Racial Disparities in Nulliparous Singleton Term Vertex Cesarean Deliveries: Rates, Reasons, and Time to Delivery

Non-Hispanic Black individuals have the highest odds of having a nulliparous term singleton vertex (NTSV) cesarean birth out of all racial and ethnic groups, but this disparity is not well understood. This study assesses the factors associated with overall rates of NTSV cesarean delivery, differences in reasons for cesarean births, and door-to-delivery time among individuals who had an NTSV cesarean delivery.

Retrospective analyses assessed n = 31,826 NTSV births from January 1, 2016 to December 31, 2021 at 11 medical centers in North Carolina. For each outcome variable, multivariate regression estimated Black-White disparities while controlling for clinical and social covariates. Models included random intercepts for facility and delivery provider.

After accounting for covariates, non-Hispanic Black patients were more likely to have an NTSV cesarean delivery compared to non-Hispanic White patients (AOR = 1.48, 95% CI 1.47, 1.69). Among those who had an NTSV cesarean delivery, non-Hispanic Black patients were more likely than non-Hispanic White patients to have a cesarean delivery due to fetal intolerance of labor (AOR = 2.10, 95% CI 1.87, 2.42). Non-Hispanic Black patients had a shorter door-to-delivery time for unscheduled NTSV cesarean deliveries than non-Hispanic White patients (b = -1.80, 95% CI -2.50, -1.11).

We confirmed the persistence of a racial disparity in cesarean delivery rates after controlling for multiple social and clinical factors. As fetal intolerance of labor has been described as a subjective indicator, and faster door-to-delivery time for cesarean deliveries may indicate faster decision making, our findings indicate a need to better understand decision making around cesarean deliveries.