Breech Choices

Adapted from Gentle Birth, Gentle Mothering: The Wisdom and Science of Gentle Choices in Pregnancy, Birth and Parenting by Dr Sarah J Buckley, (One Moon Press, 2005)

In 2002, a pregnant woman in Brisbane, Australia – a mother of three, including naturally born twins – was refused the option of a vaginal breech birth in hospital, and told she could only have her baby by caesarean. She sought a midwife to assist her and gave birth successfully at home. Her picture – glowing with new motherhood, holding her healthy, happy baby – appeared in the Brisbane Courier Mail newspaper a few days later.

In the media furor that followed this event, I was interviewed for television and I also wrote this article, which I have updated with new research findings. My interest in natural breech is personal as well as political, as my fourth baby was born easily and unexpectedly breech at home (see link for Maia’s birth story).

As a GP I am aware that breech birth is more complicated than for head-down babies, but I do not believe that this justifies coercing all women with breech babies into major abdominal surgery. The opinion that vaginal breech birth is “as dangerous as giving a child a ball to play with in a busy street”, as suggested by one Brisbane obstetrician, is not only inaccurate in terms of risk but ignores the complexity of the decision. In this situation, as in much of pregnancy and birth, there are risks on both sides and no obstetrician or midwife can guarantee a perfect outcome for any mother or baby.

Doctors have justified their refusal to offer this mother a vaginal breech birth with reference to the Term Breech Trial (TBT), a large international study that showed increased risks for women birthing breech babies vaginally under study conditions, compared to women having a planned caesarean.1

Conditions in this study were highly medicalised – for example, two-thirds of women were administered drugs to induce or speed up their labours. Many practitioners experienced with breech birth would see this as dangerous, putting the baby at extra risk of fetal distress. Almost half of the participants who gave birth vaginally had an epidural, which, as the World Health Organization notes, transforms labour from a physiological event into a medical procedure.2

Women in this study were also disadvantaged by a lack of the most basic physiological requirements for successful birth. For example, neither privacy nor choice of position for labour and birth were considered important in this study, and women were not offered continuity of carer (having the same care giver during pregnancy, birth and post-natal), which is associated with better condition of babies at birth, among other benefits.3

The TBT has also been criticised for including, in the final analysis, several babies whose poor outcome was unrelated to vaginal breech birth. These included two babies who probably died before being involved in the study (one of whom was a twin – twins were supposed to be excluded – and one of whom was actually head-down) and one baby who possibly died from a congenital abnormality (babies with lethal congenital abnormalities were supposed to be excluded). Two healthy babies who died at home after hospital discharge were also included. Although inclusion of these babies is scientifically correct, a further analysis excluding these babies would have been important.

Even with these provisos, however, the TBT actually shows that the risk of a poor outcome for this Brisbane mother and her baby were very low. With a well-positioned baby – frank breech, with straight legs – a skilful attendant, and a smooth and drug-free labour and birth, she had over 97 per cent chance of a good outcome for herself and her baby. (In the TBT, good outcome means a live mother and baby who are well for the first four to six weeks after birth.) If she had chosen a caesarean, her chance of this outcome would have been a little higher – 98.5 per cent – but in weighing up this risk, this experienced mother no doubt considered other factors about caesarean birth.

For example, recovering from major abdominal surgery is not easy while caring for a new baby – and this mother had two other young children as well. After a caesarean, she would have had a one-in-five chance of an infection, which could have delayed her recovery even more. She would also have been likely to lose more blood, and to have more ongoing fatigue – up to four years later, according to some research – than after a vaginal birth.4 Some mothers have reported difficulty in bonding with their baby after a caesarean, with comments such as: “I wasn’t even sure if it was my baby.” The risk of post-natal depression is increased, and the chance of successful breastfeeding is decreased after a caesarean, both of which can impact long-term on the mother–baby relationship, as well as on the health of both.4

This mother would also have had a small, but statistically significant, increase in her risk of dying after a caesarean compared to a vaginal birth5 and, once her uterus had been cut, she would have been labelled “high risk” in every subsequent pregnancy because of an increased risk of death for herself and her baby – even with another elective caesarean.

In contrast, in choosing a natural birth, she gave her baby the advantage of initiating her own labour at the time when she was ready – as research has shown, even with ultrasound dating, a significant number of caesarean babies are delivered prematurely.6 During labour, her birth hormones helped her baby’s lungs to prepare for breathing – caesarean babies have an increased risk of breathing difficulties partly because they lack this hormonal preparation. These same hormones also naturally protected her baby from low oxygen levels and fetal distress as her labour progressed. Her baby was no doubt alert and in good health at birth; thanks again to the hormones and processes of natural birth.7

This mother would also have been thinking of long-term implications when she made this decision, an aspect that is not often considered in the medical context, where the outcome of birth is usually assessed by how many babies are alive (and, in the TBT, healthy) for the first week, or weeks, after birth. There are very few studies of the long-term health outcome for children born by caesarean. However, several studies show an increased risk of asthma in adulthood8-10 – in one study by three times10 – highlighting that caesarean birth is a major deviation from the natural process for babies as well as for mothers.

Ironically, 18 months after this mother’s home breech birth, the TBT researchers published their two-year follow-up study, which showed no difference between the caesarean and vaginally born children, in terms of death and delayed development, at two years of age.11 This turn-around in outcome was mainly because most of those vaginally born babies who had appeared very unwell after birth had recovered, with no lasting disabilities. As Kotaska has highlighted, the use of a “short-term combined end point” (death or apparent compromise at six weeks of age) seems to have been misleading in this study.12

Unfortunately by 2004, when this follow-up study was published, many hospitals around the world had already adopted a policy of routine caesarean delivery for breech birth,13 and there has not been, in most places, a review of policy. This is despite much international criticism of the study, and of the impact that it has had on women carrying breech babies.14, 15

While the baby’s breech position made this situation unusual, this woman’s story is familiar to pregnant women and their carers, in countries where doctors are using the evidence from scientific studies to advise pregnant women. This is a welcome development when the information given is accurate and unbiased, and when both mother and caregivers are applying the principles of informed choice, well stated by Grose:
Informed choice is a process involving the provision of accurate and understandable information about treatment alternatives. The woman should then be given the time she needs to make her own decisions. Informed choice is not interchangeable with “informed consent”, nor does it mean that consumers should comply with hospital policy because well-qualified people laid down these policies.16
The woman can then take her rightful place at the centre of the decision-making process, also taking her rightful share of responsibility. This also benefits medical and other carers, who are currently shouldering an excessive responsibility for birth outcomes.

However, it appears, from women’s reports, and from the sequellae of research such as the TBT, that the process of informed choice is poorly understood or implemented in many parts of the world. For example, most women carrying breech babies are now told that they must have a caesarean, and are given very limited information about the risks and benefits of caesarean versus vaginal breech birth.

In other situations, women have felt coerced into accepting interventions such as induction and epidurals without being advised that these procedures carry risks. Like the mother in this story, many women who question their doctor’s advice receive an exaggerated and emotive response such as being told, “Your baby will die if you don’t accept my advice.”

This mother eventually found the care that she wanted and her good outcome – a happy mother and a healthy, happy baby – was not accidental. It is shameful, however, that her choice for vaginal birth was not respected in the hospital system, where she originally preferred to birth her baby.

I encourage mothers with breech babies to research all of their options; there are still many birth attendants (mostly older obstetricians and midwives who practiced in the low-caesarean era) who are skilled in assisting with vaginal breech birth, and there are many resources available to help with decision-making.17-20

I believe that it is every woman’s right to choose the birth she wants for her baby and herself – whether vaginal or caesarean; high-technology or low-technology – and that no-one can make a decision that is as trustworthy and far-sighted as that of a well-informed mother.

1. Hannah ME, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356(9239):1375-83.
2. World Health Organisation. Care in Normal Birth: a Practical Guide. Report of a Technical Working Group. Geneva: World Health Organisation, 1996.
3. Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database Syst Rev 2000(2):CD000062.
4. DiMatteo MR, et al. Cesarean childbirth and psychosocial outcomes: a meta-analysis. Health Psychol 1996;15(4):303-14.
5. Enkin M, et al. Effective Care in Pregnancy and Childbirth. 3rd ed. Oxford: Oxford University Press, 2000.
6. Hook B, et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997;100(3 Pt 1):348-53.
7. Buckley SJ. Undisturbed birth: Nature’s blueprint for ease and ecstasy. Journal of Prenatal and Perinatal Psychology and Health 2003;17(4):261-288 See also Chapter XXX, Undisturbed birth
8. Hakansson S, Kallen K. Caesarean section increases the risk of hospital care in childhood for asthma and gastroenteritis. Clin Exp Allergy 2003;33(6):757-64.
9. Kero J, et al. Mode of delivery and asthma — is there a connection? Pediatr Res 2002;52(1):6-11.
10. Xu B, et al. Caesarean section and risk of asthma and allergy in adulthood. J Allergy Clin Immunol 2001;107(4):732-3.
11. Whyte H, et al. 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;191(3):864-71.
12. Kotaska A. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. Br Med J 2004;329(7473):1039-42.
13. Hogle KL, et al. Impact of the international term breech trial on clinical practice and concerns: a survey of centre collaborators. J Obstet Gynaecol Can 2003;25(1):14-6.
14. Banks M. Commentary on the Term Breech Trial. UK midwifery archives 2001
15. Bernstein P. Who Will Deliver Breech Babies Vaginally? Medscape 2004
16. Grose C. Consumer framework for maternity service provision. AIMS Australia Quarterly Journal 1998;6(1):8-10.
17. Banks M. Breech Birth, Woman Wise. Hamilton New Zealand: Birthspirit Books, 1998.
18. Bloome P. Heads Up: All about breech babies.
19. Gaskin IM. The undervalued art of vaginal breech birth. Mothering July-August 2004;125:52-58.
20. Waites B. Breech Birth. London: Free Association Books, 2003.