346: Racial and ethnic disparities in cesarean delivery rates: Do hospital type, setting, and volume matter?

Abstract

In California, Black women are 4 times more likely to die from a pregnancy-related cause than White women. This gap has persisted despite the state’s 55% reduction in maternal mortality over the past 7 years. The causes for this disparity are not well defined, though undoubtedly mediated by structural inequities. We aimed to identify any racial disparities in cesarean delivery rates among hospitals of different type (academic vs non-academic), setting (urban vs rural), and volume (measured in annual deliveries). This retrospective cohort study included all singleton term vertex live births in nulliparous Black and non-Hispanic White women in California from 2005 to 2012. CD rates were obtained using birth certificate data and ICD-9 codes. Risk of CD was compared among Black versus White women by hospital type (academic, non-academic), setting (rural, suburban, urban), and volume (< 1200, 1200-2300, 2400-3599, ≥ 3600 deliveries annually). Federal Information Processing (FIPS) codes were use to designate hospital setting. Risks were calculated using univariable and multivariable logistic regression and adjusted for maternal age, maternal body mass index, medical comorbidities, gestational age, labor type (spontaneous versus induction), and birthweight. The sample included 59,441 Black women (CD rate 30.2%) and 363,624 white women (CD rate 26.1%). Black women were more likely to undergo CD in nearly all hospital types, settings, and volumes with aRRs ranging from 1.1 to 1.3-fold higher than White women. The only exception was rural settings in which the aRR was 1.3 but did not reach significance. Black women had significantly higher rates of CD than White women in nearly all hospital categories, even after adjusting for potential confounders. These global increased risks likely reflect structural inequities in care, which may contribute to disparities in maternal morbidity and mortality. This data should encourage providers, hospital systems, and quality care collaboratives to further investigate racial disparities in CD rates and develop mechanisms for mitigating them.