State-level structural sexism and cesarean sections in the United States

The United States (U.S.) has one of the highest cesarean rates in the world yet little research considers structural factors, like racism and sexism, associated with the higher than recommended cesarean rate. New research operationalizes and quantifies structural sexism across U.S. states, which allows for consideration of how social norms and values around women and their bodies relate to the overmedicalization of birth through cesarean sections. We obtained restricted natality data for 2018 from the U.S. National Center for Health Statistics. In 2018, among people 15-49 years, 987,187 births fit the criteria for low-risk of cesarean section. Structural sexism scores were derived from 6 elements covering economic, political, cultural, and physical arenas that were totaled and standardized to create an aggregate index for each state and DC (scores range from -1.06 to 1.4). Using multivariable logistic and multilevel mixed effects logistic regression models, we examined the associations between structural sexism and low-risk cesarean section for all fifty states and the District of Columbia, controlling for relevant confounders. We found that structural sexism in 2018 was highest in historically religious mountain states and the South. Nationally, the low-risk cesarean rate was 25.1%. Multilevel models show that people living in states with higher structural sexism scores were more likely to have a cesarean section (OR = 1.22, 95% CI: 1.07-1.39). Structural sexism is related to low-risk cesarean rates in U.S., providing evidence that social ideas and norms about women and their bodies are related to overmedicalization of birth. Health policymakers, providers and scholars should pay attention to structural drivers, including structural sexism, as a factor that affects overmedicalization of birth and subsequent health outcomes for pregnant people and their infants.