BACKGROUND: Most studies comparing vaginal breech delivery (VBD) with cesarean breech delivery (CBD) have been conducted in high-income settings. It is uncertain whether these results are applicable in a low-income setting.

OBJECTIVES: To assess the neonatal and maternal mortality and morbidity for singleton VBD compared to CBD in low- and lower-middle-income settings.

SEARCH STRATEGY: The PubMed database was searched from January 1, 2000, to January 23, 2020 (updated April 21, 2021).

SELECTION CRITERIA: Randomized controlled trials (RCTs) and non-RCTs comparing singleton VBD with singleton CBD, in low- and lower-middle-income settings, reporting infant mortality were selected.

DATA COLLECTION AND ANALYSIS: Two authors independently assessed papers for eligibility and risk of bias. The primary outcome was relative risk of perinatal mortality. Meta-analysis was conducted on applicable outcomes.

MAIN RESULTS: Eight studies (one RCT, seven observational) (12,510 deliveries) were included. VBD increased perinatal mortality (relative risk [RR] 2.67, 95% confidence interval [CI] 1.82-3.91; one RCT, five observational studies, 3289 women) and risk of 5-minute Apgar score below 7 (RR 3.91, 95% CI 1.90-8.04; three observational studies, 430 women) compared to CBD. There was a higher risk of hospitalization and postpartum bleeding in CBD. Most of the studies were deemed to have moderate or serious risk of bias.

CONCLUSIONS: CBD decreases risk of perinatal mortality but increases risk of bleeding and hospitalization.