The effect of the Term Breech Trial on Medical Intervention Behavior and Neonatal Outcome in The Netherlands: An Analysis of 35,453 Term Breech Infants

Abstract

The results of the Term Breech Trial were published in October 2000 in The Lancet. This prospective trial consisted of over 2000 pregnant women at term with a fetus in breech position. In The Netherlands, the overall caesarean section rate of term breeches increased from 50% in 2000 to 80% in 2001. The purpose of this study was to investigate the time scale in which this change in obstetric management occurred, whether it occurred in all hospitals, and whether this change in management was related to improved direct neonatal outcome. The study was conducted using data from The Netherlands Perinatal Registry that includes 95% of all approximately 200,000 deliveries per year in The Netherlands. All infants in breech position are born under secondary care, and the registry covers almost 100% of these births. The study population included infants in breech presentation who were delivered at term (between 37 and 42 weeks of gestation) with birth weights ≤4000 g. Exclusion criteria were multiple pregnancy, antenatal fetal death, and major congenital malformations. Perinatal death was defined as intrapartum death or death within a week after birth. Neonatal trauma was classified as intracerebral bleeding, cephalic hematoma, facial nerve paresis, brachial plexus lesion, fracture of the clavicle, humerus, or femur, and other trauma. A comparison was made for perinatal mortality, low Apgar score, and trauma between the period before the Term Breech Trial (years 1998, 1999, and part of 2000 until September 30; the period after the Term Breech Trial started at December 1, 2000, and included 2001 and 2002). Figure 2 shows the month-to-month trend between January 2000 and December 2002. In the first 2 months after publication of the Term Breech Trial, there was an increase in the total cesarean section rate from 50% to over 80% and this rate remained stable thereafter. This rise was mainly the result of an increase in planned cesarean section. The increase in cesarean section rate after publication of the Term Breech Trial was observed in all but 3 hospitals in The Netherlands. Comparing the 33 months before publication of the Term Breech Trial and the 25 months after for infants weighing ≤4000 g, there was a 2-fold decrease in perinatal death (0.35-0.18%, odds ratio [OR] 0.53, 95% confidence interval [CI] 0.33-0.83) and a 4-fold decrease in neonatal trauma (0.29-0.08%, OR 0.26 [0.14-0.50]). This decrease was primarily the result of the increase in planned cesarean section because of breech position, because this mode of delivery was associated with the lowest mortality and morbidity.