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
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Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.
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Indications for unplanned cesarean delivery differed significantly among racial and
ethnic groups.
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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
