Spoken language and risk of nulliparous, term, singleton, vertex cesarean births in California, 2016 to 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 (CD).

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 CD. Poisson log-linear regression was used to estimate the association between preferred language and CD overall, adjusted for demographic, hospital, and obstetric factors. Analyses were stratified by labor type (prelabor vs intrapartum), risk characteristics (standard vs high risk), and hospital characteristics (hospital type [academic vs nonacademic], setting [urban vs nonurban], and annual hospital CD 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 CD (adjusted relative risk [aRR] 0.94, 95% confidence interval [CI] 0.92-0.96), including among Chinese- (aRR 0.83, 95% CI 0.79-0.86) and Spanish-speaking patients (aRR 0.94, 95% CI 0.93-0.97), although non-English-speaking birthing people who preferred languages other than Spanish or Chinese had slightly higher risk of CD (aRR 1.06, 95% CI 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: aRR 0.94, 95% CI 0.89-1.00; induced labor: aRR 0.90, 95% CI 0.87-0.93; no indication of either: aRR 0.97, 95% CI 0.95-1.00), among standard risk patients (aRR 0.95, 95% CI 0.92-0.97), and across hospital type, setting, and annual CD volume tertile. A small decrease in cesarean risk was also observed in teaching (aRR 0.93, 95% CI 0.91-0.96) and nonteaching hospitals (aRR 0.95, 95% CI 0.92-0.97), urban settings (aRR 0.93, 95% CI 0.92-0.95), and highest volume tertile (aRR 0.93, 95% CI 0.91-0.95), though there was no increase risk in nonurban settings (aRR 1.02, 95% CI 0.95-1.11) and across lowest and middle volume tertiles (aRR 1.01, 95% CI 0.92-1.11; and aRR 0.95, 95% CI 0.91-0.98, respectively).

Non-English language preference was associated with a slight decreased risk for CD among nulliparous, term, singleton, and vertex presenting patients, and an increased risk among people who spoke other languages (ie, 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 CD outcomes.