Characteristics and Outcomes Associated with the Attempt of External Cephalic Version in U.S. Birth Certificate Data

Objectives: Malpresentation is the indication for approximately 17% of primary cesarean deliveries (CD). External cephalic version (ECV) is a safe and effective procedure to reduce CD. Our primary objective is to identify associations between patient demographics and rate of ECV attempt. Secondary objectives include determining the rate of ECV attempt in the United States, and assessing neonatal and maternal outcomes associated with ECV attempt. Study Design: Data was obtained from the National Center for Health Statistics birth certificate data from 2014-2021. We analyzed live, singleton, non-anomalous births at term (37-42 weeks). Observations lacking complete information on the mode of delivery, presentation at delivery, or whether an ECV was attempted were excluded. We reasoned that subjects who either had an ECV attempt or were non-cephalic at the time of delivery constituted an ECV-eligible cohort. The association between patient characteristics and ECV attempts was examined using logistic regression to obtain odds ratios and 95% confidence intervals. Results: 30,656,644 deliveries were recorded in the database from 2014-2021, and 925,082 subjects met inclusion criteria and were considered ECV-eligible. Only 7.9% of the ECV-eligible population had an ECV attempt. We found that non-Hispanic Black and Hispanic race/ethnicity, unmarried status, lack of a college degree, non-private insurance, delayed prenatal care, increased age, lower parity, one prior CD, and increased BMI were associated with decreased rates of ECV attempt. In regards to neonatal and maternal outcomes, differences were statistically significant but absolute differences were small. Conclusion: Our findings are limited by the quality of data collection, but strongly suggest that ECV is underutilized and not uniformly offered to patients. We identified patient characteristics including race and other demographics that were associated with decreased rates of ECV attempt, and found no clinically significant differences in neonatal or maternal outcomes with ECV attempt other than decreased CD rate.