Abstract
Objective While there are known racial disparities in cesarean delivery (CD) rates, the exact
etiologies for these disparities are multifaceted. We aimed to determine if differences
in induction of labor (IOL) management contribute to these disparities.
Study Design This retrospective cohort study evaluated all nulliparous patients with an unfavorable
cervix and intact membranes who underwent IOL of a term, singleton gestation at a
single institution from October 1, 2018, to September 30, 2020. IOL management was
at clinician discretion. Patients were classified as Black, Indigenous, and People
of Color (BIPOC) or White based on self-report. Overall rates of CD were compared
for BIPOC versus White race. Chart review then evaluated various IOL management strategies
as possible contributors to differences in CD by race.
Results Of 1,261 eligible patients, 915 (72.6%) identified as BIPOC and 346 (27.4%) as White.
BIPOC patients were more likely to be younger (26 years interquartile range (IQR):
[22–30] vs. 32 years IQR: [30–35], p < 0.001) and publicly insured (59.1 vs. 9.9%, p < 0.001). Indication for IOL and modified Bishop score also differed by race (p < 0.001; p = 0.006). There was 40% increased risk of CD for BIPOC patients, even when controlling
for confounders (30.7 vs. 21.7%, p = 0.001; adjusted relative risk (aRR) = 1.41, 95% confidence interval (CI): [1.06–1.86]).
Despite this difference in CD, there were no identifiable differences in IOL management
prior to decision for CD by race. Specifically, there were no differences in choice
of cervical ripening agent, cervical dilation at or time to amniotomy, use and maximum
dose of oxytocin, or dilation at CD. However, BIPOC patients were more likely to undergo
CD for fetal indications and failed IOL.
Conclusion BIPOC nulliparas are 40% more likely to undergo CD during IOL than White patients
within our institution. These data suggest that the disparity is not explained by
differences in IOL management prior to cesarean, indicating that biases outside of
induction management may be important to target to reduce CD disparities.
Key Points
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The etiologies for racial disparities in cesarean are likely multifaceted.
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In this work, there were no differences by race in measures of labor induction management.
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Biases outside of induction management during labor may be targeted to reduce CD disparities.
Keywords
racial disparities - labor induction - cesarean delivery - health equity - implicit
bias