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

Abstract

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

Obstetric and perinatal racial and ethnic disparities

“…Cesarean birth is more common in non-Hispanic Black women than non-Hispanic White women [25 ▪ ,26 ▪▪ ]. One study estimated that increased cesarean births account for 15.8% of non-Hispanic Black and 16.5% of Hispanic women's increased maternal morbidity [27 ▪ ].…”