(319) Impact of Healthcare Access on External Cephalic Version and Breech Delivery in a U.S. Cohort

Objective:
External cephalic version (ECV) reduces rates of cesarean delivery for malpresentation. However, access to providers skilled in ECV technique may be limited in underserved areas, leading to unnecessary cesarean deliveries. This study evaluated national ECV attempt rates in term breech pregnancies, stratified by access to maternity care.

Study Design:
This cross-sectional study used 2023 U.S. National Vital Statistics data and included singleton deliveries ≥37 weeks with breech presentation. Patients were included if they underwent an ECV attempt (successful or failed) or delivered a breech fetus (via cesarean or vaginal delivery). Healthcare access was defined using March of Dimes classifications (full, moderate, or low access to maternity care, or maternity care desert), incorporating availability of obstetric hospitals, obstetric clinicians, and insurance coverage. Logistic regression was used to assess associations between healthcare access and mode of delivery. P< 0.05 was considered statistically significant. Analyses were performed in R version 4.4.1.

Results:
Among 109,217 eligible patients, those in areas with moderate access to care were most likely to undergo ECV compared to those in full-access regions (aOR 2.82, 95% CI 2.50–3.17). In contrast, patients in low-access areas were significantly less likely to have an ECV (aOR 0.76, 95% CI 0.64–0.91) or a vaginal breech delivery (aOR 0.76, 95% CI 0.64–0.91). Living in a maternity care desert was not significantly associated with ECV rates. Hispanic (aOR 0.68, 95% CI 0.63–0.73) and Asian (aOR 0.57, 95% CI 0.49–0.65) patients were also less likely to undergo ECV.

Conclusion:
Lower ECV and vaginal breech delivery rates in low-access areas highlight potential missed opportunities to reduce cesarean deliveries. Surprisingly, ECV was more frequent in moderate-access areas than in full-access regions. Persistent disparities by race and ethnicity further emphasize the need for equitable access to ECV and skilled breech management.