Breech training: time for a new approach?

Providing advanced training to a core breech clinical teaching team is potentially more efficient and effective than training the entire maternity care team using traditional methods. The theory is strong, but rigorous research needs to be done.

Traditional training, looks something like this: Participants take time away from clinical commitments to attend a dedicated training session, ranging in length from a few hours to a whole day or more.

Challenges for this approach in the context of breech birth

1. It’s expensive

While preparing the research proposal for the #termbreech2020 Physiological Breech Trial, I worked closely with NHS Research & Development Finance specialists. Using the Agenda for Change pay scales, we calculated that providing 1 day of physiological breech birth training to 5 obstetricians and 5 senior midwives will cost the service £2,442 just to release them from clinical work. Multiplying this to cover the whole staff will obviously increase the cost exponentially. And then there is the cost of paying the trainers.

This is why most training programmes, like PROMPT, use a ‘train the trainers’ approach. It is a more efficient and effective way to disseminate training throughout an organisation. [PROMPT is a great multi-professional training package, but unfortunately, they excluded outcomes for breech births from their evaluation (Draycott et al 2006). So this training has not yet been evaluated for vaginal breech birth.]

2. The effects of training wear off before most people will have a chance to use it

Our systematic review of the effectiveness of breech training strategies showed that breech training can improve objectively assessed skill and knowledge, but that these effects wear off quickly, sometimes within 6 weeks, sometimes within 72 hours. A bigger concern was that, in some cases, confidence increased but objectively assessed skill did not. Training alone is likely not sufficient to improve breech skills, but for those who have some clinical experience, it may extend current understanding.

If you train a staff of 40 (or more) in a service that has only 1 breech birth per month, most of them will not have a chance to consolidate their learning in clinical practice. And if you do not have a plan for ensuring that someone who has attended enhanced training will attend the vaginal breech births that do occur, the enhanced training will not contribute to improvement in outcomes.

3. Clinical support in practice appears to make the biggest behavioural change

A surprising finding from our systematic review was that attendance at an obstetric emergencies-type training course was inversely associated with attendance at vaginal breech births, unless a system was in placed to provide clinical support in practice. This means that clinicians attended fewer vaginal breech births after taking breech training as part of an obstetric emergencies package. Although no quantitative evaluation was done, the studies that reported increase in breech births attended all had a model for ensuring experienced support in practice.

Conclusion

Implementing a breech clinical teaching team is a way of ‘training everyone.’ The model just differs from traditional ‘training day’ methods, which have not proven effective on their own in sustaining safe vaginal breech services.

Paying a few people who want to support breech births to be on-call occasionally and to cascade training is likely less expensive than providing enhanced training to the entire maternity care team, or even the entire senior team. But we need to implement the model and evaluate it in a systematic way in order to determine cost effectiveness. This is why experienced health economists are central to the #termbreech2020 Physiological Breech Trial and helped develop the design.

According to the evidence, breech clinical teaching team is also likely to result in greater availability of the option of vaginal breech birth for women who want them. This was a central concern of the women who participated in #termbreech2020 Physiological Breech Trial public engagement work.

But! Isn’t experienced senior clinical support what consultant obstetricians do? … Good question. We’ll discuss that next …

Shawn

Walker S, Breslin E, Scamell M, Parker P (2017) Effectiveness of vaginal breech birth training strategies: an integrative review of the literatureBirth. 44(2):101-9. (Author version archived at City Research Online)

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