45 - Is racial segregation of hospital services associated with successful vaginal birth after cesarean?

Friday, February 10, 2023

2:15 PM – 2:30 PM

Location: Room 3009, Moscone West, Level 3

Objective: Vaginal birth after cesarean (VBAC) rates vary significantly across hospitals. We assessed whether racial segregation of hospital services was associated with VBAC.

Study Design: Retrospective cohort study using U.S. Nationwide Inpatient Sample (NIS), 2017-2019. Agency for Health Care Research and Quality Inpatient Quality Indicator for VBAC was used to define inclusion/exclusion. We included term deliveries with prior Cesarean and excluded abnormal presentation, stillbirth, multiple gestation, and hospitals with < 10 deliveries. Primary outcome was VBAC. Primary exposure was hospital segregation, defined by proportion of births to Black individuals, divided into high (top 5%), medium (6-25%), and low Black-serving hospitals (BSH). Secondary exposures were urban vs rural and teaching vs non-teaching hospital. We used adjusted hierarchical logistic regression models after propensity score matching for delivery at BSHs to assess associations between racial segregation of hospital services and VBAC (Figure). NIS weights were used to provide nationally representative estimates.

Results: 1,734,919 deliveries were included. Of these, 227,775 (13.1%) had a VBAC. Table shows characteristics across BSH levels. In logistic models without hospital-level indicators, Black (aOR 1.18, 95% CI 1.12-1.26), Hispanic (aOR 1.23, 95%CI 1.14-1.32), and Asian/Pacific Islander (aOR 1.35, 95% CI 1.19-1.54) individuals had higher associated odds of VBAC compared with White individuals. Including hospital characteristics eliminated individual-level race and ethnicity differences in VBAC odds. Compared with low BSH, delivering at a high BSH is associated with higher odds of VBAC (aOR 1.44, 95% CI 1.32-1.57). Models including interactions between urban, teaching, and BSH status revealed that teaching status and location modify relationships between BSH and VBAC (Figure).

Conclusion: Delivering at a high BSH is associated with 44% increased odds of VBAC. Accounting for hospital-level factors such as racial segregation of hospital services eliminates individual-level race and ethnicity differences in VBAC odds.

Primary & Presenting Author(s)

Max Jordan Nguemeni Tiako, MD, MS (he/him/his)

Brigham and Women's Hospital
Boston, Massachusetts, United States

Coauthor(s)

Adebayo Adesomo, MD

University of Utah
Salt Lake City, Utah, United States
CZ

Chong Zhang, MS

University of Utah Health
Salt Lake City, Utah, United States
JK

Jaewhan Kim, PhD

University of Utah Health
Salt Lake City, UT, United States
Torri D. Metz, MD, MS (she/her/hers)

Associate Professor
University of Utah Health
Salt Lake City, Utah, United States
GM

George L. Maxwell, MD

Inova Health System
Falls Church, Virginia, United States
RM

Rolel Mbaidjol-Kabra, MD

Inova Health System
Falls Church, VA, United States
GL

Guoyang Luo, MD, PhD

Howard University, College of Medicine
Washington, District of Columbia, United States
Monica A. Lutgendorf, MD

Department Chair, Gynecologic Surgery & Obstetrics
Uniformed Services University of the Health Sciences
Bethesda, MD, United States
Michelle P. Debbink, MD, PhD

Assistant Professor
University of Utah Health
Salt Lake City, Utah, United States