Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care

Med Care. 2021 Feb 1;59(2):131-138. doi: 10.1097/MLR.0000000000001461.


Background: Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care.

Objective: To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide.

Research design: Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care.

Results: Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites.

Conclusions: There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.

Publication types

  • Observational Study
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • Cesarean Section / standards
  • Cesarean Section / statistics & numerical data*
  • Cohort Studies
  • Cross-Sectional Studies
  • Female
  • Health Services Accessibility / standards
  • Health Services Accessibility / statistics & numerical data
  • Humans
  • Pregnancy
  • Prospective Studies
  • Race Factors
  • Racial Groups / ethnology
  • Racial Groups / statistics & numerical data*
  • United States / ethnology
  • United States Department of Veterans Affairs / organization & administration
  • United States Department of Veterans Affairs / statistics & numerical data*
  • Veterans / statistics & numerical data*