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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 vert common.
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:
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 in Australia related to a breech birth, and a court in Spain considering pressing criminal charges against parents whose breech baby died at home.
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.