Download PDF
Am J Perinatol 2024; 41(04): 375-382
DOI: 10.1055/s-0043-1776346
SMFM Fellowship Series Article

Racial Disparities in Cesarean Delivery Rates: Do Hospital-Level Factors Matter?

E. Nicole Teal 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, San Diego, California
,
Rebecca J. Baer
2   California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
,
Laura Jelliffe-Pawlowski
2   California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
3   Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
,
Biftu Mengesha
2   California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

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

Precis

Black–White disparities in NTSV CD rates are persistent at similar magnitude across all California hospitals, regardless of academic status, rurality, delivery volume, and patient population.


Note

Preliminary findings presented in poster form at the Society for Maternal-Fetal Medicine's 40th Annual Pregnancy Meeting in February 2020 in Grapevine, Texas.


Supplementary Material



Publication History

Received: 29 October 2022

Accepted: 26 September 2023

Article published online:
01 November 2023

© 2023. Thieme. All rights reserved.

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

 

  • References

  • 1 National Center for Health Statistics. Vital statistics data available online: natality public-use file and CD–ROM. Hyattsville, MD: National Center for Health Statistics; 2018
    Google Scholar
  • 2 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
    CrossrefPubMedGoogle Scholar
  • 3 Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. 2020 Accessed January 20, 2023 at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.html
    PubMedGoogle Scholar
  • 4 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
    CrossrefPubMedGoogle Scholar
  • 5 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
    CrossrefPubMedGoogle Scholar
  • 6 Combs CA, Murphy EL, Laros Jr RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77 (01) 69-76
    PubMedGoogle Scholar
  • 7 Guendelman S, Thornton D, Gould J, Hosang N. Obstetric complications during labor and delivery: assessing ethnic differences in California. Womens Health Issues 2006; 16 (04) 189-197
    CrossrefPubMedGoogle Scholar
  • 8 Williams DR, Sternthal M. Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav 2010; 51 (suppl): S15-S27
    CrossrefPubMedGoogle Scholar
  • 9 Luke AA, Huang K, Lindley KJ, Carter EB, Joynt Maddox KE. Severe maternal morbidity, race, and rurality: trends using the national inpatient sample, 2012-2017. J Womens Health (Larchmt) 2021; 30 (06) 837-847
    CrossrefPubMedGoogle Scholar
  • 10 Lucas FL, Stukel TA, Morris AM, Siewers AE, Birkmeyer JD. Race and surgical mortality in the United States. Ann Surg 2006; 243 (02) 281-286
    CrossrefPubMedGoogle Scholar
  • 11 Skinner J, Chandra A, Staiger D, Lee J, McClellan M. Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation 2005; 112 (17) 2634-2641
    CrossrefPubMedGoogle Scholar
  • 12 Howell EA, Hebert P, Chatterjee S, Kleinman LC, Chassin MR. Black/white differences in very low birth weight neonatal mortality rates among New York City hospitals. Pediatrics 2008; 121 (03) e407-e415
    CrossrefPubMedGoogle Scholar
  • 13 Howell EA, Egorova N, Balbierz A, Zeitlin J, Hebert PL. Black-White differences in severe maternal morbidity and site of care. Am J Obstet Gynecol 2016; 214 (01) 122.e1-122.e7
    CrossrefPubMedGoogle Scholar
  • 14 Creanga AA, Bateman BT, Mhyre JM, Kuklina E, Shilkrut A, Callaghan WM. Performance of racial and ethnic minority-serving hospitals on delivery-related indicators. Am J Obstet Gynecol 2014; 211 (06) 647.e1-647.e16
    CrossrefPubMedGoogle Scholar
  • 15 Main EK, Chang SC, Cheng YW, Rosenstein MG, Lagrew DC. Hospital-level variation in the frequency of cesarean delivery among nulliparous women who undergo labor induction. Obstet Gynecol 2020; 136 (06) 1179-1189
    CrossrefPubMedGoogle Scholar
  • 16 Sebastião YV, Womack L, Vamos CA. et al. Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida. Am J Obstet Gynecol 2016; 214 (01) 123.e1-123.e18
    CrossrefPubMedGoogle Scholar
  • 17 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 2020; 8 (05) 1273-1280
    CrossrefPubMedGoogle Scholar
  • 18 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
    CrossrefPubMedGoogle Scholar
  • 19 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
    CrossrefPubMedGoogle Scholar
  • 20 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
    CrossrefPubMedGoogle Scholar
  • 21 Center for Disease Control and Prevention. Severe maternal morbidity in the United States. Accessed November 12, 2020 at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html
    PubMedGoogle Scholar
  • 22 Center for Disease Control and Prevention. Maternal mortality. Accessed March 1, 2021 at: https://www.cdc.gov/reproductivehealth/maternal-mortality/index.html
    PubMedGoogle Scholar
  • 23 Moaddab A, Dildy GA, Brown HL. et al. Health care disparity and state-specific pregnancy-related mortality in the United States, 2005-2014. Obstet Gynecol 2016; 128 (04) 869-875
    CrossrefPubMedGoogle Scholar
  • 24 Leonard SA, Main EK, Scott KA, Profit J, Carmichael SL. Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Ann Epidemiol 2019; 33: 30-36
    CrossrefPubMedGoogle Scholar
  • 25 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
    CrossrefPubMedGoogle Scholar
  • 26 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
  • 27 National Center for Health Statistics. Final natality data. Accessed July 6, 2021 at: www.marchofdimes.org/peristats
    PubMedGoogle Scholar
  • 28 Wikipedia. Teaching hospitals in California. Accessed December 1, 2021 at: https://en.wikipedia.org/wiki/Category:Teaching_hospitals_in_California
    PubMedGoogle Scholar
  • 29 Snowden JM, Cheng YW, Kontgis CP, Caughey AB. The association between hospital obstetric volume and perinatal outcomes in California. Am J Obstet Gynecol 2012; 207 (06) 478.e1-478.e7
    CrossrefPubMedGoogle Scholar
  • 30 Jha AK, Orav EJ, Li Z, Epstein AM. Concentration and quality of hospitals that care for elderly black patients. Arch Intern Med 2007; 167 (11) 1177-1182
    CrossrefPubMedGoogle Scholar
  • 31 López L, Jha AK. Outcomes for whites and blacks at hospitals that disproportionately care for black Medicare beneficiaries. Health Serv Res 2013; 48 (01) 114-128
    CrossrefPubMedGoogle Scholar
  • 32 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
  • 33 Fishel Bartal M, Chen HY, Mendez-Figueroa H, Wagner SM, Chauhan SSP. Racial and ethnic disparities in primary cesarean birth and adverse outcomes among low-risk nulliparous people. Obstet Gynecol 2022; 140 (05) 842-852
    CrossrefPubMedGoogle Scholar
  • 34 Brazier E, Borrell LN, Huynh M, Kelly EA, Nash D. Variation and racial/ethnic disparities in cesarean delivery at New York City hospitals: the contribution of hospital-level factors. Ann Epidemiol 2022; 73: 1-8
    CrossrefPubMedGoogle Scholar