Research Letter
Race and ethnicity are among the
predisposing factors for fetal malpresentation
at term
OBJECTIVE: Fetal malpresentation complicates approximately 3% to
4% of all term births. It requires special considerations for delivery and
exposes the mother and neonate to obstetrical interventions and potential
adverse outcomes, such as umbilical cord prolapse, head entrapment and
birth trauma, hypoxic ischemic encephalopathy, cesarean delivery, and
cesarean delivery−related complications. We set out to explore the mater-
nal and fetal factors associated with noncephalic malpresentation at term,
with specific interest on the impact of maternal race and ethnicity on fetal
malpresentation.
STUDY DESIGN: This was a retrospective analysis of the Centers for
Disease Control and Prevention Natality Live Birth database for the years
from 2016 through 2018. All term, singleton deliveries for the following
racial and ethnic groups were included: non-Hispanic White, non-Hispanic
Black, Asian, and Hispanic. Race and ethnicity were assigned based on
self-identification and individuals with >1 racial category were excluded
from the analysis. Malpresentation was defined as a noncephalic presen-
tation at term and included breech and transverse presentations. The mal-
presentation group included all noncephalic births and cephalic births that
occurred following successful external cephalic version, whereas all other
cephalic births served as controls. A multivariable logistic regression anal-
ysis was used to assess the rate of malpresentation, with adjustment for
potential confounders including maternal age, race and ethnicity, parity,
birthweight, fetal malformations, malformations of the central nervous sys-
tem (CNS), and chromosomal anomalies. The results are displayed as
adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Statistical
significance was set at a P value of <.05. Institutional review board
approval was not required because the de-identified data are publicly
available through a data use agreement.
RESULTS: There were 9,692,203 term, singleton births during the
study period. The malpresentation group included 354,689 births
(3.66% of the total). The Table shows the rate of malpresentation for
various maternal and fetal factors. We found a substantial racial and
Cite this article as: Bar-El L, Eliner Y, Grunebaum A, et al. Race and ethnicity are
among the predisposing factors for fetal malpresentation at term. Am J Obstet Gynecol
MFM 2021;3:100405.
ethnic disparity in the malpresentation rates. Non-Hispanic White
women had the highest malpresentation risk, whereas non-Hispanic
Black women had the lowest risk (3.93% vs 2.81%; aOR, 1.38;
95% CI, 1.36−1.39). Hispanic and Asian women were also at
increased risk for malpresentation when compared with non-Hispanic
Black women (aOR, 1.30; 95% CI, 1.29−1.32 and aOR, 1.12; 95%
CI, 1.10−1.14, respectively). In addition, several maternal and fetal
conditions were noted to be associated with an increased risk for
malpresentation at term, including older maternal age (aOR, 2.81;
95% CI, 2.74−2.88; for patients >40 years), nulliparity (aOR, 1.50;
95% CI, 1.48−1.51), low birthweight (aOR, 1.80; 95% CI, 1.77
−1.83 for birthweight under 2500 g), and fetal malformations of the
CNS and chromosomal anomalies (aOR, 3.53; 95% CI, 3.06−4.06
and aOR, 2.32; 95% CI, 2.05−2.63, respectively).
CONCLUSION: Based on a large US population database, we identi-
fied several maternal, fetal, and racial and ethnic factors that are associ-
ated with an increased rate of noncephalic malpresentation at term.
Specifically, fetal CNS malformations, congenital or chromosomal anoma-
lies, advanced maternal age, low birthweight, and nulliparity are risk fac-
tors for noncephalic presentation. Interestingly, non-Hispanic White
women have the highest risk for malpresentation, whereas non-Hispanic
Black women have the lowest risk. Previous publications found that low
birthweight, advanced maternal age, nulliparity, and congenital fetal mal-
formations are risk factors for malpresentation.1−3 Nonetheless, the cur-
rent data available on race and ethnicity are sporadic, with limited reports
suggesting that sub-Saharan ethnicity is associated with a lower rate of
malpresentation2 and that White race is associated with a higher rate.4
We present a large-scale, nationwide US-based study to confirm the racial
and ethnic disparity regarding malpresentation in the United States. This
may be explained by the known variation in the shape of the bony birth
canal in different racial and ethnic groups and populations from different
geographic locations.5 Further investigation is needed to explore the racial
and ethnic disparity described.
2021 AJOG MFM 1
Research Letter

TABLE
Rates of and risks for malpresentation for various maternal and fetal factors after adjusting for maternal age, race
and ethnicity, parity, birthweight, and congenital anomalies
Variables Malpresentation, n/N (%) aOR 95% CI P value
Maternal variables
Race and ethnicity
Non-Hispanic White 208,192/5,303,720 (3.93) 1.38 1.36−1.39 <.0001
Non-Hispanic Black 38,150/1,357,002 (2.81) 1 Ref
Hispanic 83,160/2,359,841 (3.52) 1.30 1.29−1.32 <.0001
Asian 25,187/671,640 (3.75) 1.12 1.10−1.14 <.0001
Parity
Nulliparous 132,087/3,072,084 (4.30) 1.50 1.48−1.51 <.0001
1 92,942/2,779,822 (3.34) 1.08 1.07−1.09 <.0001
2 59,130/1,806,356 (3.27) 1.01 1.00−1.02 .2365
≥3 70,530/2,033,941 (3.47) 1 Ref
Maternal age (y)
<20 12,676/475,582 (2.67) 1 Ref
20−24 55,644/1,905,657 (2.92) 1.25 1.22−1.27 <.0001
25−29 97,175/2,852,405 (3.41) 1.56 1.53−1.59 <.0001
30−34 111,091/2,790,931 (3.98) 1.89 1.85−1.93 <.0001
35−39 62,000/1,375,242 (4.51) 2.24 2.20−2.29 <.0001
≥40 16,103/292,386 (5.51) 2.80 2.74−2.87 <.0001
Fetal variables
Birthweight (g)
<2500 16,365/270,210 (6.06) 1.80 1.77−1.83 <.0001
2500−2999 70,619/1,654,448 (4.27) 1.24 1.23−1.25 <.0001
3000−3499 144,535/4,057,463 (3.56) 1 Ref
3500−3999 93,756/2,861,201 (3.28) 0.90 0.89−0.90 <.0001
4000−4499 24,687/735,273 (3.36) 0.90 0.89−0.92 <.0001
≥4500 4,727/113,608 (4.16) 1.12 1.09−1.16 <.0001
Congenital malformations 1,527/21,656 (7.05) 1.81 1.71−1.90 <.0001
CNS malformations 228/1,716 (13.29) 3.53 3.06−4.06 <.0001
Chromosomal disorders 284/2,668 (10.64%) 2.32 2.05-2.62 <.0001
aOR, adjusted odds ratio; CI, confidence interval; CNS, central nervous system; Ref, reference.
Bar-El. Race and ethnicity for fetal malpresentation at term. Am J Obstet Gynecol MFM 2021.

&SUPPLEMENTARY MATERIALS: Supplementary material Yael Eliner, MD, MPH

Department of Obstetrics and Gynecology
associated with this article can be found, in the online version,
Lenox Hill Hospital
at doi:10.1016/j.ajogmf.2021.100405.
Zucker School of Medicine at Hofstra/Northwell
New York NY
Liron Bar-El, MD
Department of Obstetrics and Gynecology Amos Grunebaum, MD
Lenox Hill Hospital Department of Obstetrics and Gynecology
Zucker School of Medicine at Hofstra/Northwell Lenox Hill Hospital
100E 77th St. Zucker School of Medicine at Hofstra/Northwell
New York NY 10075 New York NY
Lironbarel@gmail.com
2 AJOG MFM 2021
 Research Letter

Erez Lenchner, PhD REFERENCES

Department of Biostatistics and Data Management
New York University Rory Meyers College of Nursing
New York NY
Shane W. Wasden, MD
Frank A. Chervenak, MD
Eran Bornstein, MD
Department of Obstetrics and Gynecology
Lenox Hill Hospital
Zucker School of Medicine at Hofstra/Northwell
New York NY
The authors report no conflict of interest.
This study received no financial support.
This study was presented, in part, as a poster (abstract number 187) at
the 41st annual meeting of the Society for Maternal-Fetal Medicine, held
virtually, January 25−30, 2021.
1. Cammu H, Dony N, Martens G, Colman R. Common determinants of
breech presentation at birth in singletons: a population-based study. Eur
J Obstet Gynecol Reprod Biol 2014;177:106–9.
2. Fruscalzo A, Londero AP, Salvador S, et al. New and old predictive fac-
tors for breech presentation: our experience in 14 433 singleton pregnan-
cies and a literature review. J Matern Fetal Neonatal Med 2014;27:167–72.
3. Noli SA, Baini I, Parazzini F, et al. Preterm birth, low gestational age,
low birth weight, parity, and other determinants of breech presentation:
results from a large retrospective population-based study. BioMed Res
Int 2019;2019:9581439.
4. Peterson C. Are race and ethnicity risk factors for breech presenta-
tion? J Obstet Gynecol Neonatal Nurs 2010;39:277–91.
5. Betti L, Manica A. Human variation in the shape of the birth canal is sig-
nificant and geographically structured. Proc Biol Sci 2018;285:20181807.
© 2021 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.
ajogmf.2021.100405

2021 AJOG MFM 3