Factors associated with increased cesarean risk among African American women: evidence from California, 2010

Abstract

Objectives: We studied if both observed and unobserved maternal health in African American women in hospitals or communities were associated with cesarean delivery of infants.

Methods: We examined the relationship between African American race and cesarean delivery among 493 433 women discharged from 255 Californian hospitals in 2010 using administrative data; we adjusted for patient comorbidities and maternal, fetal, and placental risk factors, as well as clustering of patients within hospitals.

Results: Cesarean rates were significantly higher overall for African American women than other women (unadjusted rate 36.8% vs 32.7%), as were both elective and emergency primary cesarean rates. Elevated risks persisted after risk adjustment (odds ratio generally > 1.27), but the prevalence of particular risk factors varied. Although African American women were clustered in some hospitals, the proportion of African Americans among all women delivering in a hospital was not related to its overall cesarean rate.

Conclusions: To address the higher likelihood of elective cesarean delivery, attention needs to be given to currently unmeasured patient-level health factors, to the quality of provider-physician interactions, as well as to patient preferences.

FIGURE 1—

Schematic diagram of potential causes of racial and ethnic disparities: California, 2010. Note. Scheme is general and applicable to any care received by patients of any race/ethnicity and not intended to represent linear, ordered, or sequential effects. Cause 1 postulates that patients have different observed or unobserved health status and indications for treatment, and differences in observed care reflect the evidence base. Cause 2 supposes that differences in the interaction between patients and providers or hospitals leads to differences in care. Cause 3 conjectures that differences in patient preferences drive care differences. Finally, Cause 4 is based on clustering of patients of the same race within hospitals in which all patients receive a particular type of care.

FIGURE 2—

Relationship between hospital cesarean rates and hospital proportion of African American women among all women delivering in that hospital: California, 2010. Note. Scatterplot with superimposed local regression smoothed estimate (horizontal line) and 95% confidence interval (shaded area). Each marker represents 1 of 255 hospitals. Pearson correlation = –0.01 (P = .92).