Training and Expertise in Undertaking Assisted Vaginal Delivery (AVD)

Feeley et al. Reprod Health (2021) 18:92 https://doi.org/10.1186/s12978-021-01146-3

REVIEW Open Access Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences Claire Feeley1* , Nicola Crossland1, Ana Pila Betran2, Andrew Weeks3, Soo Downe1 and Carol Kingdon1

Abstract Background: During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers. Methods: A mixed methods systematic review was undertaken in fve databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the fndings were subjected to GRADE-CERQual assessment of confdence. Results: 31 papers, reporting on 27 studies and published 1985–2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confdence in the 10 statements of fndings was mostly low, with one exception (moderate confdence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specifc technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specifc training, where a combination of teaching methods were used, to gain skills and confdence in this feld. Clinical mentorship, and observing others confdently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised. Conclusion: Access to specifc AVD training, using a combination of teaching methods, complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain efective modalities for wider training, education, and supportive supervision for optimal AVD use.

*Correspondence: [email protected] 1 School of Community Health and Midwifery, University of Central Lancashire, Preston PR1 2HE, UK Full list of author information is available at the end of the article

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Plain language summary During the late stages of childbirth, complications can occur which require rapid birth of the baby. This can be facilitated with instruments (usually forceps or a suction cup) or by surgery (caesarean section). In some circumstances, instrumental birth (also termed assisted vaginal delivery, AVD) may be a better option than caesarean section. AVD requires practitioners to develop skills, competence and expertise in the procedure. Our aim for this review was to examine practitioners’, funders’ and policy makers’ views about competence and expertise in AVD, how they can best gain this, the barriers and facilitators to implementing training packages, and their views, opinions and perspectives of their training. We included 27 studies (published 1985–2020), mostly from high-income countries. We had moderate confdence on one fndings statement, with the rest assessed with low confdence. We found that practitioners valued extra training in AVD, observing others using the diferent instruments, and opportunities for clinical supervision, mentorship to gain experience, competence and expertise. We also found that, from the practitioners’ perspective, competence encompasses a number of inter-related skill sets; non-technical skills (e.g. efective communication with the labouring woman), broad clinical skills (e.g. capacity to assess the whole clinical picture) and technical instrumental skills (e.g. correct application of a vacuum cup to the fetal head, or capacity to turn the baby so it is in the right position). Practitioners also identifed a number of barriers and facilitators that supported (or did not support) their training needs and development. Keywords: Assisted vaginal birth, Assisted vaginal delivery, Competence, Training, Practitioners

Background Skilled AVD use is recommended by the World Health Instrumental births mainly involve the use of forceps or Organization (WHO) as a safe alternative to caesarean a vacuum cup to expedite a birth, usually in situations section rates and as a means to improve maternal and of fetal compromise or for maternal beneft [1, 2]. Also neonatal outcomes when certain complications arise [2, known as ‘assisted vaginal delivery’ (AVD), it is a valuable 4]. Indeed, important improvements in fetal outcomes tool during late second stage of labour where perform- have been reported when optimal instrumental birth ing a caesarean section may not be possible, or safe, or options are introduced into LMIC settings [1]. Our previ- acceptable to the woman [1, 2]. Te prevalence of AVD ous review [6] focused on women’s, partners’ and health- use varies widely, both internationally and within coun- care providers’ views and experiences of AVD. We found tries [3]. However, as techniques of caesarean section that views and experiences of AVD tended to fall some- have improved and become safer in the last few decades, where between extremes [6]. Where indicated, AVD can in some contexts, the use of AVD has been substantially be an efective, acceptable alternative to caesarean sec- reduced in favour of caesarean section [1]. In some con- tion. However, for childbearing women, the experience texts low rates of AVD use occurs in parallel with over- of AVD could be negatively impacted by the unexpected use of caesarean sections, raising concerns about excess nature of events that precipitated their use. Particularly maternal morbidity or mortality due to unnecessary or in high-income settings, this was associated with unmet unconsented surgery [1, 4]. In other contexts, low use of expectations [6]. We also found that positive relation- AVD and poor access to safe caesareans are associated ships, good communication, involvement in decision- with poorer neonatal outcomes, due to lack of access to making, and (believing in) the reason for intervention safe and acceptable methods for managing maternal or were important mediators of birth experience. Addition- fetal emergencies [1]. Forceps and vacuum births can ally, from the perspectives of professionals, attitudes and both be undertaken safely, but concerns have been raised skills were simultaneously barriers (where substandard) regarding inappropriate decision making about when to and facilitators (where they were of high quality) for the use them, and sub-standard levels of technical skills or acceptability of using AVD. training can cause iatrogenic harm. Tis could disincen- Te aim of the current review was to improve the tivize their use in favor of a caesarean section (if this is understanding of limitations, barriers and potential option is possible) or even be a barrier to their use where facilitating factors relating to expertise, training and they are the only technical solution available [1, 4, 5]. Feeley et al. Reprod Health (2021) 18:92 Page 3 of 22

competencies in AVD, from the perspective of maternity Refexivity care practitioners, funders and policy makers. Transparent refexivity throughout qualitative research Te objectives of the review were to establish: is central to good practice [9]. Our interdisciplinary research team considered our potential biases prior to, 1. What expertise, training and competencies are and throughout the review to reduce potential impact required for optimal use of AVD? upon the fndings. CF and SD are midwives with exten- 2. What are the barriers and facilitators to achieving sive clinical experience, CK is a sociologist and all three these levels of expertise and competence? have many years’ experience of maternity care research. 3. What are the barriers and facilitators to implementa- All three believe that AVD can be a positive experience tion of appropriate training? for women, if done well, with skill and with respect for 4. What are practitioner views, opinions, perspectives women. However, all three recognise that it can be dis- and experiences on training for use of AVD? tressing and damaging if carried out without skill, respect and compassion. NC, is a health researcher who held prior beliefs about the importance of respectful care and Methods communication for women throughout the maternity We used a systematic integrated mixed-methods design episode including AVD. ADW is an obstetrician who has with the protocol published prior to commencing the practiced AVD in both the UK and Uganda over the last review [7]. Te review was carried out according to the 25 years. He has seen perinatal deaths prevented by it, protocol with the following exceptions: we were unable and debriefed women who have sufered trauma from it. to undertake the planned meta-thematic synthesis due He therefore sees both its potential benefts and harms, to the few qualitative studies found, and the low quantity and believes that personal teaching and mentoring is and/or quality of the data presented in them. Due to this critical to a good outcome. His personal preference is for factor, we were also not able to carry out the pre-planned routine ultrasound to determine fetal head position, non- convergence matrix to assess the similarities/dissimi- rotational forceps and manual rotation when required. larities of fndings between survey and qualitative data He uses vacuum only for ‘outlet procedures’. APB is a [7]. Terefore, we adopted a mixed-methods integrated medical ofcer with 20 years of experience in maternal review design, as per Noyes et al. [8]. Tis involved using and perinatal health research and public health, who both quantitative survey and qualitative data that was held prior beliefs about the importance of women hav- integrated to answer the research questions. ing the right to evidence-based and respectful maternity care and that narrowing worldwide disparities is crucial, Criteria for inclusion including disparities in the appropriate and respectful Our focus was on the views, opinions, perspectives use of AVD for improved outcomes. and experiences of maternity care providers, maternity funders and policy makers regarding the expertise, train- Search strategy ing and competencies required for optimal AVD. We also A predesigned search strategy included pilot search- sought to examine the barriers and facilitators to achieving and information specialist input to ensure a robust ing practitioner competencies and the implementation of approach. Systematic searches were carried out in appropriate training. We included primary studies that March/April 2020 in MEDLINE, CINAHL, PyschInfo, reported participants’ views, beliefs, concerns and expe- EMBASE and Global Index Medicus (that included AJOL riences. Tese included studies using qualitative designs and LILACS databases). Searches were carried out using (e.g. ethnography, phenomenology) or qualitative meth- keywords (see Table 1) for the Population, Intervention ods for data collection (e.g. focus group interviews, indi- and Outcomes adapted as necessary for the individual vidual interviews, observation, diaries, oral histories) and database i.e. using MeSH terms. An example search studies using quantitative designs such as surveys (e.g. strategy is shown in Additional fle 1: example search questionnaires), or mixed methods approaches. Tere strategy. Additional searches were carried out, includ- were no language restrictions. Searches were carried ing reference checking of the included studies, cross- out from the inception data of each database, due to the checking with Google Scholar and reference checking of potential value in examining historic use of instruments key international guidelines (Te International Federa- for expediting birth. Studies with a principle focus on tion of Gynecology and Obstetrics, Te Royal College of breech presentation, multiple pregnancies, or where the Obstetricians and Gynaecologists, Te American Col- lie of the fetus was transverse or oblique, or where partic- lege of Obstetricians and Gynecologists, Te Society of ipants were experiencing preterm birth, were excluded. Obstetricians and Gynecologists of Canada, Te Royal Feeley et al. Reprod Health (2021) 18:92 Page 4 of 22

Table 1 Search terms relevant sections (as opposed to line-by-line coding, or Midwife or midwives or midwifery or nurse-midwife or obstetrician or statistical extraction) and tabulating. Te data across the doctor or physician or dr or ob or obstetrics or nurse-midwives or studies were then grouped as initial descriptive themes in obstetric nurse or nurse or trainee or registrar or practitioner or person- relation to the research question (1–4). A second itera- nel or resident or medical ofcer or medical or provider or worker or specialist or attendant or graduate or professional or intern tion refned these further to ensure the descriptions cap- Assisted vaginal delivery or assisted vaginal birth or ventouse or vacuum tured the data adequately and generated ‘Statements or kiwi or extraction or vacuum assisted delivery or forceps delivery or of Findings’. Tese were subjected to GRADE-CerQual instrumental delivery or instrumental birth assessments [15] which indicate the degree of conf- Skill* or knowledge or competence or train* or education or expertise or dence to be placed in each fndings statements. Assess- instruction ments included minor, moderate, or substantial concerns regarding four domains: 1. methodological limitations of included studies; 2. relevance of the included studies Australian and New Zealand College of Obstetricians to the review question; 3. coherence of the review fnd- and Gynaecologists). ing; and 4. adequacy of the data contributing to a review fnding. Ten, based on an overall assessment of these Study selection four domains, confdence in the evidence for each review Records were collated into Covidence systematic review fnding was assessed as high, moderate, low or very low software [10] and duplicates removed. Each title and [15]. As per Noyes et al. [8], data transformation in this abstract was screened against the inclusion/exclusion instance was ‘qualitised’ as in, the fndings are presented criteria by the lead author (CF) and screened indepen- narratively. A detailed exposition of the data extraction dently by one of three reviewers (CK, NC, APB). At full- can be found in Additional fle 3: data extraction. text stage, each record was screened by the lead author (CF) and screened independently by one of two review- Results ers (NC, CK). Discrepancies were resolved by consen- From the searches, 12,623 hits were identifed, and one sus. Te fnal list of included studies agreed among the further study was identifed from an additional source. reviewers. After 4389 duplicates were removed, 8064 records were discarded as irrelevant after reviewing title and Data extraction and quality assessment abstract. Of 171 full-text papers screened, 140 records Study characteristics of the included papers were col- were excluded, with 31 papers [16–46] included into lected on a data extraction form: author & date, title, the review as shown in Fig. 1: PRISMA. No studies were resource setting, country, study design, setting, popula- found from the perspectives of funders or policy makers. tion, participants, methods. Quality assessment of quan- Of the 140 excluded records, 35 studies were on topic, titative surveys was carried out using a critical appraisal but the wrong study design for example, pre/post-test checklist [11]. Quality assessment of qualitative stud- training quasi-experimental studies. Details of all the ies was carried out using criteria from Walsh & Downe excluded studies, and the reasons for exclusion can be [12]. Quality assessment of mixed methods studies was found in Additional fle 4: excluded studies. carried out using the Mixed Methods Appraisal Tool Of note, the 31 included papers, several were from the (MMAT) tool [13]. All studies were graded A-D by dis- same study (n = 4 [18–21], n = 2 [35, 43]), therefore, 27 cussion between two reviewers (CF/NC), where A: No, studies were quality assessed, analysed and synthesised. or few faws; the study credibility, transferability, depend- Table 2 gives an overview of the characteristics and qual- ability, and confrmability is high, and D: Signifcant faws ity assessment of all included studies. that are very likely to afect the credibility, transferability, Te 27 studies included n 3 qualitative [18–21, 29, 35, dependability, and/or confrmability of the study [14]. No = 43], n = 3 mixed methods [17, 41, 45], n = 21 quantitative disagreements were noted, and no study was excluded on survey designs [15, 19, 21–25, 27, 29–33, 35–39, 41, 43, the basis of quality as per our protocol. A detailed expo- 45]. Te majority were undertaken in high-income coun- sition of the quality assessments can be found in Addi- tries (n = 23), two were from upper-middle income coun- tional fle 2: QA. tries [27, 40], one was from a lower-income county [29] and one survey included 111 low-middle countries [30]. Data synthesis Te earliest study was 1985 [34] and the most recent was A data-based convergent synthesis [8] was carried out; published in 2020 [32]. Te studies included participants whereby all of the included studies were analysed and that were: trainee obstetricians [16, 23, 25, 26, 31, 33, 34, synthesised using the same methods. Tis involved 36, 39, 42, 47], recent obstetric graduates [40, 41], obste- extracting the fndings data from each paper in short tricians [22, 24, 32, 35, 37, 38, 43], GP/family medicine Feeley et al. Reprod Health (2021) 18:92 Page 5 of 22

PRISMA 2009 Flow Diagram n o

i Records idenﬁed through Addional records idenﬁed t a

c database searching through other sources i f i

t (n =12,623) (n =1) n e d I

Recordsa er duplicates removed (n =8235) g

Screenin Recordsscreened Records excluded (n =8235) (n =8,064)

Full•text arcles assessed Full•text arcles excluded, with y for eligibility reasons (n = 171) (n =140: 35 Relevant topic wrong design Eligibilit 25 Conference abstract 17 Poster presentaon 12 Commentary not research Studies included in qualitave 10 Discussion not research synthesis 9 Lit review (n=10, reporng 6 diﬀerent 8 Irrelevant to the RQ studies) 7 Citaon not found in journal or on d web search 5 Focus on training tool

Include 4 Duplicate 3 Does not answer RQ Studies included in 3 Leer not research quantave synthesis 1 Focus is device eﬃcacy (n =n = 21) 1 Not research)

Fig. 1 PRISMA 2009 Flow Diagram

doctors [44, 46], midwives [17], medical ofcers [29], and What expertise, training and competencies are required multi-professional participants [18–21, 27, 45]. Te qual- for optimal use of AVD? ity of the included papers was generally poor whereby the Tree SoF’s were relevant to this question (all with low majority of the survey studies scored C or C/D. confdence), they related to non-technical, broader clini- Te convergent synthesis generated the descriptive cal and technical AVD skills. themes and Statements of Findings (SoFs) -the development is shown in Table 2. Table 3 shows the summary Expertise in non‑technical skills of review fndings and associated CERQual assessments Five studies [17, 19, 21, 41, 43] highlighted non-techni- (Table 4). cal skills that included behaviours associated with demonstrating capability through confdence, situational Feeley et al. Reprod Health (2021) 18:92 Page 6 of 22 QA grade QA C B A/B A/B A/B A/B C survey by surveyby video recordings video recordings video recordings video recordings questionnaire Cross-sectional Cross-sectional Focus group followed followed group Focus Methods Interviews, vignettes, Interviews, vignettes, Interviews, vignettes, Interviews, vignettes, Cross-sectional Cross-sectional Quantitative Mixed methods Design Qualitative Qualitative Qualitative Qualitative Quantitative 8 focus group group 8 focus = 18 survey = 8 midwives = 8 midwives = 8 midwives = 8 midwives that were eligible that were n (100% response rate) n n n n that were eligible that were = = 10 obstetricians, = 10 obstetricians, = 10 obstetricians, = 10 obstetricians, 87/172 participated n Participants n n n n 87/233 participated obstetricians had completed had completed advanced ventouse training midwives midwives midwives midwives medicine enhanced skills programs (2004–2014) Specialist trainee Midwives who Population Obstetricians and Obstetricians and Obstetricians and Obstetricians and Graduates of family Graduates national) teaching hospitals: teaching Dundee & Bristol hospitals: teaching Dundee & Bristol hospitals: teaching Dundee & Bristol hospitals: teaching Dundee & Bristol Regional (not Regional National Setting Two university Two university Two university Two university Two National England England Country UK UK UK UK Canada HIC HIC Resource setting Resource HIC HIC HIC HIC HIC forceps: A surveyforceps: of opinions trainees’ focus group and group focus survey of a course for Midwifery- Ven Practitioners touse by interviewsby and video recordings establish the to components of a skilled low-cavity non-rotational vacuum delivery obstetricians for conducting forceps and vacuum deliveries: qualita - analysis by tive interviews and video recordings interviewsby and video recordings establish the to components of a skilled rotational delivery forceps vaginal operative delivery: when to to intervene, where and which deliver use? instrument to analysis Qualitative of expert clinical practice ing in family medi - cine maternity care: Cross-sectional study of graduates’ experiences Training on Kielland’s on Kielland’s Training An evaluation by An evaluation by Title Qualitative analysis Qualitative skillsNon-technical analysis Qualitative Decision-making in Enhanced skills train - [ 18 ] [ 19 ] [ 20 ] [ 21 ] a a a a Study characteristics 2008 2010 2013 2013 [ 16 ] [ 17 ] [ 22 ] al. 2017 et al. Wattar Al al. 2001 Alexander et al. al. Bahl et al. al. Bahl et al. Bahl et al. Bahl et al. 2019 Biringer et al. 2 Table Author & date Author Feeley et al. Reprod Health (2021) 18:92 Page 7 of 22 B/C C C/D C/D C/D C/D C/D QA grade QA - ation: program ation: program facility documents, observation, data abstraction at the and from facilities, semi-structured interviews with key (pro informants - and govern gram regional ment staf, and international experts, trainees and trainers Pilot study evalu- Pilot Purposive surveyPurposive Purposive surveyPurposive Purposive surveyPurposive Purposive surveyPurposive Randomised survey Purposive surveyPurposive Methods Qualitative Quantitative Quantitative Quantitative Quantitative Quantitative Quantitative Design = 15 = 29 = 25 = 15 Interns, = 71 medical that were eligible that were for incompleteness) incompleteness) for n n n ofcers, community service n ofcers, n registrars, specialists Canadian trainees, trainees, Canadian Irish21/48 eligible trainees that were eligible that were that were eligible that were = 17 n 86/100 participated 197/250 (30 excluded 197/250 (30 excluded 31/56 eligible 31/56 eligible 197/303 participated 597/1600 210/291 participated Participants - nal–fetal medicine nal–fetal fellows (MFM) (includes Interns / Medical Ofcers/ Community service / ofcers /Registrars Specialists) (trainee) O&G) Medical ofcers First year mater year First Healthcare workersHealthcare Trainee obstetricians Trainee Registrar obstetricians Registrar Fellow obstetricians Fellow Residents (trainee Population (Gujarat) and Jaipur (Gujarat) (Rajasthan) national) parison Two sites Surat sites Two Regional (not Regional Provincial International com - National National National Setting India US South Africa Ireland & Canada Australia US US Country LMI HIC UMIC HIC HIC HIC HIC Resource setting Resource obstetrician – capacity increasing emergency for in obstetric care rural India: An evaluation of a pilot train to program general doctors operative obstetrics operative maternal–fetal for medicine fellows professionals on professionals use of the current / ventouse forceps and skills training - vagi operative for nal delivery assessment of trainee experience, and confdence, comfort in opera - delivery vaginal tive survey of registrar training in the use forceps of Kjelland’s in Australia Delivery: A Survey of ACOG of Fellows delivery: A survey of North American residency programs Where there is no there Where Training needs in Training A survey of health An international An anonymous An anonymous Operative Vaginal Vaginal Operative Forceps and vacuum Forceps Title (continued) 2015 [ 28 ] [ 25 ] al. 2009 [ 29 ] et al. Evans al. et al. Eichelberger Devjee 2015 [ 27 ] al. 2017 [ 26 ] et al. Crosby al. 2009 Chinnoock et al. al. 1996b [ 24 ] Bofll et al. al. 1996a [ 23 ] Bofll et al. 2 Table & date Author Feeley et al. Reprod Health (2021) 18:92 Page 8 of 22 C C B D B QA grade QA C B/C - Attitude—Practice (KAP) survey posive surveyposive with open text option year 1 year repeated low due to later in rate response survey1 recordings, recordings, interviews, Delphi method Purposive surveyPurposive Purposive surveyPurposive Survey Rapid Knowledge— Cross-sectional pur Cross-sectional Purposive surveyPurposive Methods Vignettes, video Vignettes, Quantitative Quantitative Quantitative Quantitative Quantitative Quantitative Design Qualitative = 269 - 238 (20% of eligi that were eligible that were investigated that were eligible that were (23% of eligible (23% of eligible participants) in second survey ble participants) in n frst survey, = 653 = = 20 108/144 participated 219/354 n 111/121 countries 160/501 participated n Participants n - grams and fellows specialists and consultants midwives, or public midwives, health experts specializing in maternal health O&G) trainees) fed as skilled Chairmen of pro Residents (trainee) Residents (trainee), Obstetricians, Obstetricians, Residents (trainee Chief residents (senior residents Chief Population Obstetricians identi - programs hospitals in Toronto National residency National National International National National Setting Three large teaching teaching large Three across Sub-across Saharan Africa, Latin America and the Caribbean Asia, Arab States, Pacifc, and Middle East Asia Central North America North America Germany International study Canada US Country Canada HIC HIC HIC Low- middle Low- HIC HIC Resource setting Resource HIC forceps training forceps in North America 1981 delivery: Expecta - tions of residency and fellowship training program directors tive deliverytive in Germany: a national survey about experience and self-reported competency still known, taught and practiced? A worldwide KAP survey Towards Caesarean Caesarean Towards Delivery- in Cana dian Obstetrics and Gynaecology Resi - dency Programs - training in resi dency: experience and self-reported competency ence: Development Task- of a Cognitive the Assess List to Second Stage of Opera - Labour for Deliverytive Survey of obstetric Forceps and vacuum Forceps Vaginal opera - Vaginal Is vacuum extraction Resident Attitudes Vacuum and forceps and forceps Vacuum Title Learning from Experi - from Learning

b 2015 (continued) [ 34 ] [ 33 ] [ 31 ] [ 35 ] al. Hodges et al. Healyand Laufe 1985 Healyand Laufe Hankins 1999 et al. al. 2020 et al. Friedman al. 2020 [ 32 ] Hamza et al. Fauveau 2009 [ 30 ] Fauveau al. 2007 [ 36 ] et al. Powell 2 Table Author & date Author Feeley et al. Reprod Health (2021) 18:92 Page 9 of 22 C/D B B C D C/D QA grade QA B B/C ing training session with open text option recording analysis recording - follow groups Focus Purposive surveyPurposive Purposive surveyPurposive Purposive surveyPurposive Purposive surveyPurposive Purposive surveyPurposive Randomised survey Methods Vignettes, video Vignettes, data only to be data only to used MM overall, but qual MM overall, Quantitative Quantitative Quantitative Quantitative Quantitative Quantitative Design Qualitative - - that were eligible- that were arm qualitative that were eligible that were that were eligible that were ticipated that were that were ticipated eligible that were eligible that were that were eligible that were ticipated that were that were ticipated eligible = 17 25/31 participated 263/758 participated 90/92 participated 434/5061 par 323/423 participated 23/29 participated 765/1019 par Participants n were excluded) were medical doctors during their com - pulsory of rural year practice in CLUs trainees fed as skilled Residents (trainees) Residents (1st years Residents (1st years Recently graduated Recently graduated Residents (trainees) Obstetricians working Obstetricians General practitioner Population Obstetricians identi - in Southern Ecuador parison Australia) hospitals in Toronto One university site National Rural health centres Rural health centres National International com - One state (South One state National Setting Three large teaching teaching large Three Canada France Ecuador US UK & Ireland Australia UK Country Canada HIC HIC UMIC HIC HIC HIC HIC Resource setting Resource HIC - in Patient and in Patient Instrument Selec - Operative tion for Deliveries Vaginal training in instru - A mental deliveries: national survey enough prepared enough prepared performto obstet ric skills in their rural and compulsory A study from year? Ecuador vaginal delivery:vaginal the landscape of obstetrics and - gynecology resi dent training assessment of the head position fetal instrumental before delivery: a survey of obstetric practice Kingin the United - dom and Ireland Reached ‘Use Their Date? By’ hospital obstetric training vocational ence: Development Task of a Cognitive a Perform List to and Successful Safe Non-Rotational Delivery Forceps Video-Based Teaching Video-Based Teaching French residents’ residents’ French Are recent graduates graduates recent Are Forceps-assisted Forceps-assisted Strategies to enhance to Strategies Have Kielland Forceps KiellandHave Forceps GP trainees’ views on GP trainees’ Title Learning From Experi - From Learning

b 2015 (continued) 2018 [ 41 ] [ 42 ] al. 2014 [ 40 ] et al. [ 37 ] more. 1999 [ 38 ] more. [ 43 ] al. Simpson et al. al. Sarangapani et al. al. 2015 Saunier et al. Sánchez del Hierro al. 2019 [ 39 ] Rose et al. Ramphul 2012 et al. - Robson and Prid Smith 1991 [ 44 ] 2 Table & date Author Feeley et al. Reprod Health (2021) 18:92 Page 10 of 22 C/D C QA grade QA and interviews and survey (survey be used) data to Retrospective study Retrospective Retrospective audit Retrospective Methods Mixed methods Quantitative Design - 17 (unclear how 17 (unclear how many of each pro many fessional group) fessional = = 23 n n Participants trainees and midwives Consultants, junior Consultants, Family physicians Family Population One hospital site One hospital site Setting England Canada Country HIC HIC Resource setting Resource consultant resident consultant resident on-call in a District General Hospital Teaching the Use Teaching of the Vacuum Extractor Impact of introducing Babes in the Woods: Woods: Babes in the Title (continued) 1990 [ 46 ] Same study diferent research questions reported in the separate publications questions reported in the separate research Same study diferent Same study diferent research questions reported in the separate publications questions reported in the separate research Same study diferent Wilson and Casson and Casson Wilson al. 2012 [ 45 ] et al. Tang 2 Table a b Author & date Author Feeley et al. Reprod Health (2021) 18:92 Page 11 of 22 2001; Sarangapani 2018 [ 17 , 19 21 41 43 ] Ramphul 2012; Sarangapani 2018; Simpson 2015 [ 16 , 20 34 36 40 42 ] 2020; Hankins 1985 [ 28 , 1999; Healy and Laufe 31 – 33 , 42 43 ] Saunier 2015; Crosby 2017; Eichelberger 2015; 2017; Eichelberger Saunier 2015; Crosby 2007; Rose 2019; Sanchez del Heirro Powell 1990; and Casson Wilson 2014; Smith 1991; 2017; Chinnock Watter 2001; Al Alexendar 2020; Hamza 2009; Friedman 2009; Fauveau 1999; Saranga - 2020; Robson and Pridmore pani 2018 [ 15 , 16 22 – 25 29 31 33 35 37 41 43 , 45 46 ] 2015; Eichelberger 2015; Powell 2007; Ram - 2015; Powell 2015; Eichelberger 1999; Smith phul 2012; Robson and Pridmore 1990 [ 23 , 24 27 33 and Carson Wilson 1991; 36 – 38 , 44 46 47 ] 1985; Rose 2019; Wilson and Casson 1990; and Casson Wilson 1985; Rose 2019; 2017 Watter Sarangapani 2018; Bahl 2008; Al [ 15 , 17 26 33 35 38 40 45 ] 1996b; Wilson and Casson 1990; Powell 2007 1990; Powell and Casson Wilson 1996b; [ 15 , 21 23 26 35 45 ] Studies contributing Studies Bahl 2010; 2013b; Simpson 2015; Alexander Bahl 2013b; Hodges 2015; Alexander 2001; Bahl 2008; 2013a; Simpson 2015 [ 17 , 19 42 ] Evans 2009; Smith 1991; Simpson 2015; Hamz Evans Bofll 1996a; Bofll 1996b; Healy and Laufe 1985; Bofll 1996a; 1996b; Healy and Laufe Bofll 1996a; 1996b; Hankins 1999; Devjee Devjee 2015; Powell 2007; Healy and Laufe 2007; Healy and Laufe Devjee 2015; Powell Biringer 2019; Al Watter 2017; Devjee 2015; Bofll Watter Biringer 2019; Al optimal use of AVD mal use of AVD use of AVD supervision achieving com - essential to are and expertisepetence ments and the provision of opportunitiesments and the provision gain experience achieving to is essential to competency and expertise ing programme, work environment or indi - work environment ing programme, vidual practitioners infuence the appears to and continued attainment of competence use of AVD or willing clinical mentors infuences the or willing clinical mentors training implementation of AVD valued by some practitionersvalued by SoF Non-technical skillNon-technical expertise the is essential to Broader clinical skills the opti - essential to Broader are Technical skills expertise optimal is essential to Technical Proactive teaching, specifc training and teaching, Proactive Exposure to AVD including a range of instru - AVD to Exposure The attitudes and beliefs evident in the train - attitudes and beliefs The Access (or lack of) (or Access training courses and/ to Access to training in AVD is sought after and training in AVD to Access supervision Emergent themes Emergent Non-technical skillsNon-technical Clinical skills-assessing the clinical picture Technical skills Technical Proactive teaching, specifc training and teaching, Proactive Exposure and gaining experience Exposure Attitudes /beliefs Attitudes Access (or lack of) (or Access teachers/training to Training needs Training Descriptive theme iteration and SoFDescriptive development theme iteration making) explanation) Early descriptive theme Early descriptive Clinical skills instrumental birth avoid to Behaviours Decision making (multiple points of decision- Clinical skills-assessing the clinical picture Additional tools Additional Rotating the fetus Angles and force Checklist Specifc training Close supervision teaching Proactive staf (rationale/lack of communication by Poor Implementing training learning following being taught AVD to Exposure Experience leads Expectation of the course/program Lack of exposure/opportunity and/or litigation concernsSafety Attitudes /beliefs Attitudes others Challenges when teaching Lack of opportunity Lack of experienced teachers/mentors Increased consultant cover training teachers/ to Access skills in teaching proactive Colleagues of AVD training more Wanting Concerns regarding lack of training/skillsConcerns regarding 3 Table Q Q1 Q2 Q3 Q4 Feeley et al. Reprod Health (2021) 18:92 Page 12 of 22 Eichelberger 2015; Powell 2007; Al Watter Watter 2007; Al 2015; Powell Eichelberger 2017; Chinnock 2009; Smith 1991 [ 15 , 16 21 24 , 28 35 43 46 ] Healy and Laufe 1985; Rose 2019 [ 15 , 26 33 Healy and Laufe 38 , 40 ] Studies contributing Studies Evans 2009; Alexander 2001; BiringerEvans 2019; Sarangapani 2018; Al Watter 2017; Devjee 2015; Watter Sarangapani 2018; Al job satisfaction clinical and infuences later some practitionerspractice for participants SoF Training enhances competence, confdence, confdence, enhances competence, Training Practical teaching tools were valued by valued by were tools teaching Practical job satisfaction clinical and infuences later practice Emergent themes Emergent Training relates to competence, confdence, confdence, competence, to relates Training Supportive tools teaching (continued) dence Early descriptive theme Early descriptive Training increases competence and conf - competence increases Training Increased job satisfaction clinical practice infuences later Competence as a supportiveVideos tool teaching Simulation as a supportive tool teaching 3 Table Q Feeley et al. Reprod Health (2021) 18:92 Page 13 of 22 Explanation of assessment Explanation Methodological concernsMethodological data and limited Due to low number of studies reporting low Due to on this fnding Methodological concernsMethodological data and limited Due to low number of studies reporting low Due to on this fnding CerQual assessment CerQual Low confdence Low Low confdence Low Low confdence Low Low confdence Low - Hamza 2020; Hankins 1985 1999; Healy and Laufe [ 28 , 31 – 33 42 43 ] ander 2001; Sarangapani 2018 [ 17 , 19 21 41 43 ] Ramphul 2012; Sarangapani 2018; Simpson 2015 [ 16 , 20 , 34 36 40 42 ] 42 ] Studies Studies 6 studies Evans 2009; Smith 1991; Simpson 2015; 6 studies Evans 5 studies: Bahl 2010; 2013b; Simpson 2015; Alex 6 studies Bahl 2013b; Hodges 2015; Alexander 2001; 3 studies Bahl 2008; 2013a; Simpson 2015 [ 17 , 19 - - - CERQual assessments ticularly benefcial. This is infuenced by the program the program is infuenced by This ticularly benefcial. doctors training) expectations(i.e. of learning AVD, the opportunitiesthus providing compe achieve to and/or specifc training is a Lack of teaching tency. barrier in AVD achieving competence to sion are essential to achieving competence and competence achieving to essential sion are expertise. Structured training and/or proactive and supervisionteaching competence. facilitates tuition and close supervisionActive AVD throughout experiencedby colleagues skilled is par in teaching . These skillsThese - include behav . optimal use of AVD ioural skills demonstrating capability i.e. through teamwork, com - situational awareness, confdence, and with the women munication, good relationships Decision-making skills are behaviour. professional if so, of AVD, the appropriateness also essential e.g. which or theatre), (room carry to where out the AVD abandon AVD use and when to instrument to Clinical skills should encompass strate use of AVD. gies that avoid AVD to optimise the opportunity to for AVD that avoid gies clinical is clinically necessary, AVD Where an SVD. skills include history taking, maternal and fetal observation and abdominal palpation to information the pelvis. descent into include assessment of fetal Skilled examinations that assessed fetal vaginal fexion, caput, moulding station, fetal position, fetal A minority essential. suggest and engagement are the skilled determine the fetal use of ultrasound to attributes prior AVD to and the prior AVD to the women analgesia for opportunity the AVD debrief to following Technical skills expertise should encompass Technical of AVD. (manually or with the fetus profciency in rotating timing of applying the instru - appropriate forceps); ment (between contractions); in the competence application of specifc instruments; aptitude in the use of angle and consideration the necessity of an episiotomy SoF SoF Proactive teaching, specifc training and supervi specifc training - teaching, Proactive Non-technical skillNon-technical expertise the to is essential Broader clinical skills are essential to the optimal to clinical skills essential Broader are Clinical skills should also include ensuring adequate Technical skills expertise optimal use to is essential Technical 4 Table Q1 Q2 4 1 2 3 Feeley et al. Reprod Health (2021) 18:92 Page 14 of 22 of studies that generated the SoF of studies that generated dence assessment survey studies Methodological concerns are mitigated by the number by mitigated concernsMethodological are adequacyMethodological, concerns limit the conf - Substantial methodological concerns regarding the concerns regarding Substantial methodological Moderate confdence confdence Low Low confdence Low 1985; Rose 2019; Saunier 2015; Crosby 2017; Eichel - 1985; Rose 2019; Saunier 2015; Crosby 2014; 2007; Sanchez del Heirro 2015; Powell berger 1990; Alexendar and Casson Wilson Smith 1991; 2009; 2017; Chinnock 2009; Fauveau Watter 2001; Al 2020; Hamza Robson and Pridmore Friedman 1999; Sarangapani 2018 [ 15 , 16 22 – 25 29 31 33 35 37 – 41 , 43 45 46 ] 1990; Saranga - and Casson Wilson 1985; Rose 2019; 2017 [ 15 , 17 26 33 Watter pani 2018; Bahl 2008; Al 35 , 38 40 45 ] Devjee 2015; Eichelberger 2015; Powell 2007; Devjee 2015; Powell 2015; Eichelberger 1999; Smith Ramphul 2012, Robson and Pridmore 1990 [ 23 , 24 27 33 36 – 38 and Carson Wilson 1991; 44 , 46 47 ] Studies Studies 19 studies Bofll 1996a; Bofll 1996b; Healy and Laufe 19 studies Bofll 1996a; 1996b; Healy and Laufe 2007; Healy and Laufe 8 studies Devjee 2015; Powell 10 studies Bofll 1996a; 1996b; Hankins 1999; - (continued) rience is essential to achieving competency and achieving to is essential rience expertise. Competency is facilitated development instruments and support exposure by with diferent vary for - required techniques and diferent AVD for Access forceps. rotational ing clinical situations i.e. was a opportunities repeated performto to AVD the skillkey developing to facilitator achieve set to gain to a lack of exposure Conversely, competence. was a particularlyexperience, forceps to in relation barrier and confdence achieving competence to and the provision of opportunities gain expe and the provision to the implemen - infuences willing clinical mentors - environ Enabling facilitative training. of AVD tation more stafng usually by ments include appropriate skilledexperienced obstetricians who are teach to clinical infuenced by be negatively may This AVD. a particular toward instru - preferences mentor’s trainees may or vacuum), whereby ment (forceps skillsnot develop all instrumental options. across a lack of teaching also be impeded by may Training skills articulating and decision- whereby procedures making can be challenging programme, work environment or individual environment work programme, - the attain infuence practitioners appears to use of AVD. and continued of competence ment or against specifc types of towards Preferences infuence practitionerinstruments appears to use in turn, which may infuence attaining competence In fears options. some situations, in and or all AVD a lack of support litigation or through regarding caesarean staf infuenced decision-making towards AVD section over SoF SoF Exposure to AVD including a range of instruments of instruments including a range AVD to Exposure (or lack of)Access and/or courses training to he attitudes and beliefs evident in the training in the training evident and beliefs T he attitudes 4 Table Q2 Q3 5 7 6 Feeley et al. Reprod Health (2021) 18:92 Page 15 of 22 dence assessment limit the confdence assessment dence assessment Methodological, adequacyMethodological, concerns limit the conf - Methodological, coherence and adequacy coherence concernsMethodological, Methodological, adequacyMethodological, concerns limit the conf - Low confdence Low Low confdence Low Low confdence Low Bofll 1996b; Wilson and Casson 1990; Powell 2007 1990; Powell and Casson Wilson Bofll 1996b; [ 15 , 21 23 26 35 45 ] Eichelberger 2015; Powell 2007; Al Watter 2017; Chin - Watter 2007; Al 2015; Powell Eichelberger nock 2009; Smith 1991 [ 15 , 16 21 24 28 35 43 46 ] 2015; Healy and Laufe 1985; Rose 2019 [ 15 , 26 33 2015; Healy and Laufe 38 , 40 ] Studies 6 studies Biringer 2019; Al Watter 2017; Devjee 2015; Watter 6 studies Biringer 2019; Al 8 studies Evans 2009, Alexander 2001; Biringer8 studies Evans 2019; 5 studies Sarangapani 2018; Al Watter 2017; Devjee Watter 5 studies Sarangapani 2018; Al (continued) Some practitioners some practitioners. by valued seek further develop and/or advanced training to skills experi- gain more citing the need to their AVD supervision.ence and seek more Others (obstetric and obstetricians) specif - on rotation GPs trainees, was cally reported additional training with forceps necessary satisfaction and infuences later clinical practice clinical practice later satisfaction and infuences practitioners who were For some practitioners. for who midwives) not obstetricians (medical ofcers, upskilled manage emergencywere to obstetrics, in clinical of competence training enhanced feelings the training skills. Furthermore, AVD and technical their job enhanced their confdence and increased in a specialty, not yet trainee doctors, satisfaction. For infuenced their deci - extra training including AVD obstetric trainees, practise For sion to obstetrics. training enhanced their specifc AVD access to particularly in in AVD, confdence and competence the use of forceps Specifcally designed training using a range Specifcally designed pants. was reported enhance participantsof tools to viewed and simulation training were Videos learning. complement education to as formalised positively clinical learning SoF Access to training in AVD is sought after is sought and in AVD training to Access Training enhances competence, confdence, job confdence, competence, enhances Training Practical teaching tools were valued by partici by valued - were tools teaching Practical 4 Table Q4 the titles of fndings Bold are values 8 9 10 Feeley et al. Reprod Health (2021) 18:92 Page 16 of 22

awareness, teamwork, communication, good relation- Where other techniques had been tried, or where ships with the women, professional behaviour and deci- AVD was clearly the safest option, other clinical skills sion-making. Bahl et al. [19] identifed three essential were highlighted across the six studies [17, 21, 35, 37, behavioural elements; calmness, confdence/assertive- 41, 43]. Tese included assessing the woman’s history ness and self-awareness, including self-knowledge of and current clinical picture and ensuring fetal/maternal professional limitations [19]. Te importance of decision- signs of wellbeing before proceeding to AVD rather than making skills were highlighted across the fve studies [17, an emergency surgical birth [17, 21, 35]. Sarangapani 19, 21, 41, 43]. While these are also essential for clinical et al. [41] emphasised their belief in the importance of practice in general, the studies emphasised the impor- abdominal palpation skills which they divided into three tance of key decision-making points for AVD specifcally, components: including clinical skills that can be used to avoid instru- ‘(1) palpating the abdomen for a clinical assessment mental birth [17, 19, 41]. For example, a midwife who had of fetal size; (2) palpating a central gap, typically a been trained to use the ventouse commented: handbreadth between the xiphoid process and the ‘…the art…is in diagnosing the babies you don’t fetal buttock, as an indication of good head descent attempt to do a ventouse on. OPs, OTs, brows, etc., into the pelvis; and (3) performing a bimanual high heads–diagnosis during VEs in labour p.167.’ examination, with one hand on the abdomen meas- [17] uring the amount of fetal head (in fngerbreadths) above the pubic symphysis as an indication of fetal Where AVD was deemed appropriate, other decisions head descent p. 1165.’ [41] were identifed i.e. where to carry out the AVD (labour room or operating theatre) [21, 41, 43], which instrument Additionally, practitioners’ beliefs in the importance of to use [21] and when to abandon AVD in favour of caesar- skilled vaginal examinations was highlighted across the ean section [19, 21, 43]. Such decision-making involved six studies [17, 21, 35, 37, 41, 43]. One study provided a the weighing up of multiple and simultaneous factors. detailed analysis relating to vaginal examinations: Ram- For example, the likelihood of success in a particular case phul et al. [37] surveyed 323 obstetricians (trainees and infuenced the decision of whether to perform the AVD consultants) and found that between 98 and 99% of the in the labour room, or to recommend transfer to an oper- surveyed obstetricians identifed the following as benefts ating theatre before attempting the procedure [21]. of undertaking skilled vaginal examinations; establishing fetal position, fetal station, the degree of cephalic caput Clinical skills and moulding of the fetal skull; and the degree of engage- Six studies [17, 21, 35, 37, 41, 43] reported on the broader ment of the presenting fetal part. While the survey found clinical skills/assessment of the clinical picture required proportional diferences between consultants and train- for optimal use of AVD. In the frst instance, Bahl [21] ees, respondents of all grades agreed with the importance captured specifc clinical practices (as distinct from the of assessing asynclitism of the presenting fetal part, fex- decision-making skills noted above) from obstetricians ion of the head, and estimated fetal size [37]. However, and midwives deemed as experts, of techniques they some obstetricians (18.7%) and trainees (23.1%) used used to encourage a spontaneous vaginal birth in a situa- ultrasound to aid diagnosis of the fetal head position if tion where there was a chance that this might be achieved they had difculty in determining fetal position digitally safely, but with a view to moving rapidly to instrumental [37]. Simpson et al. [43] provided criteria regarding the birth if necessary. vaginal examination to guide AVD decision-making i.e. the cervix must be fully dilated; membranes must be rup- ‘If she has been pushing for 1 h and the vertex is vis- tured; and the presenting part must be at least at the level ible, one option is to continue pushing for another of the ischial spines [43]. period of time to see if she can have a spontaneous Only three papers (two studies) referred to the impor- vaginal delivery…….If the head was crowning but tance of ensuring women had adequate analgesia [21, 35, held back by the perineum, it will be an option to 43] prior to AVD, arguably an essential clinical skill. One ofer episiotomy…..Check if she has passed urine or recommended ofering ‘a debrief with parents, both at whether it would be appropriate to catheterise and the time of delivery and the following day (ideally) p. 591′ empty the bladder to allow delivery……If there is [43]. No studies mentioned the need to discuss the pro- no concern regarding CTG and the contractions are cedure with the woman, and to obtain authentic consent inadequate, consider putting up syntocinon to aug- from her prior to proceeding. ment the contractions p.337.’ D5 [21] Feeley et al. Reprod Health (2021) 18:92 Page 17 of 22

Technical skills and expertise time and some people have developed a gestalt of Te technical skills required for optimal AVD were high- doing things, and they can’t always elucidate why lighted in three papers, two of which were based on the they are doing it p. 1166.’ [41] same dataset [18, 20, 43]. Te studies noted the need for Additional barriers related to lack of opportunities. specifc skills where the presentation was not directly Preferences of existing staf, and the norms of particular occipito-anterior, including expertise in the position- hospitals, negatively infuenced clinical learning opportu- ing of the forceps blades for rotational (Kielland) forceps nities (e.g. ‘instrument selection is largely institutionally [18], and in manual rotation followed by the use of for- dependent’ [41]). Lack of theoretical or formalised edu- ceps for direct traction (non-rotational forceps deliv- cation was also noted [41]. Tis was echoed by another ery) [43]. More generally, these skills included the need survey [38] of 23 trainee obstetricians, where virtually all for specifc technical expertise in judging the timing of respondents expressed concern about a lack of training applying the instrument (between contractions); compe- opportunities with Kielland forceps. tence in the application of specifc instruments; aptitude A survey of obstetric residency program directors [33] in the appropriate angle of traction; and consideration of inferred that program expectations infuenced the oppor- the necessity, or not, of an episiotomy [18, 20, 43]. tunities available to the trainees to develop competency What are the barriers and facilitators to achieving these in AVD, both negatively and positively: levels of expertise and competence? ‘All programs expected their graduates to be pro- Tree SoF’s were relevant to this question; proactive fcient in outlet deliveries… 97% of residency and teaching, specifc training and supervision (low conf- 100% of fellowship directors expected profciency; dence), exposure to opportunities to gain experience in for vacuum, 92% expected profciency in both types AVD (moderate confdence), the attitudes and beliefs of training programs. In contrast, only 38% of resi- of mentors, training programs and/or localised clinical dency and 48% of fellowship program directors placements (low confdence). expected profciency with mid [cavity]-forceps, while 69 and 73% expected profciency with mid-vacuum Proactive teaching, and specifc training and supervision p.26.’ [33] Six studies [29, 32–34, 43, 44] highlighted facilitatory factors. Tese were: proactive teaching, specifc training, Exposure to AVD including a range of instruments and targeted supervision to enable the development of and the provision of opportunities to gain experience competence in AVD. For example, structured and spe- 19 studies illustrated facilitators and/or barriers related cifc training provided to medical ofcers for emergency to the degree to which trainees had exposure to AVD obstetric care in rural India was reported as highly ben- within their clinical practice areas, and, therefore, oppor- efcial [29], particularly for skills in undertaking AVD tunities to gain experience [16, 17, 23–26, 30–32, 34, 36, where the capacity to perform safe caesarean sections 38–42, 44, 46, 47]. Issues related to exposure (or lack of) was limited. In a high income country (UK); GP trainees was particularly highlighted regarding the rate at which survey respondents [44] reported that the more teaching specifc instruments were used locally [16, 17, 23–26, 30– they had received the more relevant they thought obstet- 32, 34, 36, 38–42, 44, 46, 47]. Inter-regional diferences ric training (including the performance of AVD) was to were found in several surveys [23, 24, 26, 34, 36, 39, 40, the provision of obstetric care in the community. In a 42, 46] highlighting that the localised context infuences national survey administered to all obstetricians in Ger- the use and teaching of instruments. For example, many [32], those actively tutored by their colleagues were signifcantly less likely to report incompetence when ‘Tere was however a signifcant diference in num- using forceps or vacuum extraction highlighting the ben- ber of [forceps assisted vaginal deliveries] FAVDs efts of proactive teaching and specifc training. performed by region (p < 0.0001). Residents from Two surveys [38, 41] found barriers to gaining com- the Midwest completed the most FAVDs compared petencies in AVD. Sarangapani et al. [41] carried out to any other region, with 9% having completed > 30 a mixed-methods study with trainee obstetricians and FAVDs and 27% having completed 11–30 FAVDs p. found several challenges to their learning, including poor 2.’ [39] communication by mentors: ‘…[I]…fnd teaching on this topic tends to happen on call and it is kind of rushed. Tey don’t go through a super detailed rationale because there isn’t always Feeley et al. Reprod Health (2021) 18:92 Page 18 of 22

The attitudes and beliefs infuence the attainment conficting messages between mentors [18, 41]. In of competence and continued use of AVD another survey of 81 trainees, (35%) were not even sure Some studies reported the cessation of teaching mid-pel- if training on the use of AVD was provided in their units, vic operative vaginal deliveries citing safety and litigation or not [16]. concerns [23, 33]. Such fears were refected in another study whereby some trainees reported they would not What are the views, opinions, perspectives use any forceps, at all, in their clinical practice [38] also and experiences of maternity care practitioners on training due to fears of safety and/or litigation. Tis concern was for use of AVD? echoed by experienced obstetricians in a survey car- Te fnal three review fndings suggested that access to ried out in South Africa [27], who reported that only training sought after and is valued (low confdence); it twenty-one (10%) of the participants continued to do enhances competence, confdence, job satisfaction and operative vaginal deliveries (OVD) (approximately 1–2 infuences later clinical practice for some practitioners every 3–6 months) following their training. Te authors (low confdence); practical teaching tools were value (low hypothesised that the majority of survey participants confdence). would resort to caesarean section because of the fear of litigation and the lack of skilled personnel in attendance Access to good quality training in AVD is sought in OVD [27]. after and valued by some practitioners Conversely, related to the vacuum extractor, a survey Six studies [16, 22, 24, 27, 36, 46] found that partici- in Canada [46] showed how exposure to the successful pants sought further and/or advanced training to further use of instrumental birth can change attitudes and beliefs develop their AVD skills or to gain more experience. For over time: example, a survey in Canada [22] with family physicians who underwent an advanced fellowship, reported 69% ’If you administered your vacuum extractor ques- of 87 respondents stated that they took the fellowship tionnaire to me now I would give much more enthu- because they wanted more experience, and the same pro- siastic responses about the use of the vacuum. Te portion did not feel ready to practise obstetrics (in gen- midwives here do the normal deliveries, and the eral that included AVD) without supervision. In another doctors are called for complications. We only have survey [16], of 87 obstetric trainees, ‘the majority felt that a small hand-held vacuum extractor but it has they needed training in using Kielland’s forceps (71/87, seen me through many difcult deliveries p. 1722.’ 81.6%)’. Tese participants identifed further training [trainee in Canada, now working in Ethiopia] [46] needs despite being on an obstetric trainee programme.

What are the barriers and facilitators to implementation Good quality training enhances competence, confdence, job of appropriate training? satisfaction and infuences later clinical practice for some One SoF was relevant to the research question; access (or practitioners lack of) to training courses and/or willing clinical men- Eight studies [16, 17, 22, 25, 29, 36, 44, 47] identifed tors infuences the implementation of AVD training (low positive experiences of training. For practitioners who confdence). were not obstetricians (medical ofcers, midwives) who were trained to manage emergency obstetrics, training Access (or lack of) to training courses and/or willing clinical enhanced feelings of competence and confdence in clini- mentors infuences the implementation of AVD training cal and technical AVD skills. Furthermore, the training Eight studies [16, 18, 27, 34, 36, 39, 41, 46] generated enhanced participants’ confdence and increased their insights regarding the barriers/facilitators to the imple- job satisfaction. A mixed methods study of midwives mentation of appropriate AVD training. In South Africa, who had undertaken ventouse training [17] found 15/18 a survey found of 197 participants, 84% had learned AVD participants felt that becoming a midwifery ventouse- from ‘essential steps in the management of obstetrics practitioner (MVP) had positively afected their overall emergencies’ (ESMOE) training modules indicating good midwifery practice, and enhanced confdence in abdomi- uptake when training was available [27]. Other studies nal palpation and vaginal examinations as well their abil- reported that willing clinical mentors who were proactive ity to ‘handle’ a prolonged labour. One respondent said in their teaching of AVD positively infuenced appropri- [17]– ‘I am much more likely to try everything to obtain a ate training [16, 18, 34, 36, 39, 41, 46]. Conversely, two normal delivery… (Midwife 14 p. 168).’ studies illustrated the negative infuence of poor teach- Likewise, family physicians who embarked on an ing, as a result of which the articulation of AVD skills was advanced fellowship were much more likely to intend to reported as challenging and some participants reported practice obstetrics following the training [22]: Feeley et al. Reprod Health (2021) 18:92 Page 19 of 22

‘Eighty-two percent of participants indicated that infuential for trainees to gain competence, confdence the ability to access extra training infuenced their and expertise in all instrumental births, or conversely was decision to practise obstetrics. Tey cited that the a negatively infuencing factor. fellowship made them more confdent and more Only three relevant qualitative studies were identi- comfortable with intrapartum care. When asked if fed in our extensive searches. Te majority of studies the fellowship was useful to their current practice, (23 out of 27 were from high-income countries). Tese 75% rated it a 6 or 7 (on a 7-point scale where 7 limitations are refected in our CERQual assessments, was “essential”; mean rating 5.9); 93% said that they which were low for all except one summary of fndings would choose to complete the extra training again statement. Tis review also includes some older stud- p.534.’ [22] ies that may not be relevant for current practice. For instance, some of the studies refer to UK general prac- Practical teaching tools were valued by participants titioners undertaking AVD, but this cadre of doctors no longer routinely attends births in the UK. An important Five studies reported the value of practical and specif- strength of the review is that it has located all studies cally designed training that incorporated diferent teach- in all languages that have been published to date, and it ing modalities [16, 27, 34, 39, 41]. Videos and simulation includes survey data. Our searches also found 28 studies training were viewed positively as an adjunct to clinical that were either pre/post-test AVD training intervention learning [27, 34, 41]. However, the authors from a study quasi-experimental, RCT training intervention studies, that introduced video based learning [41] emphasised or cross-sectional studies that examined maternal/neo- that alternate teaching methods that ‘act as complemen- natal outcomes following training [47–73]. Tose studies tary tools to clinical teaching, but there was agreement did not meet our criteria for inclusion, but they do war- that they should not replace hands-on clinical teaching (p. rant further investigation in future reviews to determine 1167).’ the attributes, efectiveness and efcacy of good training Discussion that meet the needs of practitioners, and of service users. Findings from our previous review [6] highlighted for Te aim of this review was to improve understand- both parents, the distress of unexpected interventions ing of the characteristics of competency and expertise associated with AVD (including episiotomy, need for in AVD, and to generate insights regarding the barriers unplanned pain relief, such as epidural analgesia, and and potential facilitating factors relating to expertise, concern for possible iatrogenic harm to the baby of using training, implementation of and competencies in AVD. instruments) may be mitigated by how health profession- We identifed 27 studies of health professionals’ views als communicate, both at the time of decision-making, of training and competencies for AVD, mostly in high and during the process. In the present review only three income countries. papers (two studies) referred to ensuring women had We found that AVD competency comprises three adequate analgesia and one discussed ofering parents a inter-related components; non-technical skills, broader debrief following AVD [18, 34, 42]. Although this knowl- obstetric clinical skills and specifc technical skills asso- edge may be implicit or assumed information, Te Royal ciated with particular instrument use. Practitioners College of Obstetricians and Gynaecologists (RCOG) felt that they needed additional training and exposure [48], the Royal Australian and New Zealand College of to AVD in practice to gain skills and confdence in this Obstetricians and Gynaecologists (RANZCOG) [49], feld, even after they had ofcially qualifed (including and the Society of Obstetricians and Gynaecologists of those who had undertaken specialist obstetric training). Canada (SOGC) [50] guidelines for instrumental vaginal Teaching aids such as simulation and video teaching tools birth all highlight the importance of adequate postnatal were viewed as a valuable complement to clinical men- care and counselling. torship. However, the attitudes and behaviours of their Te 2020 update of the American College of Obste- colleagues and mentors, and the norms of their training tricians and Gynaecologists (ACOG) [51] guidance on and employing institution, were critical in determining operative vaginal birth also include lists of prerequisites if an individual practitioner would consider using AVD for AVD. Several of the studies we included in our review in routine practice, or not. Tis included the degree to did generate checklists based on their research fndings which the fear of litigation in the employing organisation, to establish the components: of a skilled low-cavity non- and/or among peers and senior staf, infuenced rapid rotational vacuum delivery [17], of a skilled rotational recourse to caesarean section in preference to any kind forceps delivery [19], non-technical skills, cognitive or of vaginal birth in three studies [23, 27, 33]. Good quality decision-making aids for instrumental births [18, 20, clinical mentorship or supervision was also particularly 34, 42]. Tese tools do not appear to have been formally Feeley et al. Reprod Health (2021) 18:92 Page 20 of 22

evaluated in practice. Preparing clinicians and maintain- studies, and through rigor in study selection and analysis. ing the profciency in the recognition and management of However, there are some limitations; we were unable to events that are relatively rare such as emergency obstet- undertake the planned meta-thematic synthesis due to rics is a challenge, including AVD and caesarean section the few qualitative studies found, and the low quantity [52–56]. Evidence on the efectiveness of the multiple and/or quality of the data presented in them. Due to this methods in use (e.g. classes, simulation-based training factor, we were also not able to carry out the pre-planned methods, rehearsals, drills, interactive training) is sub- convergence. optimal. Although, multidisciplinary training has been recognized as essential including clinical and non-clinical Conclusion skills [57], identifcation of the most useful combination Most AVD techniques can be used safely in very low of methods remains uncertain and warrants future stud- resource environments, by single practitioners. Most ies to rigorously assess efectiveness. Tis is particularly women prefer to give birth vaginally. Skilled, respect- important in low- and middle-income countries where ful AVD can be a safe, acceptable, and low-cost solution healthcare providers cannot rely on strong health sys- when birth needs to be expediated. Fear of bad outcomes tems, referral structure or appropriate supplies fow. and litigation are factors likely to be compounded when AVD is one of the seven basic services as prerequisites professional training is inadequate to ensure confdence for emergency obstetric care as defned by the WHO. Te and competence in clinicians’ skills in this area, or when main reasons cited for the low rates in LMICs are known local colleagues and seniors, or organisational norms, to include lack of skilled healthcare workers and lack of deprioritise AVD in favour of caesarean section. Our resources with the establishment of training programs for fndings suggest that both pre- and post-registration all skilled birth attendants a priority [58]. training for maternity care practitioners needs to include AVD is not without risks. In this review fear of bad the development of positive attitudes. Access to specifc outcomes and litigation were concerns reported by some AVD training, using a combination of teaching meth- clinicians. Tese factors coupled with suboptimal train- ods, complements, but does not replace, close clinical ing and thus low levels of skills underpin the deprioritiza- mentorship from experts who are positive about AVD, tion of AVD in favour of caesarean section [58]. Low- and and opportunities to practice emerging AVD skills with middle-income countries are most afected by this trend supportive supervision. Further research is required to and the use of AVD is almost non-existent in these set- ascertain efective modalities for wider training, educa- tings [3]. However, caesarean section is not without tion, and supportive supervision for optimal AVD use. risks either and it is precisely in these countries and in resource constrained conditions where appropriate and Abbreviations skilled use of AVD could have a more signifcant impact AVD: Assisted vaginal delivery. by optimizing the use of caesarean section and improving perinatal outcomes [1]. Efective training programmes Supplementary Information need to be revitalized in order to foster feasible alterna- The online version contains supplementary material available at https://doi. tive solutions for emergency obstetric care. Tis also org/10.1186/s12978-021-01146-3. includes close supervision by experienced consultants, as highlighted in a recent study [59]. In addition, research is Additional fle 1: Table S1. Example search-MEDLINE. on-going on new devices such as the Odon device, with a Additional fle 2. QA. potentially safer profle and easier to use for all cadres of Additional fle 3. Data extraction. birth attendants that could possibly expand the options Additional fle 4. Excluded studies. to expedite birth and improve maternal and perinatal outcomes when certain complications arise during labour Acknowledgements [60–62]. We are very grateful for the search development support provided by Cath Harris, Information Specialist at the University of Central Lancashire and Tomas Strengths and limitations Allen, Librarian at WHO. Te strengths of this study are that a comprehensive Authors’ contributions and rigorous search strategy was undertaken, including CF-search, study selection, data extraction, data synthesis, writing the manuscript. NC-conception, study selection, data extraction, revising the reviewing papers in other languages. While an evidence manuscript. APB- conception, study selection, revising the manuscript. AW- synthesis is an interpretative process, the risk of over or revising the manuscript. SD- conception, study selection, data extraction, under interpretation of the data was minimized through data synthesis, revising the manuscript. CK- conception, study selection, data extraction, data synthesis, revising the manuscript. All authors read and author refexivity to ensure that personal beliefs and val- approved the fnal manuscript. ues did not obscure important data within the included Feeley et al. Reprod Health (2021) 18:92 Page 21 of 22

Funding 12. Walsh D, Downe S. Appraising the quality of qualitative research. Mid- This study was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special wifery. 2006;22:108–19. Programme of Research, Development and Research Training in Human 13. Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, Reproduction (HRP), Department of Sexual and Reproductive Health and Gagnon M, Grifths F, Nicolau B, O’Cathain A, Rousseau M, Vedel I, Pluye P. Research at the World Health Organization. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Educ Inf. 2018;34(4):285–91. Availability of data and materials 14. Downe S, Walsh D, Simpson L, Steen M. Template for metasynthesis. 2009, The search strategy, screening and data extraction tables have been supplied contact [email protected] as Additional fles within this submission. 15. Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin C, Gülmezoglu M, et al. Using qualitative evidence in decision making for health and social interventions: an approach to assess confdence in fndings Declarations from qualitative evidence syntheses (GRADE-CERQual). Plos Med. 2015;12(10):e1001895. Ethics approval and consent to participate 16. Al Wattar BH, Mahmud A, Janjua A, Parry-Smith W, Ismail KM. Training Not applicable. on Kielland’s forceps: a survey of trainees’ opinions. J Obstet Gynaecol. 2017;37(3):280–3. Consent for publication 17. Alexander J, Anderson T, Cunningham S. An evaluation by focus group Not applicable. and survey of a course for Midwifery Ventouse Practitioners. Midwifery. 2002;18(2):165–72. Competing interests 18. Bahl R, Murphy DJ, Strachan B. Qualitative analysis by interviews and The authors declare no competing interests. video recordings to establish the components of a skilled low-cavity non- rotational vacuum delivery. BJOG. 2009;116(2):319–26. Author details 1 19. Bahl R, Murphy DJ, Strachan B. Non-technical skills for obstetricians School of Community Health and Midwifery, University of Central Lancashire, conducting forceps and vacuum deliveries: qualitative analysis by Preston PR1 2HE, UK. 2 Department of Reproductive Health and Research, 3 interviews and video recordings. Eur J Obstet Gynecol Reprod Biol. World Health Organisation, 1211 Geneva 27, Switzerland. Sanyu Research 2010;150(2):147–51. Unit, Liverpool Women’s Hospital Women and Children’s Health, University 20. Bahl R, Murphy DJ, Strachan B. Qualitative analysis by interviews and of Liverpool, Liverpool L87SS, UK. video recordings to establish the components of a skilled rotational forceps delivery. Eur J Obstet Gynecol Reprod Biol. 2013;170(2):341–7. Received: 10 September 2020 Accepted: 26 April 2021 21. Bahl R, Murphy DJ, Strachan B. Decision-making in operative vaginal delivery: when to intervene, where to deliver and which instrument to use? Qualitative analysis of expert clinical practice. 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