RSS-Feed abonnieren
DOI: 10.1055/a-2259-0409
Are Racial Disparities in Cesarean Due to Differences in Labor Induction Management?
Funding This work was funded by the Eunice Kennedy Shriver National Institute for Child Health and Development (K23 HD102523; PI R.F.H.).![](https://www.thieme-connect.de/media/ajp/EFirst/lookinside/thumbnails/10-1055-a-2259-0409_23sep0600-1.jpg)
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
-
The etiologies for racial disparities in cesarean are likely multifaceted.
-
In this work, there were no differences by race in measures of labor induction management.
-
Biases outside of induction management during labor may be targeted to reduce CD disparities.
Publikationsverlauf
Eingereicht: 28. September 2023
Angenommen: 30. Januar 2024
Accepted Manuscript online:
01. Februar 2024
Artikel online veröffentlicht:
26. Februar 2024
© 2024. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol 2014; 210 (05) 435.e1-435.e8
- 2 Hirshberg A, Srinivas SK. Epidemiology of maternal morbidity and mortality. Semin Perinatol 2017; 41 (06) 332-337
- 3 The American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 649: Racial and Ethnic Disparities in Obstetrics and Gynecology. Obstet Gynecol 2015; 126 (06) e130-e134
- 4 Yee LM, Costantine MM, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Racial and ethnic differences in utilization of labor management strategies intended to reduce cesarean delivery rates. Obstet Gynecol 2017; 130 (06) 1285-1294
- 5 Fishel Bartal M, Chen HY, Mendez-Figueroa H, Wagner SM, Chauhan SSP. Racial and ethnic disparities in primary cesarean birth and adverse outcomes among low-risk nulliparous people. Obstet Gynecol 2022; 140 (05) 842-852
- 6 Hamm RF, Kumar NR, Riegel M, Hapuarachchy B, Wheeler SM, Howell EA. Addressing disparities in care on labor and delivery. Curr Obstet Gynecol Rep 2022; 11: 143-151
- 7 Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol 2018; 61 (02) 387-399
- 8 Howell EA, Brown H, Brumley J. et al. Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle. Obstet Gynecol 2018; 131 (05) 770-782
- 9 Howell EA, Sofaer S, Balbierz A, Kheyfets A, Glazer KB, Zeitlin J. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity. Obstet Gynecol 2022; 139 (06) 1061-1069
- 10 Falciglia GH, Grobman WA, Murthy K. Variation in labor induction over the days of the week. Am J Perinatol 2015; 32 (01) 107-112
- 11 Glantz JC. Obstetric variation, intervention, and outcomes: doing more but accomplishing less. Birth 2012; 39 (04) 286-290
- 12 Hamm RF, Srinivas SK, Levine LD. A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes. Am J Obstet Gynecol MFM 2020; 2 (03) 100148
- 13 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007; 370 (9596): 1453-1457
- 14 Caughey AB, Cahill AG, Guise JM, Rouse DJ. American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
- 15 Atallah F, Hamm RF, Davidson CM, Combs CA. Society for Maternal-Fetal Medicine (SMFM). Electronic address: smfm@smfm.org, Patient Safety and Quality Committee. Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities. Am J Obstet Gynecol 2022; 227 (02) B2-B10
- 16 Megregian M, Emeis C, Nieuwenhuijze M. The impact of shared decision-making in perinatal care: a scoping review. J Midwifery Womens Health 2020; 65 (06) 777-788
- 17 Toumi M, Lesieur E, Haumonte JB, Blanc J, D'ercole C, Bretelle F. Primary cesarean delivery rate: potential impact of a checklist. J Gynecol Obstet Hum Reprod 2018; 47 (09) 419-424
- 18 Wise G, Jolles D. Promoting effective care: reducing primary cesarean births through team engagement and standardization of care at a community hospital. Nurs Forum 2019; 54 (04) 601-610