Spoken Language and Risk of Nulliparous, Term, Singleton, Vertex Cesarean Births in California, 2016-2021

Non-English-speaking individuals have noted disparities in health outcomes in the United States, but the role of language in obstetric settings is not well characterized.

We examined the association between primary spoken (preferred) language and the risk of nulliparous, term, singleton vertex cesarean delivery.

We conducted a retrospective cohort study of nulliparous, term, singleton vertex deliveries in California (2016-2021) using birth certificates linked to hospital discharge records. The primary outcome was the risk of cesarean delivery. Poisson log-linear regression was used to estimate the association between preferred language and cesarean delivery overall, adjusted for demographic, hospital, and obstetric factors. Analyses were stratified by labor type (pre-labor versus intrapartum), risk characteristics (standard versus high risk), and hospital characteristics (hospital type [academic versus nonacademic], setting [urban versus non-urban], and annual hospital cesarean delivery volume by sample tertiles).

Among 721,263 birthing people in California, 87,538 (12.1%) indicated that their preferred language was not English and 359,988 (49.9%) had no measured medical comorbidities (termed standard risk). Non-English speaking patients had a decreased risk of cesarean delivery (adjusted relative risk 0.94, 95% confidence interval 0.92-0.96), including among Chinese- (adjusted relative risk 0.83, 95% confidence interval 0.79-0.86) and Spanish-speaking patients (adjusted relative risk 0.94, 95% confidence interval 0.93-0.97), although non-English speaking birthing people who preferred languages other than Spanish or Chinese had slightly higher risk of cesarean delivery (adjusted relative risk 1.06, 95% confidence interval 1.02-1.10). There was a decreased cesarean risk among non-English speaking patients across labor types (spontaneous labor or prelabor rupture of membranes: adjusted relative risk 0.94, 95% confidence interval 0.89-1.00; induced labor: adjusted relative risk 0.90, 95% confidence interval 0.87-0.93; no indication of either: adjusted relative risk 0.97, 95% confidence interval 0.95-1.00), among standard risk patients (adjusted relative risk 0.95, 95% confidence interval 0.92-0.97), and across hospital type, setting, and annual cesarean delivery volume tertile. A small decrease in cesarean risk was also observed in teaching (adjusted relative risk 0.93, 95% confidence interval 0.91-0.96) and non-teaching hospitals (adjusted relative risk 0.95, 95% confidence interval 0.92-0.97), urban settings (adjusted relative risk 0.93, 95% confidence interval 0.92-0.95), and highest volume tertile (adjusted relative risk 0.93, 95% confidence interval 0.91-0.95), though there was no increase risk in non-urban settings (adjusted relative risk 1.02, 95% confidence interval 0.95-1.11) and across lowest and middle volume tertiles (adjusted relative risk 1.01, 95% confidence interval 0.92-1.11; and adjusted relative risk 0.95, 95% confidence interval 0.91-0.98, respectively).

Non-English language preference was associated with a slight decreased risk for cesarean delivery among nulliparous, term, singleton, and vertex presenting patients, and an increased risk among people who spoke other languages (i.e., not Chinese or Spanish). Our findings suggest that populations that speak less common non-English languages in California may be at elevated risk of disparate cesarean delivery outcomes.