To compare contemporary primary cesarean delivery (CD) rates and indications for primary CD by race/ethnicity at South Carolina’s largest regional perinatal center, and to compare rates of maternal and neonatal complications associated with primary CD by race/ethnicity. Retrospective cohort study of all women undergoing primary CD. Data extraction included a comprehensive manual review of individual prenatal records, labor notes, operative reports, discharge summaries, and postpartum records to determine the indication for and morbidity from cesarean. Statistical analysis included Chi square, Fisher’s exact test, t-tests and logistic regression. 827 women delivered via primary CD, of which 66.1%, 20.1%, 10.2% and 3.6% were non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and Other, respectively. There was no significant difference in primary CD rate when stratified by race/ethnicity (17.17% NHW, 18.78% NHB, 12.16% Hispanic, and 16.85% Other; p=0.15). When compared to NHW women, NHB women were delivered significantly more often for non-reassuring fetal heart rate (23% vs 39%, p < 0.001), but significantly less frequently for arrest of the second stage (12% vs 4%, p=0.009). NHB women were 2.5 times more likely to receive a blood transfusion and four times more likely to be admitted to the ICU when compared to NHW women (p=0.013 and 0.010, respectively). In logistic regression analysis, NHB and Hispanic women were more likely than NHW women to experience at least one adverse maternal outcome (AOR 1.56, 95% CI 1.01, 2.41, and AOR 1.98, 95% CI 1.14, 3.29). Adverse neonatal outcomes were statistically similar across the four race/ethnicity groups with the exception of umbilical cord pH< 7, which was six times more common in NHB women when compared to NHW women (0.01% vs 0.06%, p=0.006; Table 4). In the state’s largest regional perinatal center, significant variation exists in risk of morbidity from primary cesarean delivery, with a disproportionate burden borne by NHB women.