Abstract
Objective This study aimed to assess whether racial disparities in nulliparous, term, singleton,
vertex cesarean delivery rates vary among hospitals of different type (academic vs.
nonacademic), setting (urban vs. rural), delivery volume, and patient population.
Study Design This is a retrospective cohort study including singleton term vertex live births
in nulliparous Black and non-Hispanic White birthing people in California between
2011 and 2017. Cesarean delivery rates were obtained using birth certificate data
and International Classification of Diseases, 9th/10th Revision codes. Risk of cesarean
delivery was compared among Black versus White birthing people by hospital type (academic,
nonacademic), setting (rural, suburban, urban), volume (< 1,200, 1,200–2,300, 2,400–3,599,
≥3,600 deliveries annually), and patient population (proportion Black-serving). Federal
Information Processing codes were used to designate hospital setting. Risks were calculated
using univariable and multivariable logistic regression and adjusted for birthing
person age, body mass index, medical comorbidities, gestational age, labor type (spontaneous
vs. induction), and infant birthweight.
Results The sample included 59,441 Black (cesarean delivery rate: 30.2%) and 363,624 White
birthing people (cesarean delivery rate: 26.1%). Black birthing people were significantly
more likely than White birthing people to have a cesarean delivery across nearly all
hospital-level factors considered with adjusted relative risks ranging from 1.1 to
1.3. The only exception was rural settings in which the adjusted relative risk was
1.3 but did not reach statistical significance.
Conclusion Black–White disparities in nulliparous, term, singleton, vertex cesarean delivery
rates were persistent across all hospital-level factors we considered: academic status,
rurality, delivery volume, and patient population. Furthermore, disparities existed
at roughly the same magnitude regardless of hospital characteristics. These global
increased risks likely reflect structural inequities in care, which contribute to
disparities in pregnancy-related morbidity and mortality. These data should encourage
providers, hospital systems, and quality collaboratives to further investigate racial
disparities in cesarean delivery rates and develop strategies for eliminating them.
Key Points
Nulliparous Black birthing people are more likely than White to undergo cesarean delivery.
This persists across hospitals of all academic status, rurality, delivery volume,
and patient population.
These findings likely reflect structural rather than institutional inequities in obstetric
care.
Keywords Black–White disparities - cesarean section - hospital characteristics - academic hospitals
- rurality - delivery volume - black serving - structural inequity
