Is examining home breech outcomes problematic? A response to Hilda Bastian

After the publication of my article Breech birth at home, co-authored with Dr. Stuart Fischbein, we were invited to write a guest blog for Biomed Central. We wanted our paper to start a conversation about breech birth generally, and breech birth at home specifically. With access to vaginal breech birth in hospital settings nearly nonexistent in the United States, women who want to avoid a cesarean section often have no choice but a home breech birth. Some of these would choose a home birth even if a hospital option existed, while others would prefer a supportive hospital setting.

A few days ago, several people alerted me to a blog post objecting to the publication of our article. Written by Hilda Bastian, the post was titled The Dangerous Allure of Breech Birth at Home – and a Problematic New Paper.

If I had the chance to sit down and have lunch with Hilda, here are some thoughts I would share.

First, I am grateful that she took the time to write up her responses and to be so thorough with her bibliography. I am an academic, and I love long lists of references! She included several that I hadn’t looked at yet since they did not come up in my literature searches (“breech” and “pelvic presentation” were my primary keywords). I will add them to the lecture on home breech outcomes that I give at my breech workshops. A sincere thank-you for that. (To date, my current lecture references Mehl-Madrona 1997, Bastian 1998, Johnson 2005, Deline 2012, Cheyney 2014, Cox 2015, Fischbein 2015, Bovbjerg 2017, Grünebaum 2017, and Fischbein & Freeze 2018).

A slide from one of my breech workshop lectures.

Hilda critiqued us for only including 4 studies about home breech outcomes in our introduction. This was in part a deliberate decision as we had already far exceeded the normal number of references for a research article (many journals limit the number of references to 25-30). We chose to include those 4 studies as they had the largest datasets of home breech births.

When I give my lecture on home breech outcomes, I usually start it by saying, “If you are a home birth provider, this is going to make you very uncomfortable. The numbers do not look good.”

I am surprised by Hilda’s certainty that the question of breech birth at home has been answered for good. I don’t disagree that the existing literature shows poorer outcomes for home breech birth. But—and this is very important—we also found that these studies lacked information about nearly every aspect of a planned vaginal breech birth: training and experience levels of the birth attendants, selection criteria, labor management, maternal motivations for choosing a breech at home, or local hospital options for a breech presentation. None of these factors were measured or studied.

In other words, all we have are raw numbers: X number of breech babies had poor outcomes. We don’t know what caused those higher levels of bad outcomes. With the existing research, we could only speculate: Was it lack of adequate experience with some of the attendants? Lack of ultrasound to confirm head flexion? A mother insisting on having her baby at home and the midwife agreeing to honor her autonomy despite less-than-optimal circumstances? Undiagnosed fetal anomalies? Problems with hospital transports?

Our study is significant because it was the first to begin answering these questions. We know the provider’s skill level, selection criteria, and labor protocols. We know what equipment was present at the birth and the training of the entire birth team. We know why women chose home birth and what the local hospital options were (very few, if any, which led women to seek Dr. Fischbein’s services).

Yes, there were some poor outcomes, and we gave information about the circumstances and sequelae surrounding each one. Although we didn’t have complete medical records for some of the hospital transfers, the parents personally transmitted information about their hospital stays to Dr. Fischbein. We reported all adverse outcomes whether in hospital or at home. (The author suggests we might have left some unreported.)

There was one brachial plexus injury (ongoing at 6 months of age) that occurred at home after a terminal bradycardia and subsequent maneuver to help the baby be born quickly. The other 4 adverse outcomes all occurred after the women had transported to a hospital in stable condition due to stalled labor. 3 of the 4 were neonatal morbidities; they occurred with a receiving physician who offered augmentation and vaginal delivery with forceps and vacuum extraction if needed. One neonatal death occurred when a woman was admitted for a cesarean due to stalled labor, and the surgery was inexplicably delayed for more than 2 hours.

From an intention-to-treat paradigm, all of these poor outcomes would be attributed to home birth as that was the original intent at the beginning of labor. However, Dr. Fischbein and I believe that the circumstances that led to poor outcomes in the hospital transports were not primarily related to the planned location of birth.

I participated in the first two Home Birth Consensus Summits in 2011 and 2013. One area of consensus was that hospital transports need to be seamless. When women fall through the cracks, they and their babies suffer the consequences (as we can see with the one neonatal demise). The solution isn’t to outlaw homebirth, but rather to work on better collaboration and communication so women can move from home to hospital with loving support, professionalism, and respect from both the transporting and receiving care teams. Please refer to the summit's Best Practice Guidelines.

I don’t expect everyone to support home birth with a breech presentation. However, I want to keep dialogue open. I worry that the author’s rhetorical techniques stir controversy rather than engage productively in making birth better for women with breech babies. For example, the author used click-bait titles (“the dangerous allure of breech birth at home”), chose emotionally-charged language (“dangerous and misleading,” “go off the rails,.” midwives who are filled with “hubris” and involved in the “heady stuff of euphoric legend-making”), and misrepresented my qualifications (she says I am a “doula and midwife’s assistant” and neglects to add that I have a PhD). To give Hilda credit, I don't think this last omission was intentional.

I’d like to step away from the fiery rhetorical flourishes and instead talk about the reality of what’s happening on the ground. Right now. With women in California or Oklahoma or Connecticut who are 39 or 40 weeks pregnant and have just discovered their babies are breech and have no options but cesarean at any hospital, anywhere.

To quote from the musical Hamilton, we have "three fundamental truths at the exact same time”:

1. Hospitals in the USA continue to refuse to offer vaginal breech birth. Some even ban it despite having providers willing to attend vaginal breech births.
2. Women continue to find a mandatory cesarean unacceptable.
3. Breech is happening at home.

We can stay in the stratosphere of rhetoric and idealism, bemoaning the dangers of home breech birth. But I prefer to stay firmly rooted on the ground. It’s pointless to argue that home breech birth shouldn’t happen when there are no other alternatives offered. And none foreseeable in the near or distant future, either. ACOG certainly hasn’t done more than give watered-down lip service to vaginal breech birth. Even the SOGC’s vigorous support of vaginal breech training and re-education has done little to move the needle in Canada.

So that leaves us with this reality: breech is happening at home. How safe is breech birth at home, and can it be made safer? Our study only begins to answer those questions. The solution isn’t to stop asking the questions altogether because ACOG considers breech at home an “absolute contraindication.” (If we took ACOG at their every word, we wouldn’t be having any home births at all!) Instead, we need to keep seeking out more information. We need larger datasets of planned home breech birth with skilled attendants.

I am thrilled to announce that I will be working on one such dataset in the near future: over 550 vaginal breech births with a single home birth midwife. I know of another team currently doing data entry with another midwife’s breech outcomes (again, with numbers in the several hundreds). Between these two datasets, we might have 1,000+ home breech births to analyze. This far exceeds any of the largest datasets on home breech we have so far. Grunebaum’s birth certificate data (2017) included 553 breeches. Johnson (2005) had 80. MANAStats 2.0 and 4.0 combined had 539 breeches (Bovbjerg 2017). And unlike these other studies, we can account for numerous variables.

More importantly, I am on the ground actively training providers—midwives or doctors, home or hospital, anyone is welcome!—in vaginal breech birth. Under the umbrella of my nonprofit Breech Without Borders, I provide a full day of academic lectures on term breech outcomes (both home & hospital), maneuvers, normal & abnormal mechanisms, and nomenclature systems. An experienced physician or midwife colleague then provides another full day’s worth of instruction and hands-on training. I am optimistic that, with good training, we can make vaginal breech birth safer and more satisfying in any setting. I am disappointed that, to date, midwives have outnumbered physicians, residents, and medical students more than 50:1 in our workshops (and not for lack of invitations on our part!).

No matter if you vehemently disagree with breech birth at home, wouldn’t a policy of harm reduction (providing as much training & education to the people who are actually attending breech births) be better than simply stating it shouldn’t happen or, even worse, attempting to outlaw it (which will lead to some women choosing unassisted birth rather than being forced into a mandatory cesarean)?

I’ve gone on long enough. Dr. Fischbein and I both feel that our paper and our blog post speak for themselves. Take a minute to read them, and then come back and share your thoughts.

And more importantly, get out into your community and start demanding that your local hospitals offer vaginal breech births! Breech Without Borders will bring a vaginal breech workshop to any community that wants it.

Dr. Rixa Freeze, PhD