A recent research paper (Walker et al 2017) discusses the question of how professionals develop skills in facilitating physiological breech birth. This is an important question because, although there is a demand for physiological breech birth, many women find it very difficult (and sometimes impossible) to access a provider who is able to support this. Worse, women often encounter hostile and resistant attitudes in maternity care systems instead of supportive care. Part of the problem, as Walker et al (2017) note in their paper, is that, “implementing the option of physiological breech birth requires professionals to learn complex skills not readily available or supported within their local practice settings, with minimal opportunity to practice under the guidance of experienced mentors”.
This is a qualitive study, involving interviews with nine midwives and five obstetricians who were experienced in attending physiological breech birth. They worked in Australia, Brazil, Canada, the Netherlands, New Zealand, the Philippines, the United Kingdom, and the United States.
The key and overarching finding was “that these professionals engaged in a process of deliberate acquisition of competence in physiological breech birth” (Walker et al 2017). That is, they didn’t rely on local training and existing knowledge, but deliberately sought information, training and opportunities to develop their knowledge and skills.
Some key elements that really struck me from reading the paper were the emphasis that interviewees placed on understanding the physiology and mechanisms of normal breech birth (which differ from and are not always helped by the manoeuvres that are taught in ‘birth emergencies’ workshops) and the value of watching videos and learning hands-on skills from practitioners skilled in physiological breech birth.
The paper concludes with the suggestion that “Training models based [on] the stages described in this research may enable more sustainable provision of vaginal breech birth support within contemporary maternity services. The impact and safety of such models should be explored in further research and evaluation.” (Walker et al 2017). But perhaps the most poignant sentence in the whole paper is another one of those in the conclusion: “Institutions may also consider implementing policies which reduce the burdens of isolation and disproportionate responsibility on those who attend breech births.” (Walker et al 2017)
Problem: Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems.
Background: Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear.
Question: How do professionals develop competence and expertise in physiological breech birth?
Methods: Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition.
Results: Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners.
Discussion: The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices.
Conclusion: Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.