Disparities in Provider Recommendations for Birth Plan Changes to Elective Deliveries during COVID‐19
Authors: Hung Peiyin , Prasad Shailendra , Cullen John S. , Liu Jihong 
Published: September 2021

Research ObjectiveBefore the COVID‐19 pandemic, about one in ten childbirths were elective deliveries – labor induction and cesarean deliveries without medical indications – which evidently increased adverse maternal and neonatal outcomes. Anecdotal evidence shows that during COVID‐19, providers are increasingly recommending these deliveries, but little is known regarding the extent and the patterns of such recommendations across pregnant women in the United States (U.S.).Study DesignWe conducted a nationwide cross‐sectional survey of 740 racial‐diverse U.S. pregnant women with >8‐week pregnancy, and aged 18–44 years during 5/4/2020–5/6/2020 to evaluate maternal and provider characteristics associated with birth plan changes due to the COVID‐19 pandemic. To understand the birth plan changes, we asked each participant, “has a health care professional recommended a change to your birth plan as a result of COVID‐19?” Options include 1) No, there have been no recommended changes to my original birth plan as a result of COVID‐19. 2) Yes, my provider recommended inducing labor as a result of COVID‐19. 3) Yes, my provider recommended a planned cesarean (c‐section) delivery as a result of COVID‐19. 4) I don't know yet. Women who responded, “I don't know yet” were excluded, yielding a total of 678 sample pregnant women in the analysis. Multivariable regressions were used to assess rural–urban differences in the likelihoods of provider recommendations for birth plan changes to labor induction or planned c‐section, controlling for race/ethnicity, age, insurance‐type, education, employment, household income, pregnancy condition, pre‐pregnancy Body Mass Index, parity, trimester, provider specialty, delayed prenatal care initiation, positive‐tested family member, state positivity rates as of 5/6/2020, and census region.Population Studied740 racial‐diverse U.S. pregnant women with >8‐week pregnancy, and aged 18–44 years in 2020.Principal FindingsOf 678 eligible pregnant women, the majority lived in urban communities (87.0%). Rural women reported lower household income, were less likely to initiate prenatal care at the first trimester, visit obstetricians for prenatal care, be privately insured, be employed full‐time than urban women participants. They were similar in age, race/ethnicity, education, pregnancy condition, pre‐pregnancy BMI, and state COVID‐19 positivity rates. Overall, 22.6% were recommended to change delivery plans to either labor induction or planned c‐section due to the pandemic, with a higher rate in rural women (34.5%) than urban women (20.9%). Controlling for other maternal, provider, and state COVID‐19 characteristics, these recommendations were disproportionately prevalent among rural women (Odds ratios [OR]: 1.6), primiparous women (OR: 7.7), women delaying prenatal care initiation (OR: 5.2), those visiting family physicians but no obstetricians for prenatal care (OR: 4.3), Medicaid insured (OR: 3.2), and those with family members tested positive for COVID‐19 (OR: 5.4).ConclusionsIn May 2020, women living in rural areas, Medicaid insured, having delayed prenatal care initiation, and visiting only family physicians for prenatal care were more likely to be recommended for elective procedures.Implications for Policy or PracticeThere is an urgent need for health system and policymakers to establish safe and effective protocols to ensure pregnant women obtain evidence‐based care as needed during the pandemic and beyond to avoid long‐term detrimental effects.Primary Funding SourceUniversity of South Carolina Vice Office of the Vice President for Research.