At first glance, I thought I’d misunderstood it. I just didn’t expect to see a paper with so much spin about high-risk home birth in a mainstream specialist journal. This one claimed that, in essence, all you need is the right practitioner for breech birth to be safe at home. And it was amplified by the authors on the journal’s blog, too. Why do I think this was dangerous and misleading, and what does the case show about the editorial process of the journal that published and promoted it?
Babies are usually born head first. That’s called vertex or cephalic presentation. The head nestles into the bottom of the womb, and once head and shoulders emerge, the rest of the body tends to slip out fairly easily afterwards.
Breech presentation only happens in 3 to 4% of full-term births. It means the baby is coming bottom first, or, less often, foot or knee. It is complicated in comparison to head first. The baby is more likely to get stuck, injured, and have reduced oxygen flow. A baby with problems might be more likely to not get head down, too.
So whether the baby is in great shape or not, advanced specialist equipment and help is more likely to be urgently needed during or after the birth – like forceps, cesarean, resuscitation, and intensive care. That’s why breech presentation at the end of the pregnancy is a ‘no go’ criterion for most midwives who support home births, and 1 of only 3 “absolute contraindications” to home birth according to the American College of Obstetricians and Gynecologists (ACOG). Breech when the baby is due means you will be referred to an obstetrician and hospital birth in the Netherlands, too, where home births are very common [PDF*].
Before we go further, you should know that both my children were born at home. I was a home birth activist for years – including leading the national home birth organization in Australia, and I was all for pushing the boundaries of risk in the early years.
Home birth was my introduction to epidemiology. I thought the data I worked to gather for years would show what great outcomes we were having in home births in Australia – including higher risk ones. That’s not how it worked out, though. Our study is one of the ones cited by ACOG to support its “absolute contraindications”. We concluded:
Australian home births carried a high death rate compared with both all Australian births and home births elsewhere. The two largest contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress.
Our dataset had one of the higher rates of death published for planned breeches at home: 1 in 14 died. All the studies with more than a few breech births reported I found while preparing this post showed much higher rates of death for breech babies than vertex. There aren’t many, though, given that most home birth midwives won’t go ahead if they know the baby is breech. (They are listed at the bottom of this post.)
Breech births at home are legally perilous, too, given the clear advice against the practice from both midwifery and obstetric professional organizations internationally. When I searched for news reports about breech birth at home in 2018, I found a report from Australia of an upcoming trial for manslaughter of a former midwife related to a breech birth, and a court in Spain considering pressing criminal charges against parents whose breech baby died at home.
So what does this new paper provide to argue against all this?
It was published in October 2018 in BMC Pregnancy and Childbirth by an American obstetrician, Stuart Fischbein, and doula and midwife’s assistant, Rixa Freeze. This is what they report:
This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity….
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. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.
“This study is underpowered to calculate uncommon adverse neonatal outcomes” is a curious statement, and it’s key. This isn’t the kind of study that can be “powered” to provide an answer to a question. It’s just a description of outcomes. And not reporting the death and serious harms to babies right up there obviously with the other findings – including in the abstract – is misleading and manipulative.
Yes, the numbers in the study are too small for the mortality and serious neonatal morbidity rates to mean a lot. But that would also be true for outcomes that they did report clearly and prominently.
Without a very close reading, though, you get the impression that it worked out well for all 50 full term, non-twin babies who were born after starting labor with out-of-hospital birth still planned. Yet, there was 1 death and 4 serious adverse outcomes reported in the text. That’s not good. And that’s with more than one pair of hands – critical, as complications can arise for both mother and baby at the same time at high-risk birth in particular – including an experienced obstetrician bringing a great deal of equipment rarely seen at a home birth.
For perspective: perinatal death – stillbirths and newborn deaths – is measured per 1,000, because it’s so rare for most term, single-baby pregnancies. Low risk home birth can be less than 1 out of a thousand, or not a great deal more.
The small number of births isn’t the only key issue here, although the study wouldn’t carry much weight against the rest of the evidence, even if the outcomes for babies had been better. It’s that there could be an under-estimate of harm. They can’t be sure if they know of every death or serious adverse event, because they did not have follow-up data for all the babies – especially when they transferred to hospital care.
This paper and accompanying journal blog post fall into several traps that fuel breech births at home. There’s a biased take on a selection of existing evidence about vaginal breech birth. (I recommend reading this instead.) The selection of evidence extends to the data on breech births at home. The authors cite only 4 studies. (I added a list of those, and a further 10 studies I could find, below this post.)
Then there’s the belief that other practitioners’ negative results don’t apply, because they aren’t all as skilled as you judge yourself to be. And the temptation to shift responsibility for bad outcomes to the hospitals where women and babies were transferred. Allocating responsibility requires independent audit, for a start. Yet, even if the problem lay hospital-side, the safety of out-of-hospital birth is predicated on hospitals being able to bail people out. You can’t control that, or extract the risk of less-than-ideal backup from the equation.
It doesn’t come up in this paper, but another common rationalization for a bad outcome at home, is that hospital wouldn’t have made any difference in that particular case. Sometimes that has to be true, of course, but I’ve heard this even from people for whom this happened far more often than it happens in hospital.
How did this paper get published and promoted uncritically like this? This paper had just one peer reviewer – clinical, not statistical. And what now? Well, this is one of those journals that doesn’t have letters to the editor, and no dedicated email address for editors. Slender pre-publication peer review and no post-publication accountability isn’t a good editorial combination for a journal, is it? This paper is a good example of how that can go off the rails. And that can have public health consequences. In this case, this paper could encourage midwives and women into choices they will bitterly regret for the rest of their lives.
Earlier this year, Kelly Zafman and co-authors published data showing that planned home births in all 3 of the ACOG “absolute contraindications” are on the rise in the US. This increase, they say, “requires public health action”. Because the women tend to be well-educated and paying for private midwifery care, they wrote, this is a choice, and we need to address this with information.
I agree we need to ensure that there is trustworthy information out there for women considering this – especially the data on harm to babies, and a realistic portrayal of what the high number of complicated labors and transfers are like. Even when disasters are averted, these experiences can be nightmare-ish.
But information won’t solve the problem for some midwives. The risks for babies in breech, and the extra skill they require, are actually part of the allure of breech births, I think. In the years I spent countless hours talking with midwives and mothers about this, I saw shades of hubris in some midwives, and enjoyment of the challenge and the sense of mastery and empowerment when it works out beautifully – as it will do, most of the time. Vaginal births after low-pregnancies can be taken for granted, at least a little. When the odds would have been against it in a hospital, though, a vaginal birth can mean elation, with the midwife a hero. It’s the heady stuff of euphoric legend-making, and that’s seductive for some midwives and parents.
This is an area where I agree with Fischbein and Freeze on the phenomenon, that Zafman and colleagues don’t address. Women want the option of well-supported vaginal breech birth in hospitals, or more of them will be tempted to stick with their planned home birth – or choose home birth when it hadn’t been planned originally. Fischbein shows that the reduced chances for vaginal breech births in hospital isn’t only a lack of practitioners with the skills and willingness as cesareans became common: some hospitals are banning it.
If the trend against vaginal breech births in hospital continues, though, we need to get more real about what doing it at home means. The price of staying out of hospital to avoid the risk (or certainty) of cesarean for breech is a high risk of a traumatic birth experience, with serious harm for babies, and far too often, shattering grief and regret.
Disclosures: Both my children were born at home, and I was the Convenor of the national home birth organization, Homebirth Australia, from 1986 to 1992. I established a national epidemiological monitoring and perinatal death review system for home births in Australia with the National Perinatal Statistics Unit with National Health and Medical Research Council (NHMRC) funding, and research projects on consumers’ views of home births (Consumers’ Health Forum of Australia funding). I was a member of the NHMRC’s working party to develop home birth guidelines in 1991, which recommended against breech births. I have published articles on perinatal death at home and women’s views of home birth, as well as monographs on home birth statistics and birth position in home births, and a booklet to support informed choice for people considering giving birth at home.
* The midwifery care guidelines from the Netherlands are in Dutch [PDF]. Non-vertex presentation, including breech, is listed as category C – requiring referral to an obstetrician and secondary care in 4.43 on page 115.
Previous studies of planned home births including perinatal outcomes for breech births (or all non-vertex births)
Studies cited by Fischbein and Freeze (2018):
From Midwives Alliance of North America (MANA) data:
From the US Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics birth certificate data:
- Grünebaum (2015) (USA)
Studies not cited by Fischbein and Freeze (also with some overlap in datasets):
- Mehl-Madrona (1997) (USA)
- Bastian (1998) (Australia)
- Murphy (1998) (USA)
- Koehler (1994) (USA)
- Nove (2011) (UK) (thesis)
- Sullivan (2011) (USA)
- Doser (2012) (USA) (thesis)
- Hargan (2013) (USA) (conference presentation)
- Bachilova (2018) (USA)
- Davies-Tuck (2018) (Australia)
The drawing of a breech birth is from Ramsbotham’s 1841 book, The principles and practice of obstetric medicine and surgery, in reference to the process of parturition, from Wellcome Library via Wikimedia Commons.
The image of crying is my own (CC BY-NC-ND license). (More cartoons at Statistically Funny and on Tumblr.)