Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates
Authors: Yee Lynn M. , Costantine Maged M. , Rice Madeline Murguia , Bailit Jennifer , Reddy Uma M. , Wapner Ronald J. , Varner Michael W. , Thorp John M. , Caritis Steve N. , Prasad Mona , Tita Alan T. N. , Sorokin Yoram , Rouse Dwight J. , Blackwell Sean C. , Tolosa Jorge E. ,   for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network
Published: November 2017

OBJECTIVE:
To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity.

METHODS:
This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008–2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery.

RESULTS:
A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36–1.59; Asian adjusted OR 1.26, 95% CI 1.14–1.40; Hispanic adjusted OR 1.17, 95% CI 1.07–1.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Nonapplication of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or cervical ripening did not contribute to increased odds of cesarean delivery for non-Hispanic black and Hispanic women. Compared with non-Hispanic white women, Hispanic women were actually less likely to experience elective cesarean delivery (adjusted OR 0.60, 95% CI 0.42–0.87) or cesarean delivery for arrest of dilation before 4 hours (adjusted OR 0.67, 95% CI 0.49–0.92). Additionally, compared with non-Hispanic white women, Asian women were more likely to experience cesarean delivery for nonreassuring fetal status (adjusted OR 1.29, 95% CI 1.09–1.53) and to have had that cesarean delivery be performed in the setting of a 1-minute Apgar score 7 or greater (adjusted OR 1.79, 95% CI 1.07–3.00). A similar trend was seen among multiparous women with prior vaginal deliveries.

CONCLUSION:
Although racial and ethnic disparities exist in the frequency of cesarean delivery, differential use of labor management strategies intended to reduce the cesarean delivery rate does not appear to be associated with these racial and ethnic disparities.