Am J Perinatol
DOI: 10.1055/a-1785-8843
Original Article

Mode of Delivery and Unplanned Cesarean: Differences in Rates and Indication by Race, Ethnicity, and Sociodemographic Characteristics.

Alexandria Williams
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
2   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General, Boston, Massachusetts
,
Sarah E. Little
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
,
Allison S. Bryant
2   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General, Boston, Massachusetts
,
Nicole A. Smith
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Objective We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery.

Study Design We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t-tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test.

Results Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001).

Conclusion Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings.

Key Points

  • Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.

  • Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.

  • There may be unmeasured provider level factors which contribute to disparities in cesarean rates.

Keywords

racial disparities - ethnic disparities - pregnancy - zip code income strata - provider bias - non-reassuring fetal status - labor dystocia - cesarean - operative vaginal delivery - equity


Publication History

Received: 27 April 2021

Accepted: 18 February 2022

Accepted Manuscript online:
02 March 2022

Article published online:
12 June 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol 2018; 61 (02) 387-399
    CrossrefPubMedGoogle Scholar
  • 2 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol 2014; 210 (05) 435.e1-435.e8
    CrossrefPubMedGoogle Scholar
  • 3 Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol 2012; 36 (01) 2-6
    CrossrefPubMedGoogle Scholar
  • 4 March of Dimes.. 2020 . Accessed November 12, 2020 at: https://www.marchofdimes.org/peristats/ViewSubtopic.aspx?reg=99&top=8&stop=355&lev=1&obj=1&cmp=&slev=1&sty=&eny=&chy=20162018
    PubMed
  • 5 CDC.. Pregnancy Mortality Surveillance System. 2020 . Accessed November 12, 2020 at: https://www.cdc.gov/nchs/fastats/delivery.htm
    PubMedGoogle Scholar
  • 6 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (with CD). National Academies Press;; 2003: 12875
    Google Scholar
  • 7 Vedam S, Stoll K, Taiwo TK. et al; GVtM-US Steering Council. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health 2019; 16 (01) 77
    CrossrefPubMedGoogle Scholar
  • 8 Huesch M, Doctor JN. Factors associated with increased cesarean risk among African American women: evidence from California, 2010. Am J Public Health 2015; 105 (05) 956-962
    CrossrefPubMedGoogle Scholar
  • 9 National Partnership for Women & Families. Black Women's Maternal Health: A Multifaceted Approach to Addressing Persistent and Dire Health Disparities. April 2021. Accessed October 19, 2021 at: https://www.nationalpartnership.org/our-work/resources/health-care/maternity/black-womens-maternal-health-issue-brief.pdf
    PubMedGoogle Scholar
  • 10 Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight—reconsidering the use of race correction in clinical algorithms. . N Engl J Med 2020; 383 (09) 874-882
    CrossrefPubMedGoogle Scholar
  • 11 Cerdeña JP, Plaisime MV, Tsai J. From race-based to race-conscious medicine: how anti-racist uprisings call us to act. Lancet 2020; 396 (10257): 1125-1128
    CrossrefPubMedGoogle Scholar
  • 12 Fernandez A, Schillinger D, Warton EM. et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011; 26 (02) 170-176
    CrossrefPubMedGoogle Scholar
  • 13 Kandula NR, Lauderdale DS, Baker DW. Differences in self-reported health among Asians, Latinos, and non-Hispanic whites: the role of language and nativity. Ann Epidemiol 2007; 17 (03) 191-198
    CrossrefPubMedGoogle Scholar
  • 14 Diamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A systematic review of the impact of patient-physician non-English language concordance on quality of care and outcomes. J Gen Intern Med 2019; 34 (08) 1591-1606
    CrossrefPubMedGoogle Scholar
  • 15 Kim EJ, Kim T, Paasche-Orlow MK, Rose AJ, Hanchate AD. Disparities in hypertension associated with limited English proficiency. J Gen Intern Med 2017; 32 (06) 632-639
    CrossrefPubMedGoogle Scholar
  • 16 Manfredini R, De Giorgi A, Tiseo R. et al. Marital status, cardiovascular diseases, and cardiovascular risk factors: a review of the evidence. J Womens Health (Larchmt) 2017; 26 (06) 624-632
    CrossrefPubMedGoogle Scholar
  • 17 Hill-Briggs F, Adler NE, Berkowitz SA. et al. Social determinants of health and diabetes: a scientific review. Diabetes Care 2020; 44 (01) 258-279
    CrossrefPubMedGoogle Scholar
  • 18 Stringhini S, Carmeli C, Jokela M. et al; LIFEPATH consortium. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet 2017; 389 (10075): 1229-1237
    CrossrefPubMedGoogle Scholar
  • 19 Schultz WM, Kelli HM, Lisko JC. et al. Socioeconomic status and cardiovascular outcomes: challenges and interventions. Circulation 2018; 137 (20) 2166-2178
    CrossrefPubMedGoogle Scholar
  • 20 Perlman NC, Cantonwine DE, Smith NA. Toxicology testing in pregnancy: evaluating the role of social profiling. Obstet Gynecol 2020; 136 (03) 607-609
    CrossrefPubMedGoogle Scholar
  • 21 Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol 2010; 202 (04) 335-343
    CrossrefPubMedGoogle Scholar
  • 22 Edmonds JK, Yehezkel R, Liao X, Moore Simas TA. Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study. BMC Pregnancy Childbirth 2013; 13 (01) 168
    CrossrefPubMedGoogle Scholar
  • 23 Chung JH, Garite TJ, Kirk AM, Hollard AL, Wing DA, Lagrew DC. Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery. Am J Obstet Gynecol 2006; 194 (05) 1323-1328
    CrossrefPubMedGoogle Scholar
  • 24 Stark EL, Grobman WA, Miller ES. The association between maternal race and ethnicity and risk factors for primary cesarean delivery in nulliparous women. Am J Perinatol 2021; Mar; 38 (04) 350-356
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Getahun D, Strickland D, Lawrence JM, Fassett MJ, Koebnick C, Jacobsen SJ. Racial and ethnic disparities in the trends in primary cesarean delivery based on indications. Am J Obstet Gynecol 2009; 201 (04) 422.e1-422.e7
    CrossrefPubMedGoogle Scholar
  • 26 Washington S, Caughey AB, Cheng YW, Bryant AS. Racial and ethnic differences in indication for primary cesarean delivery at term: experience at one U.S. Institution. Birth 2012; 39 (02) 128-134
    CrossrefPubMedGoogle Scholar
  • 27 Yee LM, Costantine MM, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Racial and ethnic differences in utilization of labor management strategies intended to reduce cesarean delivery rates. Obstet Gynecol 2017; 130 (06) 1285-1294
    CrossrefPubMedGoogle Scholar
  • 28 Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol 2012; 120 (05) 1181-1193
    CrossrefPubMedGoogle Scholar