(1047) Contextualizing Disparities in NTSV Cesarean Rates with County-Level Data

The rate of cesarean births among nulliparous women with a term singleton fetus in vertex presentation (NTSV) is a quality indicator for perinatal care. Black women are disproportionately affected by high rates of unplanned cesarean birth and are at increased risk for the associated complications. We sought to describe disparities in the county-level NTSV cesarean birth rate in the United States to understand how cesarean disparities vary by place.

Study Design:

In this retrospective cross-sectional study, birth certificate data from the CDC Wonder Natality database from 2016-2020 for counties with a population ≥100,000 were merged with county-level region, urbanization, and poverty estimates from the U.S. Census Bureau. A multiple linear regression was calculated to predict the county-level odds ratio for Black vs White NTSV cesarean birth. 

Results:

The NTSV cesarean rate for Black women (mean = 30.3%, SD = .05) was higher than for White women (mean = 25.1 %, SD = .04) in 91.5% of counties (mean difference = 5.2%, p < .001). The odds ratio for NTSV cesarean birth in Black women was significantly predicted by the county cesarean rate (β = -1.45, R² = 0.11, p < .001), the proportion of birthing people in the county who were Black (β = -.42, R² = 0.09, p < .001), geographic region (F = 54.78, p = .006), and the poverty index (β = -.26, R² = 0.001, p = .008) (full model R² = 0.17). Differences in cesarean rates between Black and White women were greater in counties with lower overall cesarean rates, in counties with fewer Black mothers, slightly higher in counties with a higher poverty index, and were unrelated to urbanization. Counties in the West had the highest cesarean disparities (Δ = .18, p < .001).

Conclusion:

Variation in racial differences in the NTSV cesarean rate indicates a complex relationship between social and environmental factors contributing to disparities in cesarean outcomes. Research describing county-level protective and risk factors for cesarean birth among Black pregnant people is needed to guide clinical and policy changes to optimize perinatal health in Black communities.