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. SETTTING. 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 leaf- lets 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