necessary to maintain expertise 30. Success rates of ECV increase when special office hours are reserved 31. Success rates of ECV increase when performed in specialized centres 32. Complication rates of ECV can be reduced when performed in specialized centres. 33. If ECV could only be performed in hospitals, the number of ECVs decreases 34. Feedback of results of ECV and consequences of care to the referrer, increases the number of clients counselled 35. If referrers have a better perception of the expertise and success rates of the specialists, more women are referred for ECV. 36. There is shortage of time to counsel clients properly in daily practice 37. Current cooperation in the region hinders me in offering ECV to clients 2
E. Self-­‐efficacy 38. To what extend do you feel able to counsel all clients? 39. To what extend do you feel able to explain that ECV is the best choice? 40. To what extend do you feel able to explain the safety of ECV? 41. To what extend do you feel able to plan all clients opting for ECV for an attempt? 3
Adherence to guidelines (dependent variables) A. How many clients do you counsel? B. How many clients do you convince of the advantages of ECV? C. For how many clients do you succeed in arranging an ECV attempt? (Either referring or performing it yourself) *Client; women with breech presentation at term eligible for ECV 1
Percentage of respondents who filled in ‘agree’ to ‘strongly agree’. 2
Percentage of respondents who filled in ‘feeling totally able to perform’
3
Percentage of respondents who filled in ‘almost all’ to ‘all’ 132
% of gynaecologists agree 96 84 30 66 49 32 % of midwives agree 99 77 22 29 25 22 94 28 91 69 97 94 91 92 73 52 86 85 66 66 88 95 76 77 84 48 73 81 80 93 90 59 69 28 77 82 86 80 97 88 7 77 73 93 80 92 92 88 39 64 72 44 29 8 72 78 71 65 52 37 23 54 75 72 24 6 64 46 41 55 56 8 51 35 35 55 86 74 72 74 82 80 Chapter 7 Facilitators and barriers to external cephalic version
To evaluate whether the association between a determinant and the adherence outcomes was different for gynaecologists and midwives, also interaction variables for all constructs with specialism were included in the
multivariable analyses. A backward selection method was applied, and associations with p<0.05 were considered significant. Standardised betas
and p-values were reported to quantify the relation between the constructs
and the outcome. Statistical Products Services and Solutions (SPSS), version
17.0.1, Chicago, IL, was used for the statistical analyses.
FINDINGS
Respondent characteristics
The survey was online accessible from February 2010 until April 2010. Of
1217 gynaecologists and residents initially contacted, 281 (23%) completed
the online survey. The majority (91%) of gynaecologists and residents were
working in a teaching hospital and 75 (37%) gynaecologists were specialised
in obstetrics. More than half of the gynaecologists were trained in ECV during their residency and 238 (85%) had performed one or more ECV attempts
in the past year. Of 300 midwifery practices 66 representatives completed
the online survey for their own practice. The vast majority worked in a group
practice. Eleven (17%) had performed one or more ECV attempts in the past
year. The results of the questionnaire are presented in Table 1. If more than
80% of respondents agreed with an item, it was considered to be a significant facilitating or impeding factor. Table 2��������������������������������
presents the respondents'������
characteristics.
Perceived facilitating determinants
Over 90% of professionals acknowledged that ECV is an effective treatment
to decrease the number of CS due to breech presentation (Table 2, item 9).
The majority of the respondents (over 90%) agreed with the statement ‘every client with a fetus in breech presentation should be counselled for ECV’
and felt it was their responsibility to counsel clients (items 1 and 11). Eighty
per cent agreed that counselling would increase the number of women undergoing an ECV (item 20) and thought that knowledge of the guidelines improves counselling (items 10). To be able to offer all clients ECV, good working arrangements between gynaecologists and midwives regarding referral
of patients was thought of to be essential (91% of respondents, item 27).
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Chapter 7 Facilitators and barriers to external cephalic version
Perceived impeding determinants
One-third agreed on the statement ‘every client should undergo ECV’ and
only two-third felt responsible to convince the client to opt for ECV (Table 2,
items 3 and 12). Just 35–46% of the respondents felt able to successfully explain the importance and safety of ECV to all clients (items 39 and 40). Only
55% of respondents felt able to plan an ECV attempt for all of their clients
(item 41). Regarding success rates of ECV, midwives and gynaecologists disagreed on the usefulness of a second version attempt. Only a small majority
felt responsible to refer to the professional with the highest success rate
within their region (items 8 and 13). Time and lack of finance (for the extra
invested time) to inform a client on ECV was a barrier for more than half
of the respondents, thereby reported significantly more often by midwives
(56% versus 78%) as compared to gynaecologists (24% versus 39%) (items
28 and 36).
Adherence to key recommendations of the guidelines
Adherence to the guidelines is expressed in three key recommendations (Table 2, items A, B, and C). Of all respondents, 84% stated to counsel all of their
clients, and 72% reported to positively advice (almost) all of their clients to
opt for an ECV. Over 82% of respondents reported to successfully arrange an
ECV attempt for (almost) all of their clients after the client opted for an ECV.
Scale construction
The factors obtained with principal components analyses only partially confirmed our a priori constructs, and also no clinically plausible alternative interpretation could be given to these factors. Face validity of the constructs is
essential, as the results need to be translated back to clinical practice; scale
construction was therefore based on our initial classification of items. Scale
properties were further optimised using reliability analysis. In one construct
(attitude), two items (6 and 8) were removed because this substantially improved Cronbach's alpha. Concerning the development of the constructs,
the generally recommended critical level of Cronbach's alpha of >0.7 was
reached in three of five constructs, but were >0.6 in the other two constructs. This is considered acceptable for newly developed scales and was
therefore accepted by the researchers.
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Chapter 7 Facilitators and barriers to external cephalic version
Determinants predicting the professional’s adherence to the guidelines
We explored whether the five constructs were associated with adherence to
guidelines in the univariable and multivariable regression analysis (Table 3).
Specialism (gynaecologist working in a hospital versus midwives working in
an out of hospital setting) was taken into account as well.
Within the multivariate analysis, midwives had a better reported adherence
to the key recommendation ‘advising ECV’ than gynaecologists (unstandardized beta 0.35, p-value 0.004). Attitude towards ECV and a positive self-efficacy contributed evenly. The reported adherence to ‘counselling’ was better among gynaecologists (unstandardized beta −0.28, p-value <0.0001) and
was positively influenced by an increased self-efficacy as well. Adherence to
arranging an ECV attempt was only influenced by a positive self-efficacy.
We evaluated whether the relation between the five constructs and the
three outcomes differed among the gynaecologist and midwives by taking
interaction variables into account. None of these resulted in statistically significant in the multivariate analyses of the three outcomes.
DISCUSSION
The results of our national survey show that Dutch gynaecologists and midwives perceive multiple barriers and facilitators for adherence to the guidelines on ECV in clinical practice. The vast majority of professionals consider
ECV as a good treatment to prevent CS, agrees that all clients should be offered the treatment and think that counselling could improve the number of
clients opting for ECV. However, only two-third of the professionals consider
convincing clients to undergo ECV as their task.
The perceived self-efficacy to perform the key recommendations is rather
low. The low agreement on the self-efficacy item of ‘successful planning of
an ECV attempt’ could indicate that referral for an ECV attempt not necessarily leads to an ECV attempt. The most remarkable finding regarding the
construct ‘attitude’ is the low agreement on the item ‘every client should
undergo ECV’. An explanation might be found in the free-text comments,
where many respondents argued that not all clients are eligible due to contra indications. The introduction of the questionnaire explained that ‘every
135
136
Specialism; gynaecologists or midwives Summary score of constructs 1. Attitude towards ECV 2. ECV as task orientation 3. Outcome expectations 4. Preconditions of successful ECV 5. Self-­‐efficacy 0.92 <0.0001 <0.0001 <0.0001 0.16 <0.0001 P-­‐value Un-­‐stan-­‐
dardized beta -­‐0.01 0.33 0.28 0.28 0.07 0.37 0.35 0.29 0.28 Un-­‐stand-­‐
ardized beta 001 0.00
4 <0.0
001 <0.0
P-­‐
value Multivariable analyses Adherence to advise ECV Univariable analyses Outcome variables -­‐0.38 0.12 0.22 0.18 -­‐0.03 0.33 Unstan-­‐dardized beta 1 0.006 0.06 <0.000
0.001 1 0.65 <0.000
P-­‐value Univariable analyses -­‐0.28 0.32 Unstan-­‐
dardized beta <0.0
001 0.03 P-­‐
value Multivariable analyses Adherence to counsel ECV Table III: Relationship of the professions and constructs of barriers/facilitators to advising, counselling, and arranging ECV -­‐0.02 0.03 0.08 0.13 -­‐0.01 0.28 Unstan-­‐dardized beta 001 0.87 0.59 0.12 0.00
0.91 8 <0.0
P-­‐
value 0.28 Unstan-­‐
dardized beta 1 <0.000
P-­‐value Multivariable analyses Adherence to arrange ECV attempt Univariable analyses Chapter 7 Facilitators and barriers to external cephalic version
Chapter 7 Facilitators and barriers to external cephalic version
client’ in the statements referred to ‘every eligible client’ according to contra indications mentioned in the guidelines. Respondents mentioned that in
clinical practice additional contra indications are used as compared to those
reported in the guidelines. Most examples did not reflect absolute contra
indications but (combinations of) clinical factors related to success rate of
ECV. Kok et al. have developed a clinical prediction model for the success rate
of ECV (based on parity, estimated fetal weight, placenta localisation and
amniotic fluid). They concluded that still 20–30% of women with the lowest
predicted success rates had a successful ECV. Thus, in our opinion, low predicted success rates are no reason not to offer ECV.19 Organisational factors
influencing the adherence to the guidelines were evaluated in the construct
‘precondition of successful ECV’. Time and financial compensation to counsel
clients for ECV were reported as a barrier particularly for midwives. To comply with this precondition required for a successful implementation of ECV,
this barrier could be taken away by the health insurance companies.
The most important determinant for adherence to all three key recommendations is self-efficacy; health care providers feel unable to perform the activities involved in the guidelines due to lack of counselling skills.
This study has some strengths and weaknesses. The importance of this study
is that a quantitative assessment of barriers and facilitators enables us to
develop an implementation strategy that has the potential to truly affect the
adoption and implementation of the guideline and as a consequence, the
number of ECV attempts.
The response rate to our online questionnaire might be topic of debate. In
quantitative research, the response rate is inferior to the absolute number of
respondents and more importantly, the representativeness of these respondents to the total cohort of gynaecologists and midwives. The high number of specialists in favour of ECV could insinuate unwillingness to respond
of those health care providers who disagree with (the importance) of ECV.
However, we do think this is likely based on the results of a national survey
we had performed among all hospital and midwifery practices; there was
no region where ECV was not performed at all. The reason we did invite all
gynaecologists to participate in this study was a more pragmatic one: the
Dutch Society of Obstetrics and Gynaecology was unable to make a random
selection of their membership database, and therefore all members received
the mass mail.
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Chapter 7 Facilitators and barriers to external cephalic version
CONCLUSION
In conclusion, the vast majority of professionals consider ECV as a good treatment to prevent CS, agrees that all clients should be offered the treatment
and think that counselling could improve the number of clients opting for
ECV. However only two-third of the professionals consider convincing clients
to undergo ECV as their task. Self-efficacy appears to be the most significant
determinant for counselling, advising and arranging an ECV. Thus, improving
self-efficacy is an important element of an implementation strategy to improve adherence to the guidelines on ECV.
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Chapter 7 Facilitators and barriers to external cephalic version
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140
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