The Problem with Research by Press Release: Another Attack on Breech Delivery

 Breech born yesterday as   nature intended.

Breech born yesterday as nature intended.

Here again is proof we are living in the age of stupidity and the continued dumbing down of all that was once held dear. Standards are eroding and the term “Truth in Advertising” is truly an oxymoron. Ideology trumps truth from politics to science, if there is even any difference anymore between them. Anyone can publish anything if they have the right connections or the proper bank account. And social media has no filter so how does anyone know truth anymore? I have written before on the awful problem of science by press release. Here are a couple I made up and one that sounds just as foolish.

Growing Older Is Inevitable: Study Finds

U.S. Government spends 10 billion dollars to confirm.

Twitter Use Linked To National Debt Increase!

“Both Rising at Same Time” says expert.

For Breech Baby, C-Section May Be Safer Option: Study

Death rate with vaginal birth is 10 times higher, researchers find

See for yourself.

http://consumer.healthday.com/women-s-health-information-34/birth-health-news-61/breech-babies-death-risk-aogs-release-batch-1319-690587.html

(See the actual study here: http://onlinelibrary.wiley.com/doi/10.1111/aogs.12449/full )

In the age of the millisecond attention span it has never been truer that sensationalism sells and the snappy headline is paramount to attracting readers and viewers. Like most of these articles this one seems to be based on a press release. One would have to actually analyze the data, methodology, numbers and inclusion criteria before any judgment should be offered. Term or preterm? Planned or unplanned? Experience vs. inexperience? Time has taught me that if something sounds ridiculous and defies common sense then it usually is. But there is no depth to this article. No probing questions. No investigative journalism. Just the reprinting of what is fed to these “news” outlets desperate for space filling stories.

There is much chatter about this paper online and I feel we have been through this before. More than a decade ago the Term Breech Trial (TBT) came out, did horrific damage to birthing options around the world and then was refuted. But the damage has remained. Do we really have to do this all over again? This new retrospective study of birth registries has many of the same flaws and refers often to the TBT as if it still has validity. I am curious about the ideology and background of the authors of this study. I am concerned that they did not describe their selection process or criteria (such as flexed head) for vaginal breech birth. There is no control or description of the skill of the practitioner. Large retrospective studies can be useful but the data can be interpreted in different ways, often agenda driven. What is the agenda here? I am very wary of retrospective data derived from voluntary registries of multiple institutions with unknown controls and often differ in all things that matter. 

I have corresponded with my respected colleague in Frankfurt, Germany about this new research. She states this paper has already had an impact in Europe with a newspaper titled "Breech babies should be delivered by CS- data from a new Dutch study". She felt it is important to ask the authors of the study for more information about the specifics surrounding the high perinatal mortality in the breech deliveries (46 cases). As in the TBT, we feel every single case has to be looked at. For when that happened in the TBT its conclusions fell completely apart.

She goes on to say, “At present the Dutch paper is not saying it but it implies (that after adjusting for several things, e.g. type of breech, onset of labour, weight etc. which made no difference) the death of the babies is inevitable- we strongly disagree with that. All the points which we made over the years that are the safeguards such as: selection of the woman, expertise and confidence of the team and ongoing teaching and its effect on safety are not addressed. Because, of course, we know that with these safeguards the figures will improve and we doubt if really the Dutch data does appreciate these things. I feel strongly that the Dutch conclusion, “that this study should lead to a revision of breech guidelines”, is going much too far.”

I agree with my colleague and also must again point out the difference between relative risk and absolute risk. With all the flaws in this retrospective study, the lack of any data about criteria and the 10-fold hysteria in the title they conclude that 338 cesarean sections would need to be done to prevent one perinatal death. And that the risk of perinatal mortality remains about 1.6/1000 or 0.16% for the vaginal group. Perinatal mortality is clearly an important issue when it comes to mode of delivery but it is not the only issue! As I have said over and over, ultimately, whose choice is it?

Here are the results and the conclusion from the abstract of the Dutch paper. I can’t help but notice the tone of acceptance and nonchalance when they mention the change in cesarean section rates incurred from the TBT:

Results

We studied 58,320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3‰ vs. 0.7‰; odds ratio 0.51 (95% confidence interval 0.28–0.93)], whereas it remained stable in the planned vaginal birth group [1.7‰ vs. 1.6‰; odds ratio 0.96 (95% confidence interval 0.52–1.76)]. The number of cesareans done to prevent one perinatal death was 338.

Conclusions

Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies. 

Lastly, on a more optimistic note for those of us who focus on breech delivery, especially at dedicated breech centers like the one in Frankfurt, these numbers defy our experience and common sense. Our findings are much different and safety much more assured. The conclusions in this paper make me feel even stronger about our recommendation to retrain practitioners in these skills through creation of breech referral centers and/or have dedicated breech teams available at urban hospitals. Cesarean section as the answer to the breech issue makes sense only if you are living in a vacuum and deny the immediate and long term risks to mothers and babies from surgical birth.   

Here are two thoughtful blogs by breechmidwife worthy of your time.

http://breechmidwife.wordpress.com/2014/08/14/can-we-eliminate-all-risk-for-breech-babies/

http://breechmidwife.wordpress.com/2014/08/15/the-longer-term-effects-of-cs-for-breech-in-denmark/

I am honored quote her:

Turning now to the elephant in the room

“Being born vaginally may be more risky for some babies than being born by CS. Most of the evidence seems to indicate that, in the short-term at least, using standard lithotomy delivery practices, this is the case. On the other hand, most of the long-term evidence does not indicate lasting effects.

What concerns me about literature like this, which makes predictions about what would be saved or not, financially or physically, with this approach or that – is that women, as long as they are human, will continue to have their own unique approach, and they should. That is what being human is about. Many will want to deliver their breech babies by CS, and they should have access to that care, even if it means a greater financial burden. And many will want to give birth vaginally, even in awareness that the rare outcome of neonatal mortality is more likely to happen to them, even in the awareness that if something goes wrong, they will need to live with it for the rest of their lives. We will always have death, and handicapped children that require our grief, our love and our devotion. This cannot be eradicated. Women deserve to be able to make this very personal decision without being made to feel criminal.

Instead of continuing to do research which tells us what we already know, we should invest in research exploring modern management strategies which are showing promise in reducing risk to babies born vaginally, so that women who live in countries where there ought to be a choice actually have one, and women who live in countries where CS is either inaccessible or a real danger to their health have the best chance of going home with a healthy baby. We should stop trying to have the last word on how breech babies should be born, let women decide how to balance the complex array of risks and benefits in their own lives and families, and develop our skills at being ‘with woman’ and her breech.”

Shawn


Thank you, Shawn. I could not have said it better. The battle for common sense and respect for informed autonomous decision making goes on.  Dr. Stu