Abstract
(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai‘i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state’s largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai‘i.
Highlights
IntroductionDecision-making with regard to cesarean delivery is complex and involves the patient, the provider, and both objective and subjective assessments, which can be an ingress for conscious or unconscious biases to influence decisions
In 2003, the Institute of Medicine summarized evidence of racial/ethnic disparities in the United States (U.S.) and concluded that stereotyping and provider bias contribute to inequities in health [1]
The analyses reveal that Micronesian women had significantly greater odds of having a cesarean delivery due to subjective indications (NRFHT or arrest of labor) compared to objective indications after adjusting for age, parity, any diabetes, any hypertension, and newborn birth weight
Summary
Decision-making with regard to cesarean delivery is complex and involves the patient, the provider, and both objective and subjective assessments, which can be an ingress for conscious or unconscious biases to influence decisions. Both the American College of Obstetricians and Gynecologists and the Society of Maternal and Fetal Medicine have highlighted the need for additional research into implicit biases within the field of obstetrics and gynecology [7,8]. While disparities in cesarean delivery are noted, there is relatively little research examining variation in indications for cesarean delivery by race/ethnicity, leaving substantial knowledge gaps regarding the mechanisms that may contribute to differences in rates [12]. Of the limited studies that have examined cesarean delivery indications by race/ethnicity, findings indicate that Black women are more likely than White women to have cesarean delivery for NRFHT, but the reason for this difference is unclear [2,13]
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