ObjectiveThe preferred route of delivery for breech presentation has been controversial. We compared the birth weight-specific neonatal mortality of vaginal births to cesarean births in singleton births with breech presentation.MethodsA total of 371, 692 singleton live births with breech presentation were selected for the study from the United States birth cohorts for the years 1989–1991. Differences in birth weight specific mortality were compared using az-statistic for differences in proportions and by logistic regression.ResultsCompared to primary vaginal births, primary cesarean births had significantly lower neonatal mortality for all birth weight groups, despite increased prevalence of fetal malformations in the cesarean as compared with vaginally delivered group. This mortality difference was greatest in the first hour of life. Difference in overall neonatal (less than 28 days) mortality rate ranged from a low of 1.6-fold in the 500–749 g group (726.6 per 1000 vaginal births compared with 456.3 per 1000 cesarean births,P< .001) to as high as about three-fold in the 1250–1499 g group (232.9 per 1000 vaginal births compared to 72.5 per 1000 cesarean births,P< .001). In the group with birth weights over 2500 g, neonatal mortality in the primary vaginal births was 5.3 per 1000 and in the primary cesarean births, 3.2 per 1000 (P< .001). Similarly, repeat cesarean births had significantly lower birth weight-specific neonatal mortality, compared with vaginal births after previous cesarean.ConclusionSingleton live births with breech presentation delivered by cesarean had lower birth weight-specific neonatal mortality as compared with vaginal births.