Methodological Challenges and Solution Strategies During Implementation of a Midwife-led Multicentre Randomized-controlled Trial (RCT) in Maternity Hospitals
Abstract Background: RCTs with complex interventions are methodically challenging. Careful planning under everyday conditions in compliance with the relevant international quality standard (ICH-GCP guideline) is crucial. Specific challenges exist for RCTs conducted in delivery rooms due to various factors that cannot be planned beforehand, such as “peak hours” of births and a high work burden for midwives and obstetricians. Moreover, in Germany as well as in other countries, midwives and obstetricians have frequently little experience as investigators in clinical trials. Methods: The randomised controlled trial “BE-UP” tests the effectiveness of an alternative birthing room on the rate of vaginal births and woman-oriented outcomes. In the process of implementing the trial in 17 obstetrical units and in the endeavour to reach the calculated sample size of 3,800 women, the research team encountered a variety of unexpected challenges. The aim is to describe in greater detail the methodical and organisational challenges and to inform about the research team’s strategies to overcome them.Results:The results are presented in five sectors: 1) Selection of and support for cooperating hospitals: they are to be selected according to predefined criteria and strategies to offer continuous support in trial implementation must be mapped out.2) Establishing a process of requesting informed consent: a quality-assured process to inform pregnant women early on must be feasible and effective. 3) Individual, digital real time randomization: besides instructing the maternity teams appropriate measures for technical failure must be provided.4) The standardized birthing room: the complex intervention is to be implemented according to study protocol, yet adapted to the prevailing conditions in the delivery rooms.5) GCP-compliant documentation: midwives and obstetricians is to be instructed in high quality data collection, supported by external monitoring throughout the trial.Conclusion:Since not all potential challenges can be anticipated in the planning of a trial, study teams need to be flexible and react promptly to any problems that threaten recruitment or the implementation of the complex intervention. Thought should be given to the perspectives of midwives and obstetricians as recruiters and how clinic-intern processes could be adapted to correspond with the trial’s requirements.