Optimal Mode of Delivery for Individuals With Low-Risk Term Breech Presentation

We read with great interest the study by Sharma et al1 in the October 2025 issue, which reported higher odds of adverse neonatal outcomes with vaginal breech delivery compared with cesarean delivery, albeit with low absolute risks. Although the topic is clinically important, we are concerned that several methodologic limitations may bias the findings and limit their clinical applicability. The principal concern is the heterogeneity of the cesarean delivery group. Grouping together women who underwent emergent cesarean delivery after a trial of labor with those who had a planned elective cesarean delivery obscures the fundamental distinction between these two groups, which differ markedly in their baseline risk for the neonatal and maternal complications under study. Because delivery management is guided by the planned mode rather than the eventual outcome, this approach introduces significant confounding. A more appropriate design would compare planned vaginal breech delivery with planned cesarean delivery, consistent with the Term Breech Trial.2 The authors acknowledge that their analysis was based on actual mode rather than intention to treat, but this limitation critically affects interpretation. Furthermore, the reported estimate that only 10% of patients in the cesarean delivery group had an attempt at labor is potentially misleading. Table 1 shows that 21.3% of women in the cesarean delivery group underwent induction of labor in the propensity score–matched cohort, whereas the 10% figure refers to the entire original cohort before matching. Because the outcome analyses were performed on the matched cohort, the higher percentage is the relevant one and suggests that the proportion of women who initiated labor before cesarean delivery was likely underestimated in the main text. Parity is another key determinant of maternal and neonatal outcomes. Nulliparous and multiparous women were analyzed together without stratification, limiting the study's utility for patient counseling and shared decision making. Finally, characterizing a neonatal mortality rate of 0.4% as low requires caution. Extrapolated nationally, this difference could represent approximately 750 additional neonatal deaths among otherwise healthy term neonates, a clinically significant figure. These limitations mean that the study does not adequately address whether planned vaginal breech delivery is associated with greater neonatal risk than planned elective cesarean delivery.