From Pub Med:Five years to the term breech trial: the rise and fall of a randomized controlled trial.

CONCLUSION: The original term breech trial recommendations should be withdrawn.

How many of you have heard about this? Probably very few. This is probably one of the most significant findings in the world of birth in recent years, and I don’t think it made even a mild ripple outside of the birth community.

That pisses me off.

Research studies that support the current birth paradigm - regardless of how flawed the methodology or how harsh the criticism drawn (see the Pang homebirth study or the 2002 JAMA study on VBAC) are splashed across the mainstream press with enough sensationalistic headlines, partial information, incorrect conclusions, and utterly mind-boggling gaps in information to make me want to puke. The media machine that is ACOG has powerful influence over national media. (That ain’t conspiracy theory folks - them’s just the facts).

On the other hand - studies and new information that fall in line with the other side of the birthin’ coin seem to be swept under the rug faster than you can say ‘Obstetrician-Gynecologist’. ACOG finally released a practice bulletin recommending against episiotomy (hooray, sometimes I really, really do like ACOG) – but when the JAMA episiotomy study was released last year, I watched in vain for widespread media coverage – it didn’t come. Likewise for the BMJ “Outcomes of planned home births with certified professional midwives”. Although the poorly designed Pang study mentioned above gave the mainstream press plenty of dead baby sound bites – this comprehensive and well-designed research (the best data the North American homebirth community has probably had since the 1977 Mehl study) captured comparatively little attention. I suppose healthy babies born at home just don’t make the news.

Good data sometimes isn’t quite as interesting as bad data. That is just too bad, because in an area like childbirth – where the term ’evidence-based obstetrical care’ is often as much of an oxymoron as ‘definite-maybe’ – we need all the good data we can get.

This new information, whether it be about breech birth, episiotomy or homebirth, is so vitally important that it lifts my heart to read it. To know that there are people out there sifting through the data and performing rigorous analysis to get real answers into the hands of the women that need them. Scientific data that supports the truths the birth community has been working with for years is a gift to all who devote themselves to supporting women in birth.

We need to shout this information from our rooftops, email it to our friends, bring it up in conversation at the playground. We need to spread the word because true change can only come from us – the women who give birth, from women who are medical consumers, from women who carefully choose our care providers and birth places. When we learn of new information that impacts our birthing future we need to take it upon ourselves to do further research, and then we need to take this research to our care providers, and open a dialogue with them about the data. Sometimes, if people still are not listening, we need to force the issue.

We also make our voice heard by the choices we make in our healthcare, by giving our healthcare dollars to providers who pay attention to the research, providers who pay attention to us. We need to choose providers who are able to look beyond the headlines and the powers that be at ACOG and take time to do a critical analysis of current research. We need to choose providers who are willing to change their modus operandi to reflect changes in evidence. - even when that evidence does not jive with the party line. We need to choose providers who are astute enough to know the difference between good science and bad science, and who are willing to listen to the women they serve to fill in the blanks that science can never completely fill. We need to demand that the people we trust with our care at our most vulnerable moments are willing to step back from their education and what they accept as fact if new evidence supports a different conclusion. We need to stand behind the providers in our community who are willing to put themselves on the line to support us they way we deserve to be supported. When we do this, our money speaks for us. And money, my dear friends, has a very loud voice.

I’m thrilled to think that the new information about breech delivery might increase options for women in the future. I’m cautiously optimistic that some renegades out there might take this information to heart and change they way they practice and the advice they give women. I am realistic, because regardless of how much data we find supporting the safety of vaginal breech, we’ve got a generation of doctors who are not trained or experienced in the nuances of breech delivery, and (because of state laws prohibiting midwives from serving at a breech delivery) a generation of midwives that are in grave danger of loosing this skill as well. I am cynical, because despite what the data might say, a c-section is still viewed as the safe and controlled option for any birth that might not be completely straightforward (and thus, in the eyes of many, the safe and controlled option for ANY birth, period). We’ve got a plethora of information about VBAC safety, but frighteningly low access to VBACs. My prediction is that the issue of breech birth will be much the same.

Mostly, I am sad. I am sad whenever options are taken from women, whenever choice is withheld. I am sad that we live in such a litigious society that dollars almost always win over the autonomy of a woman (and her baby) to choose her birth. I am mostly sad for my sweet Leigh, she of beautiful spirit and purity of heart, whose daughter Kaia was born by cesarean after a perfect pregnancy and a perfect labour, because midwives in Arizona are not permitted to catch breech babies, and because the doctor who met her at the hospital when she transported did not give her a REAL choice.

And that pissed me off.

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More information on the Term Breech Trial below from the Citizens For Midwifery Grassroots E-Newsletter.

Grassroots Network Message 602003

Term Breech Trial flawed

Dear Friends,
The infamous “Term Breech Trial” (Hannah et al, “Planned cesarean section versus planned vaginal birth for breech presentations at term.” Lancet 2000. 21:1375-83), published five years ago, claimed that planned cesarean was safer for breech babies than vaginal delivery. The study had a dramatic effect; quickly it became difficult to find any OB in the US who would “allow” a vaginal delivery for a breech baby

Now the Green Journal (American Journal of Obstetrics and Gynecology) has published a stinging critique that concludes the original study was deeply flawed and its conclusions completely suspect (Glezerman M, “Five years to the term breech trial: The rise and fall of a randomized controlled trial.” Amer J Ob & Gyn (2006) 194, 20-5). The article, published as a “clinical opinion” in the journal, thoroughly itemizes the methodological flaws and clinical problems with the Term Breech Trial. The conclusion: the recommendations of the original trial should be withdrawn. He found that “most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery.”

The author is pessimistic that even withdrawal of the original study and its recommendations will make any difference, because the recommendations were so in line with what American obstetricians wanted – a planned cesarean is easier and carries less legal risk for the OB.

However, even if this critique does not change hospital policy, it is still a powerful tool for both midwives and mothers. Now we have a paper published in a peer-reviewed journal pointing out that the term breech trial in fact did not find any difference between vaginal and cesarean deliveries of breech babies. Furthermore, the article articulates some of the drawbacks inherent in randomized controlled trials (RCTs); that not all research questions can be answered with this “gold standard” research technique is important to understand.

One mother wrote to me: I am glad to have a refutation like this finally published but I am deeply saddened for all the women, including my daughter, who were forced to have c-sections based on the now-discredited article.
Sincerely,

Susan Hodges, “gatekeeper”