Disparities in indication for primary cesarean delivery before and after implementation of quality initiatives

Racial and ethnic disparities exist in the rates of and indication for cesarean delivery, prompting the implementation of quality initiatives designed to target the drivers of these inequities. Few studies have assessed the impact of these initiatives on reducing these disparities.

To determine the rates of and indications for cesarean delivery before and after the implementation of perinatal quality improvement (QI) initiatives.

Retrospective cohort study of 3629 nulliparous individuals with full-term live-born, singleton gestations in vertex position (NTSV) who delivered at a large academic tertiary care center in the United States from October 2019 through December 2022. Perinatal QI initiatives, designed to promote vaginal birth and improve equity in birth outcomes, were implemented during this period. This included the Promoting Vaginal Birth (PVB) initiative implemented in October 2020, followed by the Birth Equity (BE) initiative in May 2021. An interrupted time series analysis was performed to examine the relationship between the implementation of perinatal QI initiatives and trends in cesarean delivery rates. Distributions of demographic, clinical, and structural characteristics were examined by indication for cesarean and race and ethnicity. Multivariable multinomial logistic regression models assessed the independent association between race and ethnicity and indication for cesarean delivery after adjusting for maternal, perinatal, and system-level risk factors before and after implementation of perinatal quality initiatives.

The rate of NTSV deliveries increased immediately following the start of quarter I (step-change β = 3.6%, 95% confidence interval [CI], 1.4%-5.8%, p = 0.004). However, across the study period, the rate of NTSV cesarean deliveries decreased compared to the estimated trend prior to the initiatives for a difference in slope per quarter of -0.6% (95% CI, -1.0 to -0.1, p = 0.019). Non-Hispanic (NH) Black pregnant people had the highest cesarean delivery rate: 29% compared to a range of 21%-23% in other racial and ethnic groups (p < 0.001). NH Black individuals had higher relative proportions of NTSV cesarean delivery for non-reassuring fetal status as compared to NH White individuals (38.1% vs. 25.9%), and Hispanic individuals had higher relative proportions of NTSV cesarean delivery for arrest of dilation as compared to NH White individuals (33.4% vs. 24.5%). After adjusting for maternal, perinatal, and systems-level risk factors, NH Black individuals had a higher risk of NTSV cesarean delivery for non-reassuring fetal status compared to NH White pregnant people over the entire study period (relative risk ratio [RRR] 1.91, 95% CI, 1.27-2.86). The association between race and indication for cesarean delivery did not differ by the implementation period of QI initiatives.

Quality initiatives to promote vaginal birth and birth equity may reduce the overall rate of NTSV cesarean delivery. However, additional efforts are necessary to understand and mitigate disparities in indication for cesarean delivery among minority pregnant individuals.