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Malpresentation in low- and middle-income countries: Associations with perinatal and maternal outcomes in the Global Network


Breech presentation and other less common malpresentations affect up to 3–4% of pregnancies at term and are even more common in earlier gestation. Risk factors for malpresentation are diverse and include maternal age, parity, uterine anomalies, prematurity, fetal growth restriction, fetal anomalies, and amniotic fluid abnormalities. Questions exist regarding the independent impact of malpresentation, especially breech presentation, on fetal and neonatal outcomes, and much attention has been given to the best mode of delivery for these pregnancies. Following publication of the multi-country Term Breech Trial, which showed decreased neonatal morbidity and mortality with planned cesarean delivery compared to planned vaginal delivery for term breech presentations, most high-income countries have adopted cesarean as the preferred mode of delivery for breech presentation. Subsequent meta-analyses of additional studies examining mode of delivery have likewise shown an increase in neonatal morbidity and mortality with planned vaginal delivery compared to cesarean for breech presentation, although the absolute risk remains low.

In low- and middle-income countries (LMIC), there is even more uncertainty as to the significance of malpresentation for pregnancy outcomes and controversy exists over the optimal management of pregnancies affected by malpresentation. Several factors may influence outcomes. For one, the risk of neonatal morbidity and mortality and stillbirth is often greater in LMIC compared to high-income countries. Cesarean delivery is also less available in many LMIC settings and may not be uniformly accessible, competently practiced, or routinely performed for breech presentations. Furthermore, there is heightened concern over the increased maternal risk associated with operative delivery in these settings.

Given this knowledge gap, we sought to compare fetal, neonatal, and maternal outcomes between cephalic and non-cephalic pregnancies in LMIC, to examine rates of cesarean delivery for malpresentation and to explore the association between mode of delivery and fetal, neonatal, and maternal outcomes.

By: Duffy C, Saleem S, Moore J, Patel A, Bose C, Carlo W et al.

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