Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates

Abstract

We sought to examine racial/ethnic differences in deliveries by caesarean section (CS) over time, particularly among women at low risk for this procedure. To do so, we conducted a retrospective cohort study at the University of California, San Francisco, a tertiary care academic centre. Births occurring between 1980 and 2001 were included in the analyses. Women with multiple gestations, fetuses in other than the cephalic presentation or with other known contraindications to vaginal birth were excluded. A total of 28 493 African American, Asian, Latina and White women were studied. Risk-adjusted models were created to explore differences in CS risk by race/ethnicity. We also performed analyses of subgroups of women at relatively low risk of CS, and explored changes in observed disparities over time. The overall CS rate was 15.8%. The absolute rate was highest among Latinas (16.7%) and lowest among Asians (14.7%). After adjustment for known risk factors, African American women had a 1.48 times greater odds of having a CS than did White women [95% confidence interval (CI) 1.31, 1.68], and Latina women had a 1.19 times greater odds [95% CI 1.05, 1.34]. Stepwise adjustment for confounders showed that this variation is not entirely explained by known risk factors. These differences exist even for women at low risk of CS, and have persisted over time. We conclude that racial and ethnic disparities in CS delivery exist, even among women presumed to be at lower risk of CS; rates have not improved with time. Disparities in risk-adjusted CS should be considered as a quality metric for obstetric care, whether at the national, state, hospital or provider level.

Interpersonal Processes of Care and Cesarean Delivery in Two Health Care Settings

“…As expected, 13 the strongest independent predictor of cesarean delivery was prior cesarean delivery. Although the American College of Obstetricians and Gynecologists recommends that most pregnant women with a history of 1 low, transverse cesarean delivery should be counseled to consider vaginal birth after cesarean delivery (VBAC), 9 we found that VBAC was very uncommon.…”

Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates

“…10,12 Yet, the reasons for these disparities in overall rate and indication remain unknown. 10,11,32 Although some have hypothesized minority women are at greater risk of cesarean delivery for “subjective” indications such as NRFS, 10 our data do not support this hypothesis. This finding is consistent with data from a 1997–2002 California cohort in which, although specific labor and delivery practices could not be examined, racial differences in cesarean delivery rate were not fully explained by delivery hospital or physician.…”

Comparison of intrapartum outcome among immigrant women from Ethiopia and the general obstetric population in Israel

“…Disparities have been suggested to be attributed to differences in healthcare quality, care during pregnancy and labor, and probably birth against a background of distinct genetic influences [13,14]. Disparities were not found to be due to differences in maternal age, parity, socioeconomic status, educational achievement beyond college, marital status, pre-existing chronic disease, gestational age, newborn gender, or birth weight, or to other significant independent predictors of cesarean delivery such as pre-eclampsia or macrosomia [17,22,23].…”