Researchers at Oregon Health & Science University's Center for Women's Health have identified recent national trends in cesarean births, noting significant racial and ethnic disparities.
The study, published today in JAMA Network Open, found that despite a slight decrease in the overall rate of cesarean births in the United States, the increased risk of cesarean births for Black individuals has persisted.
A concerted effort to decrease the rates of cesarean births in the United States began in 2014, when the American College of Obstetrics and Gynecology published obstetric care and labor management guidelines aimed to safely encourage vaginal births.
In the decade following this guidance, the overall rate of cesarean births has decreased slightly, but not for everyone: OHSU's study found that the rate of cesarean births increased for Black individuals, a group that already experiences the highest rate of this procedure of all races and ethnicities.
"There are many reasons why someone might come into a labor and delivery unit and need a cesarean delivery — it's a critically important, life-saving procedure — but race is not one of them," said Marie Boller, M.D., an OBGYN and maternal-fetal medicine specialist in OHSU's Center for Women's Health and the study's lead author. "These findings are cause for concern, because we know these disparities have no biological basis and are rooted in structural racism."
In a retrospective observational cohort study, researchers analyzed data from over 30 million births between 2012 and 2021. Findings revealed that for Black individuals, the risk of cesarean birth was higher compared with individuals from other racial and ethnic groups, and further, the disparity only continued to increase over the study period.
After adjusting for other reasons cesarean might be indicated, risk of cesarean birth for Black individuals was 12% higher in 2012 and 17% higher in 2021 compared to other racial and ethnic groups. This was consistent across the spectrum of birthing scenarios: For a first birth, risk of cesarean was 20% higher for Black individuals in 2012 and rose to 23% higher in 2021. For Black individuals who'd had a prior vaginal delivery and no prior cesarean, the risk of cesarean birth was 32% higher in 2012 and 33% higher in 2021.
The research team hopes this work can contribute to the important national conversation around structural racism in maternal health care and inspire hospitals and health systems to develop interventions to better support Black birthing people.
"We need to implement quality improvement efforts that reduce unnecessary cesarean births among this population but also address the structural racism that drives these outcomes," Boller said. "This should include upstream interventions that support healthier pregnancies from the very beginning, even before conception."
Patient-centered care, improved birth outcomes
Researchers emphasize that this data is just one element of a much larger story of obstetric inequity. Stark disparities exist across the spectrum of maternal and infant health: Black individuals face significantly higher rates of pregnancy-related death rates, and their infants are much more likely to have certain birth risk factors, such as preterm birth.
Aaron Caughey M.D., Ph.D., chair of the Department of Obstetrics and Gynecology in the OHSU School of Medicine and senior author of the study, says implicit bias, or the internalized stereotypes that unconsciously affect actions and decisions being made by clinicians, play a big role.
"At OHSU, we strive to provide compassionate, high-quality care to everyone who comes through our doors," Caughey said. "This work requires ongoing evaluation of the systems and societal factors that influence that care, and how each of us as individual providers play into that."
On an institutional level, it's important to acknowledge implicit bias and offer ongoing education, training and resources for clinicians to address their biases, he says. At OHSU, every cesarean delivery is reviewed on a case-by-case basis so clinicians can discuss the medical indications that led to that method of delivery and identify learnings and potential areas for improvement in patient care.
On a structural level, building a diverse health care workforce that reflects the communities being cared for is key, he says. In practice, this would require significant investments in pipeline programs that improve access to education and career opportunities for the communities that are disproportionately impacted.
Ultimately, Boller says it will take a collective effort among obstetrics providers to create an impact for patients.
"Moving the cesarean rate down happens one family at a time, one conversation at a time, so we need to continue to be thoughtful with each person in front of us," Boller said. "It requires all of us to be patient, curious and committed to continuous improvement in our practice."
