This is the first qualitative study to explore, compare and contrast women’s and health professionals’ attitudes towards ECV. The use of semi-structured interviews to collect data enabled an in-depth exploration of attitudes that was not possible in previous cross sectional surveys, and the findings contribute to the limited evidence base on women’s and clinicians’ experiences of and beliefs about breech presentation.
Four main themes emerged from the data from the interviews with women with a breech presentation. The first theme was ECV as means of enabling natural birth with many participants perceiving it as a way of achieving the vaginal birth they wanted. The second theme was women’s concerns about ECV, in particular concerns about pain, risks and likely success. The third theme was lay and professional accounts of ECV which were often in contrast. The final theme was breech presentation as a means of choosing planned CS. Some women declined ECV because they had a preference for planned CS to avoid a painful labour, vaginal birth and possible perineal injury and because they perceived that planning a CS gave them control over the birth. Two main themes emerged from the interview data about health professionals’ attitudes towards ECV; directive counselling and attitudes towards lay beliefs about ECV and breech presentation.
Consistent with previous quantitative research, women described varied attitudes to ECV. Some women’s decisions about ECV appeared to be strongly influenced by their attitudes towards vaginal birth and CS. Many participants had also discussed breech presentation and ECV with friends and relatives, and many of the lay accounts of ECV they described were discouraging to them. Both Guittier et al. and Founds also described that women sought information about mode of delivery for breech presentation from their social networks and that the accounts they received included negative information, focusing on the risks of breech presentation [9, 10]. Guittier et al. found that women reported they had made a decision about mode of delivery before being given information or counselled at the hospital . Similarly, in this study, women reported being put off ECV by friends and relatives who had told them ECV was painful; likely to be unsuccessful; that babies often subsequently reverted to breech presentation; and that babies become distressed.
In contrast to the negative lay accounts of ECV women in this study described, they reported that health professionals had been positive about ECV. In agreement with this, participating professionals generally reported having a preference for ECV and were open about their practice of trying to convince women to choose it. They were concerned about women making their decisions based on what they perceived as inaccurate lay beliefs and misconceptions about ECV. As experts, they positioned themselves as the most appropriate source of information for women.
These findings reveal some challenges for SDM about breech presentation. Firstly, SDM may not occur as many health professionals described a clear preference for attempting ECV and reported counselling women directively. Some professionals seemed to define the ‘right decision’ as the one which matched their own opinion and values rather than the woman’s. Decision quality has been defined as ‘the extent to which a decision reflects the considered preferences of a well-informed patient, and is implemented’ . Thus if a woman understands the pros and cons of each option, but highly values the outcomes associated with planned CS (for example avoiding the discomfort of ECV), by making that choice she has made a high quality decision as she is informed and has selected the option which best matches her own health goals. This may be challenging for health professionals, particularly when women’s preferences do not match their own or if they believe women have been influenced by accounts of ECV in the community which they perceive to be inaccurate.
Furthermore, health policy, while rhetorically supporting patient choice (‘no decision about us without us’) may include recommendations which potentially obstruct shared decision making. For example, the NHS Institute for Innovation and Improvement made recommendations to reduce England’s CS rate  and promoted directive counselling to achieve this. For example, they suggested that maternity units should aim for 80% uptake of vaginal birth after caesarean section (VBAC) by encouraging women to choose VBAC rather than a repeat CS. While they recommended that all eligible women should be offered ECV, they did not set a target for uptake. Nevertheless, increasing ECV uptake has been identified internationally as a potential way to reduce CS rates [17, 18].
To overcome these challenges a variety of approaches may be needed. Education and training for health professionals to inform them about SDM and to help them develop relevant competences such as risk communication; methods of exploring women’s attitudes towards treatments; and ways to discuss lay beliefs without appearing dismissive . Antenatal education could also prepare women for SDM, by informing them about what to expect, such as to expect the professional to ask them to consider what is important to them in making a particular decision. Clinicians (and politicians) should also be explicit about health policy which seeks to influence the choices women need to make in pregnancy.
Further support for decision making about breech presentation might also be helpful, such as a decision aid. Decision aids are interventions which can help people make choices about healthcare by providing information about treatment options –in this case evidence-based information about ECV, CS and vaginal breech delivery- and by clarifying personal values [20, 21]. A decision aid consisting of a workbook and audio component has been developed for decision making about ECV by a group in Australia . Results were promising, as women who used it had higher knowledge, lower decisional conflict, were more satisfied with the amount of information they had been given and were more likely to state that they intended to have an ECV . There was no difference in anxiety; the proportion of women actually choosing ECV; or in the rate of CS . Using a web-based decision aid may enable women to readily access high quality information whenever, and with whomever, they prefer and should help them clarify their own attitudes about options, in preparation for discussion with health professionals. Common misconceptions about ECV or the different methods of delivery could also be addressed, and women could be encouraged to discuss any conflicting lay accounts of ECV or delivery methods with their clinicians. We are currently developing such a web-based decision aid.
A limitation to this study was that, during interviews, RS was open about her role as a trainee obstetrician and also answered any clinical questions which arose (or referred women back to their clinical team if she could not answer the question). Thus, participants may have been affected by knowing the interviewer had prior knowledge and experience herself of managing breech presentation and by her role as a doctor. However, RS was not involved in the clinical care of any participants. Limitations to interviewing health professionals may have included difficulty in accessing their underlying beliefs due to them being experienced in presenting themselves in public . All the professionals were known to RS which may also have affected the interactions. Findings of the study may not be generalisable to other settings and interpretive limitations such as over-complexity or reductionism are possible.