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

Abstract

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 >115,000 pregnant women from 25 hospitals (2008–2011). Term women 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) 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 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 were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black aOR 1.47, 95% CI 1.36–1.59; Asian aOR 1.26, 95% CI 1.14–1.40; Hispanic aOR 1.17, 95% CI 1.07–1.27), due to 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, Hispanic women were actually less likely to experience elective cesarean (aOR 0.60, 95% CI 0.42–0.87) or cesarean for arrest of dilation prior to 4 hours (aOR 0.67, 95% CI 0.49–0.92). Additionally, compared with non-Hispanic white, Asian women were more likely to experience cesarean for nonreassuring fetal status (aOR 1.29, 95% CI 1.09–1.53) and to have had that cesarean be performed in the setting of a 1-minute Apgar score ≥7 (aOR 1.79, 95% CI 1.07–3.00). A similar trend was seen among multiparous women with prior vaginal deliveries. Conclusions 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–ethnic disparities.

Influence of midwifery presence in United States centers on labor care and outcomes of low‐risk parous women: A Consortium on Safe Labor study

“…10,[13][14][15] To ensure independent samples, we only included the first documented birth to each parous woman in the CSL, excluding subsequent pregnancies and births in the data set. 10,[13][14][15] To ensure independent samples, we only included the first documented birth to each parous woman in the CSL, excluding subsequent pregnancies and births in the data set.…”

“…We excluded cases of women with no documented age, race, or health insurance type in the data set, as these variables have been shown in previous studies to influence both cesarean rate and labor processes. 10,[13][14][15] To ensure independent samples, we only included the first documented birth to each parous woman in the CSL, excluding subsequent pregnancies and births in the data set. Finally, we excluded six centers that had inconsistent documentation about whether midwives provided intrapartum care.…”

“…Therefore, a composite was developed to assess differences between groups. 8,14,16 We also analyzed neonatal intensive care unit (NICU) admission after birth. Since NICU admissions occurred more frequently than other adverse neonatal outcomes, we were also able to model NICU admission by interprofessional mix.…”

Midwifery presence in United States medical centers and labor care and birth outcomes among low‐risk nulliparous women: A Consortium on Safe Labor study

“…We also excluded women with preexisting and antepartum health conditions including diabetes, hypertension, heart disease, renal disease, gastrointestinal disease, depression, seizure disorders, thyroid disease, asthma, anemia, or HIV/herpes. Women without documented age, race, or health insurance type were excluded because those variables were considered critical potential confounders of the analyses since maternal age, 1,[16][17][18][19] race, 1,20 and health insurance type 21 are associated with variations in cesarean rates and certain labor processes. Finally, we excluded medical centers where the presence or absence of midwife practitioners could not be explicitly determined.…”

Fidelity to individual components of a standardized labor induction protocol and association with improved obstetric outcomes: secondary analysis of a randomized controlled trial

“…Black women in the United States are twice as likely to experience a fetal mortality and nearly 4 times more likely to die themselves in and around pregnancy [33][34]. In addition, Black women have higher cesarean rates than non-Black women even when accounting for sociodemographic and clinical differences [35].…”