Strategies to Reduce Cesarean Deliveries: Surveying Polish Midwives and Midwifery Students on External Cephalic Version Practices

Strategies to Reduce Cesarean Deliveries: Surveying Polish Midwives and Midwifery Students on External Cephalic Version Practices | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Strategies to Reduce Cesarean Deliveries: Surveying Polish Midwives and Midwifery Students on External Cephalic Version Practices Maisa Manasar-Dyrbuś, Anna Janik, Cecylia Jendyk, Agnieszka Drosdzol-Cop, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5792328/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 May, 2025 Read the published version in BMC Nursing → Version 1 posted 9 You are reading this latest preprint version Abstract Objectives This study aimed to evaluate the knowledge and experiences of Polish midwives regarding the external cephalic version (ECV), as well as to examine their practices related to this procedure and the perceived barriers to its implementation. Materials and Methods A cross-sectional, online survey was conducted using a 22-item questionnaire developed by the authors. The survey targeted midwives and midwifery students, collecting demographic data, professional experiences, and detailed responses about knowledge, practices, and perceptions related to ECV. Results Among 535 respondents, 29.3% were midwifery students, 23.7% held a bachelor’s, and 46.9% a master’s degree. Over half had less than five years of experience. ECV was practiced in 27.5% of workplaces, and 39.6% had personal experience with the procedure. Support for ECV in primiparas was highest among students (74.5%) and midwives with a master’s degree (61.4%), and lowest among those with a bachelor’s (47.2%). A similar pattern was observed in multiparas, with elective cesarean section more often chosen by bachelor’s-level midwives (29.1%) and least by students (7.6%, p < 0.001). Less experienced midwives more frequently expressed concerns about complications and emergency cesarean delivery. Cesarean section was preferred in outpatient and prenatal class settings, while ECV was favored in clinical and district hospitals. Regardless of experience, the majority recognized the need for ECV training, with strongest support among students (90.4%, p = 0.031). Conclusions The study highlights moderate awareness and limited experience with ECV among Polish midwives. The findings emphasize the necessity of structured educational programs to improve competency and confidence in ECV, particularly in outpatient and prenatal classes. external cephalic version breech presentation delivery midwives Figures Figure 1 Figure 2 Figure 3 Introduction Background Cesarean deliveries are increasingly standard worldwide, raising concerns about associated maternal and neonatal morbidity as well as healthcare costs. Strategies to reduce cesarean delivery rates are a critical focus of obstetric care. Among these, the external cephalic version (ECV) has been identified as an effective intervention for lowering non-cephalic presentations at term, thereby promoting vaginal births. Evidence suggests that ECV is a safe procedure when performed in eligible women with breech presentations, with complications being infrequent [1,2]. The procedure is endorsed by major obstetric and midwifery societies, which recommend offering ECV to all eligible women at term [3,4]. Despite its proven safety and efficacy, access to ECV is inconsistent, with considerable variability in uptake among different regions and healthcare providers. Studies indicate that not all obstetricians and midwives routinely offer or perform ECV, leading to missed opportunities to reduce cesarean deliveries. Barriers may include lack of training, provider confidence, or institutional support [1]. The role of midwives in performing ECV has garnered attention, with research demonstrating that trained midwives can consult and perform ECV with success rates comparable to those of other healthcare professionals [1,2]. Non-cephalic fetal presentation remains a well-established indication for cesarean delivery in Poland. Recently, our study highlighted that Polish obstetricians consistently advocate for cesarean delivery in term pregnancies presenting with non-cephalic fetal presentations. Knowledge about ECV was relatively low, indicating a need for improved educational efforts in this area. Addressing concerns about ECV's safety and efficacy through enhanced training and anesthesia options could promote its adoption and reduce cesarean section rates [5]. However, limited data exists on ECV practices among Polish midwives. Understanding midwives' perspectives, knowledge, and attitudes toward ECV is essential for identifying gaps in practice and potential strategies to increase its utilization. By addressing these gaps, there is an opportunity to enhance the role of midwives in promoting vaginal births and reducing cesarean delivery rates. Objectives The study aimed to evaluate Polish midwives' knowledge and experiences regarding the external cephalic version and examine their practices related to this procedure and the perceived barriers to its implementation. Materials And Methods Design The study was designed and conducted by the Chair and Department of Gynecology, Obstetrics, and Gynecological Oncology, Faculty of Health Sciences, Medical University of Silesia, Katowice, Poland, in collaboration with the Regional Chamber of Nurses and Midwives in Katowice, Katowice, Poland. A cross-sectional survey study was conducted online through verified social media groups aimed at gynecologists and obstetricians, utilizing the CAWI (Computer Assisted Web Interview) method. Data were gathered via an online questionnaire, which enabled the collection of information from participants while preserving their anonymity and ensuring their comfort. Participants could complete the questionnaire voluntarily and at any time and place using their computers or mobile devices. The study was conducted from June 10, 2024, to July 15, 2024. This report was prepared following the guidelines for observational studies (STROBE) [6] and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [7]. Study group The study group comprised 535 midwives with bachelor’s and master’s degrees and midwifery students. Participants were informed about the study's purpose and assured of the exclusive scientific use of the data. The anonymous survey was voluntary, with no compensation provided, and consent was implied through questionnaire completion. Tool Researchers M.M.-D. and J.S. designed a 22-question survey based on a thorough literature review. During the pilot phase, 25 surveys were completed, incorporating feedback from obstetrics and gynecology residents and specialists. Subsequently, M.M.-D., A.D.-C., C.J., A.J., R.S., and J.S. reviewed the feedback, reached a consensus, and revised the survey. . Internal consistency of the 5-item concern scale was assessed using Cronbach’s alpha. The resulting Cronbach’s alpha was 0.81 (95% CI: 0.67–0.90), indicating good internal consistency. The final version was approved by all authors, ensuring usability and technical functionality through pilot testing. The finalized survey included 22 questions on participants' professional experiences and workplaces and additional items assessing knowledge of the external cephalic version (ECV). Correct answers were scored at 1 point each, with a maximum possible score of 12 points. The “correct” response criteria in the knowledge section were defined based on current clinical guidelines and the most up-to-date evidence. For questions where expert opinion or evolving research could influence the answer, the authors agreed on the most evidence-supported option to designate as the correct answer, ensuring that the scoring reflected contemporary best practices. The survey was hosted on the Google Survey platform (www.obrotzewnetrzny.pl), ensuring all questions were completed before submission. The unique survey link made it accessible to all site visitors. The questionnaire was included in the publication as Appendix 1. Recruitment Midwives were recruited for the study through social media and direct contacts. The survey link and description were shared in the largest closed social media groups for midwives in Poland. Additionally, direct links to the survey were sent to midwives affiliated with the Regional Chamber of Nurses and Midwives in Katowice, Poland. Direct links were also forwarded to midwifery students via the electronic platform for students managed by the Dean's Office of the Faculty of Health Sciences in Katowice at the Medical University of Silesia in Katowice, Poland. Study size The sample size was calculated based on the total number of midwives and midwifery students, as reported in the Report on the State of Nursing and Midwifery in Poland by the Polish Supreme Chamber of Nurses and Midwives (2023). This population includes 29,203 midwives and approximately 25,000 undergraduate midwifery students [8]. The sample size was determined assuming a 95% confidence level, a 5% margin of error, and a 50% response distribution. The calculations were performed using a calculator available at https://www.naukowiec.org/dobor.html. Based on this analysis, the minimum required sample size was 381 respondents. Statistical analysis The statistical software package STATISTICA version 13.3 was used to analyze the collected data (TIBCO Software Inc., Palo Alto, California, USA). Quantitative variables with a normal distribution were presented as the mean with standard deviation. Data with a distribution significantly different from normal were presented as the median with an interquartile range. Normality was assessed using histograms and quantile-quantile plots. (Supplementary file 1) The Wilcoxon and Kruskal-Wallis tests were applied for between-group comparisons of quantitative variables with distributions significantly deviating from normal. For data with a normal distribution, a one-way analysis of variance (ANOVA) was used to compare differences among multiple groups (for example, professional experience: Student, 20 years), followed by the Tukey post-hoc test to determine which groups differed significantly. Analysis was performed using R in the RStudio environment, with p-values below 0.05 considered significant. Results Overall study results A total of 535 women participated in the study. Among them, 23.7% held a bachelor's degree in midwifery, 46.9% had obtained a master's degree, and 29.3% were enrolled as midwifery students. Tables 1 and 2 present detailed characteristics of the study population and survey responses. The analysis of the results reveals diverse approaches among midwives to this method. In the case of nulliparous women with a non-cephalic fetal presentation, 38.1% of the respondents (204 individuals) opted for a cesarean section. In comparison, 61.9% (331 individuals) preferred an attempt at an external cephalic version. For multiparous women, 17.6% of the respondents (94 individuals) chose a cesarean section, 54.4% (291 individuals) opted for an attempt at ECV, and 28.0% (150 individuals) considered vaginal delivery. Most respondents (75.3%, 403 individuals) reported being aware of centers that perform external cephalic versions; however, only 27.5% (147 individuals) confirmed the availability of this procedure at their workplace. A significant portion (60.4%, 323 individuals) had no personal experience with this method, which may explain its limited practical knowledge. Concerns regarding the procedure were primarily related to the risk of complications (44.7%, 239 individuals) and emergency cesarean sections (47.8%, 256 individuals). Less pronounced concerns included patient discomfort during the procedure, highlighted by 35.3% of respondents (189 individuals), and the procedure's effectiveness, deemed a significant issue by 21.5% (115 individuals). Regarding the estimated effectiveness of the external cephalic version for nulliparous women, 35.7% of respondents (191 individuals) assessed it at 40-60%, while 50.1% (268 individuals) rated it similarly for multiparous women. According to 49% of respondents (262 individuals), the estimated complication rate was 1-5%. After a successful version, 53.1% of respondents (284 individuals) believed the risk of fetal repositioning to the previous presentation was 1-5%. A high percentage of respondents (86.7%, 464 individuals) expressed the need for training on this procedure, indicating a significant demand for education in this area. The median overall score was 3 points. Concerns about the risk of complications associated with the external cephalic version (ECV) had a median score of 3, as did concerns about the risk of emergency cesarean delivery and significant pain experienced by the patient during the procedure. Similarly, the median concern about the method's limited effectiveness was 3. In contrast, concerns about the distance to a facility performing ECV had a lower median score of 2. Table 1 Characteristics of the study group. Descriptive statistics N % Education Midwifery student 157 29.3% Bachelor of Midwifery 127 23,7% Master of Midwifery 251 46,9% Years of service Below 5 years 159 50,1% 5 - 20 years 179 33,5% Above 20 years 88 16,4% Reference level of the hospital Level I st 68 12,7% Level II nd 157 29,3% Level III rd 71 13,3% Not applicable 239 44,7% Pregnancy management 15 2,8% Workplace University hospital 92 17,2% Regional hospital 65 12,1% District hospital 145 27,1% Outpatient clinic 116 21,7% Antenatal class 76 14,2% Not applicable 41 7,7% Table 2 Survey on external cephalic version (N=535). Each correct answer was granted with one point. Question/Answer N % Management of choice of the respondents in a primiparous in term pregnancy with a non-cephalic fetal presentation Elective cesarean section 204 38.1% External cephalic version 331 61.9% Management of choice of the respondents in a multiparous in term pregnancy with a non-cephalic fetal presentation Elective cesarean section 94 17.6% External cephalic version 291 54.4% Vaginal delivery in case of breech presentation 150 28.0% Experience with external cephalic versions (the sum could exceed 100%) Knowledge concerning a facility performing the procedure 403 75.3% Working in a facility performing the procedure 147 27.5% History of observing the procedure 212 39.6% Providing information concerning the patient diagnosed with non-cephalic fetal position for the procedure 224 41.9% The estimated effectiveness of external cephalic versions performed in primiparous women according to the respondents <20% 82 15.3% 20%-40% 228 42.6% 40%-60% 191 35.7% 60%-80% 34 6.4% The estimated effectiveness of external cephalic version performed in multiparous women according to the respondents <20% 15 2.8% 20%-40% 122 22.8% 40%-60% 268 50.1% 60%-80% 130 24.3% Optimal time for performing the external cephalic version of the fetus: at the earliest on the due date 50 9.3% at 35 weeks’ gestation 80 15.0% at 37 weeks’ gestation 405 75.7% The estimated total percentage of external cephalic version complications is: 1-5% 262 49.0% 5-15% 245 45.8% More than 15% 28 5.2% The risk of emergency cesarean section in external cephalic version procedure is: <1% 156 29.2% 1-10% 298 55.7% 10-15% 81 15.1% The estimated percentage of cases where the fetus returns to its previous position after a successful external cephalic version: 1-5% 284 53.1% 5-15% 172 32.1% More than 15% 79 14.8% The estimated percentage of vaginal births after successful external cephalic version: >70% 153 28.6% 10%-30% 48 9.0% 30%-70% 334 62.4% Absolute contraindications for external cephalic version according to respondents: Placenta previa 527 98.5% History of lower uterine segment cesarean section 169 31.6% Oligohydramnios 353 66.0% History of classical cesarean section 241 45.0% Intrauterine fetal growth restriction 277 51.8% Placental abruption 489 91.4% Uterine defects 440 82.2% Lack of fetal well-being before the procedure 477 89.2% Estimated fetal weight >3500g 244 45.6% Detailed between-group comparisons Comparison based on work experience Individuals with greater professional experience (over 20 years) more frequently chose elective cesarean sections as the preferred approach for both primiparas (51.1%, p < 0.001) and multiparas (17.0%, p < 0.001). In contrast, students were more likely to favor attempting vaginal delivery for multiparas (37.7%) and external cephalic versions for primiparas (74.8%). Awareness of facilities performing external cephalic versions was highest among respondents with 5–20 years of experience (83.2%) and over 20 years of experience (81.8%), while students demonstrated the lowest awareness (60.4%, p < 0.001). Similarly, personal experience with the procedure was most common in the most experienced group (65.9%, p < 0.001). There were differences in evaluating the efficacy of the external cephalic version for primiparas and multiparas. Respondents with over 20 years of experience were more likely to estimate the efficacy below 20% for primiparas (33.0%, p < 0.001). Students more frequently reported contraindications to the procedure, such as oligohydramnios (74.8%, p = 0.048). Less experienced groups were also more cautious in assessing complications, including the risk of emergency cesarean delivery (>10%, p = 0.004). Despite differences in experiences and approaches, most respondents across all groups believed that training in the external cephalic version procedure is necessary. The highest support was expressed by students (89.9%) and those with 5–20 years of experience (87.2%, p = 0.002). Figure 1 contains concerns of midwives regarding the external cephalic version (ECV) procedure based on years of professional experience (responses on a Likert scale (1–5); graph displays mean and standard deviation): A) High risk of complications related to ECV: p < 0.001; posthoc (Tukey, all p 20 years); (Student) vs. (<5 years); (20 years). B) High risk of emergency cesarean section during ECV: p < 0.001; posthoc (Tukey, p 20 years); (Student) vs. (<5 years); (20 years). C) Patient's pain during the procedure: p < 0.001; posthoc (Tukey, p < 0.001): (5–20 years) vs. (Student); (Student) vs. (20 years). D) Low efficacy of the procedure: p = 0.012; post-hoc (Tukey, p < 0.01): (Student) vs (<5 years). E) Distance between the facility performing the procedure and the patient's residence: p = 0.032; posthoc (Tukey, no significant differences) Comparison based on education Bachelor’s degree midwives most frequently chose elective cesarean section as the preferred management option for primiparas in full-term pregnancy with non-cephalic fetal presentation (52.8%). In comparison, master’s degree midwives chose this option less often (38.6%), and students the least usually (25.5%) (p < 0.001). Conversely, the external cephalic version was preferred by students (74.5%) and master’s degree midwives (61.4%), less often by bachelor’s degree midwives (47.2%). A similar trend was observed for multiparas – elective cesarean section was most frequently chosen by bachelor’s degree midwives (29.1%) and least frequently by students (7.6%) (p < 0.001). Students most frequently indicated attempting vaginal delivery (38.2%). Awareness of facilities performing external cephalic versions was highest among master’s degree midwives (88.8%) and lowest among students (59.2%) (p < 0.001). Similarly, personal experience with the procedure was most common among master’s degree midwives (45.8%) and least common among students (31.8%) (p = 0.015). In terms of providing information to patients about the possibility of external versions, master’s degree midwives were the most likely to report doing so (60.6%), and students were the least likely (15.9%) (p < 0.001). When assessing the effectiveness of the external cephalic version for primiparas, students were more likely to estimate higher effectiveness (60%-80%, 11.5%) compared to master’s degree midwives (3.6%) and bachelor’s degree midwives (5.5%) (p = 0.003). Similar optimism was observed in their assessment of the risk of emergency cesarean section, where students more frequently indicated a risk below 1% (37.6%) than master’s degree midwives (24.3%) and bachelor’s degree midwives (28.3%) (p = 0.002). Among contraindications for the procedure, oligohydramnios was most frequently indicated by students (75.8%) and least frequently by bachelor’s degree midwives (55.9%) (p = 0.002). Intrauterine growth restriction as a contraindication was most reported by students (89.8%) compared to master’s degree midwives (32.7%) and bachelor’s degree midwives (42.5%) (p < 0.001). Despite differences in assessment and experience, all respondents agreed on the need for training in external cephalic version procedures, with the highest support expressed by students (90.4%) (p = 0.031). Figure 2 contains concerns of the medical staff regarding the external cephalic version (ECV) procedure depending on education level (responses on a Likert scale (1–5); presented on a chart: mean and standard deviation): A) High risk of complications from external cephalic version: p < 0.001; post-hoc (Tukey, p < 0.001): Bachelor of Midwifery vs Midwifery Student without professional license; Master of Midwifery vs Midwifery Student without professional license. B) High risk of emergency cesarean section during external cephalic version: p < 0.001; post-hoc (Tukey, p < 0.001): Bachelor of Midwifery vs Midwifery Student without professional license; Master of Midwifery vs Midwifery Student without professional license. C) Patient's pain during the procedure: p < 0.001; post-hoc (Tukey, p < 0.001): Bachelor of Midwifery vs Midwifery Student without professional license; Master of Midwifery vs Midwifery Student without professional license. D) Low effectiveness of the procedure: p = 0.031; post-hoc (Tukey, p = 0.029): Bachelor of Midwifery vs Midwifery Student without professional license. E) Distance of the facility performing the procedure from the patient's residence: p = 0.012; post-hoc (Tukey, p = 0.017): Bachelor of Midwifery vs Master of Midwifery. Comparison based on the workplace Hospital care For primiparas with non-cephalic fetal presentation, elective cesarean section was most frequently chosen in level I and II departments (51.5% and 51.6%) and less frequently in level III departments (29.6%) (p < 0.001). Conversely, the external cephalic version was preferred in level III departments (70.4%). For multiparas, cesarean section was more commonly chosen in level I (32.4%) and least frequently in level III (9.9%). Attempting vaginal delivery was most often preferred in level III departments (35.2%). Knowledge of centers performing external cephalic versions was highest among workers in level III departments (90.1%) (p < 0.001). Similarly, the highest percentage of those with personal experience of external cephalic version was in level III departments (59.2%), and the lowest in level I departments (23.5%) (p < 0.001). Regarding the effectiveness of the external cephalic version for primiparas, the highest effectiveness (40%-60%) was reported by level III departments (47.9%), while the lowest effectiveness (<20%) was reported in level II departments (21.0%) (p = 0.024). For multiparas, effectiveness at 60%-80% was most frequently reported by level III departments (39.4%). In terms of contraindications, fetal growth restriction and estimated fetal weight >3500 g, as contraindication was least reported in level III departments (29.6%) (p < 0.001) and (29.6%) (p < 0.001). Figure 3 contains concerns of the medical staff regarding the external cephalic version (ECV) procedure based on the referral level of the hospital where they work (responses on a Likert scale (1–5); graph displays mean and standard deviation): A) High risk of complications related to ECV: p = 0.054. B) High risk of emergency cesarean section during ECV: p = 0.955. C) Patient's pain during the procedure: ANOVA p = 0.35. D) Low efficacy of the procedure: p = 0.033; post-hoc (Tukey, no significant differences). E) Distance between the facility performing the procedure and the patient's residence: p = 0.686. Ambulatory care Midwives in outpatient clinics were more likely to opt for elective cesarean section for primiparas with non-cephalic presentations (51.7%) compared to midwives in other facilities (34.4%; p = 0.001). Personal experience with the external cephalic version was less common among outpatient clinic midwives (31.0%) than in other workplaces (42.0%; p = 0.042). Midwives working in outpatient clinics expressed significantly higher concerns about the risk of complications (mean = 3.53 ± 1.09 vs. 3.07 ± 1.17; p < 0.001). Concerns about the low effectiveness of the procedure were marginally higher (mean = 2.83 ± 1.05 vs. 2.65 ± 0.99; p = 0.050). In midwives working in prenatal classes, elective cesarean section was more frequently chosen (64.5%) compared to other settings (33.8%; p < 0.001). Following classical cesarean section, the state was more often identified as a contraindication (63.2%) than in other facilities (42.0%; p = 0.001). Midwives in prenatal classes were also more likely to estimate the risk of emergency cesarean section during the external version at 1%-10% (71.1%) compared to their counterparts in other workplaces (53.2%; p = 0.001). This group of midwives also had higher concerns about the risk of complications (mean = 3.49 ± 1.16 vs. 3.12 ± 1.16; p = 0.008). Elective cesarean section was more frequently chosen by midwives working in outpatient clinics and prenatal classes. Knowledge of centers performing external cephalic versions and personal experience with the procedure was lowest in midwives who work in prenatal classes. Risk perception also differed, as midwives in prenatal classes were more likely to estimate a higher risk of emergency cesarean section during the external cephalic version. In the outpatient clinics group, concerns about complications and slight skepticism regarding procedural effectiveness were significantly higher. Discussion External Cephalic Version (ECV) is a relatively simple and effective procedure [9,10] that can help reduce the rate of cesarean sections [11,12]. Although term breech presentation occurs in only 3–5% of pregnancies, the high cesarean section rate among more than 270,000 childbirths each year in Poland—exceeding 50%—emphasizes the urgent need to promote natural childbirth and vaginal deliveries in cases of non-cephalic fetal presentations. Moreover, evidence suggests that reducing the number of cesarean sections can offset the costs associated with performing ECV [13]. Existing literature shows midwives are willing and qualified to perform ECV, demonstrating adequate theoretical knowledge and practical competencies. Studies report that ECV conducted by trained midwives is safe and effective in low-risk pregnancies complicated by breech presentation [1]. In a large observational study, midwives achieved a 47% success rate, with complications occurring in only 2.6% of cases [2]. Despite these positive data, counseling about, referring for, and performing ECV remains relatively uncommon in Poland. Our study is the first nationwide analysis of midwives’ knowledge and behaviors regarding ECV, drawing on data from 535 participants—midwifery students and midwives holding bachelor’s or master’s degrees employed in diverse healthcare environments. Midwives maintain close contact with pregnant women and must be well-informed about the most optimal delivery modalities, including ECV. This research also extends our previous findings obtained from a survey of physicians [5]. Our results reveal a favorable attitude toward ECV among midwives, with 61.9% recommending an attempt at ECV for primiparas. Among multiparas, 54.4% endorsed ECV, 17.6% favored cesarean delivery, and 28.0% considered vaginal breech delivery. Educational background influenced these preferences: midwives with bachelor’s degrees were likelier to suggest cesarean section than students or midwives with master’s degrees. This discrepancy may reflect differences in training and exposure; those with a master’s degree usually receive the most extensive and up-to-date recommendations. Moreover, midwives with more than 20 years of experience expressed more reservations regarding ECV’s efficacy (<20%) and were more concerned about potential complications. In our study, many respondents were either very experienced midwives or professionals who began practicing in an era when ECV was less common or not emphasized, which could contribute to their more conservative attitudes toward the procedure. Conversely, students demonstrated a stronger inclination toward ECV, reflecting their recent exposure to evidence-based guidelines. However, despite general enthusiasm towards the procedure, the basic knowledge survey on ECV revealed insufficient understanding in this area. Our respondents estimated that ECV success rates for nulliparas primarily fall within 20–40% (42.6%) or 40–60% (35.7%), whereas 50.1% indicated 40–60% for multiparas. Students tended to be more optimistic, with many citing success rates of 60–80%. This discrepancy reflects ongoing debates in the literature concerning actual ECV effectiveness [14]. In terms of complications, 47.8% of participants highlighted an increased risk of emergency cesarean section, while 44.7% noted the risk of severe complications. The most frequently mentioned contraindications included placenta previa (98.5%), placental abruption (91.4%), and uterine anomalies (82.2%), with students more likely to include oligohydramnios and fetal growth restriction. Although 75.3% of respondents in our study were aware of ECV availability, only 27.5% had direct access to the procedure at their workplace. Moreover, 39.6% of participants had firsthand experience with ECV, most frequently in tertiary referral hospitals (59.2%). This discrepancy suggests that midwives practicing in smaller hospitals or outpatient settings often lack firsthand exposure to ECV, which can diminish their confidence in the procedure, as midwives working in outpatient clinics and prenatal classes expressed greater concerns about the safety and efficacy of ECV. Nonetheless, across all respondent groups, 86.7% recognized the need for formal ECV training, with students showing the highest level of support for such initiatives (approximately 90%). This is consistent with our earlier research among physicians and aligns with Green-top Guideline No. 20a, which advocates for broad educational initiatives to allay concerns and increase ECV uptake [5,15]. Hutton [2] indicated that establishing a regular ECV clinic may increase referrals and successful attempts. Burgos et al. [10] point out the importance of comprehensive, structured periprocedural care and operator experience, which parallels our observation that tertiary care hospitals reported higher rates of ECV. This is consistent with Kok et al. [16], who highlighted seven key clinical factors facilitating a more frequent and successful ECV. These findings further align with Lim et al. [17], who emphasize the value of comprehensive training and multidisciplinary collaboration. The ultimate uptake of ECV depends also on whether pregnant women are willing to undergo the procedure, which in turn is influenced by their understanding and comfort level with it. Midwives and physicians should engage in open, evidence-based discussions with expectant mothers when a breech presentation is identified, addressing any fears (for example, concerns about the baby’s safety or the pain of the version) and setting realistic expectations about the procedure’s success rate. It has been observed that some women decline ECV due to worries about potential risks or because ECV does not guarantee avoiding cesarean section; therefore, providing balanced information and reassurance is crucial. Encouraging shared decision-making respects patient autonomy and may increase the acceptance of ECV. Regalia et al. [18] underline the importance of incorporating ECV to reduce cesarean sections, echoed by most of our respondents, with other studies similarly emphasizing that structured protocols, education, and access to ECV are pivotal to its successful implementation [19-21]. However, beyond individual knowledge and institutional support, broader systemic factors in Poland’s healthcare system may also contribute to the low utilization of ECV. For instance, current national guidelines may not strongly incentivize or mandate offering ECV, which could lead providers to default scheduling cesarean deliveries for breech presentations. Financial and organizational factors play a role as well. Hospitals and clinicians might be less inclined to adopt it if there is no precise reimbursement for ECV or if performing the procedure is time-consuming without adequate compensation. These systemic and institutional barriers, coupled with potential medico-legal concerns (e.g., fear of liability if an ECV attempt leads to an emergency), create an environment where cesarean delivery becomes the default for breech cases. Increasing the acceptance and use of ECV in Poland requires targeted educational interventions and ongoing postgraduate training for midwives and obstetricians. Developing standardized protocols, promoting interdisciplinary teamwork, and strengthening institutional support are critical steps toward bridging existing knowledge and practice gaps [22]. By doing so, unnecessary cesarean sections for breech presentation can be reduced. Indeed, Walker et al. [19] emphasize that the availability of ECV and institutional endorsement are key to enhancing its uptake. Clinical implementation Midwives, as primary caregivers maintaining close and regular contact with pregnant women, should be equipped with up-to-date, evidence-based knowledge to actively promote and support using the External Cephalic Version as a procedure of confirmed safety and efficacy. In our study, the most significant gaps were noted for questions on the risk of complications, emergency cesarean section during the procedure, and the absolute contraindications for the external cephalic version, suggesting that educational efforts should emphasize these aspects. This is particularly important as the concerns of pregnant patients usually relate to potential complications, and midwives have a major role in presenting patients with reliable data and comprehensively answering questions about indications and contraindications to the procedure. Furthermore, the study emphasizes the need to improve access to ECV and optimize conditions for its implementation in lower-level healthcare facilities, where midwives working in outpatient clinics and antenatal classes—positioned on the front lines of maternal care—must possess comprehensive, evidence-based knowledge. Establishing personalized educational initiatives, starting with their implementation at the undergraduate and graduate levels and providing continuous postgraduate training aligned with current clinical guidelines and scientific evidence, would enable midwives to perform ECV more effectively. Additionally, improving the availability of ECV services and increasing awareness of its benefits could significantly reduce the number of cesarean sections performed solely due to breech presentation, thereby enhancing the overall quality of perinatal care in Poland. Declarations Authors' contributions: Conceptualization: M.M.-D., methodology: M.M.-D.; data collection: M.M.-D.; C.J., A.J. and A.B.; formal analysis: M.M-D. and J.S.; writing—original: M.M.-D.; writing—review and editing: J.S., M.M.-D., A.J., A.B. and R.S.; supervision: J.S..; All authors have read and agreed to the published version of the manuscript. Funding: No funding. Ethics, Consent to Participate, and Consent to Publish declarations: This study was conducted using the principles of medical research ethics, including the Declaration of Helsinki. All personal data were securely protected and were not shared outside the participating research center. According to Polish law, including Article 21 of the Act on the Profession of a Physician (Journal of Laws 2021, item 790), this study did not meet the definition of a medical experiment. It, therefore, did not require approval or a waiver of consent from a bioethics committee, as it was based solely on medical records without patient involvement or additional procedures. It also did not meet the criteria for a clinical trial under Regulation (EU) No 536/2014. Participation in the study was entirely voluntary, and informed consent was implied by accessing the provided link and completing the survey. This procedure was approved by the Chair and Clinical Department of Gynecology, Obstetrics and Oncological Gynecology Review Board, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, and all participants were made aware that their submission of responses constituted an agreement to participate. Data availability: The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Clinical trial number: Not applicable. Acknowledgments: Not applicable. Competing interests: Not applicable. References Beuckens A, Rijnders M, Verburgt‐Doeleman G, Rijninks‐van Driel G, Thorpe J, Hutton E. An observational study of the success and complications of 2546 external cephalic versions in low‐risk pregnant women performed by trained midwives. BJOG Int J Obstet Gynaecol. 2015;123(3):415–23. Midwives should undertake Hutton E. External cep. BJOG Int J Obstet Gynaecol. 2015;123(3):426. Taylor P, Robson S. Midwifery‐led ECV. BJOG Int J Obstet Gynaecol. 2015;123(3):425. Hutton G, Kok R, Walker MW. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015. Manasar-Dyrbus M, Drosdzol-Cop A, Stojko S, Stojko R, Staniczek J. Strategies to reduce cesarean deliveries: surveying Polish obstetricians on external cephalic version practices. Ginekol Pol. Published online November 29, 2024. doi:10.5603/gpl.102550 Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34. RAPORT-O-STANIE-PIELEGNIARSTWA-I-P-OLOZNICTWA-W-POLSCE-MAJ-2023. Available at: https://nipip.pl/wp-content/uploads/2023/12/RAPORT-O-STANIE-PIELEGNIARSTWA-I-P-OLOZNICTWA-W-POLSCE-MAJ-2023.pdf. Accessed March 22, 2025. McParland P, Farine D. External cephalic version. Does it have a role in modern obstetric practice? Can Fam Physician Med Fam Can. 1996;42:693–8. Burgos J, Cobos P, Rodriguez L, Osuna C, Carlos Melchor J, Fernandez-Llebrez L, et al. External Cephalic Version: A Review of the Evidence. Curr Womens Health Rev. 2011;7(4):405–15. Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. The Lancet. 2018;392(10155):1358–68. Hakem E, Lindow SW, O’Connell MP, von Bünau G. External cephalic version - A 10-year review of practice. Eur J Obstet Gynecol Reprod Biol. 2021;258:414–7. Gifford DS, Keeler E, Kahn KL. Reductions in cost and cesarean rate by routine use of external cephalic version: a decision analysis. Obstet Gynecol. 1995;85(6):930–6. Grootscholten K, Kok M, Oei SG, Mol BWJ, van der Post JA. External cephalic version-related risks: a meta-analysis. Obstet Gynecol. 2008;112(5):1143–51. External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a. BJOG Int J Obstet Gynaecol. 2017;124(7):e178–92. Kok M, Van Der Steeg JW, Mol BWJ, Opmeer B, Van Der Post JA. Which factors play a role in clinical decision-making in external cephalic version? Acta Obstet Gynecol Scand. 2008;87(1):31–5. Lim S, Lucero J. Obstetric and Anesthetic Approaches to External Cephalic Version. Anesthesiol Clin. 2017;35(1):81–94. Regalia AL, Curiel P, Natale N, Galluzzi A, Spinelli G, Ghezzi GV, et al. Routine use of external cephalic version in three hospitals. Birth Berkeley Calif. 2000;27(1):19–24. Walker S, Perilakalathil P, Moore J, Gibbs CL, Reavell K, Crozier K. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery. 2015;31(5):e79-86. Vlemmix F, Rosman A, Kok M, van der Post J. Re: An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnancies performed by trained midwives. BJOG Int J Obstet Gynaecol. 2016;123(3):477–8. Vlemmix F, Rosman AN, te Hoven S, et al. Implementation of external cephalic version in the Netherlands: a retrospective cohort study. Birth. 2014;41(4):323-329. doi:10.1111/birt.12133 Manasar-Dyrbus M, Jendyk C, Janik A, Drosdzol-Cop A, Stojko R, Staniczek J. Professional perspectives on external cephalic version: survey results among Polish midwives and obstetricians. Ginekol Pol. 2025 Mar 12. doi: 10.5603/gpl.104146. Epub ahead of print. PMID: 40070251. Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx SUPPLEMENTARYMATERIAL.pdf Cite Share Download PDF Status: Published Journal Publication published 22 May, 2025 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 05 May, 2025 Reviews received at journal 01 May, 2025 Reviewers agreed at journal 21 Apr, 2025 Reviews received at journal 16 Apr, 2025 Reviewers agreed at journal 16 Apr, 2025 Reviewers agreed at journal 14 Apr, 2025 Reviewers invited by journal 05 Apr, 2025 Submission checks completed at journal 05 Apr, 2025 First submitted to journal 31 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5792328","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":439753607,"identity":"ffd55d57-47f4-41df-acf7-115336785918","order_by":0,"name":"Maisa Manasar-Dyrbuś","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYFACxgYE+wMQs7GTooVxBkgLMykWMvOASQKqdNsPN3/4mWOXx99/+Nlnm1/b5PmYGRg/fMzBrcXsTGKbZO+25GKJG2nGs3P7bhu2MTMwS87chkfLgcQ2Bt5tzIkNNxiMmXN7bjMCtbAx8+LTcv5h88e/2+oT558//pnZsue2PWEtNxIbpHm3HU7ccCDHmJnhx+1EIrQ8bJOW3XY8ceONnGLG3obbyW3MjM34/XI+/fHHt9uqE+edP76Z4cef27bz25sPfviIRwsqYGwDkw3EqgeBP6QoHgWjYBSMgpECANbyVYwsXh31AAAAAElFTkSuQmCC","orcid":"","institution":"Medical University of Silesia in Katowice","correspondingAuthor":true,"prefix":"","firstName":"Maisa","middleName":"","lastName":"Manasar-Dyrbuś","suffix":""},{"id":439753608,"identity":"6b71b5dc-86aa-43ab-93c3-4dd9652ef57c","order_by":1,"name":"Anna Janik","email":"","orcid":"","institution":"District Chamber of Nurses and Midwives in Katowice","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Janik","suffix":""},{"id":439753609,"identity":"19b4eeaa-6f2a-42ad-a797-6f0c685d559e","order_by":2,"name":"Cecylia Jendyk","email":"","orcid":"","institution":"Medical University of Silesia in Katowice","correspondingAuthor":false,"prefix":"","firstName":"Cecylia","middleName":"","lastName":"Jendyk","suffix":""},{"id":439753610,"identity":"fa7eac9c-0ae1-466a-9afd-4a72bdd538fa","order_by":3,"name":"Agnieszka Drosdzol-Cop","email":"","orcid":"","institution":"Medical University of Silesia in Katowice","correspondingAuthor":false,"prefix":"","firstName":"Agnieszka","middleName":"","lastName":"Drosdzol-Cop","suffix":""},{"id":439753611,"identity":"b4606f05-d62a-4650-964a-37a3f85b586d","order_by":4,"name":"Anna Brzęk","email":"","orcid":"","institution":"Medical University of Silesia in Katowice","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Brzęk","suffix":""},{"id":439753612,"identity":"cc2ea7f0-5d56-430e-9604-51d133c9fe71","order_by":5,"name":"Rafał Stojko","email":"","orcid":"","institution":"Medical University of Silesia in Katowice","correspondingAuthor":false,"prefix":"","firstName":"Rafał","middleName":"","lastName":"Stojko","suffix":""},{"id":439753613,"identity":"fca88415-c5b1-4431-9f0d-b208eead1cee","order_by":6,"name":"Jakub Staniczek","email":"","orcid":"","institution":"Medical University of Silesia in Katowice","correspondingAuthor":false,"prefix":"","firstName":"Jakub","middleName":"","lastName":"Staniczek","suffix":""}],"badges":[],"createdAt":"2025-01-09 01:38:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5792328/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5792328/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-025-03220-8","type":"published","date":"2025-05-22T15:57:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80203781,"identity":"a10e80b2-d3a7-4e06-80a9-f5fce8b295f3","added_by":"auto","created_at":"2025-04-09 07:21:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74588,"visible":true,"origin":"","legend":"\u003cp\u003eConcerns of midwives regarding the external cephalic version (ECV) procedure based on years of professional experience (S-Students; \u0026lt;5 years; 5-20 years; \u0026gt;20 years).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5792328/v1/9d9ff7c545f3166565b9184a.png"},{"id":80203572,"identity":"fcfc912c-f33e-4414-a68d-310b220ec2a1","added_by":"auto","created_at":"2025-04-09 07:13:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":67952,"visible":true,"origin":"","legend":"\u003cp\u003eConcerns of the medical staff regarding the external cephalic version (ECV) procedure depending on education level (S-Student; B-Bachelor degree; M-Master degree)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5792328/v1/127344b2e9ff2f1dc1672bbf.png"},{"id":80202712,"identity":"8c0add94-a27a-443a-997f-fc2722caf987","added_by":"auto","created_at":"2025-04-09 07:05:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70731,"visible":true,"origin":"","legend":"\u003cp\u003eMidwives' concerns regarding the external cephalic version (ECV) procedure are based on the hospital's referral level. (I-I\u003csup\u003est\u003c/sup\u003e level; II\u003csup\u003end\u003c/sup\u003e level; III\u003csup\u003erd\u003c/sup\u003e level)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5792328/v1/3157db4a2b0184b3a4a977b2.png"},{"id":83460023,"identity":"a3021e7a-12ed-4b58-9a2c-ecf31370f6d8","added_by":"auto","created_at":"2025-05-26 16:09:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1423778,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5792328/v1/22331345-ceff-47b7-bfeb-1a809c93cdf9.pdf"},{"id":80202716,"identity":"8a5bc427-2889-432e-a150-b53decc32e63","added_by":"auto","created_at":"2025-04-09 07:05:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18718,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5792328/v1/b4b2301a420649844e883fce.docx"},{"id":80202727,"identity":"b68f57d7-844f-4b74-864a-5e661200b392","added_by":"auto","created_at":"2025-04-09 07:05:14","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":5776944,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYMATERIAL.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5792328/v1/4729829289756fc26754f8e0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eStrategies to Reduce Cesarean Deliveries: Surveying Polish Midwives and Midwifery Students on External Cephalic Version Practices\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCesarean deliveries are increasingly standard worldwide, raising concerns about associated maternal and neonatal morbidity as well as healthcare costs. Strategies to reduce cesarean delivery rates are a critical focus of obstetric care. Among these, the external cephalic version (ECV) has been identified as an effective intervention for lowering non-cephalic presentations at term, thereby promoting vaginal births. Evidence suggests that ECV is a safe procedure when performed in eligible women with breech presentations, with complications being infrequent [1,2]. The procedure is endorsed by major obstetric and midwifery societies, which recommend offering ECV to all eligible women at term [3,4].\u003c/p\u003e\n\u003cp\u003eDespite its proven safety and efficacy, access to ECV is inconsistent, with considerable variability in uptake among different regions and healthcare providers. Studies indicate that not all obstetricians and midwives routinely offer or perform ECV, leading to missed opportunities to reduce cesarean deliveries. Barriers may include lack of training, provider confidence, or institutional support [1]. The role of midwives in performing ECV has garnered attention, with research demonstrating that trained midwives can consult and perform ECV with success rates comparable to those of other healthcare professionals [1,2].\u003c/p\u003e\n\u003cp\u003eNon-cephalic fetal presentation remains a well-established indication for cesarean delivery in Poland. Recently, our study highlighted that Polish obstetricians consistently advocate for cesarean delivery in term pregnancies presenting with non-cephalic fetal presentations. Knowledge about ECV was relatively low, indicating a need for improved educational efforts in this area. Addressing concerns about ECV's safety and efficacy through enhanced training and anesthesia options could promote its adoption and reduce cesarean section rates [5]. However, limited data exists on ECV practices among Polish midwives. Understanding midwives' perspectives, knowledge, and attitudes toward ECV is essential for identifying gaps in practice and potential strategies to increase its utilization. By addressing these gaps, there is an opportunity to enhance the role of midwives in promoting vaginal births and reducing cesarean delivery rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study aimed to evaluate Polish midwives' knowledge and experiences regarding the external cephalic version and examine their practices related to this procedure and the perceived barriers to its implementation.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was designed and conducted by the Chair and Department of Gynecology, Obstetrics, and Gynecological Oncology, Faculty of Health Sciences, Medical University of Silesia, Katowice, Poland, in collaboration with the Regional Chamber of Nurses and Midwives in Katowice, Katowice, Poland. A cross-sectional survey study was conducted online through verified social media groups aimed at gynecologists and obstetricians, utilizing the CAWI (Computer Assisted Web Interview) method. Data were gathered via an online questionnaire, which enabled the collection of information from participants while preserving their anonymity and ensuring their comfort. Participants could complete the questionnaire voluntarily and at any time and place using their computers or mobile devices. The study was conducted from June 10, 2024, to July 15, 2024. This report was prepared following the guidelines for observational studies (STROBE) [6] and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [7].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study group comprised 535 midwives with bachelor\u0026rsquo;s and master\u0026rsquo;s degrees and midwifery students. Participants were informed about the study\u0026apos;s purpose and assured of the exclusive scientific use of the data. The anonymous survey was voluntary, with no compensation provided, and consent was implied through questionnaire completion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTool\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearchers M.M.-D. and J.S. designed a 22-question survey based on a thorough literature review. During the pilot phase, 25 surveys were completed, incorporating feedback from obstetrics and gynecology residents and specialists. Subsequently, M.M.-D., A.D.-C., C.J., A.J., R.S., and J.S. reviewed the feedback, reached a consensus, and revised the survey.\u0026nbsp;. Internal consistency of the 5-item concern scale was assessed using Cronbach\u0026rsquo;s alpha. The resulting Cronbach\u0026rsquo;s alpha was 0.81 (95% CI: 0.67\u0026ndash;0.90), indicating good internal consistency. The final version was approved by all authors, ensuring usability and technical functionality through pilot testing. The finalized survey included 22 questions on participants\u0026apos; professional experiences and workplaces and additional items assessing knowledge of the external cephalic version (ECV). Correct answers were scored at 1 point each, with a maximum possible score of 12 points. The \u0026ldquo;correct\u0026rdquo; response criteria in the knowledge section were defined based on current clinical guidelines and the most up-to-date evidence. For questions where expert opinion or evolving research could influence the answer, the authors agreed on the most evidence-supported option to designate as the correct answer, ensuring that the scoring reflected contemporary best practices.\u003c/p\u003e\n\u003cp\u003eThe survey was hosted on the Google Survey platform (www.obrotzewnetrzny.pl), ensuring all questions were completed before submission. The unique survey link made it accessible to all site visitors. The questionnaire was included in the publication as Appendix 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives were recruited for the study through social media and direct contacts. The survey link and description were shared in the largest closed social media groups for midwives in Poland. Additionally, direct links to the survey were sent to midwives affiliated with the Regional Chamber of Nurses and Midwives in Katowice, Poland. Direct links were also forwarded to midwifery students via the electronic platform for students managed by the Dean\u0026apos;s Office of the Faculty of Health Sciences in Katowice at the Medical University of Silesia in Katowice, Poland.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated based on the total number of midwives and midwifery students, as reported in the \u003cem\u003eReport on the State of Nursing and Midwifery in Poland\u003c/em\u003e by the Polish Supreme Chamber of Nurses and Midwives (2023). This population includes 29,203 midwives and approximately 25,000 undergraduate midwifery students [8]. The sample size was determined assuming a 95% confidence level, a 5% margin of error, and a 50% response distribution. The calculations were performed using a calculator available at https://www.naukowiec.org/dobor.html.\u0026nbsp;Based on this analysis, the minimum required sample size was 381 respondents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical software package STATISTICA version 13.3 was used to analyze the collected data (TIBCO Software Inc., Palo Alto, California, USA). Quantitative variables with a normal distribution were presented as the mean with standard deviation. Data with a distribution significantly different from normal were presented as the median with an interquartile range. Normality was assessed using histograms and quantile-quantile plots. (Supplementary file 1) The Wilcoxon and Kruskal-Wallis tests were applied for between-group comparisons of quantitative variables with distributions significantly deviating from normal. For data with a normal distribution, a one-way analysis of variance (ANOVA) was used to compare differences among multiple groups (for example, professional experience: Student, \u0026lt;5 years, 5\u0026ndash;20 years, \u0026gt;20 years), followed by the Tukey post-hoc test to determine which groups differed significantly. Analysis was performed using R in the RStudio environment, with p-values below 0.05 considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eOverall study results\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 535 women participated in the study. Among them, 23.7% held a bachelor\u0026apos;s degree in midwifery, 46.9% had obtained a master\u0026apos;s degree, and 29.3% were enrolled as midwifery students. Tables 1 and 2 present detailed characteristics of the study population and survey responses.\u003c/p\u003e\n\u003cp\u003eThe analysis of the results reveals diverse approaches among midwives to this method. In the case of nulliparous women with a non-cephalic fetal presentation, 38.1% of the respondents (204 individuals) opted for a cesarean section. In comparison, 61.9% (331 individuals) preferred an attempt at an external cephalic version. For multiparous women, 17.6% of the respondents (94 individuals) chose a cesarean section, 54.4% (291 individuals) opted for an attempt at ECV, and 28.0% (150 individuals) considered vaginal delivery.\u003c/p\u003e\n\u003cp\u003eMost respondents (75.3%, 403 individuals) reported being aware of centers that perform external cephalic versions; however, only 27.5% (147 individuals) confirmed the availability of this procedure at their workplace. A significant portion (60.4%, 323 individuals) had no personal experience with this method, which may explain its limited practical knowledge. Concerns regarding the procedure were primarily related to the risk of complications (44.7%, 239 individuals) and emergency cesarean sections (47.8%, 256 individuals). Less pronounced concerns included patient discomfort during the procedure, highlighted by 35.3% of respondents (189 individuals), and the procedure\u0026apos;s effectiveness, deemed a significant issue by 21.5% (115 individuals).\u003c/p\u003e\n\u003cp\u003eRegarding the estimated effectiveness of the external cephalic version for nulliparous women, 35.7% of respondents (191 individuals) assessed it at 40-60%, while 50.1% (268 individuals) rated it similarly for multiparous women. According to 49% of respondents (262 individuals), the estimated complication rate was 1-5%. After a successful version, 53.1% of respondents (284 individuals) believed the risk of fetal repositioning to the previous presentation was 1-5%. A high percentage of respondents (86.7%, 464 individuals) expressed the need for training on this procedure, indicating a significant demand for education in this area.\u003c/p\u003e\n\u003cp\u003eThe median overall score was 3 points. Concerns about the risk of complications associated with the external cephalic version (ECV) had a median score of 3, as did concerns about the risk of emergency cesarean delivery and significant pain experienced by the patient during the procedure. Similarly, the median concern about the method\u0026apos;s limited effectiveness was 3. In contrast, concerns about the distance to a facility performing ECV had a lower median score of 2.\u003c/p\u003e\n\u003cp\u003eTable 1\u003c/p\u003e\n\u003cp\u003eCharacteristics of the study group.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescriptive statistics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 208px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eMidwifery student\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e29.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eBachelor of Midwifery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e23,7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eMaster of Midwifery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e46,9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 208px;\"\u003e\n \u003cp\u003eYears of service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eBelow 5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e50,1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e5 - 20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e33,5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eAbove 20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e16,4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 208px;\"\u003e\n \u003cp\u003eReference level of the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eLevel I\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e12,7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eLevel II\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e29,3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eLevel III\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e13,3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e44,7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003ePregnancy management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e2,8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorkplace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e17,2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003eRegional hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e12,1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003eDistrict hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e27,1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003eOutpatient clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e21,7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003eAntenatal class\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e14,2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 416px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e7,7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2\u003c/p\u003e\n\u003cp\u003eSurvey on external cephalic version (N=535). Each correct answer was granted with one point.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion/Answer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement of choice of the respondents in a primiparous in term pregnancy with a non-cephalic fetal presentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eElective cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e38.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eExternal cephalic version\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e61.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement of choice of the respondents in a multiparous in term pregnancy with a non-cephalic fetal presentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eElective cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e17.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eExternal cephalic version\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e54.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eVaginal delivery in case of breech presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience with external cephalic versions (the sum could exceed 100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eKnowledge concerning a facility performing the procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e403\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e75.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eWorking in a facility performing the procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e27.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHistory of observing the procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e39.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eProviding information concerning the patient diagnosed with non-cephalic fetal position for the procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e41.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe estimated effectiveness of external cephalic versions performed in primiparous women according to the respondents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e\u0026lt;20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e20%-40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e42.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e40%-60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e35.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e60%-80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe estimated effectiveness of external cephalic version performed in multiparous women according to the respondents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e\u0026lt;20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e20%-40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e22.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e40%-60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e50.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e60%-80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e24.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOptimal time for performing the external cephalic\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eversion\u0026nbsp;of the fetus:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eat the earliest on the due date\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eat 35 weeks\u0026rsquo; gestation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eat 37 weeks\u0026rsquo; gestation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e405\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e75.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe estimated total percentage of external cephalic version complications is:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e1-5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e49.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e5-15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eMore than 15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe risk of emergency cesarean section in external cephalic version procedure is:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e\u0026lt;1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e29.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e1-10% \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e55.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e10-15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe estimated percentage of cases where the fetus returns to its previous position after a successful external cephalic version:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e1-5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e53.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e5-15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e32.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eMore than 15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe estimated percentage of vaginal births after successful external cephalic version:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e\u0026gt;70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e28.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e10%-30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003e30%-70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e334\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e62.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 605px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbsolute contraindications for external cephalic version according to respondents:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003ePlacenta previa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e527\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e98.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHistory of lower uterine segment cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e31.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eOligohydramnios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e66.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eHistory of classical cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eIntrauterine fetal growth restriction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e51.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003ePlacental abruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e489\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e91.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eUterine defects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e82.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eLack of fetal well-being before the procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e89.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 415px;\"\u003e\n \u003cp\u003eEstimated fetal weight \u0026gt;3500g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 66px;\"\u003e\n \u003cp\u003e45.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eDetailed between-group comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison based on work experience\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividuals with greater professional experience (over 20 years) more frequently chose elective cesarean sections as the preferred approach for both primiparas (51.1%, p \u0026lt; 0.001) and multiparas (17.0%, p \u0026lt; 0.001). In contrast, students were more likely to favor attempting vaginal delivery for multiparas (37.7%) and external cephalic versions for primiparas (74.8%).\u003c/p\u003e\n\u003cp\u003eAwareness of facilities performing external cephalic versions was highest among respondents with 5\u0026ndash;20 years of experience (83.2%) and over 20 years of experience (81.8%), while students demonstrated the lowest awareness (60.4%, p \u0026lt; 0.001). Similarly, personal experience with the procedure was most common in the most experienced group (65.9%, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThere were differences in evaluating the efficacy of the external cephalic version for primiparas and multiparas. Respondents with over 20 years of experience were more likely to estimate the efficacy below 20% for primiparas (33.0%, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eStudents more frequently reported contraindications to the procedure, such as oligohydramnios (74.8%, p = 0.048). Less experienced groups were also more cautious in assessing complications, including the risk of emergency cesarean delivery (\u0026gt;10%, p = 0.004). Despite differences in experiences and approaches, most respondents across all groups believed that training in the external cephalic version procedure is necessary. The highest support was expressed by students (89.9%) and those with 5\u0026ndash;20 years of experience (87.2%, p = 0.002).\u003c/p\u003e\n\u003cp\u003eFigure 1 contains concerns of midwives regarding the external cephalic version (ECV) procedure based on years of professional experience (responses on a Likert scale (1\u0026ndash;5); graph displays mean and standard deviation):\u003c/p\u003e\n\u003cp\u003eA)\u0026nbsp;High risk of complications related to ECV: p \u0026lt; 0.001; posthoc (Tukey, all p \u0026lt; 0.001): (5\u0026ndash;20 years) vs. (Student, \u0026gt;20 years); (Student) vs. (\u0026lt;5 years); (\u0026lt;5 years) vs. (\u0026gt;20 years).\u003c/p\u003e\n\u003cp\u003eB)\u0026nbsp;High risk of emergency cesarean section during ECV: p \u0026lt; 0.001; posthoc (Tukey, p \u0026lt; 0.001): (5\u0026ndash;20 years) vs. (Student, \u0026gt;20 years); (Student) vs. (\u0026lt;5 years); (\u0026lt;5 years) vs. (\u0026gt;20 years).\u003c/p\u003e\n\u003cp\u003eC)\u0026nbsp;Patient\u0026apos;s pain during the procedure: p \u0026lt; 0.001; posthoc (Tukey, p \u0026lt; 0.001): (5\u0026ndash;20 years) vs. (Student); (Student) vs. (\u0026lt;5 years, \u0026gt;20 years).\u003c/p\u003e\n\u003cp\u003eD)\u0026nbsp;Low efficacy of the procedure: p = 0.012; post-hoc (Tukey, p \u0026lt; 0.01): (Student) vs (\u0026lt;5 years).\u003c/p\u003e\n\u003cp\u003eE) Distance between the facility performing the procedure and the patient\u0026apos;s residence: p = 0.032; posthoc (Tukey, no significant differences)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison based on education\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBachelor\u0026rsquo;s degree midwives most frequently chose elective cesarean section as the preferred management option for primiparas in full-term pregnancy with non-cephalic fetal presentation (52.8%). In comparison, master\u0026rsquo;s degree midwives chose this option less often (38.6%), and students the least usually (25.5%) (p \u0026lt; 0.001). Conversely, the external cephalic version was preferred by students (74.5%) and master\u0026rsquo;s degree midwives (61.4%), less often by bachelor\u0026rsquo;s degree midwives (47.2%). A similar trend was observed for multiparas \u0026ndash; elective cesarean section was most frequently chosen by bachelor\u0026rsquo;s degree midwives (29.1%) and least frequently by students (7.6%) (p \u0026lt; 0.001). Students most frequently indicated attempting vaginal delivery (38.2%).\u003c/p\u003e\n\u003cp\u003eAwareness of facilities performing external cephalic versions was highest among master\u0026rsquo;s degree midwives (88.8%) and lowest among students (59.2%) (p \u0026lt; 0.001). Similarly, personal experience with the procedure was most common among master\u0026rsquo;s degree midwives (45.8%) and least common among students (31.8%) (p = 0.015). In terms of providing information to patients about the possibility of external versions, master\u0026rsquo;s degree midwives were the most likely to report doing so (60.6%), and students were the least likely (15.9%) (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eWhen assessing the effectiveness of the external cephalic version for primiparas, students were more likely to estimate higher effectiveness (60%-80%, 11.5%) compared to master\u0026rsquo;s degree midwives (3.6%) and bachelor\u0026rsquo;s degree midwives (5.5%) (p = 0.003). Similar optimism was observed in their assessment of the risk of emergency cesarean section, where students more frequently indicated a risk below 1% (37.6%) than master\u0026rsquo;s degree midwives (24.3%) and bachelor\u0026rsquo;s degree midwives (28.3%) (p = 0.002).\u003c/p\u003e\n\u003cp\u003eAmong contraindications for the procedure, oligohydramnios was most frequently indicated by students (75.8%) and least frequently by bachelor\u0026rsquo;s degree midwives (55.9%) (p = 0.002). Intrauterine growth restriction as a contraindication was most reported by students (89.8%) compared to master\u0026rsquo;s degree midwives (32.7%) and bachelor\u0026rsquo;s degree midwives (42.5%) (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eDespite differences in assessment and experience, all respondents agreed on the need for training in external cephalic version procedures, with the highest support expressed by students (90.4%) (p = 0.031).\u003c/p\u003e\n\u003cp\u003eFigure 2 contains concerns of the medical staff regarding the external cephalic version (ECV) procedure depending on education level (responses on a Likert scale (1\u0026ndash;5); presented on a chart: mean and standard deviation):\u003c/p\u003e\n\u003cp\u003eA) High risk of complications from external cephalic version: p \u0026lt; 0.001; post-hoc (Tukey, p \u0026lt; 0.001): Bachelor of Midwifery vs Midwifery Student without professional license; Master of Midwifery vs Midwifery Student without professional license.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eB) High risk of emergency cesarean section during external cephalic version: p \u0026lt; 0.001; post-hoc (Tukey, p \u0026lt; 0.001): Bachelor of Midwifery vs Midwifery Student without professional license; Master of Midwifery vs Midwifery Student without professional license.\u003c/p\u003e\n\u003cp\u003eC) Patient\u0026apos;s pain during the procedure: p \u0026lt; 0.001; post-hoc (Tukey, p \u0026lt; 0.001): Bachelor of Midwifery vs Midwifery Student without professional license; Master of Midwifery vs Midwifery Student without professional license.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eD) Low effectiveness of the procedure: p = 0.031; post-hoc (Tukey, p = 0.029): Bachelor of Midwifery vs Midwifery Student without professional license.\u003c/p\u003e\n\u003cp\u003eE) Distance of the facility performing the procedure from the patient\u0026apos;s residence: p = 0.012; post-hoc (Tukey, p = 0.017): Bachelor of Midwifery vs Master of Midwifery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison based on\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe workplace\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHospital care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor primiparas with non-cephalic fetal presentation, elective cesarean section was most frequently chosen in level I and II departments (51.5% and 51.6%) and less frequently in level III departments (29.6%) (p \u0026lt; 0.001). Conversely, the external cephalic version was preferred in level III departments (70.4%). For multiparas, cesarean section was more commonly chosen in level I (32.4%) and least frequently in level III (9.9%). Attempting vaginal delivery was most often preferred in level III departments (35.2%).\u003c/p\u003e\n\u003cp\u003eKnowledge of centers performing external cephalic versions was highest among workers in level III departments (90.1%) (p \u0026lt; 0.001). Similarly, the highest percentage of those with personal experience of external cephalic version was in level III departments (59.2%), and the lowest in level I departments (23.5%) (p \u0026lt; 0.001). Regarding the effectiveness of the external cephalic version for primiparas, the highest effectiveness (40%-60%) was reported by level III departments (47.9%), while the lowest effectiveness (\u0026lt;20%) was reported in level II departments (21.0%) (p = 0.024). For multiparas, effectiveness at 60%-80% was most frequently reported by level III departments (39.4%).\u003c/p\u003e\n\u003cp\u003eIn terms of contraindications, fetal growth restriction and estimated fetal weight \u0026gt;3500 g, as contraindication was least reported in level III departments (29.6%) (p \u0026lt; 0.001) and (29.6%) (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eFigure 3 contains concerns of the medical staff regarding the external cephalic version (ECV) procedure based on the referral level of the hospital where they work (responses on a Likert scale (1\u0026ndash;5); graph displays mean and standard deviation):\u003c/p\u003e\n\u003cp\u003eA) High risk of complications related to ECV: \u003cem\u003ep = 0.054.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eB) High risk of emergency cesarean section during ECV: \u003cem\u003ep = 0.955.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eC) Patient\u0026apos;s pain during the procedure: \u003cem\u003eANOVA p = 0.35.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eD) Low efficacy of the procedure: \u003cem\u003ep = 0.033; post-hoc (Tukey, no significant differences).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eE) Distance between the facility performing the procedure and the patient\u0026apos;s residence: \u003cem\u003ep = 0.686.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAmbulatory care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives in outpatient clinics were more likely to opt for elective cesarean section for primiparas with non-cephalic presentations (51.7%) compared to midwives in other facilities (34.4%; \u003cem\u003ep\u003c/em\u003e = 0.001). Personal experience with the external cephalic version was less common among outpatient clinic midwives (31.0%) than in other workplaces (42.0%; \u003cem\u003ep\u003c/em\u003e = 0.042).\u003c/p\u003e\n\u003cp\u003eMidwives working in outpatient clinics expressed significantly higher concerns about the risk of complications (mean = 3.53 \u0026plusmn; 1.09 vs. 3.07 \u0026plusmn; 1.17; p \u0026lt; 0.001). Concerns about the low effectiveness of the procedure were marginally higher (mean = 2.83 \u0026plusmn; 1.05 vs. 2.65 \u0026plusmn; 0.99; p = 0.050).\u003c/p\u003e\n\u003cp\u003eIn midwives working in prenatal classes, elective cesarean section was more frequently chosen (64.5%) compared to other settings (33.8%; \u003cem\u003ep\u003c/em\u003e\u0026lt; 0.001). Following classical cesarean section, the state was more often identified as a contraindication (63.2%) than in other facilities (42.0%; \u003cem\u003ep\u003c/em\u003e = 0.001). Midwives in prenatal classes were also more likely to estimate the risk of emergency cesarean section during the external version at 1%-10% (71.1%) compared to their counterparts in other workplaces (53.2%; \u003cem\u003ep\u003c/em\u003e = 0.001). This group of midwives also had higher concerns about the risk of complications (mean = 3.49 \u0026plusmn; 1.16 vs. 3.12 \u0026plusmn; 1.16; p = 0.008).\u003c/p\u003e\n\u003cp\u003eElective cesarean section was more frequently chosen by midwives working in outpatient clinics and prenatal classes. Knowledge of centers performing external cephalic versions and personal experience with the procedure was lowest in midwives who work in prenatal classes.\u003c/p\u003e\n\u003cp\u003eRisk perception also differed, as midwives in prenatal classes were more likely to estimate a higher risk of emergency cesarean section during the external cephalic version. In the outpatient clinics group, concerns about complications and slight skepticism regarding procedural effectiveness were significantly higher.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eExternal Cephalic Version (ECV) is a relatively simple and effective procedure [9,10] that can help reduce the rate of cesarean sections [11,12]. Although term breech presentation occurs in only 3–5% of pregnancies, the high cesarean section rate among more than 270,000 childbirths each year in Poland—exceeding 50%—emphasizes the urgent need to promote natural childbirth and vaginal deliveries in cases of non-cephalic fetal presentations. Moreover, evidence suggests that reducing the number of cesarean sections can offset the costs associated with performing ECV [13].\u003c/p\u003e\n\u003cp\u003eExisting literature shows midwives are willing and qualified to perform ECV, demonstrating adequate theoretical knowledge and practical competencies. Studies report that ECV conducted by trained midwives is safe and effective in low-risk pregnancies complicated by breech presentation [1]. In a large observational study, midwives achieved a 47% success rate, with complications occurring in only 2.6% of cases [2].\u003c/p\u003e\n\u003cp\u003eDespite these positive data, counseling about, referring for, and performing ECV remains relatively uncommon in Poland. Our study is the first nationwide analysis of midwives’ knowledge and behaviors regarding ECV, drawing on data from 535 participants—midwifery students and midwives holding bachelor’s or master’s degrees employed in diverse healthcare environments. Midwives maintain close contact with pregnant women and must be well-informed about the most optimal delivery modalities, including ECV. This research also extends our previous findings obtained from a survey of physicians [5].\u003c/p\u003e\n\u003cp\u003eOur results reveal a favorable attitude toward ECV among midwives, with 61.9% recommending an attempt at ECV for primiparas. Among multiparas, 54.4% endorsed ECV, 17.6% favored cesarean delivery, and 28.0% considered vaginal breech delivery. Educational background influenced these preferences: midwives with bachelor’s degrees were likelier to suggest cesarean section than students or midwives with master’s degrees. This discrepancy may reflect differences in training and exposure; those with a master’s degree usually receive the most extensive and up-to-date recommendations. Moreover, midwives with more than 20 years of experience expressed more reservations regarding ECV’s efficacy (\u0026lt;20%) and were more concerned about potential complications. In our study, many respondents were either very experienced midwives or professionals who began practicing in an era when ECV was less common or not emphasized, which could contribute to their more conservative attitudes toward the procedure. Conversely, students demonstrated a stronger inclination toward ECV, reflecting their recent exposure to evidence-based guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, despite general enthusiasm towards the procedure, the basic knowledge survey on ECV revealed insufficient understanding in this area. Our respondents estimated that ECV success rates for nulliparas primarily fall within 20–40% (42.6%) or 40–60% (35.7%), whereas 50.1% indicated 40–60% for multiparas. Students tended to be more optimistic, with many citing success rates of 60–80%. This discrepancy reflects ongoing debates in the literature concerning actual ECV effectiveness [14]. In terms of complications, 47.8% of participants highlighted an increased risk of emergency cesarean section, while 44.7% noted the risk of severe complications. The most frequently mentioned contraindications included placenta previa (98.5%), placental abruption (91.4%), and uterine anomalies (82.2%), with students more likely to include oligohydramnios and fetal growth restriction.\u003c/p\u003e\n\u003cp\u003eAlthough 75.3% of respondents in our study were aware of ECV availability, only 27.5% had direct access to the procedure at their workplace. Moreover, 39.6% of participants had firsthand experience with ECV, most frequently in tertiary referral hospitals (59.2%). This discrepancy suggests that midwives practicing in smaller hospitals or outpatient settings often lack firsthand exposure to ECV, which can diminish their confidence in the procedure, as midwives working in outpatient clinics and prenatal classes expressed greater concerns about the safety and efficacy of ECV. Nonetheless, across all respondent groups, 86.7% recognized the need for formal ECV training, with students showing the highest level of support for such initiatives (approximately 90%). This is consistent with our earlier research among physicians and aligns with Green-top Guideline No. 20a, which advocates for broad educational initiatives to allay concerns and increase ECV uptake [5,15]. Hutton [2] indicated that establishing a regular ECV clinic may increase referrals and successful attempts. Burgos et al. [10] point out the importance of comprehensive, structured periprocedural care and operator experience, which parallels our observation that tertiary care hospitals reported higher rates of ECV. This is consistent with Kok et al. [16], who highlighted seven key clinical factors facilitating a more frequent and successful ECV. These findings further align with Lim et al. [17], who emphasize the value of comprehensive training and multidisciplinary collaboration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ultimate uptake of ECV depends also on whether pregnant women are willing to undergo the procedure, which in turn is influenced by their understanding and comfort level with it. Midwives and physicians should engage in open, evidence-based discussions with expectant mothers when a breech presentation is identified, addressing any fears (for example, concerns about the baby’s safety or the pain of the version) and setting realistic expectations about the procedure’s success rate. It has been observed that some women decline ECV due to worries about potential risks or because ECV does not guarantee avoiding cesarean section; therefore, providing balanced information and reassurance is crucial. Encouraging shared decision-making respects patient autonomy and may increase the acceptance of ECV.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegalia et al. [18] underline the importance of incorporating ECV to reduce cesarean sections, echoed by most of our respondents, with other studies similarly emphasizing that structured protocols, education, and access to ECV are pivotal to its successful implementation [19-21]. However, beyond individual knowledge and institutional support, broader systemic factors in Poland’s healthcare system may also contribute to the low utilization of ECV. For instance, current national guidelines may not strongly incentivize or mandate offering ECV, which could lead providers to default scheduling cesarean deliveries for breech presentations. Financial and organizational factors play a role as well. Hospitals and clinicians might be less inclined to adopt it if there is no precise reimbursement for ECV or if performing the procedure is time-consuming without adequate compensation. These systemic and institutional barriers, coupled with potential medico-legal concerns (e.g., fear of liability if an ECV attempt leads to an emergency), create an environment where cesarean delivery becomes the default for breech cases.\u003c/p\u003e\n\u003cp\u003eIncreasing the acceptance and use of ECV in Poland requires targeted educational interventions and ongoing postgraduate training for midwives and obstetricians. Developing standardized protocols, promoting interdisciplinary teamwork, and strengthening institutional support are critical steps toward bridging existing knowledge and practice gaps [22]. By doing so, unnecessary cesarean sections for breech presentation can be reduced. Indeed, Walker et al. [19] emphasize that the availability of ECV and institutional endorsement are key to enhancing its uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMidwives, as primary caregivers maintaining close and regular contact with pregnant women, should be equipped with up-to-date, evidence-based knowledge to actively promote and support using the External Cephalic Version as a procedure of confirmed safety and efficacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the most significant gaps were noted for questions on the risk of complications, emergency cesarean section during the procedure, and the absolute contraindications for the external cephalic version, suggesting that educational efforts should emphasize these aspects. This is particularly important as the concerns of pregnant patients usually relate to potential complications, and midwives have a major role in presenting patients with reliable data and comprehensively answering questions about indications and contraindications to the procedure.\u003c/p\u003e\n\u003cp\u003eFurthermore, the study emphasizes the need to improve access to ECV and optimize conditions for its implementation in lower-level healthcare facilities, where midwives working in outpatient clinics and antenatal classes—positioned on the front lines of maternal care—must possess comprehensive, evidence-based knowledge. Establishing personalized educational initiatives, starting with their implementation at the undergraduate and graduate levels and providing continuous postgraduate training aligned with current clinical guidelines and scientific evidence, would enable midwives to perform ECV more effectively. Additionally, improving the availability of ECV services and increasing awareness of its benefits could significantly reduce the number of cesarean sections performed solely due to breech presentation, thereby enhancing the overall quality of perinatal care in Poland.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e Conceptualization: M.M.-D., methodology: M.M.-D.; data collection: M.M.-D.; C.J., A.J. and A.B.; formal analysis: M.M-D. and J.S.; writing—original: M.M.-D.; writing—review and editing: J.S., M.M.-D., A.J., A.B. and R.S.; supervision: J.S..; All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics, Consent to Participate, and Consent to Publish declarations:\u003c/strong\u003e This study was conducted using the principles of medical research ethics, including the Declaration of Helsinki. All personal data were securely protected and were not shared outside the participating research center. According to Polish law, including Article 21 of the Act on the Profession of a Physician (Journal of Laws 2021, item 790), this study did not meet the definition of a medical experiment. It, therefore, did not require approval or a waiver of consent from a bioethics committee, as it was based solely on medical records without patient involvement or additional procedures. It also did not meet the criteria for a clinical trial under Regulation (EU) No 536/2014. Participation in the study was entirely voluntary, and informed consent was implied by accessing the provided link and completing the survey. This procedure was approved by the Chair and Clinical Department of Gynecology, Obstetrics and Oncological Gynecology Review Board, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, and all participants were made aware that their submission of responses constituted an agreement to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBeuckens A, Rijnders M, Verburgt‐Doeleman G, Rijninks‐van Driel G, Thorpe J, Hutton E. An observational study of the success and complications of 2546 external cephalic versions in low‐risk pregnant women performed by trained midwives. \u003cem\u003eBJOG Int J Obstet Gynaecol.\u003c/em\u003e 2015;123(3):415\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eMidwives should undertake Hutton E. External cep. \u003cem\u003eBJOG Int J Obstet Gynaecol.\u003c/em\u003e 2015;123(3):426.\u003c/li\u003e\n\u003cli\u003eTaylor P, Robson S. Midwifery‐led ECV. \u003cem\u003eBJOG Int J Obstet Gynaecol.\u003c/em\u003e 2015;123(3):425.\u003c/li\u003e\n\u003cli\u003eHutton G, Kok R, Walker MW. External cephalic version for breech presentation at term. \u003cem\u003eCochrane Database Syst Rev.\u003c/em\u003e 2015.\u003c/li\u003e\n\u003cli\u003eManasar-Dyrbus M, Drosdzol-Cop A, Stojko S, Stojko R, Staniczek J. Strategies to reduce cesarean deliveries: surveying Polish obstetricians on external cephalic version practices. \u003cem\u003eGinekol Pol.\u003c/em\u003e Published online November 29, 2024. doi:10.5603/gpl.102550\u003c/li\u003e\n\u003cli\u003eVon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. \u003cem\u003eJ Clin Epidemiol.\u003c/em\u003e 2008;61(4):344\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eEysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). \u003cem\u003eJ Med Internet Res.\u003c/em\u003e 2004;6(3):e34.\u003c/li\u003e\n\u003cli\u003eRAPORT-O-STANIE-PIELEGNIARSTWA-I-P-OLOZNICTWA-W-POLSCE-MAJ-2023. Available at: https://nipip.pl/wp-content/uploads/2023/12/RAPORT-O-STANIE-PIELEGNIARSTWA-I-P-OLOZNICTWA-W-POLSCE-MAJ-2023.pdf. Accessed March 22, 2025.\u003c/li\u003e\n\u003cli\u003eMcParland P, Farine D. External cephalic version. Does it have a role in modern obstetric practice? \u003cem\u003eCan Fam Physician Med Fam Can.\u003c/em\u003e 1996;42:693\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eBurgos J, Cobos P, Rodriguez L, Osuna C, Carlos Melchor J, Fernandez-Llebrez L, et al. External Cephalic Version: A Review of the Evidence. \u003cem\u003eCurr Womens Health Rev.\u003c/em\u003e 2011;7(4):405\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eBetr\u0026aacute;n AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. \u003cem\u003eThe Lancet.\u003c/em\u003e 2018;392(10155):1358\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eHakem E, Lindow SW, O\u0026rsquo;Connell MP, von B\u0026uuml;nau G. External cephalic version - A 10-year review of practice. \u003cem\u003eEur J Obstet Gynecol Reprod Biol.\u003c/em\u003e 2021;258:414\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eGifford DS, Keeler E, Kahn KL. Reductions in cost and cesarean rate by routine use of external cephalic version: a decision analysis. \u003cem\u003eObstet Gynecol.\u003c/em\u003e 1995;85(6):930\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGrootscholten K, Kok M, Oei SG, Mol BWJ, van der Post JA. External cephalic version-related risks: a meta-analysis. \u003cem\u003eObstet Gynecol.\u003c/em\u003e 2008;112(5):1143\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eExternal Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a. \u003cem\u003eBJOG Int J Obstet Gynaecol.\u003c/em\u003e 2017;124(7):e178\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eKok M, Van Der Steeg JW, Mol BWJ, Opmeer B, Van Der Post JA. Which factors play a role in clinical decision-making in external cephalic version? \u003cem\u003eActa Obstet Gynecol Scand.\u003c/em\u003e 2008;87(1):31\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eLim S, Lucero J. Obstetric and Anesthetic Approaches to External Cephalic Version. \u003cem\u003eAnesthesiol Clin.\u003c/em\u003e 2017;35(1):81\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eRegalia AL, Curiel P, Natale N, Galluzzi A, Spinelli G, Ghezzi GV, et al. Routine use of external cephalic version in three hospitals. \u003cem\u003eBirth Berkeley Calif.\u003c/em\u003e 2000;27(1):19\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eWalker S, Perilakalathil P, Moore J, Gibbs CL, Reavell K, Crozier K. Standards for midwife practitioners of external cephalic version: A Delphi study. \u003cem\u003eMidwifery.\u003c/em\u003e 2015;31(5):e79-86.\u003c/li\u003e\n\u003cli\u003eVlemmix F, Rosman A, Kok M, van der Post J. Re: An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnancies performed by trained midwives. \u003cem\u003eBJOG Int J Obstet Gynaecol.\u003c/em\u003e 2016;123(3):477\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eVlemmix F, Rosman AN, te Hoven S, et al. Implementation of external cephalic version in the Netherlands: a retrospective cohort study. \u003cem\u003eBirth.\u003c/em\u003e 2014;41(4):323-329. doi:10.1111/birt.12133\u003c/li\u003e\n\u003cli\u003eManasar-Dyrbus M, Jendyk C, Janik A, Drosdzol-Cop A, Stojko R, Staniczek J. Professional perspectives on external cephalic version: survey results among Polish midwives and obstetricians. Ginekol Pol. 2025 Mar 12. doi: 10.5603/gpl.104146. Epub ahead of print. PMID: 40070251.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"external cephalic version, breech presentation, delivery, midwives","lastPublishedDoi":"10.21203/rs.3.rs-5792328/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5792328/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the knowledge and experiences of Polish midwives regarding the external cephalic version (ECV), as well as to examine their practices related to this procedure and the perceived barriers to its implementation.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA cross-sectional, online survey was conducted using a 22-item questionnaire developed by the authors. The survey targeted midwives and midwifery students, collecting demographic data, professional experiences, and detailed responses about knowledge, practices, and perceptions related to ECV.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 535 respondents, 29.3% were midwifery students, 23.7% held a bachelor\u0026rsquo;s, and 46.9% a master\u0026rsquo;s degree. Over half had less than five years of experience. ECV was practiced in 27.5% of workplaces, and 39.6% had personal experience with the procedure. Support for ECV in primiparas was highest among students (74.5%) and midwives with a master\u0026rsquo;s degree (61.4%), and lowest among those with a bachelor\u0026rsquo;s (47.2%). A similar pattern was observed in multiparas, with elective cesarean section more often chosen by bachelor\u0026rsquo;s-level midwives (29.1%) and least by students (7.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Less experienced midwives more frequently expressed concerns about complications and emergency cesarean delivery. Cesarean section was preferred in outpatient and prenatal class settings, while ECV was favored in clinical and district hospitals. Regardless of experience, the majority recognized the need for ECV training, with strongest support among students (90.4%, p\u0026thinsp;=\u0026thinsp;0.031).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe study highlights moderate awareness and limited experience with ECV among Polish midwives. The findings emphasize the necessity of structured educational programs to improve competency and confidence in ECV, particularly in outpatient and prenatal classes.\u003c/p\u003e","manuscriptTitle":"Strategies to Reduce Cesarean Deliveries: Surveying Polish Midwives and Midwifery Students on External Cephalic Version Practices","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-09 07:05:09","doi":"10.21203/rs.3.rs-5792328/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-05T04:43:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-02T02:21:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325563161447235489211417381482356393200","date":"2025-04-22T02:06:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-16T19:18:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15517614034285797874643229159972338702","date":"2025-04-16T10:24:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14527642917025668446390646657247268417","date":"2025-04-14T07:45:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-05T10:14:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-05T07:25:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-03-31T20:29:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54067b7b-99c7-4c95-a609-045b28aaf197","owner":[],"postedDate":"April 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:01:38+00:00","versionOfRecord":{"articleIdentity":"rs-5792328","link":"https://doi.org/10.1186/s12912-025-03220-8","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2025-05-22 15:57:41","publishedOnDateReadable":"May 22nd, 2025"},"versionCreatedAt":"2025-04-09 07:05:09","video":"","vorDoi":"10.1186/s12912-025-03220-8","vorDoiUrl":"https://doi.org/10.1186/s12912-025-03220-8","workflowStages":[]},"version":"v1","identity":"rs-5792328","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5792328","identity":"rs-5792328","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}