Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time?

Abstract

Objective The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017.

Methods This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders.

Results A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2–1.3). From 2011 to 2017, the CD rate fell 11% (26.4–23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4–30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1–1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9–0.9 and 0.3–0.5).

Conclusion The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people.

Precis Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017.

Key Points

• Black birthing people are more likely to undergo CD than White despite controlling for confounders.

• There are unexplained differences in CD indication among Black and White birthing people.

• These disparities persisted from 2011 to 2017 despite increasing efforts to decrease CD rates in CA.

Keywords

racial disparities - cesarean delivery - cesarean section - cesarean indication - California

Publication History

Received: 06 May 2021

Accepted: 03 October 2021

Article published online:
02 December 2021

• References

• 1 Petersen EE, Davis NL, Goodman D. et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
• 2 State of California DoPH. Data from: California Birth and Death Statistical Master Files: Maternal mortality rate, California and United States. 1999-2013
• 3 Statistics NCfH. Vital Statistics Data Available Online: Natality Public-Use File and CD–ROM. Hyattsville, MD: National Center for Health Statistics; 2018
• 4 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176 (04) 455-460
• 5 Control CfD. Severe Maternal Morbidity in the United States. Accessed November 12, 2020 at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html
• 6 Butwick AJ, Blumenfeld YJ, Brookfield KF, Nelson LM, Weiniger CF. Racial and ethnic disparities in mode of anesthesia for cesarean delivery. Anesth Analg 2016; 122 (02) 472-479
• 7 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
• 8 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: 168
• 9 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
• 10 Grobman WA, Bailit JL, 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 disparities in maternal morbidity and obstetric care. Obstet Gynecol 2015; 125 (06) 1460-1467
• 11 Caughey AB. The safe prevention of the primary cesarean. Clin Obstet Gynecol 2015; 58 (02) 207-210
• 12 Teleki S. Birthing a Movement to Reduce Unnecessary C-Sections: An Update from California. Health Affairs Blog. 2017 . Accessed November 12, 2020 at: 10.1377/hblog20171031.709216
• 13 McLemore MR, Berkowitz RL, Oltman SP. et al. Risk and protective factors for preterm birth among Black women in Oakland, California. J Racial Ethn Health Disparities 2021; 8 (05) 1273-1280
• 14 Scott KA, Chambers BD, Baer RJ, Ryckman KK, McLemore MR, Jelliffe-Pawlowski LL. Preterm birth and nativity among Black women with gestational diabetes in California, 2013-2017: a population-based retrospective cohort study. BMC Pregnancy Childbirth 2020; 20 (01) 593
• 15 Singh N, Baer RJ, Swaminathan M. et al. Pregnancy after bariatric surgery in women with rheumatic diseases and association with adverse birth outcomes. Surg Obes Relat Dis 2021; 17 (02) 406-413
• 16 Talge NM, Mudd LM, Sikorskii A, Basso O. United States birth weight reference corrected for implausible gestational age estimates. Pediatrics 2014; 133 (05) 844-853
• 17 Bryant A, Mhyre JM, Leffert LR, Hoban RA, Yakoob MY, Bateman BT. The association of maternal race and ethnicity and the risk of postpartum hemorrhage. Anesth Analg 2012; 115 (05) 1127-1136
• 18 Chauhan SP, Klauser CK, Woodring TC, Sanderson M, Magann EF, Morrison JC. Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: interobserver variability. Am J Obstet Gynecol 2008; 199 (06) 623.e1-623.e5
• 19 Figueras F, Albela S, Bonino S. et al. Visual analysis of antepartum fetal heart rate tracings: inter- and intra-observer agreement and impact of knowledge of neonatal outcome. J Perinat Med 2005; 33 (03) 241-245
• 20 Scott K. Redesigning Perinatal Quality Improvement Initiative: Community Driven Measures, Meanings, and Methods. 2019 Accessed November 7, 2021 at: https://www.brooklyngrows.com/blog/2019/11/3/redesigning-perinatal-quality-improvement-community-driven-measures-meanings-and-methodsnbsp?fbclid=IwAR0fy_674bz0DqJoS8B4zl3BR6LzYGYa-P1xjwFjqCFPFFN8uRbD1XfTdyY
• 21 Grimes DA, Schulz KF. False alarms and pseudo-epidemics: the limitations of observational epidemiology. Obstet Gynecol 2012; 120 (04) 920-927