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
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Black birthing people are more likely to undergo CD than White despite controlling
for confounders.
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There are unexplained differences in CD indication among Black and White birthing
people.
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These disparities persisted from 2011 to 2017 despite increasing efforts to decrease
CD rates in CA.
Keywords
racial disparities - cesarean delivery - cesarean section - cesarean indication -
California
