What are women’s experiences of seeking to plan a vaginal breech birth? A systematic review and qualitative meta-synthesis

Paternalistic healthcare

In the ‘isolated constraint’ quadrant of our schematic, women’s experiences were characterised by disconnection from their healthcare providers and little ability to make autonomous decisions about mode of birth.

In many instances, women were denied the choice of a VBB: “There was a void between the information they received and the information they wanted. For the most part, an alternative to CS was not provided.”^13(p4) Where the option was mentioned, it was accompanied by highly emotive and frightening descriptions of breech births that had gone wrong: “You don’t have a choice, your babies are going to die, you are going to die, why did you come here if you don’t want us to help you, your kids will be left without a mother …”^14(p43)

It was a priority for most women that they “retained control of decision-making, retained a sense of personal choice and retained the option of having a vaginal birth,”^15(p10) but this did not happen in many cases. Many women felt their rights and choices were forcibly denied: “It was the most disempowering experience of my life.”^14(p43) “We discover that our experience isn’t worth anything and we should just be listening to what we are told.”^16(pe212)

This created disconnect between women seeking a VBB and their providers. Some women perceived the support from encouraging healthcare professionals to be curtailed by their colleagues, which undermined their trust in the healthcare team. Women expected providers to have adequate training to support VBB but found this was often not the case: “I feel it's a shame there is not more education and support for new doctors coming through. They can't support us mums of breechlings if they aren't supported themselves.”^14(p45) This highlights the imbalanced power dynamic between mothers and healthcare professionals, and amongst professionals themselves, that enforces paternalistic care.

Even in settings where VBBs were more common, some of this lack of control persisted. Women planning a vaginal birth reported lack of involvement in decision-making more often (29.6% versus 2.9%)¹⁷ and fewer felt the final decision on mode of delivery was theirs rather than the doctor’s (60% versus 85%)¹⁸, compared to women planning a caesarean birth. Toivanen et al reported the only significant difference between the experience of women attempting breech and vertex births was a significantly reduced sense of participation in their birth¹⁹.

Emotional turmoil

Experiences of ‘isolated constraint’ also led to significant ‘emotional turmoil.’ Women felt strong negative emotions when receiving their breech diagnosis, including fear and anxiety^{14,16,18–22}, uncertainty^16,23–25, powerlessness^23,25 and grief: “I don’t talk about it I guess but when I do I get quite upset. It has probably upset me more than I realise... it took me quite a while to get over it.”^25(p131) Their emotional turmoil was exacerbated when women were not given an opportunity to express their feelings and wishes²³.

Women’s emotions surrounding breech were influenced by their own experiences, and those of people around them. Family pregnancy and childbirth experiences were especially important, with unresolved trauma from previous experiences generally influencing mothers to opt for planned caesarean birth.

Women also felt that breech diagnosis was ‘a time-sensitive issue’. Transitioning from passive to autonomous decision-making required information, which took time to receive or seek out. The timing of breech diagnosis often played a role in mothers’ reactions and decisions. Discovering breech presentation during labour was often “chaotic and traumatic.”^26(p3127) Many women felt they missed the chance to be better prepared, and most studies found that women preferred earlier diagnosis of breech presentation²⁴.

Judgement and self-doubt

Most women who actively tried to plan a VBB experienced ‘judgement and self-doubt,’ an experience of ‘lonely autonomy.’ Women reported frustration that they were considered “not capable of making the right decision”^15(p9) about their birth and feeling devalued as part of their own healthcare. Enhanced communication was an important and recurrent suggestion for improvement, as women often felt their motivations for a VBB were misunderstood.

In addition to healthcare professionals, “pressure and judgement from family members”^14(p43) also influenced the decision-making process^{16,20–22,24–28}. Many felt “upset when family and friends accused them of being selfish and ‘putting the birth before the baby.’”^15(p8) “People in women’s social networks related to the women that breech presentation posed life-threatening risks for mother and baby.”^22(p1394) Avoiding the self-doubt this engendered required women to distance themselves from others: “I switched off to it because I was confident with my decision.”^15(p7) One woman shared how she withheld information about her birth plans from friends and how she “disengaged from the ‘ones that doubted.’”^25(p141)

Women felt alone in assuming responsibility for their decision: “It’s a decision where you are fundamentally alone at the end. Even if there are people who are there with you, you’re finally the only one to have to assume such a decision. Because... , finally, we are the only person who must push and must expel the infant.”^16(pe212) Where they ultimately chose to plan a caesarean birth, often women still felt misunderstood and alone with their grief. One woman explained “And the fact that I thought I was going to miss out on that part, I was already grieving it. So the grief - nobody really understood the grief apart from my partner.”^13(p4)

Mother vs society: refusing to conform

This category was also characterised by ‘lonely autonomy’. Women with plans for a VBB encountered resistance and barriers at all levels: social circles, clinicians, and institutional policies: “To try for a natural breech birth and go against the status quo - that’s a really hard thing to do.”^15(p10) Many possessed strong self-determination and self-efficacy at odds with systems that failed to accommodate this. Many women felt they were ‘fighting’ the people and systems who were supposed to be caring for them.

In “‘going against the tide’ of current practice,”^15(p23) most women also had to “circumvent a system that was blocking them from attempting a VBB.”^13(p5) Where local providers were inexperienced or unwilling, choosing not to have an elective caesarean birth meant women had to transfer hospitals to access a VBB. Women “seeking a VBB highlight[ed] the lack of supportive/adequately experienced clinicians as a barrier to achieving the birth that they wanted.”^26(p3129) Some women were forced to travel long distances^{13–15,22,24–26,28}, introducing a physical disconnect between them and their primary providers.

After overcoming these challenges, women often encountered additional institutional barriers, such as policies preventing experienced providers from caring for them, at all or outside of regularly scheduled working hours. Although balanced information made a significant difference to women’s decision-making^7,29, many women encountered systemic barriers to accessing balanced, evidence-based information²¹.

Isolated but united by breech

Some women found support in social media networks. These served as an “alternative support system”^15(p13) to women experiencing judgement and isolation from their usual social networks after deciding to pursue VBB. Women accessed social media during their information seeking activities, finding it helpful to “read birth stories and get good support online from breech moms across the globe”^14(p44) which in turn, often helped to alleviate anxiety²³. For many, participation in these networks was influential in their decision-making process, with the effects of social media ranging from “an additional support”^20(p119) to “hugely helpful and motivating when making [their] decision”^14(p44). They used these forums to counter the isolation they were experiencing and seek validation and assurance.

Supported self-determination and self-efficacy

A small minority of women had experiences of planning a VBB that were characterised by ‘supported self-determination and self-efficacy,’ an experience of ‘connected autonomy’. These women received care that aligned with their expectations of how services should operate: “My appointment with the specialist went so well today! … It’s all systems go for an active breech birth! Woohoo! He didn’t even question my decision. He just spoke to me like it was a done deal and made me feel so confident … I’m so relieved!”^27(pe99)

Multiple papers described how women sought out clinicians, described as ‘specialist[s]’^{14,20,24–27,30}, who presented them with unbiased information and encouraged them to be an active part of decision-making, even if this meant changing providers. Finding this person significantly alleviated many women’s anxieties and boosted their personal feelings of self-efficacy in decision-making and birth. Women also highlighted continuity of carer as an important factor in building a trusting relationship. Midwives were often seen as ‘allies’, with the ability to navigate the healthcare system to meet mothers’ needs.

Women who attempted a VBB experienced a range of emotions, very similar to their counterparts who experienced cephalic birth¹⁹. Some who achieved a planned VBB felt proud of their birth experience and recalled the importance of being ‘fully-engaged’^25(p141) in the birthing process. In many cases, the eventual outcome of the birth route was less important than having the choice and opportunity to try for a VBB, of ‘having a go’¹³.

Multiple studies concluded that “experience of healthcare professionals is also a key characteristic that is perceived to increase the likelihood of a more positive experience and a more favourable outcome to [a] breech birth”^23(p77). Some doctors were honest with women about their personal inexperience, and supported them to find a clinician who could provide them the care they wanted: “Once I said to her I wanted to change to someone who would give me a chance she said ‘(names another private OB) he'll let you give it a go and so it's not that I believe that you can't do it but I’ve never done one myself.”^26(p3126)

Welcomed direction

While most women sought active decision-making roles about their care, some preferred to defer to their care provider, welcoming their direction. This experience fell in the ‘supported direction’ quadrant of our schematic.

Some women preferred not to share decision-making; they preferred clear advice from professionals: “It was their decision not mine which was fine. It [would have been] much more difficult had I had to make the decision.”^25(p151) This preference appeared to apply to both caesarean and vaginal birth: “…I’ll be scheduled for a c-section on Wednesday. Personally I wouldn’t deliver him vaginally … my hospital don’t even consider vaginal breech delivery! So I couldn’t have one if I wanted to.”^27(pe99)

Although most women expressed a preference for earlier, antenatal diagnosis of breech presentation²³, a small minority preferred their late diagnosis. These were mostly women whose baby’s breech presentation was diagnosed during a labour that ended in a healthy vaginal birth. This is because they knew less of the potential complications, which they perceived would have negatively impacted their experience. For example, one mother, “claimed she would have been afraid during labour, if she knew that breech could be life threatening.”^22(p1395)

We placed this category in a lower quadrant due to the lack of autonomy exercised by women in decision-making. The women themselves chose to pass this responsibility to their care providers which is distinguished from the experience of ‘paternalistic healthcare,’ where women experienced their right to choose as withheld.

Main findings

Our study highlights the need for women to experience ‘connected autonomy’ and ‘supported direction’ during breech pregnancy and childbirth. Most women prefer autonomy over their mode of delivery and want non-judgemental support from skilled healthcare professionals regardless of their choice of birth mode. Most women value discussing their priorities with their healthcare providers and receiving balanced advice, i.e., supported direction.

Unfortunately, our review found that many women experience lonely autonomy and isolated constraint. In fighting for their birth choices many women found themselves alone and unsupported. Complying with the advice of their healthcare professionals, when in direct conflict with their preferences, led to feelings of regret and dissatisfaction.

Despite guidelines recommending that women be offered a choice regarding their delivery, our research indicates that many women found the choice of VBB is neither offered nor available. Even when willing and/or skilled birth attendants are available, systems are not set up to facilitate this. As a result, many women feel disconnected from their healthcare providers when they are most in need.