Thank you so much for taking the time to read our article so carefully and for reminding us of the danger of interpreting association as causation. Indeed, a retrospective cohort study does not afford us the ability to draw conclusions regarding causation. As such, it was not our aim to establish a causal relationship but rather to test the association between the mode of delivery and neonatal morbidity and death. As you note, wordsmithing can be a challenge, particularly under word-count constraints; therefore, in summarizing our findings, it appears we have fallen into the trap of using language that suggests causation. Your critique of the paragraph that you highlight is entirely warranted and much appreciated.

However, when taken as a whole, we hope that readers will find that the article makes a fair and balanced set of claims. You voice concern that physicians may read only the conclusion and think that they should perform cesarean deliveries without indication. We certainly hope this is not the case. In fact, the goal of our efforts was to the contrary.

Our discussion, again taken as a whole, attempts to caution providers both in how they use these and previous findings that show associations between cesarean delivery and survival to inform their clinical judgments and in how they present the benefits and risks of cesarean delivery to parents. We argue that the associations between cesarean delivery and survival, although reported in multiple retrospective cohort studies, are likely to reflect a far more nuanced set of clinical, institutional, and contextual factors than we can fully account for using retrospective cohort analyses. And so, our conclusion is not that cesarean delivery is better or “causes” greater survival. In fact, our hope is that our study findings complicate, rather than oversimplify, clinical decision-making about mode of delivery in this setting. We hope that our efforts to wordsmith and rephrase our summative statements did not belie the overarching intent. More importantly, we hope that, when obstetricians present neonatal risks and benefits of cesarean delivery to parents who are facing the threat of breech periviable delivery, they will consider not only the reported association with survival but also a host of other issues, which include the association between cesarean delivery and neonatal morbidity.

Thank you for opening this important dialogue.