Am J Perinatol 2021; 38(04): 350-356
DOI: 10.1055/s-0039-1697587
Original Article

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

Elisabeth L. Stark
1   Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
William A. Grobman
1   Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Emily S. Miller
1   Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
› Institutsangaben
Funding This study was funded by National Institute of Child and Human Development K12 HD050121–09, the National Institutes of Health's National Center for Advancing Translational Sciences, Grant Number UL1TR001422, and Northwestern Medicine Enterprise Data Warehouse Pilot Data Program. The funding sources had no role in study design, data collection, analysis or interpretation, and writing the report or submitting the article for publication.


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.


Eingereicht: 29. Oktober 2018

Angenommen: 12. August 2019

Artikel online veröffentlicht:
28. September 2019

© 2019. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Betrán AP, Torloni MR, Zhang JJ, Gülmezoglu AM. WHO Working Group on Caesarean Section. WHO Statement on caesarean section rates. BJOG 2016; 123 (05) 667-670
  • 2 Betrán AP, Merialdi M, Lauer JA. et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007; 21 (02) 98-113
  • 3 Molina G, Weiser TG, Lipsitz SR. et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA 2015; 314 (21) 2263-2270
  • 4 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176 (04) 455-460
  • 5 Rossen LM, Osterman MJK, Hamilton BE, Martin JA. Quarterly provisional estimates for selected birth indicators, 2015-Quarter 3, 2017. National Vital Statistics System, Vital Statistics Rapid Release Program. 2017
  • 6 Rosenberg TJ, Garbers S, Lipkind H, Chiasson MA. Maternal obesity and diabetes as risk factors for adverse pregnancy outcomes: differences among 4 racial/ethnic groups. Am J Public Health 2005; 95 (09) 1545-1551
  • 7 Gregory KD, Korst LM. Age and racial/ethnic differences in maternal, fetal, and placental conditions in laboring patients. Am J Obstet Gynecol 2003; 188 (06) 1602-1606
  • 8 Min CJ, Ehrenthal DB, Strobino DM. Investigating racial differences in risk factors for primary cesarean delivery. Am J Obstet Gynecol 2015; 212 (06) 814.e1-814.e14
  • 9 Bryant AS, Washington S, Kuppermann M, Cheng YW, Caughey AB. Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates. Paediatr Perinat Epidemiol 2009; 23 (05) 454-462
  • 10 Washington S, Caughey AB, Cheng YW, Bryant AS. Racial and ethnic differences in indication for primary cesarean delivery at term: experience at one U.S. Institution. Birth 2012; 39 (02) 128-134
  • 11 Getahun D, Strickland D, Lawrence JM, Fassett MJ, Koebnick C, Jacobsen SJ. Racial and ethnic disparities in the trends in primary cesarean delivery based on indications. Am J Obstet Gynecol 2009; 201 (04) 422.e1-422.e7
  • 12 Grobman WA, Bailit JL, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Can differences in obstetric outcomes be explained by differences in the care provided? The MFMU Network APEX study. Am J Obstet Gynecol 2014; 211 (02) 147.e1-147.e16
  • 13 Chung JH, Garite TJ, Kirk AM, Hollard AL, Wing DA, Lagrew DC. Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery. Am J Obstet Gynecol 2006; 194 (05) 1323-1328
  • 14 Haile ZT, Chavan B, Teweldeberhan AK, Chertok IRA, Francescon J. Gestational weight gain and unplanned or emergency cesarean delivery in the United States. Women Birth 2018; 32 (03) 263-269
  • 15 Thurman AR, Zoller JS, Swift SE. Non-pregnant patients' preference for delivery route. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15 (05) 308-312
  • 16 Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med 2013; 28 (11) 1504-1510
  • 17 Sabiani L, Le Dû R, Loundou A. et al. Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management. Am J Obstet Gynecol 2015; 213 (06) 856.e1-856.e8
  • 18 Yee LM, Liu LY, Grobman WA. Obstetrician call schedule and obstetric outcomes among women eligible for a trial of labor after cesarean. Am J Obstet Gynecol 2017; 216 (01) 75.e1-75.e6
  • 19 Barber EL, Eisenberg DL, Grobman WA. Type of attending obstetrician call schedule and changes in labor management and outcome. Obstet Gynecol 2011; 118 (06) 1371-1376