Homebirth Breech Research: A Reminder to Continue Breech Competent Options

“A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital breech birth.”    

“Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births” 2018 

Dr. Stuart Fischbein, MD OBGyn and Dr. Rixa Freeze, PhD  have published a paper on homebirth breech statistics demonstrating the safety of breech at home with a skilled provider.  Breech birth is feared among many, especially those who have trained after the 2000 Term Breech Trial (TBT) where many doctors were taught only to do a cesarean for breech due to the dangers of vaginal breech birth.  This study had many flaws outlined in the Term Breech Trial 2 Year Follow up, but is unfortunately still held as a standard here in the USA.  Many of the doctors who learned under older doctors who taught breech were limited by this overall fear,  lack of training by their colleagues, lack of acceptance and pressure to not do breech, and also by hospital policy and standardization.   Breech also gets a bum rap because, in most places, the training for breech is not seen as a specialized or advanced skill and, in hospital, was typically in a supine and managed position.  As we know from Louwen and Reitter, outcomes are better and fewer maneuvers are used when gravity is employed in upright breech birth.  This radically shifts the landscape for hospital breech delivery.    

Breech presentation, both known ahead of time and surprise, make up 11% of the cesarean births here in the United States.  This percentage does not include planned cesarean for subsequent babies where parents were not given a choice of having a Vaginal Birth After Cesarean (VBAC).  This means the number of breech actually contributed down the line to more cesareans, and we now know it also contributes to a higher morbidity and mortality rate for the person birthing and for subsequent babies.  

What Fischbein and Freeze’s statistics are demonstrating is that skilled providers in an Out of Hospital (OOH) setting provides a safe option.  More importantly, they are demonstrating that not only should the option to birth vaginally with a skilled provider exist, but the parents have the right to make this decision to birth how they want to birth, where they want to birth, and have the support of a skilled attendant. 

When hospitals are not providing options for skilled providers or even a “trial of labor” for a vaginal delivery, families are turning to alternative methods for delivery.  For some families this includes unattended births.  One of the agenda items for ACOG and its lobbying efforts is to limit midwives attending breech.  Not only is this denying families support for their informed choices, but it is also forcing the polarization of options for breech delivery.  At the same time ACOG works towards regulating a skill that they can’t provide, they offer no alternative options for families to deliver with trained and skilled providers and the pressure for a cesarean birth is quite high.  No one wants to force a vaginal delivery with scared providers whose interventions and fear could cause damage or iatrogenic consequences from unnecessary and uninformed assistance.

Studies like this of Fischbein and Freeze or that of Louwen and Reitter are showing that vaginal breech is an advanced skill subset that lends safety to breech.  To withhold this information and training from new birth workers is not just dumbing down attendants, but it is unethical.  To withhold those with breech competency skills from attending breech births is also unethical as it forces cesareans or unassisted deliveries.  The unintended consequences down the line must be called out, and the advanced skills taught.  

What is next?  As midwives (or even obstetricians) are facing more and more regulations of breech, we cannot allow ourselves to become deskilled in breech or other aspects of midwifery that have traditionally been part of its service or scope of practice.  Even in regions where providers are not attending breech, surprise breech must be attended on the spot whether by doctors, EMTs or midwives.  Studies like these lend credibility to shifting laws and availability of practitioners for safe breech birth.  As the future opens to breech, let’s make sure that we are ready to provide the resources and skills that families presenting breech deserve.   

ACOG:  State Legislative Toolkit:  Licensure and Regulation of Certified Professional Midwives (CPMs). 

Driscoll, Anne K. , PhD, and Danielle Ely, Ph.D., of the U.S. Centers for Disease Control and Prevention: Preliminary 2016 data from personal correspondence on September 13, 2017 with Anne Driscoll, Ph.D., at the Centers for Disease Control and Prevention.  https://evidencebasedbirth.com/what-is-the-evidence-for-using-an-external-cephalic-version-to-turn-a-breech-baby/

Fischbein, Stuart and Rixa Freeze. “Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births.”  BMC Pregnancy and Childbirth October 11, 2018 18:397 Open Peer Review Reports.

Hannah ME1, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.  “Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.” Term Breech Trial Collaborative Group. Lancet. 2000 Oct 21;356(9239):1375-83.

Louwen, F. , Daviss, B. , Johnson, K. C. and Reitter, A. (2017), Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. Int J Gynecol Obstet, 136: 151-161. doi:10.1002/ijgo.12033 Open Access  

Reitter, Anke. Obstetric MR Pelvimetry changes according to position. Am J Obstetrics and Gynecology 2014. Dec;211(6):662.e1-9. doi: 10.1016/j.ajog.2014.06.029. Epub 2014 Jun 17.

Shutte J. M.  Maternal Mortality Committee Of The Netherlands Society Of Obstetrics , “Maternal deaths after elective cesarean section for breech presentation in the Netherlands.” Acta Obstet Gynecol Scand. 2007;86(2):240-3.

Whyte H1, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett ED, Hutton E, Kung R, McKay D, Ross S, Willan A; Term Breech Trial Collaborative Group. “Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial.” Am J Obstet Gynecol. 2004 Sep;191(3):864-71.