Racial and Ethnic Differences in Indication for Primary Cesarean Delivery at Term: Experience at One U.S. Institution

Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana.
Birth (Impact Factor: 1.26). 06/2012; 39(2):128-34. DOI: 10.1111/j.1523-536X.2012.00530.x
Source: PubMed


Black and Latina women in the United States are known to undergo cesarean delivery at a higher rate than other women. We sought to explore the role of medical indications for cesarean delivery as a potential explanation for these differences.
A retrospective cohort study was conducted of 11,034 primiparas delivering at term at the University of California, San Francisco, between 1990 and 2008. We used multivariable analyses to evaluate racial and ethnic differences in risks of, and indications for, cesarean delivery.
The overall rate of cesarean delivery in our cohort was 21.9 percent. Black and Latina women were at significantly higher odds of undergoing cesarean delivery than white women (adjusted odds ratio or AOR: 1.54; 95% CI: 1.30, 1.83, and 1.21; 95% CI: 1.03, 1.43, respectively). Black women were at significantly higher odds of undergoing cesarean delivery for nonreassuring fetal heart tracings than white women (AOR: 2.19; 95% CI: 1.55, 3.09), and black women (AOR: 1.55; 95% CI: 1.21, 1.98), Latina women (AOR: 1.48; 95% CI: 1.19, 1.85), and Asian women (AOR: 1.47; 95% CI: 1.22, 1.85) were at significantly higher odds of undergoing cesarean delivery for failure to progress. Black, Latina, and Asian women were at significantly lower odds of undergoing cesarean delivery for malpresentation than white women (AOR: 0.56; 95% CI: 0.34, 0.89, 0.66; 95% CI: 0.44, 0.98, and 0.55; 95% CI: 0.40, 0.76, respectively).
Racial and ethnic differences exist in specific indications for cesarean delivery among primiparas. Clarifying the possible reasons for increased cesareans for nonreassuring fetal heart tracing in black women, in particular, may help to decrease excess cesarean deliveries in this racial and ethnic group. (BIRTH 39:2 June 2012).

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    • "Our finding of higher risk of CD for fetal distress among Black women is consistent with those of two studies from California [4,23]. Getahun, et al.’s study, based on data from Kaiser Permanente Southern California over 17 years, found Black women had higher rates of more subjective indications such as fetal distress and ‘other indications’, compared with White, Hispanic, and Asian/Pacific Islander women. "
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    ABSTRACT: Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three is now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center. A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006--2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups. The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor. Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.
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    ABSTRACT: Our objective was to examine differences in risk of cesarean delivery among diverse ethnic groups in New York City. Using cross-sectional New York City birth and hospitalization data from 1995 to 2003 (n = 961,381) we estimated risk ratios for ethnic groups relative to non-Hispanic whites and immigrant women relative to US-born women. Adjusting for insurance, pre-pregnancy weight, maternal age, education, parity, birthweight, gestational age, year, medical complications, and pregnancy complications, all ethnic groups except East Asian women were at an increased risk of cesarean delivery, with the highest risk among Hispanic Caribbean women [adjusted risk ratio (aRR) = 1.27, 95 % CI (confidence interval) = 1.24, 1.30] and African American women (aRR = 1.20, 95 % CI = 1.17, 1.23). Among Hispanic groups, immigrant status further increased adjusted risk of cesarean delivery; adjusted risk ratios for foreign-born women compared to US-born women of the same ethnic group were 1.27 for Mexican women (95 % CI = 1.05, 1.53), 1.23 for Hispanic Caribbean women (95 % CI = 1.20, 1.27), and 1.12 for Central/South American women (95 % CI = 1.04, 1.21). Similar patterns were found in subgroup analyses of low-risk women (term delivery and no pregnancy or medical complications) and primiparous women. We found evidence of disparities by ethnicity and nativity in cesarean delivery rates after adjusting for multiple risk factors. Efforts to reduce rates of cesarean delivery should address these disparities. Future research should explore potential explanations including hospital environment, provider bias, and patient preference.
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    ABSTRACT: Background Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts.Methods Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified “American” mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research.ResultsWhile 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09–1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66–0.92), compared with self-identified “Americans.” Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and “Other” women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12–1.47), while there were no differences for Asian or Pacific Islander women.Conclusions Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.
    Full-text · Article · Apr 2014 · Birth
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