When choice isn’t really a choice: Finding confident support for vaginal breech birth

AIMS Journal, 2026, Vol 38, No 3

By Charlotte Butterworth-Pool

When choice isn’t enough

On paper the situation seems straight forward. Women and birthing people, whose babies remain breech at term are offered the choice between either a planned caesarean or a vaginal breech birth. Their role is to make an informed choice after hearing the benefits, risks and evidence that is important to them. Why then are so many women feeling like they don’t have a choice at all?

The choice is one that women and birthing people in the UK have the legal right to make, and national guidance supports informed choice between planned caesarean and breech vaginal birth. It is a conundrum then, that when we speak to women who have been in this situation, what they describe cannot be labelled as a true choice.

The RCOG guideline states that 3-4% of babies remain breech at term¹ and literature shows that 35-58% of women would choose a vaginal birth depending on the counselling received.^{2, 3}

It’s difficult to find out how many of these babies are born vaginally; the most referenced figure comes from 2017 and shows that only 0.4% of breech babies are born this way.⁴ So why, if as the guidelines suggest, we have the choice of either birth option, is the actual vaginal breech figure birth so low?

Feeling like choice has been taken away can have a profound impact on how women and birthing people view their own experience. One study showed that feelings of ‘Stress, fear, anger and injustice’ were present when women did not feel as though they had a choice.⁵

I am a Virtual Doula who is passionate about evidence-based care, and I have supported women through this decision-making process. In this article, I hope to explore the perceived lack of choice around breech birth, and how the confidence women have in their care team impacts this decision-making process.

How did we get here?

For much of the twentieth century, breech birth was an expected part of maternity care. Midwifery and obstetric textbooks detailed how to support breech births, and clinicians gained experience because they were relatively commonplace both at home and hospital.

As the caesarean became increasingly safe, and evidence and professional opinion evolved, planned caesarean gradually became the preferred method of delivery for breech births. As fewer vaginal breech births took place, opportunities to develop and maintain the breech skills also declined. This declining experience reduced confidence, making vaginal breech birth increasingly difficult to support. It became a self-fulfilling prophecy.

The Term Breech Trial⁶ was published in 2000 and concluded that ‘Planned caesarean section is better than planned vaginal birth for the term foetus in the breech presentation’. ⁷The publication of this trial meant that the number of vaginal breech births declined rapidly; maternity staff no longer had the experience and therefore the confidence to support it.

Even as the culture shift that had already started was accelerated, vaginal breech birth remained part of national guidance, recognising that not every breech presentation is diagnosed antenatally, and that some women or birthing people may choose it.

Recently there has been renewed interest in some areas about reclaiming this skill, with the OptiBreech⁸ project setting up centres across the UK, aiming to ‘optimise care and options for women across the UK’.

Despite this resurgence, it is still proving difficult for women to find care providers who are experienced and confident in their skills. For some women, the search for care which inspires confidence ends successfully, for others despite months of research and careful decision making, the absence of confident, experienced support means they feel they must choose a planned caesarean.

What we don’t have data for

Women weigh the published evidence alongside their own values, plans for future pregnancies and feelings about birth. But they also ask questions the literature rarely addresses. Is there a hospital nearby? Will experienced clinicians be on duty? Can I trust the team? These are not questions about the safety of vaginal breech birth. They are questions about the availability of skilled care.

‘I certainly don’t want a breech birth with an inexperienced team’

Jane (not her real name) was a first-time mum who had already done significant research and made decisions about her place of birth and the type of care she wanted.

She was told her baby was breech early on, and was able to do her own research into the available evidence and her options. She said:

‘What I gathered from it is that you really want supportive midwives and many aren’t confident. Most breeches end in C-sections so they don’t have the experience. I have a couple of names in XXXX but that would be a different hospital’

Originally planning private maternity care to protect her personal priorities of continuity of care and postpartum support, Jane soon discovered that all the private obstetricians she approached were unable to offer planned vaginal breech birth because of indemnity arrangements. She therefore began exploring NHS options instead. This meant:

‘A lot of upheaval and uncertainty at a time where I’ve already had a lot of that already’

She met with one of the leading experts in vaginal breech birth in the country; she described how the experience immediately put her at ease, and initially she believed she would be able to give birth in a hospital nearby. She described a sense of safety.

Although Jane felt elated that someone was willing and positive about supporting her breech birth, she did not have confidence that the wider team would feel the same. Jane felt that knowing a team of doctors would be waiting outside her door waiting for something to go wrong, would make her anxious and could lead to a higher chance of adverse outcomes.

Ultimately, she was not willing to take the risk of the psychological impacts an emergency c-section and postpartum experience that birthing within the NHS could bring.

As a first-time mum, she did not want to become one of the first women to navigate a newly developing service. In the end, it was not the evidence comparing vaginal breech birth with caesarean that changed her mind. It was her confidence in the support that would be available when labour began.

“It’s not the choice I was struggling with; it was trusting a system that kept repeatedly telling me they couldn’t promise the support we needed when we needed it.”

Lauren (not her real name) was a first-time mum planning a homebirth, because of a family history of traumatic experiences within the hospital. Her baby was diagnosed as breech and she described feeling stressed after the diagnosis.

She spent time attempting to encourage her baby to turn holistically.

She also spent time reviewing research, listening to podcasts and attending live online training on vaginal breech birth.

‘Based on some of what I read and the zoom, it’s a bit of a dying art delivering breech babies naturally, but totally depends on the midwives / team’

She continued planning for her homebirth in the hopes that her baby would turn, and as a form of distraction she sought contacts within the local midwifery team and consultants to discuss their vaginal breech birth experience.

Initially things seemed positive as the head of the midwifery team had recently attended external training on vaginal breech birth, but it soon became clear that a vaginal breech birth would only be supported in hospital, not at home or in the birth centre as she had hoped.

‘She said that’s the system unfortunately at the moment. She said it’s changing but unfortunately it depends on the midwives on shift.’

‘She said I’m trained but not everyone in my team is’

A conversation with the head of the homebirth team left her feeling overwhelmed and emotional.

Lauren spoke to an independent midwife who spoke about her experience in facilitating breech birth at home.

After an unsuccessful ECV Lauren ultimately chose an elective caesarean feeling that this was the safest option. She described a feeling of calm and that a weight had been lifted now she had a plan.

‘If there are confident professionals, then I’ll weigh it up’

Lia was told her baby was breech during a routine pregnancy scan. She was a second time older mum planning a home birth after caesarean, so had already done a lot of research and work to be confident in that decision. She initially felt devastated that everything she was working towards might change.

‘If the baby stays breech, I’d be gutted after all I’ve gone through internally and externally to get to planning this homebirth’

After I shared details of an Optibreech centre, she was considering if her most local site was too far.

‘I don’t know if I have the courage to try for a breech birth’

After a phone call from a breech midwife from the Optibreech centre closest to her, she was reassured that they support lots of ‘out of guidelines women’ and that the birth would be as ‘low intervention’ as possible.

Lia explained that the midwife she spoke to was ‘calm, confident and genuinely caring’

‘I genuinely felt like she wanted me to achieve what I wanted’

Following that conversation, Lia's tone changed noticeably. She no longer sounded overwhelmed by uncertainty. Instead, she spoke as though she had regained the freedom to make her own decision.

Regardless of whether her baby ultimately remained breech, the conversation had already changed something important. Lia once again felt she had a genuine choice.

Confidence shapes choice

Although each woman's circumstances were different, their decision-making followed a remarkably similar pattern. None described deciding based solely on published data. Instead, each spent considerable time researching their options, reflecting on their own values and seeking clinicians they felt they could trust.

What ultimately influenced their decisions was not simply the evidence, but their confidence that the care available to them would support the birth they had chosen.

Perhaps this is why the apparent contradiction between national guidance and women's experiences exists. On paper, women are offered a choice between planned vaginal breech birth and planned caesarean section. In reality, many feel unable to choose a vaginal breech birth, not because of the evidence, but because they cannot find a service in which they have confidence.

Genuine informed choice is about more than understanding risks and benefits. It is also about having confidence that, whichever option is chosen, the care available can support that decision. Until we acknowledge the role confidence plays in decision making, we risk mistaking the presence of choice on paper for the experience of choice in practice.

Perhaps the question is not whether women are being offered a choice, but whether they can ever feel free to choose an option that the system itself no longer feels confident supporting.

Author Bio: Charlotte is a virtual doula who uses her background in clinical research and passion for evidence based informed consent to support families remotely during pregnancy and birth.