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Unequal Motherhood: Racial-Ethnic and Socioeconomic Disparities in Cesarean Sections in the United States
Abstract and Figures
Disparities in cesarean rates in the United States represent an important social problem because cesareans are related to maternal deaths and to the high cost of American health care. There are pervasive racial-ethnic and socioeconomic disparities in maternity care as in health care more generally, yet there has been little scrutiny of how overuse of cesarean deliveries might be linked to these disparities. There are at least two possibilities when it comes to c-sections: black, Hispanic, Native American, and low socioeconomic status (SES) mothers could be less likely to have needed cesareans, leading to more negative outcomes for both mothers and babies, or they could be more likely to have medically unnecessary cesareans, leading to more negative outcomes as a result of the surgery itself. This research uses data on all recorded births in the United States in 2006 to analyze differences in the odds of a cesarean delivery by race-ethnicity and SES. The analysis reveals that non-Hispanic black, Hispanic/Latina, and Native American mothers are more likely to have cesarean deliveries than non-Hispanic white or Asian mothers. Also, after accounting for medical indications, increasing education is associated with a decline in odds of a cesarean delivery, especially for non-Hispanic whites. The results suggest that high cesarean rates are an indicator of low-quality maternity care, and that women with racial and socioeconomic advantages use them to avoid medically unnecessary cesarean deliveries rather than to request them.
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... Additionally, trends of chronic comorbidities may vary across US census regions and urbanicity [12,13]. Because these factors have been shown to increase the risk of pregnancy-related health complications, they ultimately contribute to higher rates of medically necessary CS [14,15]. ...
Context
Cesarean sections (CSs) can reduce maternal and fetal risk in medically necessary cases. However, studies show that CSs are associated with negative fetal outcomes, including birth defects, low birth weight, delayed fetal resuscitation, neonatal acidosis, and even infant mortality. Maternal comorbidities play a role in determining if a CS is necessary and may contribute to negative fetal outcomes following a CS.
Objectives
The primary objective of this study was to determine the prevalence of negative fetal outcomes such as low birth weight, birth defects, prolonged hospital stay, and infant mortality in CS deliveries and their increased risk of occurrence among mothers with comorbidities.
Methods
We conducted a cross-sectional study of the Phase 8 (2016–2019) Pregnancy Risk Assessment Monitoring System (PRAMS) to assess the associations of the aforementioned birth outcomes with pre-existing conditions such as high blood pressure (HBP), depression, and type II diabetes mellitus, as well as demographic factors in the United States (US).
Results
Our findings showed that mothers who delivered via CS with pre-existing or gestational HBP, or gestational diabetes, were less likely to experience infant mortality (adjusted odds ratio [AOR]: 0.4; confidence interval [CI]: 0.17–0.92, AOR: 0.2; CI: 0.09–0.44, and AOR: 0.09; CI: 0.03–0.33, respectively). However, mothers who delivered via CS with pre-existing or gestational diabetes, pre-existing or gestational HBP, or pre-existing or gestational depression had higher rates of prolonged infant hospital stay (AOR: 1.73; CI: 1.41–2.11, AOR: 1.21; CI: 1.05–1.39, AOR: 1.77; CI: 1.5–2.09, AOR: 2.58; CI: 2.31–2.88, AOR: 1.25; CI: 1.09–1.43 and AOR: 1.33; CI: 1.16–1.52, respectively). Likewise, mothers who delivered via CS with pre-existing or gestational HBP, or pre-existing or gestational depression, were more likely to deliver an infant with low birth weight (AOR: 1.88; CI: 1.62–2.19, AOR: 2.7; CI: 2.45–2.98, AOR: 1.24; CI: 1.09–1.41, and OR: 1.28; CI: 1.14–1.42, respectively).
Conclusions
Our study revealed a lower incidence of infant mortality following CS deliveries among mothers with pre-existing or gestational HBP, or gestational diabetes. This suggests a potential benefit in antenatal testing in mothers experiencing depression or those with no comorbidities. Additionally, infants born to mothers with these comorbidities experienced longer hospital stays, and infants of mothers with pre-existing or gestational HBP and depression had a higher incidence of low birth weight. Given the increasing rates of diabetes, HBP, and depression in the US, it is crucial to provide healthcare professionals with the necessary guidance to prevent and manage these comorbidities and improve fetal outcomes following CS deliveries.
En Suisse, un accouchement sur trois est une césarienne. Ce taux contraste avec les critiques émises par les organismes de santé publique et certain·e·s praticien·ne·s concernant l’interventionnisme obstétrical, cause de iatrogénie et vécu de manière délétère par les parents. Des hôpitaux suisses ont introduit les césariennes « participatives » dans le but de renforcer l’agentivité des parents, toutefois restreinte par les normes institutionnelles. Fondé sur une ethnographie combinant des observations lors de consultations prénatales dans deux hôpitaux publics et des entretiens approfondis avec des obstétricien·ne·s, des anesthésistes (médecins et infirmièr·e·s) et des sages-femmes, cet article examine la mise en œuvre de la césarienne « participative » dans des maternités suisses romandes et le dialogue transdisciplinaire qu’elle a suscité. S’inscrivant dans la continuité du mouvement pour l’humanisation de la naissance, cette nouvelle modalité de césarienne montre également les continuités et les limites de cette évolution.
OBJECTIVE
To estimate the association between doula support and cesarean delivery compared with standard of care.
DATA SOURCES
We conducted a systematic review of randomized controlled trials (RCTs) and observational studies comparing in-person intrapartum doula support with standard care. We searched studies published in Ovid Medline, Embase.com, Scopus, Cochrane Central, and ClinicalTrials.gov before August 30, 2024. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, low 5-minute Apgar score, and regional anesthesia.
METHODS OF STUDY SELECTION
Titles, abstracts, and articles were screened and reviewed by two authors. Eighteen studies were included in the final analysis (n=367,662): eight RCTs (n=2,497) and 10 observational studies (n=365,165). The primary analysis was restricted to RCTs. Additional analyses were limited to studies that were observational, high quality (Downs and Black quality score in top quartile), or RCTs conducted in the United States.
TABULATION, INTEGRATION, AND RESULTS
Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean difference. Heterogeneity was assessed with the Cochran Q test and I ² statistic. Intrapartum doula support was associated with a lower rate of cesarean delivery compared with standard care in RCTs (n=7, 17.5% doula support vs 23.6% standard care, pooled RR 0.71, 95% CI, 0.53–0.95). However, there were substantial study heterogeneity ( I ² =60.1%) and borderline evidence of small-study effects, which could suggest publication bias (Harbord test P =.046). Patients receiving intrapartum doula support in RCTs had significantly lower rates of operative vaginal delivery (n=5, 7.9% doula support vs 13.2% standard care, pooled RR 0.64, 95% CI, 0.44–0.94, I ² =46.0%) but no difference in low 5-minute Apgar score (n=3, 1.6% doula support vs 4.1% standard care, pooled RR 0.47, 95% CI, 0.16–1.34; I ² =0%) or regional anesthesia (n=7, 57.3% doula support vs 69.5% standard care, pooled RR 0.64, 95% CI, 0.36–1.12, I ² =98.75%). Findings were similar in a sensitivity analysis limited to high-quality studies. Doula support was associated with lower cesarean delivery rates among all subgroup analyses except RCTs in the United States (four studies, 16.1% doula support vs 22.2% standard care, pooled RR 0.71, 95% CI, 0.47–1.06).
CONCLUSION
Intrapartum doula support was associated with lower rates of cesarean delivery. Results were consistent across study types and when limited to high quality studies; however, significant heterogeneity and concern for publication bias were noted.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42023423577.
In the US, there is substantial variability in low-risk cesarean birth rate by hospitals and race/ethnicity. The contribution of inequitable hospital quality to disparities in low-risk cesarean births is uncertain. We examine the contribution of birth hospital to racial/ethnic disparities in low-risk cesarean births.
We used vital records linked with maternal birth hospitalization data (California, 2007–18). We examined self-reported race/ethnicity and low-risk cesarean birth, i.e., nulliparous, term, singleton, and vertex (NTSV) births. Poisson regression models with a mixed effect for hospital and bootstrapped errors were used to compare racial/ethnic differences in cesarean prevalence, adjusted for maternal and hospital characteristics. We used G-computation to assess how the prevalence of cesarean section by racial/ethnic group would change if all births occurred at the same distribution of hospitals as births to White individuals.
Among 1,594,277 NTSV births at 212 hospitals, 26.9% were cesarean. After adjustment for hospital characteristics, risk ratios for cesarean birth ranged from 1.05 for foreign-born Hispanic (95% CI 1.02–1.09) to 1.28 for Black (95% CI 1.22–1.33) individuals, relative to White individuals. In the G-computation substitution, cesarean prevalence among NTSV births was reduced for some race/ethnicities and increased for others, ranging from 87 excess events (0.3% increase) in Black populations to 6473 avoided events (5.6% decrease) among US-born Hispanic populations.
Racial/ethnic disparities in cesarean prevalence among low-risk births in California are not explained by individual-level maternal or hospital characteristics.
To evaluate race and ethnicity differences in rates of cesarean delivery on maternal request (CDMR) in nulliparous, term, singleton, vertex presentation (NTSV) cesarean deliveries.
We conducted a retrospective cohort study of NTSV cesarean deliveries within our institution from 2016 to 2020. The primary outcome was CDMR and the primary predictor was maternal race and ethnicity. Multivariable logistic regression models were used to evaluate associations between race and ethnicity, CDMR, and various maternal and perinatal factors.
Among 12,351 NTSV cesarean deliveries, 594 (4.81%) underwent CDMR; 4605 (37.28%) identified as non-Hispanic White, 3731 (30.21%) as Asian/Hawaiian/Pacific Islander, 2840 (22.99%) as Hispanic, 785 (6.36%) as Black, and 390 (3.16%) as multiple races/American Indian/Alaskan Native. Adjusted models showed increased odds of CDMR among non-Hispanic White people. Multiple races/American Indian/Alaskan Native people had the lowest odds of CDMR compared to non-Hispanic White people (adjusted OR [aOR] = 0.48, 95% CI 0.26–0.82), followed by Asian/Hawaiian/Pacific Islander (aOR = 0.58, 95% CI 0.47–0.72), Black (aOR = 0.61, 95% CI 0.40–0.89), and Hispanic (aOR = 0.70, 95% CI 0.55–0.88) people.
Non-Hispanic White people undergo CDMR more frequently compared to Asian/Hawaiian/Pacific Islander, Black, and Hispanic people. Our findings are notable in light of the growing body of research demonstrating that White people have the lowest odds of cesarean delivery overall.
Profound racial disparities in maternal obstetric outcomes exist in the United States. It is well established that non-Hispanic Black people have disproportionately higher cesarean birth rates and higher rates of birth complications, including maternal death. Racial and ethnic differences in rates of primary elective cesarean delivery, or cesarean delivery on maternal request, are not well understood. This research shows that non-Hispanic White people have more cesarean deliveries on maternal request than other racial and ethnic groups among low-risk nulliparous patients.
Objective
To examine racial inequities in low‐risk and high‐risk (or “medically appropriate”) cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak.
Study Setting and Design
This retrospective repeated cross‐sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed‐level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM).
Data Sources and Analytic Sample
We used all‐payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP‐code Tabulation Area (ZCTA)‐level racialized economic segregation index data were from the 2007–2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases‐9‐CM (ICD‐9) diagnosis and procedure codes and Diagnosis‐Related Group codes, and created an indicator of cesarean delivery using ICD‐9 codes.
Principal Findings
Among low‐risk deliveries, Black patients, particularly those in the age group of 35–39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black‐adjusted predicted probability = 24.0%; vs. White‐adjusted predicted probability = 17.3%). Among high‐risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts.
Conclusions
This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low‐risk Black patients at higher odds of cesarean delivery and high‐risk Black patients at lower odds of cesarean than their White counterparts. The significant Black‐White inequities highlight the need to address misalignment of evidence‐based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients.
Background
It is known that cesarean birth affects maternal outcomes in subsequent pregnancies, but specific effect estimates are lacking. We sought to quantify the effect of cesarean birth reduction among nulliparous, term, singleton, vertex (NTSV) births ( i.e., preventable cesarean births) on severe maternal morbidity (SMM) in the second birth.
Methods
We examined birth certificates linked with maternal hospitalization data (2007-19) from California for NTSV births with a second birth (N = 779,382). The exposure was cesarean delivery in first birth and the outcome was SMM in the second birth. We used adjusted Poisson regression models to calculate risk ratios and population attributable fraction for SMM in the second birth and conducted a counterfactual impact analysis to estimate how lowering NTSV cesarean births could reduce SMM in second birth.
Results
The adjusted risk ratio for SMM in the second birth given a prior cesarean birth was 1.7 (95% CI 1.5-1.9); 15.5% (95% CI 15.3%-15.7%) of this SMM may be attributable to prior cesarean birth. In a counterfactual analysis where 12% of the California population least likely to get a cesarean birth instead delivered vaginally, we observed 174 fewer SMM events in a population of individuals with a low-risk first birth and a subsequent birth.
Conclusions
In our counterfactual analysis, lowering primary cesarean birth among a NTSV population was associated with fewer downstream SMM events in subsequent births and overall. Additionally, our findings reflect the importance of considering the cumulative accrual of risks across the reproductive life-course.
Our objective was to assess the relationship of socioeconomic disadvantage and race/ethnicity with low-risk cesarean birth. We examined birth certificates (2007-18) linked with maternal hospitalization data from California; the outcome was cesarean birth among low-risk deliveries (i.e., nulliparous, term, singleton, vertex [NTSV]). We used GEE Poisson regression with an interaction term for race/ethnicity (7 groups) and a measure of socioeconomic disadvantage (census tract-level neighborhood deprivation index [NDI], education, or insurance). Among 1,815,933 NTSV births, 26.6% were cesarean. When assessing the joint effect of race/ethnicity and socioeconomic disadvantage among low-risk births, risk of cesarean birth increased with socioeconomic disadvantage for most racial/ethnic groups, and disadvantaged Black individuals had the highest risks; e.g., Black individuals with a high school education or less had a risk ratio of 1.49 (95% CI 1.45-1.53), relative to White individuals with a college degree. The disparity in risk of cesarean birth between Black and White individuals was observed across all strata of socioeconomic disadvantage. Asian American and Hispanic individuals had higher risks than White individuals at lower socioeconomic disadvantage; this disparity was not observed at higher levels of disadvantage. Black individuals have a persistent, elevated risk of cesarean birth, relative to White individuals, regardless of socioeconomic disadvantage.
Context The prevalence of obesity and overweight increased in the United States
between 1978 and 1991. More recent reports have suggested continued increases
but are based on self-reported data.Objective To examine trends and prevalences of overweight (body mass index [BMI]
≥25) and obesity (BMI ≥30), using measured height and weight data.Design, Setting, and Participants Survey of 4115 adult men and women conducted in 1999 and 2000 as part
of the National Health and Nutrition Examination Survey (NHANES), a nationally
representative sample of the US population.Main Outcome Measure Age-adjusted prevalence of overweight, obesity, and extreme obesity
compared with prior surveys, and sex-, age-, and race/ethnicity–specific
estimates.Results The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared
with 22.9% in NHANES III (1988-1994; P<.001).
The prevalence of overweight also increased during this period from 55.9%
to 64.5% (P<.001). Extreme obesity (BMI ≥40)
also increased significantly in the population, from 2.9% to 4.7% (P = .002). Although not all changes were statistically significant,
increases occurred for both men and women in all age groups and for non-Hispanic
whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did
not differ significantly in the prevalence of obesity or overweight for men.
Among women, obesity and overweight prevalences were highest among non-Hispanic
black women. More than half of non-Hispanic black women aged 40 years or older
were obese and more than 80% were overweight.Conclusions The increases in the prevalences of obesity and overweight previously
observed continued in 1999-2000. The potential health benefits from reduction
in overweight and obesity are of considerable public health importance.
As the cesarean rate rises in the United States, it is sometimes hailed as a move toward increased safety or increased autonomy. But the industrialization of birth may have consequences which actually decrease women’s autonomy and strip choices away.
In this rare, behind-the-scenes look at what goes on in hospitals across the country, a longtime medical insider and international authority on childbirth assesses the flawed American maternity care system, powerfully demonstrating how it fails to deliver safe, effective care for both mothers and babies. Written for mothers and fathers, obstetricians, nurses, midwives, scientists, insurance professionals, and anyone contemplating having a child, this passionate exposé documents how, in the most expensive maternity care system in the world, women have lost control over childbirth and what the disturbing results of this phenomenon have been. Born in the USA examines issues including midwifery and the safety of out-of-hospital birth, how the process of becoming a doctor can adversely affect both practitioners and their patients, and why there has been a rise in the use of risky but doctor-friendly interventions, including the use of Cytotec, a drug that has not been approved by the FDA for pregnant women. Most importantly, this gripping investigation, supported by many troubling personal stories, explores how women can reclaim the childbirth experience for the betterment of themselves and their children.
In this rare, behind-the-scenes look at what goes on in hospitals across the country, a longtime medical insider and international authority on childbirth assesses the flawed American maternity care system, powerfully demonstrating how it fails to deliver safe, effective care for both mothers and babies. Written for mothers and fathers, obstetricians, nurses, midwives, scientists, insurance professionals, and anyone contemplating having a child, this passionate exposé documents how, in the most expensive maternity care system in the world, women have lost control over childbirth and what the disturbing results of this phenomenon have been. Born in the USA examines issues including midwifery and the safety of out-of-hospital birth, how the process of becoming a doctor can adversely affect both practitioners and their patients, and why there has been a rise in the use of risky but doctor-friendly interventions, including the use of Cytotec, a drug that has not been approved by the FDA for pregnant women. Most importantly, this gripping investigation, supported by many troubling personal stories, explores how women can reclaim the childbirth experience for the betterment of themselves and their children.
To examine the association between excessive prepregnancy weight and adverse outcomes, with a focus on women weighing over 200 lbs (91 kg) before pregnancy.
OBJECTIVE:: To examine trends in the rates of severe obstetric complications and the potential contribution of changes in delivery mode and maternal characteristics to these trends. METHODS:: We performed a cross-sectional study of severe obstetric complications identified from the 1998-2005 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regression was used to examine the effect of changes in delivery mode and maternal characteristics on rates of severe obstetric complications. RESULTS:: The prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n≤48,645) in 1998-1999 to 0.81% (n≤68,433) in 2004-2005. Rates of complications that increased significantly during the study period included renal failure by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57). In logistic regression models, adjustment for maternal age had no effect on the increased risk for these complications in 2004-2005 relative to 1998-1999. However, after adjustment for mode of delivery, the increased risks for these complications in 2004-2005 relative to 1998-1999 were no longer significant, with the exception of pulmonary embolism (odds ratio 1.30) and blood transfusion (odds ratio 1.72). Further adjustment for payer, multiple births, and select comorbidities had little effect. CONCLUSION:: Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery. © 2009 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins.