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

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.
(© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)