Sometimes moving forward means taking a step back…

For quite some time now when a woman was nearing the end of her pregnancy and the baby was known to be in a breech position in the womb, her doctor automatically scheduled her for a Caesarean. Even in cases where the woman was seeing a midwife, that breech presentation led to a transfer of care and a scheduled Caesarean. It was believed that, despite the risks of major surgery, a birth via Caesarean was the safer choice for both mom and baby. In many cases, women were able to get their babies to turn – by using acupuncture, chiropractic treatments, moxabustion, pelvic tilts, swimming (complete with headstands in the pool!), visualizations and/or external versioning. Sometimes those stubborn babes would just turn right back around though, frustrating their moms who were hoping to avoid surgery. No one really knows why, but some babies just don’t want to come out head first. Sometimes they’re curled up and their bums present first (frank breech), sometimes their feet are the first thing to emerge (footling breech) and sometimes they lie sideways (transverse breech), but no matter what, if their heads weren’t positioned to come out first, their moms were booked in for surgery.

Ina May Gaskin – aka America’s Leading Midwife and once referred to by the head of the WHO as “the most important person in maternity care in North America” – has caught thousands of babies since the 1970s, many of them breech, and her birth centre’s overall Caesarean rate (since, there are, of course, certain times when a transfer is necessary and surgery must be performed) is a very impressive 1.7% (keep in mind that she is only caring for women with low-risk, normal pregnancies – though she does catch twins and breech babies unlike midwives here – but this is nonetheless an amazingly low rate). She also boasts a 0% maternal mortality rate, a 0% maternal morbidity rate and a neonatal mortality rate of 1.7 deaths per 1000 births (the latest data available for Canada puts us at a national neonatal mortality rate of 4.1 deaths per 1000 births). While breech births have been treated as high-risk here in Ontario for a while now – automatic Caesarean has been the standard protocol across Canada since 2000 – Gaskin and the other midwives on The Farm have not treated them as such and, between 1970 and 2010, attended 99 breech births (3.5% of their total number of births for that period). Of those, fewer than 10% resulted in a transfer of care for the purposes of emergency Caesarean and in cases where Caesareans were required, there were no maternal deaths (I do not know if any of the 4 deaths total out of the 2844 babies born on The Farm were breech babies born via Caesarean or not).

Gaskin has been saying for years that the automatic scheduling of Caesareans in response to breech presentation is a mistake. In her 2011 book, Birth Matters: A Midwife’s Manifesta she states, “No one can point to any real gain that has come from the increased number of surgical births. We can’t say, for instance, that it has made birth safer for babies. Credit for the reductions in newborn death rates that have taken place since the seventies belongs to innovations in neonatology; not to higher C-section rates. It’s well known that, if anything, higher C-section rates increase the incidence of breathing problems in newborns, they don’t reduce them… Some women who opt for elective C-sections will inevitably die unnecessarily. The Dutch Maternal Mortality Committee studied just those elective C-sections related to breech that took place between 2000 and 2002, and found that four women died after elective C-sections performed simply because of breech presentation. During that same period, there was no maternal death after an emergency C-section for a breech. These Dutch data undermine the argument that emergency C-sections are necessarily more dangerous for the mother than those that are scheduled.” (p. 126-127) She notes throughout the book that the skills that were taught to doctors and midwives in the past have, in recent years, been removed from obstetrics curricula for reasons unrelated to actual evidence supporting them as a means of improving rates of maternal or neonatal mortality. Obviously, this is frustrating for Gaskin and for safe birth advocates everywhere who champion evidence-based practice.

In 2009 the Society of Obstetricians and Gynecologists of Canada (SOGC) released new guidelines acknowledging that what Gaskin and safe birth advocates the world over have been saying for decades is true: that a Caesarean is not always or even usually the safest choice when there is breech presentation. The new guidelines state that physicians should no longer automatically opt for Caesarean when a baby is breech. This is based on evidence that shows that safe vaginal breech birth is a viable option for many women.

So, good news right? Well, yes, but… Read that last paragraph again and make a note of the year. 2009? So, three years ago the SOGC said that women shouldn’t be pushed into Caesareans just because their babies are breech? It’s 2012! Why is this still happening? Well, the problem is that the necessary skills have been removed from standard obstetrics curriculum. That means if your baby is breech there may be no one available to catch her because medical schools just haven’t been teaching breech vaginal delivery for the past three decades. This article, in the Globe and Mail, indicated that “With the release of the new guidelines, the SOGC will launch a nationwide training program to ensure that doctors will be adequately prepared to offer vaginal breech births.” The article was published in 2009 and then updated in 2011, but there is no indication whether this training program was announced in 2009 or in 2011 and, if the former, what steps have been taken to implement it since 2009. I plan to write to the Globe and Mail to find out which it was – hopefully I’ll have more to report on that soon.

Obviously, the availability of trained practitioners is key and women deserve to know whether the training of OBs currently in practice or those that are still in medical school is going on and if not, why this training has not been initiated in the three years since the new guidelines were released. This lack of training is something that Gaskin touched on in Birth Matters. She relates a story to highlight her point, “I find it sad that obstetrics has been so dumbed down in the US that few doctors are taught anymore (sic) how to deal with a vaginal breech birth. They especially fear the case in which the baby’s feet present before its head. The very prospect frightens many because they have never witnessed a breech birth. This fact really came home to me in the early eighties when I was invited to show videos and speak to ob-gyn residents at a medical school in North Carolina. Just before introducing me, the department chairman who had invited me to speak whispered, ‘Do you realize that you and I are the only people in this room who have ever witnessed a breech birth?’ What astounded me was the speed of change in the very content of the obstetrics curriculum. When I learned that the reason for such a change was insurance companies that began threatening teaching hospitals during the seventies and eighties that they would deny them malpractice coverage if they provided opportunities for residents to witness a breech birth attended by an experienced practitioner, I had to wonder if doctors of the future would ever regain such skills.”

Obviously, the Canadian system and the American system have some important differences when it comes to legal concerns and insurance related matters in the realm of healthcare, but given that we are finding ourselves in the same murky water with regard to evidence-based practice that is not being taught in our medical schools, the outcome is the same, even if the motivations are distinct. Women are not being granted access to safe vaginal breech birth when everyone – up to and including the SOGC – has acknowledged that, “The safest way to deliver has always been the natural way. Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.” (Dr. André Lalonde, executive vp of the SOGC).

I hope that the next steps I plan to take in researching this issue lead to promising results – maybe our med schools and midwifery programs in Canada have started teaching these skills. Maybe currently practising OBs are undergoing new training to equip them with the skills that ought to have been taught to them when they were in med school (to my knowledge, retraining licensed practitioners was not part of the plan in 2009, though really, shouldn’t it be?). Maybe I will find out that evidence-based care for every Canadian woman whose baby is breech at 37 weeks is just around the corner. There can be no question though that this must happen – and soon – if we are to provide good, evidence-backed maternity care to women in Canada. We need to step back, right now, so that we can move forward.

If your baby is breech and your doctor is recommending a Caesarean, get informed, know your rights and don’t make your decision out of a concern for “being polite”. It’s your body, your baby and your choice. Check out the Coalition for Breech Birth’s website for more info.

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