Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery

Socioeconomic disadvantage and racial/ethnic disparities in low-risk cesarean birth in California

Our objective was to assess the relationship of socioeconomic disadvantage and race/ethnicity with low-risk cesarean birth. We examined birth certificates (2007-2018) linked with maternal hospitalization data from California; the outcome was cesarean birth among low-risk deliveries (ie, nulliparous, term, singleton, vertex [NTSV]). We used generalized estimation equation Poisson regression with an interaction term for race/ethnicity (n = 7 groups) and a measure of socioeconomic disadvantage (census tract-level neighborhood deprivation index, education, or insurance). Among 1 815 933 NTSV births, 26.6% were by cesarean section. 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. For example, 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.

A Counterfactual Analysis of Impact of Cesarean Birth in a First Birth on Severe Maternal Morbidity in the Subsequent Birth

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 (2007-2019) from California for NTSV births with a second birth (N = 779,382). The exposure was cesarean delivery in the 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 the second birth.

RESULTS

The adjusted risk ratio for SMM in the second birth given a prior cesarean birth was 1.7 (95% confidence interval: 1.5, 1.9); 15.5% (95% confidence interval: 15.3%, 15.7%) of this SMM may be attributable to prior cesarean birth. In a counterfactual analysis where 12% of the California population was 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 subsequent birth.

CONCLUSION

In our counterfactual analysis, lowering primary cesarean birth among an 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.

Mode of Delivery and Unplanned Cesarean: Differences in Rates and Indication by Race, Ethnicity, and Sociodemographic Characteristics

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

· Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.. · Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.. · There may be unmeasured provider level factors which contribute to disparities in cesarean rates..

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

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..

Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time?

OBJECTIVE

The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017.

METHODS

This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders.

RESULTS

A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2-1.3). From 2011 to 2017, the CD rate fell 11% (26.4-23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4-30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1-1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9-0.9 and 0.3-0.5).

CONCLUSION

The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people.

PRECIS

Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017.

KEY POINTS

· Black birthing people are more likely to undergo CD than White despite controlling for confounders.. · There are unexplained differences in CD indication among Black and White birthing people.. · These disparities persisted from 2011 to 2017 despite increasing efforts to decrease CD rates in CA..

Racial and Ethnic Disparities in Primary Cesarean Birth and Adverse Outcomes Among Low-Risk Nulliparous People

OBJECTIVE

To compare trend of primary cesarean delivery rate and composite neonatal and maternal adverse outcomes in low-risk pregnancies among racial and ethnic groups: non-Hispanic White, non-Hispanic Black, and Hispanic.

METHODS

This population-based cohort study used U.S. vital statistics data (2015-2019) to evaluate low-risk, nulliparous patients with nonanomalous singletons who labored and delivered at 37-41 weeks of gestation. The primary outcome was the primary cesarean delivery rate. Secondary outcomes included composite neonatal adverse outcome (Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure, or death), and composite maternal adverse outcome (intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy), as well as infant death. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% CIs.

RESULTS

Among 4.3 million births, 60.6% identified as non-Hispanic White, 14.6% identified as non-Hispanic Black, and 24.8% identified as Hispanic. The rate of primary cesarean delivery was 18.5% (n=804,155). An increased risk for cesarean delivery was found in non-Hispanic Black (21.7%, aRR 1.24, 95% CI 1.23-1.25) and Hispanic (17.3%, aRR 1.09, 95% CI 1.09-1.10) individuals, compared with non-Hispanic White individuals (18.1%) after multivariable adjustment. There was an upward trend in the rate of primary cesarean delivery in all racial and ethnic groups ( P for linear trend<0.001 for all groups). However, the racial and ethnic disparity in the rate of primary cesarean delivery remained stable during the study period. The composite neonatal adverse outcome was lower in Hispanic individuals in all newborns (10.7 vs 8.3 per 1,000 live births, aRR 0.74, 95% CI 0.72-0.75), and in newborns delivered by primary cesarean delivery (18.5 vs 15.0 per 1,000 live births, aRR 0.73, 95% CI 0.70-0.76), compared with non-Hispanic White individuals.

CONCLUSION

Using a nationally representative sample in the United States, we found racial and ethnic disparities in the primary cesarean delivery rate in low-risk nulliparous patients, which persisted throughout the study period.

Maternal education and racial/ethnic disparities in nulliparous, term, singleton, vertex cesarean deliveries in the United States

BACKGROUND

Racial and ethnic disparities in obstetrical and neonatal outcomes are prevalent in the United States. Such racial or ethnic disparities have also been documented in the prevalence of cesarean deliveries.

OBJECTIVE

We aimed to evaluate the impact of maternal education on racial or ethnic disparities in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States.

STUDY DESIGN

This is a retrospective analysis of the Centers for Disease Control and Prevention live births database (2016–2019). Nulliparous, term, singleton, vertex births from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. Pregnancies complicated by gestational or pregestational diabetes mellitus and hypertensive disorders were excluded. Data were analyzed on the basis of the level of maternal education (less than high school graduate, high school graduate, college graduate, and advanced degree). We compared the prevalence of cesarean deliveries among the different racial or ethnic groups within each education level using Pearson chi-square test with Bonferroni adjustment. Multivariate logistic regression was performed to assess the association between cesarean deliveries and maternal race/ethnicity, maternal education, and the interaction between maternal race or ethnicity and education level, while controlling for potential confounders. To demonstrate the effect of the interaction, separate logistic regression models with similar covariates were performed for each education level and for each race/ethnicity group. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios with 95% confidence intervals.

RESULTS

The overall prevalence of cesarean deliveries during the study period was 23.4% (695,214 of 2,969,207 births). All racial or ethnic minority groups had higher rates of cesarean deliveries than non-Hispanic White women (non-Hispanic Black, 27.4%; non-Hispanic Asian, 25.6%; Hispanic, 23.0%; and non-Hispanic White, 22.4%; [P<.001 for all comparisons]). Similar racial or ethnic differences in cesarean delivery rates were detected among all education levels. Higher levels of education were associated with a lower likelihood of cesarean delivery (adjusted odds ratio, 0.88; [95% confidence interval, 0.87–0.89]) in women with advanced degrees than in women who did not graduate from high school. However, although maternal education was associated with a protective effect in non-Hispanic White and non-Hispanic Asian women (adjusted odds ratio, 0.83 [95% confidence interval, 0.81–0.85] and adjusted odds ratio, 0.81 [95% confidence interval, 0.77–0.86], respectively, for women with advanced degrees), it had a smaller protective effect in non-Hispanic Black women (adjusted odds ratio, 0.93 [95% confidence interval, 0.89–0.97]) and no protective effect in Hispanic women (adjusted odds ratio, 0.98 [95% confidence interval, 0.96–1.01]).

CONCLUSION

We document a significant racial/ethnic disparity in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. Furthermore, our findings suggest that although a higher level of maternal education is associated with a lower likelihood of cesarean delivery, this protective effect varies among racial or ethnic groups. Further research is needed to investigate the underlying causes for this racial/ethnic disparity.

The Association between Maternal Race and Ethnicity and Risk Factors for Primary Cesarean Delivery in Nulliparous Women

OBJECTIVE

To understand whether maternal, perinatal, and systems-level factors can be identified to explain racial/ethnic disparities in cesarean delivery rates.

STUDY DESIGN

This retrospective cohort study included nulliparous women with singleton gestations who delivered at a tertiary care center from 2015 to 2017. Maternal, perinatal, and systems-level factors were compared by race/ethnicity. Multilevel multivariable logistic regression was used to identify whether race/ethnicity was independently associated with cesarean. Effect modification was evaluated using interaction terms. Bivariable analyses and multinomial logistic regression were used to determine differences in indication for cesarean.

RESULTS

Of 9,865 eligible women, 2,126 (21.5%) delivered via cesarean. The frequency of cesarean was lowest in non-Hispanic white women (19.2%) and highest in non-Hispanic black women (28.2%; p < 0.001). Accounting for factors associated with cesarean delivery did not lessen the odds of cesarean associated with non-Hispanic black race (aOR: 1.58, 95% CI: 1.31-1.91). Compared with non-Hispanic white women, non-Hispanic black women were more likely to undergo cesarean for nonreassuring fetal status (aOR: 2.73, 95% CI: 2.06-3.61).

CONCLUSION

Examined maternal, perinatal, and systems-level risk factors for cesarean delivery did not explain the racial/ethnic disparities observed in cesarean delivery rates. Increased cesarean delivery for nonreassuring fetal status contributed substantially to this disparity.

Mediating Effects of Cardiometabolic Risk Factors on the Association Between Maternal Race-Ethnicity and Cesarean Delivery Among Low-Risk Women

Background: While racial-ethnic disparities in cesarean delivery rates among nulliparous women delivering a term singleton in the vertex position (NTSV) exist, it remains unclear the extent to which potentially modifiable maternal cardiometabolic risk factors (obesity, maternal hyperglycemia and hypertensive disorders) underlie these disparities. We examined race-ethnicity and risk of NTSV cesarean deliveries and whether the associations were mediated by maternal cardiometabolic risk factors. Materials and Methods: A cohort study of 62,048 NTSV deliveries in Kaiser Permanente Northern California. The outcome was cesarean delivery. Results: Black, Asian, and Hispanic women were at increased risk of having a NTSV cesarean delivery compared with White women (relative risks and 95% confidence intervals: 1.37 [1.28-1.45]; 1.11 [1.07-1.16]; 1.12 [1.07-1.16], respectively), independent of established risk factors and prenatal care utilization. The extent to which cardiometabolic risk factors mediated the associations between race-ethnicity (each group vs. White, in separate analyses) and NTSV cesarean delivery varied by race-ethnicity. Maternal overweight/obesity (body mass index ≥25.0) mediated the association between Black and Hispanic race-ethnicity and NTSV cesarean delivery (21.1% [15.8-26.4] and 24.7% [14.6-34.8, respectively), but not for Asian race. Maternal hyperglycemia (gestational diabetes mellitus or preexisting diabetes) mediated the association between Asian and Hispanic race and NTSV cesarean delivery (18.5% [9.8-27.2] and 9.8% [5.0-14.7], respectively), but not for Black race. Hypertensive disorders mediated 3.2% (0.70-5.8) of the association between Black race and cesarean delivery, but not for other race-ethnicities. Conclusion: Black, Asian, and Hispanic women are at increased risk for NTSV cesarean deliveries. Maternal cardiometabolic risk factors only partially mediate the associations between race-ethnicity and NSTV cesarean deliveries.

Elucidating the role of overweight and obesity in racial and ethnic disparities in cesarean delivery risk

PURPOSE

We aimed to quantify the extent to which overweight and obesity explain cesarean delivery risk among women of different racial and ethnic backgrounds.

METHODS

Using administrative records for 216,481 singleton, nulliparous births in New York City from 2008 to 2013, we calculated risk ratios, risk differences, and population attributable fractions for associations between body mass index (BMI) and cesarean, stratified by race and ethnicity.

RESULTS

The population attributable fraction (95% confidence interval) for BMI was 6.8% (6.2%-7.3%) among Asian, 10.9% (10.4%-11.4%) among White, 14.6% (13.7%-15.5%) among Hispanic, and 17.4% (16.2%-18.6%) among Black women. Although overweight and obesity were most prevalent among Black and Hispanic women, the risk gradient was strongest among Whites (adjusted risk ratio [95% CI] from 1.37 [1.33-1.41] for overweight to 2.23 [2.07-2.39] for class III obesity). Additional adjustment for gestational complications partially attenuated associations, and accounting for delivery hospital eliminated the stronger gradient among White women.

CONCLUSIONS

Prepregnancy overweight and obesity contribute proportionally more to cesarean risk among Black and Hispanic women because of higher prevalence compared to White or Asian women. Although preconception weight management is important to decrease cesarean risk, results encourage attention to clinical approaches in low-risk pregnancies to mitigate racial and ethnic perinatal disparities.

Anaphylaxis in Pregnancy in the United States: Risk Factors and Temporal Trends Using National Routinely Collected Data

BACKGROUND

Anaphylaxis in pregnancy is an understudied, rare, and severe complication of pregnancy.

OBJECTIVE

To describe the incidence and temporal trends, and to identify potential risk factors for anaphylaxis-related hospitalizations while pregnant in the United States.

METHODS

All hospitalizations while pregnant and any anaphylactic reactions were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes from the National Inpatient Sample, United States, over the period 2004 to 2014. Annual incidence rates of anaphylaxis during pregnancy were calculated. Logistic regression models assessed risk factors for anaphylaxis during pregnancy, presented as odds ratios (ORs) and 95% CIs.

RESULTS

During the period 2004 to 2014, the incidence of anaphylaxis during pregnancy was 3.8 (95% CI, 3.4-4.2) per 100,000 hospitalizations while pregnant. The incidence did not statistically differ during the period 2004 to 2014. After adjustment, there were 3 factors that increased the odds of anaphylaxis during pregnancy: cesarean delivery (adjusted OR [aOR], 4.19; 95% CI, 3.28-5.35) compared with noncesarean delivery; history of an allergic reaction (aOR, 4.05; 95% CI, 2.64-6.23) compared with no history; and a black race (aOR, 1.57; 95% CI, 1.15-2.15) and other race (aOR, 1.69; 95% CI, 1.08-2.63) compared with white race.

CONCLUSIONS

Despite increased rates of cesarean delivery in the United States and consequent drug administration, there was no evidence of an increasing trend in anaphylaxis. Cesarean delivery and history of an allergic reaction allow the identification of women at risk of anaphylaxis. Not all women had clear risk factors, and preparations should always be in place to ensure timely management if this uncommon event occurs.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities

BACKGROUND

Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade.

OBJECTIVE

To estimate trends and differences in obstetric quality measures by race/ethnicity.

RESEARCH DESIGN

We used 2008-2014 linked birth certificate-hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated.

RESULTS

ED<39 decreased among whites [AAPC=-2.7; 95% confidence interval (CI), -3.7 to -1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1-2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4-3.4). Low-risk cesarean decreased among whites (AAPC=-2.8; 95% CI, -4.6 to -1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2-4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5-6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period.

CONCLUSIONS

Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.

Placebo effects and racial and ethnic health disparities: an unjust and underexplored connection

While a significant body of bioethical literature considers how the placebo effect might introduce a conflict between autonomy and beneficence, the link between justice and the placebo effect has been neglected. Here, we bring together disparate evidence from the field of placebo studies and research on health inequalities related to race and ethnicity, and argue that, collectively, this evidence may provide the basis for an unacknowledged route by which health disparities are exacerbated. This route is constituted by an uneven distribution of placebo effects, resulting from differences in expressions of physician warmth and empathy, as well as support and patient engagement, across racial and ethnic lines. In a discussion of the ethical implications of this connection, we argue that this contribution to health disparities is a source of injustice, consider ways in which these disparities might be ameliorated and suggest that this conclusion is likely to extend to other realms of inequality as well.

Perceptions of the effects of childbirth on sexuality among nulliparous individuals

BACKGROUND

Media representations of sexuality after childbirth depict vaginal birth as harmful and cesarean delivery as protective, although research does not support these depictions. The objective of the current study was to investigate perceptions of the effects of mode of delivery on sexuality.

METHODS

Nulliparous participants who were able to and interested in giving birth (N = 1428) completed an online survey about their preferences for mode of delivery and their perceptions of childbirth as they specifically relate to sexuality. Participants provided demographic information, rated how influential different sources of information about childbirth were, and completed the Attitudes Toward Women's Genitals Scale.

RESULTS

Up to half (16-48%), the participants agreed with different statements about vaginal birth as harmful to, and cesarean delivery as protective of, future sexuality. Participant characteristics that were independently predictive of endorsing these beliefs were: self-identifying as heterosexual, holding negative attitudes toward women's genitals, and reporting that reality media, nonreality media, and online media sources are influential sources of childbirth information. Participants who rated health care professionals as an influential source of information were less likely to endorse these beliefs.

CONCLUSION

Given that there is no clear evidence in the empirical literature to support the claim that vaginal births are harmful and cesarean delivery is protective to one's future sexual life, it is important to dispel the existing misconceptions. Various media sources likely play a role in the perpetuation of this misinformation.

Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status

OBJECTIVES

Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status.

METHODS

Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms.

RESULTS

Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured.

CONCLUSIONS

There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth.

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

OBJECTIVE

To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity.

METHODS

This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008-2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery.

RESULTS

A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36-1.59; Asian adjusted OR 1.26, 95% CI 1.14-1.40; Hispanic adjusted OR 1.17, 95% CI 1.07-1.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Nonapplication of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or cervical ripening did not contribute to increased odds of cesarean delivery for non-Hispanic black and Hispanic women. Compared with non-Hispanic white women, Hispanic women were actually less likely to experience elective cesarean delivery (adjusted OR 0.60, 95% CI 0.42-0.87) or cesarean delivery for arrest of dilation before 4 hours (adjusted OR 0.67, 95% CI 0.49-0.92). Additionally, compared with non-Hispanic white women, Asian women were more likely to experience cesarean delivery for nonreassuring fetal status (adjusted OR 1.29, 95% CI 1.09-1.53) and to have had that cesarean delivery be performed in the setting of a 1-minute Apgar score 7 or greater (adjusted OR 1.79, 95% CI 1.07-3.00). A similar trend was seen among multiparous women with prior vaginal deliveries.

CONCLUSION

Although racial and ethnic disparities exist in the frequency of cesarean delivery, differential use of labor management strategies intended to reduce the cesarean delivery rate does not appear to be associated with these racial and ethnic disparities.

Maternal Asian ethnicity and obstetric intrapartum intervention: a retrospective cohort study

BACKGROUND

Maternal ethnicity is a recognized risk factor for stillbirth, such that South Asian women have higher rates than their Caucasian counterparts. However, whether maternal ethnicity is a risk factor for intrapartum outcomes is less clear. The aim of this study is to explore associations between maternal country of birth, operative vaginal delivery and emergency cesarean section, and to identify possible mechanisms underlying any such associations.

METHODS

We performed a retrospective cohort study of singleton term births among South Asian, South East/East Asian and Australian/New Zealand born women at an Australian tertiary hospital in 2009-2013. The association between maternal country of birth, operative vaginal birth and emergency cesarean was assessed using multivariate logistic regression.

RESULTS

Of the 31,932 births, 54% (17,149) were to Australian/New Zealand-born women, 25% (7874) to South Asian, and 22% (6879) to South East/East Asian born women. Compared to Australian/New Zealand women, South Asian and South East/East Asian women had an increased rate of both operative vaginal birth (OR 1.43 [1.30-1.57] and 1.22 [1.11-1.35] respectively, p < 0.001 for both) and emergency cesarean section (OR 1.67 [1.53-1.82] and 1.16 [1.04-1.26] respectively, p < 0.001 and p = 0.007 respectively). While prolonged labor was the predominant reason for cesarean section among Australian/New Zealand and South East/East Asian women, fetal compromise accounted for the majority of operative births in South Asian women.

CONCLUSION

South Asian and South East/East Asian women experience higher rates of both operative vaginal birth and cesarean section in comparison to Australian/New Zealand women, independent of other risk factors for intrapartum interventions.

Investigating racial differences in risk factors for primary cesarean delivery

OBJECTIVE

The objective of the study was to investigate differences in sociodemographic, medical, and obstetric risk factors for primary cesarean delivery between black and white women.

STUDY DESIGN

We conducted a retrospective cohort study among 25,251 black and white women delivering a live, singleton infant with vertex presentation at a large, regional hospital between 2004 and 2010. Demographic and clinical data were derived from electronic hospital records. Differences in risk factors for primary cesarean delivery were analyzed using a modified Poisson regression approach stratified by race and parity.

RESULTS

Black and white women had a primary cesarean delivery rate of 24.7% and 22.2%, respectively (P < .001). Black women had an increased risk of cesarean delivery after adjusting for sociodemographic and clinical risk factors (adjusted relative risk [RR], 1.23; 95% confidence interval [CI], 1.17-1.29). Among nulliparas, labor induction had a greater effect on cesarean delivery for black women (adjusted RR, 1.32; 95% CI, 1.20-1.44) than for white women (adjusted RR, 1.13; 95% CI, 1.07-1.20). Among multiparas, labor induction reduced the risk of cesarean delivery for white women (adjusted RR, 0.63; 95% CI, 0.55-0.72), whereas no association was observed for black women (adjusted RR, 1.08; 95% CI, 0.92-1.28). Advanced maternal age was a stronger risk factor for black women (adjusted RR, 1.72; 95% CI, 1.43-2.08) than for white women (adjusted RR, 1.30; 95% CI, 1.11-1.52) among multiparas only. Among nulliparas, delivery at 37-38 weeks' gestation reduced the risk of cesarean delivery for black women (adjusted RR, 0.82; 95% CI, 0.73-0.92), whereas no association was observed for white women (adjusted RR, 0.96; 95% CI, 0.90-1.04).

CONCLUSION

Labor induction, among nulliparous women, and advanced maternal age, among multiparous women, are stronger risk factors for primary cesarean delivery for black women than for white women.

Factors associated with increased cesarean risk among African American women: evidence from California, 2010

OBJECTIVES

We studied if both observed and unobserved maternal health in African American women in hospitals or communities were associated with cesarean delivery of infants.

METHODS

We examined the relationship between African American race and cesarean delivery among 493 433 women discharged from 255 Californian hospitals in 2010 using administrative data; we adjusted for patient comorbidities and maternal, fetal, and placental risk factors, as well as clustering of patients within hospitals.

RESULTS

Cesarean rates were significantly higher overall for African American women than other women (unadjusted rate 36.8% vs 32.7%), as were both elective and emergency primary cesarean rates. Elevated risks persisted after risk adjustment (odds ratio generally > 1.27), but the prevalence of particular risk factors varied. Although African American women were clustered in some hospitals, the proportion of African Americans among all women delivering in a hospital was not related to its overall cesarean rate.

CONCLUSIONS

To address the higher likelihood of elective cesarean delivery, attention needs to be given to currently unmeasured patient-level health factors, to the quality of provider-physician interactions, as well as to patient preferences.

Disparities in cesarean delivery by ethnicity and nativity in New York city

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.

Racial/Ethnic Differences in Labor Outcomes with Prostaglandin Vaginal Inserts

OBJECTIVE

The aim of this study is to compare labor outcomes across race/ethnicity in women undergoing prostaglandin labor induction.

METHODS

Secondary analysis of misoprostol vaginal insert (MVI) trial, a double-blind, randomized, control trial of 1,308 patients comparing sustained release vaginal inserts containing dinoprostone 10 mg and misoprostol 50 mcg (MVI 50) or 100 mcg (MVI 100).

RESULTS

Achievement of active labor and induction failures were similar across race/ethnicity. Cesareans were performed less frequently in whites (29 %) and Hispanics (24.5 %) compared to blacks (32.7 %) (adjusted odds ratio (aOR) 0.87, 95 % confidence interval (CI) 0.47-0.97, p = 0.03 and aOR 0.86, 95 % CI 0.44-0.97, p = 0.03, respectively). When compared to blacks, whites were less likely to undergo cesarean for non-reassuring fetal heart rate tracing (aOR 0.41, 95 % CI 0.25-0.66, p = 0.0003), as were Hispanics (aOR 0.38, 95 % CI 0.22-0.65, p = 0.0004). Postpartum hemorrhage occurred more frequently in Hispanics (8.8 %) versus blacks (4.1 %) and whites (OR 2.27, 95 % CI 0.23-0.82, p = 0.02 and OR 3.69, 95 % CI 0.14-0.51, p < 0.0001, respectively). Birth weights of black infants were lower than whites (p < 0.0001) and Hispanics (p = 0.0003). Neonatal outcomes did not differ between groups.

CONCLUSION

Differences in labor induction outcomes with prostaglandin labor induction exist based on race/ethnicity. Blacks delivered smaller babies, were more likely to undergo cesarean, and have cesareans performed for non-reassuring fetal heart tracing compared to other groups. Hispanics were more likely to experience postpartum hemorrhage compared to the other races.

The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts

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.

RESULTS

While 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.

Racial and ethnic differences in primary, unscheduled cesarean deliveries among low-risk primiparous women at an academic medical center: a retrospective cohort study

Background

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 are 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.

Methods

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.

Results

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.

Conclusions

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.

Ethnicity and risk of caesarean section in a term, nulliparous New Zealand obstetric cohort

BACKGROUND

One in four New Zealand (NZ) women undergo caesarean section (CS); however, little is understood about how ethnicity influences CS rates. Previous NZ studies do not include many of NZ's ethnic groups and have been unable to account comprehensively for clinical risk factors.

AIM

To investigate ethnicity as an independent risk factor for elective and emergency CS in nulliparous women at term. We hypothesised that compared with European, Māori and Pacific women would have a lower risk of elective CS, but there would be no ethnic differences in emergency CS.

METHODS

This was a retrospective cohort analysis of prospectively recorded maternity data at National Women's Health, Auckland, NZ from 2006 to 2009. The study population was 11 848 singleton, nulliparous, term births. Multivariable logistic regression analysis was performed for elective and emergency CS, accounting for comprehensive confounding factors.

RESULTS

The overall CS rate was 31.2% (elective 7.8%, n = 923 and emergency 23.4%, n = 2770). Compared with European ethnicity, Pacific and Chinese women had a reduced odds of elective CS (adjusted odds ratios, aOR 0.42, [95% CI 0.24-0.73] and 0.68, [0.49-0.94], respectively), while Indian women had an increased odds of emergency CS (aOR 1.54, [1.26-1.88]). Rates of elective or emergency CS for other ethnicities were similar to European.

CONCLUSIONS

After adjustment for confounding, we report ethnic differences in elective and emergency CS rates, which may be related to patient and/or care provider factors. Further prospective research is recommended to examine reasons for these ethnic differences in CS rates.

Relationship between race and abdominal anatomy: effect on robotic port placement

OBJECTIVES

We sought to characterize differences between African American women and white women in abdominal wall dimensions that could affect robotic port placement. By better understanding these differences, surgeons could assess and adjust port placement to accommodate varying abdominal wall anatomy.

METHODS

A radiologist blinded to race-reviewed abdominal/pelvic computed tomographic scans of women aged 30 to 70 prescreened for demographic inclusion criteria. These consecutive scans were screened for radiologic exclusion criteria until 40 consecutive scans from each race were identified and included.

RESULTS

Eighty of 663 patients, 40 of each race, met demographic inclusion criteria. The most common radiologic feature disqualifying the scans included absence of the xiphoid process on the scan and anterior abdominal wall deformity. Demographic variables including age, weight, height, and body mass index were similar between groups. Symphysis pubis to umbilicus measurement was shorter in the African American group (15.7 [2.1] vs 17.1 [2.0]; P < 0.001) and intra-anterior superior iliac spine distance was narrower (21.4 [1.2] vs 23.8 [2.0]; P = 0.003), creating an overall smaller lower abdomen in African American women. Total abdominal length was the same between groups (36.6 [2.6] vs 36.7 [2.8]; P = 0.851). Using linear regression, height, weight, and body mass index did not affect lower abdominal dimensions, whereas age (P < 0.001) had a significant inverse relationship with the symphysis pubis to umbilicus measurement.

CONCLUSIONS

Lower abdominal dimensions between races vary, with the umbilicus serving as an inconsistent landmark. Variance exists that can be attributed to racial differences. Assessment of these dimensions at the time of robotic surgery could lead to improved port spacing and therefore fewer arm collisions, improving robotic efficiency.

Maternal racial origin and adverse pregnancy outcome: a cohort study

OBJECTIVE

To examine the association between maternal racial origin and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics.

METHODS

This was a retrospective study in women with singleton pregnancies attending their first routine hospital visit at 11 + 0 to 13 + 6 weeks of gestation. Data on maternal characteristics, and medical and obstetric history were collected and pregnancy outcomes ascertained. Regression analysis was performed to examine the association between racial origin and adverse pregnancy outcomes including pre-eclampsia (PE), gestational hypertension (GH), gestational diabetes mellitus (GDM), preterm delivery (PTD), small-for-gestational age (SGA), large-for-gestational age (LGA), miscarriage, stillbirth and elective and emergency Cesarean section (CS).

RESULTS

The study population included 76 158 singleton pregnancies with a live fetus at 11 + 0 to 13 + 6 weeks. In addition to maternal characteristics and obstetric history, Afro-Caribbean racial origin was associated with increased risk for miscarriage, stillbirth, PE, GH, spontaneous PTD, GDM, SGA and CS. In women of South Asian racial origin there was increased risk for PE, GDM, SGA and CS, and East Asian race contributed to the prediction of GDM and SGA.

CONCLUSION

Maternal racial origin should be combined with other maternal characteristics and obstetric history when calculating an individualized adjusted risk for adverse pregnancy outcome.

Investigating the association between birth weight and complementary air pollution metrics: a cohort study

BACKGROUND

Exposure to air pollution is frequently associated with reductions in birth weight but results of available studies vary widely, possibly in part because of differences in air pollution metrics. Further insight is needed to identify the air pollution metrics most strongly and consistently associated with birth weight.

METHODS

We used a hospital-based obstetric database of more than 70,000 births to study the relationships between air pollution and the risk of low birth weight (LBW, <2,500 g), as well as birth weight as a continuous variable, in term-born infants. Complementary metrics capturing different aspects of air pollution were used (measurements from ambient monitoring stations, predictions from land use regression models and from a Gaussian dispersion model, traffic density, and proximity to roads). Associations between air pollution metrics and birth outcomes were investigated using generalized additive models, adjusting for maternal age, parity, race/ethnicity, insurance status, poverty, gestational age and sex of the infants.

RESULTS

Increased risks of LBW were associated with ambient O(3) concentrations as measured by monitoring stations, as well as traffic density and proximity to major roadways. LBW was not significantly associated with other air pollution metrics, except that a decreased risk was associated with ambient NO(2) concentrations as measured by monitoring stations. When birth weight was analyzed as a continuous variable, small increases in mean birth weight were associated with most air pollution metrics (<40 g per inter-quartile range in air pollution metrics). No such increase was observed for traffic density or proximity to major roadways, and a significant decrease in mean birth weight was associated with ambient O3 concentrations.

CONCLUSIONS

We found contrasting results according to the different air pollution metrics examined. Unmeasured confounders and/or measurement errors might have produced spurious positive associations between birth weight and some air pollution metrics. Despite this, ambient O(3) was associated with a decrement in mean birth weight and significant increases in the risk of LBW were associated with traffic density, proximity to roads and ambient O(3). This suggests that in our study population, these air pollution metrics are more likely related to increased risks of LBW than the other metrics we studied. Further studies are necessary to assess the consistency of such patterns across populations.

Classification of cesarean sections among immigrants in Belgium

OBJECTIVE

To provide insight into the differential effect of immigration on cesarean section (CS) rates, using the Robson classification.

DESIGN

A population-based study using birth certificates from the birth registry of 2009.

SETTING

All births in two of the three Belgian regions excluding Flanders.

POPULATION

37 628 deliveries from Belgian and immigrant mothers from sub-Saharan Africa, Maghreb and Eastern Europe.

METHODS

Multivariate analyses using CS as the dependent variable and immigration status as the primary independent variable. Several multivariate logistic regression models were built including medical, anthropometric, socio-economic characteristics, and medical interventions. The impact of analyzing all delivery sites together was tested using mixed-effect analyses.

MAIN OUTCOME MEASURES

CSs of immigrant subgroups compared with Belgian women.

RESULTS

CS rates varied according to immigrant subgroups. Mothers from sub-Saharan Africa had an adjusted odds ratio of 2.06 (1.62-2.63) for CS compared with Belgian natives. Increased risk for mothers from sub-Saharan Africa compared with Belgian natives was found among nulliparous and multiparous women without previous CS, and a term, singleton fetus in cephalic position. In comparison, nulliparous East European mothers with a term singleton fetus in cephalic position in spontaneous labor had an adjusted odds ratio of 0.29 (0.08-0.99) for CS.

CONCLUSIONS

CS rates currently vary between Robson categories in immigrant subgroups. Immigrant mothers from sub-Saharan Africa with a term, singleton infant in cephalic position, without previous CS, appear to carry the highest burden.

Interpersonal processes of care and cesarean delivery in two health care settings

OBJECTIVES

We examined whether interpersonal processes of care (IPC) were associated with cesarean delivery.

METHODS

We performed a cross-sectional study of 1308 postpartum women at Kaiser Permanente Medical Center in Walnut Creek, CA (KP-WC), and San Francisco General Hospital (SFGH) from 2004 to 2006. Using interview and medical record data, logistic regression analyses estimated the odds of cesarean delivery as a function of IPC domains.

RESULTS

After adjustment for demographic and reproductive factors, women at KP-WC who reported higher scores for their provider's "elicitation of patient concerns and responsiveness" were less likely to have delivered by cesarean, whereas women who reported higher scores for "empowerment and self-care" were more likely. At KP-WC, women who reported low English proficiency were less likely to have delivered by cesarean than women who reported high proficiency. At SFGH, none of the IPC measures were significant; however, younger age was associated with a lower risk of cesarean delivery, whereas higher educational attainment was associated with an increased risk.

CONCLUSIONS

To reduce record-high rates of cesarean delivery, more emphasis should be placed on addressing the nonmedical factors associated with operative delivery.

Ethnicity and newborn outcomes: the case of African American women

PURPOSE

Although previous studies have confirmed the relationship between socioeconomic status, ethnicity, education, and occupation on birth outcomes, less is known about the relationship of providers influence or hospital characteristics on birth outcomes for minority women. It is not well understood whether hospital or physician characteristics exert an equal or greater affect compared with maternal sociodemographic factors, particularly for Black childbearing women known to be at particular risk for adverse birth outcomes.

DESIGN

This retrospective descriptive study sought to determine whether variation in neonatal birth outcomes for Black women was attributable to hospital characteristics, physician influence, or patient sociodemographics.

METHODS

Fixed and random effects were conducted to empirically determine the relative importance of hospital, physician, and patient characteristics (partitioning the variation of differences in birth outcome to each component) using a large administrative dataset.

FINDINGS

Considerable variability existed among hospitals over and above hospital ownership or number of hospital beds.

CONCLUSIONS

Ethnicity was a statistically significant predictor of adverse outcomes, as was the number of prenatal visits and maternal education. There is a significant relationship between adverse newborn outcomes and ethnicity after controlling for hospital and physician characteristics.

CLINICAL RELEVANCE

Ongoing birth disparities in African American childbearing women are a significant public policy issue with important research and clinical implications. This research adds to nursing knowledge by helping eliminate some factors previously thought to have contributed to the high incidence of perinatal complications for African American women and their newborns.

Predictors of cesarean delivery for periviable neonates

OBJECTIVE

To test for racial or ethnic disparities or both in periviable cesarean delivery and describe sociodemographic and clinical characteristics associated with periviable cesarean delivery.

METHODS

This was a retrospective cohort study of state-level maternal and neonatal hospital discharge data linked to vital statistics data for deliveries occurring between 23 0/7 and 24 6/7 [corrected] weeks of gestation in California, Missouri, and Pennsylvania from 1995 to 2005 (N=8,290).

RESULTS

Approximately 79% of the population was aged 18-35 years, and almost half were nulliparous. Almost 20% of the women were African American, 36.4% were Hispanic, and 33.6% were white. Overall, 33.6% of periviable neonates were delivered by cesarean. In multivariable analyses adjusting for sociodemographic and clinical characteristics, cesarean delivery did not differ among African American and Hispanic women compared with white women (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.76-1.05; and OR 0.95, 95% CI 0.83-1.09, respectively). Women presenting with preterm labor were significantly less likely to undergo cesarean delivery (OR 0.84, 95% CI 0.73-0.96), whereas women presenting with preterm premature rupture of membranes (OR 1.29, 95% CI 1.14-1.45) or abruption (OR 2.43, 95% CI 2.09-2.81) were more likely to have cesarean deliveries. The strongest predictor of periviable cesarean delivery was pregnancy-induced hypertension (OR 15.6.4, 95% CI 12.3-19.7).

CONCLUSION

Unlike disparities observed at later gestational ages, cesarean delivery did not differ by race and ethnicity among this periviable cohort. Instead, medical indications such as pregnancy-induced hypertension, preterm premature rupture of membranes, or abruption were associated with a higher likelihood of cesarean delivery. Periviable deliveries represent a subset of deliveries, wherein race and ethnicity do not influence mode of delivery; the acuity of the clinical encounter dictates the course of care.

Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants

Wide disparities in obstetric outcomes exist between women of different race/ethnicities. The prevalence of preterm birth, fetal growth restriction, fetal demise, maternal mortality, and inadequate receipt of prenatal care all vary by maternal race/ethnicity. These disparities have their roots in maternal health behaviors, genetics, the physical and social environments, and access to and quality of health care. Elimination of the health inequities because of sociocultural differences or access to or quality of health care will require a multidisciplinary approach. We aim to describe these obstetric disparities, with an eye toward potential etiologies, thereby improving our ability to target appropriate solutions.

Association between local traffic-generated air pollution and preeclampsia and preterm delivery in the south coast air basin of California

BACKGROUND

Preeclampsia is a major complication of pregnancy that can lead to substantial maternal and perinatal morbidity, mortality, and preterm birth. Increasing evidence suggests that air pollution adversely affects pregnancy outcomes. Yet few studies have examined how local traffic-generated emissions affect preeclampsia in addition to preterm birth.

OBJECTIVES

We examined effects of residential exposure to local traffic-generated air pollution on preeclampsia and preterm delivery (PTD).

METHODS

We identified 81,186 singleton birth records from four hospitals (1997-2006) in Los Angeles and Orange Counties, California (USA). We used a line-source dispersion model (CALINE4) to estimate individual exposure to local traffic-generated nitrogen oxides (NO(x)) and particulate matter < 2.5 mum in aerodynamic diameter (PM(2.5)) across the entire pregnancy. We used logistic regression to estimate effects of air pollution exposures on preeclampsia, PTD (gestational age < 37 weeks), moderate PTD (MPTD; gestational age < 35 weeks), and very PTD (VPTD; gestational age < 30 weeks).

RESULTS

We observed elevated risks for preeclampsia and preterm birth from maternal exposure to local traffic-generated NO(x) and PM(2.5). The risk of preeclampsia increased 33% [odds ratio (OR) = 1.33; 95% confidence interval (CI), 1.18-1.49] and 42% (OR = 1.42; 95% CI, 1.26-1.59) for the highest NO(x) and PM(2.5) exposure quartiles, respectively. The risk of VPTD increased 128% (OR = 2.28; 95% CI, 2.15-2.42) and 81% (OR = 1.81; 95% CI, 1.71-1.92) for women in the highest NO(x) and PM(2.5) exposure quartiles, respectively.

CONCLUSION

Exposure to local traffic-generated air pollution during pregnancy increases the risk of preeclampsia and preterm birth in Southern California women. These results provide further evidence that air pollution is associated with adverse reproductive outcomes.

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

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.

Racial differences in pelvic anatomy by magnetic resonance imaging

OBJECTIVES

To use static and dynamic magnetic resonance imaging (MRI) to compare dimensions of the bony pelvis and soft tissue structures in a sample of African-American and white women.

METHODS

This study used data from 234 participants in the Childbirth and Pelvic Symptoms Imaging Study, a cohort study of 104 primiparous women with an obstetric anal sphincter tear, 94 who delivered vaginally without a recognized anal sphincter tear and 36 who underwent by cesarean delivery without labor. Race was self-reported. At 6-12 months postpartum, rapid acquisition T2-weighted pelvic MRIs were obtained. Bony and soft tissue dimensions were measured and compared between white and African-American participants using analysis of variance, while controlling for delivery type and age.

RESULTS

The pelvic inlet was wider among 178 white women than 56 African-American women (10.7+/-0.7 cm compared with 10.0.+0.7 cm, P<.001). The outlet was also wider (mean intertuberous diameter 12.3+/-1.0 cm compared with 11.8+/-0.9 cm, P<.001). There were no significant differences between racial groups in interspinous diameter, angle of the subpubic arch, anteroposterior conjugate, levator thickness, or levator hiatus. In addition, among women who delivered vaginally without a sphincter tear, African-American women had more pelvic floor mobility than white women. This difference was not observed among women who had sustained an obstetric sphincter tear.

CONCLUSION

White women have a wider pelvic inlet, wider outlet, and shallower anteroposterior outlet than African-American women. In addition, after vaginal delivery, white women demonstrate less pelvic floor mobility. These differences may contribute to observed racial differences in obstetric outcomes and to the development of pelvic floor disorders.

Assessing the effects of age, gestation, socioeconomic status, and ethnicity on labor inductions

PURPOSE

To evaluate the likelihood of cesarean births, related to race, ethnicity, socioeconomic status (SES), maternal education and age, and gestational status for labor inductions on primiparous and multiparous women.

DESIGN AND METHODS

A retrospective descriptive correlational design was used with 1,325 women scheduled for induction at a large tertiary hospital in a southwestern U.S. state from January 1 through December 31, 2005. Birth outcomes were matched against inpatient hospital scheduling induction logs to verify the reason for induction, whether elective or clinically indicated.

FINDINGS

Age and gestation had nonlinear and significant associations with cesarean birth. Elective inductions for primiparous women significantly increased the likelihood of cesarean delivery. The independent effect of being a primiparous woman with an elective induction increased the probability of a cesarean birth by 50%, but this association was not significant for multiparous women. Mother's educational level was a significant predictor for cesarean births with multiparous women being induced. Ethnicity and SES did not increase the odds of cesarean delivery following labor induction for either primiparous women or multiparous women.

CONCLUSIONS

Elective inductions for primiparous women increased the probability of cesarean births. Elective labor induction for primiparous women should be offered with caution, particularly for women with advanced maternal age.

Lawsuit activity, defensive medicine, and small area variation: the case of cesarean sections revisited

This paper examines whether delivery practice patterns (Cesarean sections or vaginal) are influenced by lawsuits or whether the hypothesized relationship is confounded by small area variation. The analysis uses multilevel analysis to deal with hospital- and Dartmouth Hospital Referral Region-level variation. The model includes patient clinical variables, patient socio-economic status, and hospital characteristics as control variables. The secondary data sources include hospital discharges from the 2002 Texas Health Care Information Council as well as 1988–2001 Texas Department of Insurance Closed Claim File data. After extracting the variation in delivery practice between hospitals and between Dartmouth Hospital Referral Regions in a multilevel model, the effects of lawsuits on defensive medicine are reduced but are still significant.