Implementation of client versus care-provider strategies to improve external cephalic version rates: a cluster randomized controlled trial

Abstract

Objective: To determine the effectiveness of a client or care-provider strategy to improve the implementation of external cephalic version.

Design: Cluster randomized controlled trial.

Setting: Twenty-five clusters; hospitals and their referring midwifery practices randomly selected in the Netherlands.

Population: Singleton breech presentation from 32 weeks of gestation onwards.

Methods: We randomized clusters to a client strategy (written information leaflets and decision aid), a care-provider strategy (1-day counseling course focused on knowledge and counseling skills), a combined client and care-provider strategy and care-as-usual strategy. We performed an intention-to-treat analysis.

Main outcome measures: Rate of external cephalic version in various strategies. Secondary outcomes were the percentage of women counseled and opting for a version attempt.

Results: The overall implementation rate of external cephalic version was 72% (1169 of 1613 eligible clients) with a range between clusters of 8-95%. Neither the client strategy (OR 0.8, 95% CI 0.4-1.5) nor the care-provider strategy (OR 1.2, 95% CI 0.6-2.3) showed significant improvements. Results were comparable when we limited the analysis to those women who were actually offered intervention (OR 0.6, 95% CI 0.3-1.4 and OR 2.0, 95% CI 0.7-4.5).

Conclusions: Neither a client nor a care-provider strategy improved the external cephalic version implementation rate for breech presentation, neither with regard to the number of version attempts offered nor the number of women accepting the procedure.

Keywords: Breech delivery; breech presentation; external cephalic version; implementation; mode of delivery.