| dc.description.abstract | Background: Despite newer research and professional organizational recommendations supporting shared decision-making and vaginal breech birth as a reasonable option for appropriately screened candidates, planned vaginal breech birth is rarely an option in the United States. Cesarean birth remains the only option for most pregnant persons due to a lack of access to skilled and willing breech birth providers and institutional opposition to planned vaginal breech birth. Unable to find care for vaginal breech birth in a hospital setting, a small number of individuals chose to pursue a breech birth at home, potentially placing themselves and their infants at increased risk.
Aim: The goal of this research was to better understand the experience of decision-making of individuals who left the hospital system to pursue a home breech birth and use these findings to guide clinical practice and health system recommendations to improve perinatal care.
Design: A cross-sectional, sequential mixed methods design was used for this study. Data collection included a survey and semi-structured interviews. Qualitative analysis used an interpretive description approach informed by situational analysis. Use of reflective journaling, theoretical memoing, and detailed field notes enhanced interpretation and analysis.
Setting/participants: This study was conducted in the United States and included a diverse sample of 25 women who transferred care out of the hospital system to pursue a home breech birth within the past 5 years.
Results: Decision-making for breech birth was an evolving, multiphase process with 5 interwoven and dynamic themes: valuing and trusting in normal birth, being “backed into a corner,” asserting agency, making an informed choice, and drawing strength from the experience. Key decisional factors in pivotal decision-making moments were identified. Individuals who declined planned cesarean for breech presentation frequently described coercion, disempowerment, and/or withdrawal of care. Rates of perceived lack of access to supportive care (71%) and consideration of unassisted homebirth due to difficulty finding a provider (52%) were high. There was a weak inverse correlation between having autonomy in decision-making and decisional satisfaction which did not reach statistical significance (rs= -0.21, p=0.32).
Conclusions: Individuals leave the hospital system to pursue a home breech birth due to a lack of opportunity for informed choice, supportive care for vaginal breech birth, or access to skilled breech providers within the hospital setting. Barriers to care and current practices for breech birth decision-making may be placing birthing people and their infants at increased risk in both the short and long term. Health care providers and systems should increase the provision of person-centered care to facilitate informed choice and access to skilled breech birth providers. These recommendations have the potential to expand ethical, safe, and respectful perinatal care and reduce the number of individuals leaving hospital care to have home breech births. Prospective, longitudinal studies are needed to assess the efficacy of recommendations on the quality of care for breech birth decision-making and associated health outcomes. | |
