(918) Is racial segregation of hospital services associated with low-risk primary cesarean delivery?

Objective: Rates of low-risk primary cesarean delivery (pCD) vary significantly across hospitals and by race and ethnicity. We assessed whether racial segregation of hospital services was associated with pCD.

Study Design: Retrospective cohort study using U.S. Nationwide Inpatient Sample (NIS), 2017-2019. We included individuals with term pregnancy at low-risk for pCD as defined by SMFM criteria. Primary outcome was pCD. Primary exposure was hospital segregation, defined by proportion of births to Black individuals, divided into high (top 5%), medium (5-25%), and low Black-serving hospitals (BSH). Secondary exposures were urban location, teaching hospital, and US region. Adjusted hierarchical logistic regression models after propensity score matching for delivery at BSHs were used to assess associations between low-risk pCD and racial segregation of hospital services (Figure). NIS weights were used to provide nationally representative estimates.

Results: 7,503,660 (weighted) deliveries were included. Of these, 1,127,874 (15%) had a low-risk pCD. Table provides individual and hospital characteristics across BSH levels. Compared with low BSHs, delivering at high (aOR 0.91, 95% CI 0.87-0.96) and medium (aOR 0.96, 95% CI 0.93-0.99) BSHs was associated with lower odds of low-risk pCD. Compared with rural hospitals, delivering at urban non-teaching (aOR 0.90, 95% CI 0.85-0.96) and urban teaching (aOR 0.94, 95% CI 0.90-0.99) hospitals was associated with lower odds of low-risk pCD. US Census region was also associated with pCD, with all regions having lower odds of pCD compared to the South (Figure). Interactions between BSH and hospital teaching status, and individual maternal race/ethnicity and hospital characteristics, were not statistically significant. Accounting for hospital-level characteristics, both Black and Asian/Pacific Islander maternal race remained associated with increased odds of pCD (Figure).

Conclusion: Delivering at high Black-serving hospitals and urban non-teaching hospitals are independently associated with 10% lower odds of low-risk pCD after adjusting for individual- and hospital-level factors.