Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates

The cultural adaptation and psychometric evaluation of the Mothers on Respect Index for Native Hawaiians and Pacific Islanders

BACKGROUND

Native Hawaiian and Pacific Islanders (NHPI) are disproportionately burdened by pregnancy-related deaths in the United States and have the lowest engagement in prenatal care compared to all other US racial groups. Aside from access barriers, studies suggest that NHPI face challenges with patient-clinician communication, perceived discrimination, and cultural conflicts within healthcare settings. This paper describes the cultural adaptation of the 14-item Mothers On Respect index for NHPI, originally developed by Vedam et al. (2017) for diverse communities in British Columbia, Canada, and reports the findings of the preliminary psychometric assessment of the adapted measure.

METHODS

Data from 26 interviews with NHPI women, expert, and cognitive interviews were conducted to inform the adaptation. An online survey was administered to a sample of 90 NHPI women to assess construct validity, convergent validity, and internal reliability of the adapted measure using exploratory and confirmatory factor analyses.

RESULTS

The adaptation resulted in substantial changes to the original measure, mainly by the addition of items related to 'feeling cared for by and connected to the provider' and 'perceived threats hindering communication.' The psychometric analyses identified a three-factor structure for the culturally adapted index and confirmatory factor analyses were employed to refine the measure. The result was a 25-item index with acceptable goodness of fit indices, high internal reliability (Cronbach's alpha of 0.96, 95% CI = .94-.97) and convergent validity with a related scale. Overall, participants in this sample indicated high levels of respectful care; however, people who received < 8 prenatal care visits had significantly lower ratings on average.

CONCLUSIONS

Our findings suggest that the elements valued by NHPI are not fully captured in existing measures of respectful maternity care. Efforts to assess more discrete aspects of the patient-provider relationship for culturally distinct and racialized groups could help improve the quality of care and advance equity in maternal and perinatal health marginalized communities.

Evaluation of Statewide Program to Reduce Cesarean Deliveries Among Nulliparous Individuals With Singleton Pregnancies at Term Gestation in Vertex Presentation

OBJECTIVE

To evaluate the effect of statewide efforts to reduce nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates in California.

METHODS

This was a population-based study of all NTSV births in California from 2015 to 2019. In 2015, all California hospitals with NTSV cesarean delivery rates above the 23.9% Healthy People 2020 target were invited to join a CMQCC (California Maternal Quality Care Collaborative)-sponsored, 3-year, multifaceted collaborative or a system-level quality collaborative to safely support vaginal birth. We examined the cesarean delivery rate overall and by participation or nonparticipation in a collaborative program. Secondarily, for hospitals that started with an NTSV cesarean delivery rate above 23.9%, we compared patient-level, hospital-level, and obstetric management characteristics between hospitals that met the Healthy People 2020 target (cesarean delivery rate below 23.9%) in 2019 and those that did not.

RESULTS

There were 758,268 NTSV births at 238 hospitals. Annual mean NTSV cesarean delivery rates decreased among all racial and ethnic groups statewide and among all patients, regardless of payer, maternal age, or body mass index (BMI). The decrease in cesarean delivery was driven largely by a decrease in the frequency of cesarean delivery performed for labor dystocia (14.9% in 2015 to 12.8% in 2019) and from cesarean delivery before the onset of labor (4.2% in 2015 to 3.3% in 2019). For hospitals that started with an NTSV cesarean delivery rate above 23.9%, NTSV cesarean delivery rates among 80 hospitals participating in the CMQCC had a mean±SD decline of 6.9±5.9%, 13 hospitals participating in the system-level collaborative had a 5.0±4.5% decline, and those not participating in any collaborative had a 2.1±6.0% decline. In multivariable analysis, there was no association between meeting the Healthy People target and any of the hospital-level factors or aggregated patient-level characteristics. Rates of induction of labor increased in both groups and were not associated with a change in cesarean delivery rates.

CONCLUSION

Hospitals in California between 2015 and 2019 with a wide variation in institutional and patient characteristics successfully reduced their NTSV cesarean delivery rates. Reduction in the NTSV cesarean delivery rate at hospitals that started above the Healthy People target was not associated with differences in patient characteristics but rather a reduction in cesarean deliveries for labor dystocia and cesarean deliveries performed before the onset of labor.

Racial inequities in cesarean use among high- and low-risk deliveries: An analysis of childbirth hospitalizations in New Jersey from 2000 to 2015

OBJECTIVE

To examine racial inequities in low-risk and high-risk (or "medically appropriate") cesarean delivery rates in New Jersey during the era surrounding the United States cesarean surge and peak.

STUDY SETTING AND DESIGN

This retrospective repeated cross-sectional study examined the universe of childbirth hospitalizations in New Jersey from January 1, 2000 through September 30, 2015. We estimate the likelihood of cesarean delivery by maternal race and ethnicity, with mixed-level logistic regression models, stratified by cesarean risk level designated by the Society of Maternal Fetal Medicine (SMFM).

DATA SOURCES AND ANALYTIC SAMPLE

We used all-payer hospital discharge data from the Healthcare Cost and Utilization Project's State Inpatient Discharge Database and linked this data to the American Hospital Association Annual Survey. ZIP-code Tabulation Area (ZCTA)-level racialized economic segregation index data were from the 2007-2011 American Community Survey. We identified 1,604,976 statewide childbirth hospitalizations using International Classification of Diseases-9-CM (ICD-9) diagnosis and procedure codes and Diagnosis-Related Group codes, and created an indicator of cesarean delivery using ICD-9 codes.

PRINCIPAL FINDINGS

Among low-risk deliveries, Black patients, particularly those in the age group of 35-39 years, had higher predicted probabilities of giving birth via cesarean than White people in the same age categories (Black-adjusted predicted probability = 24.0%; vs. White-adjusted predicted probability = 17.3%). Among high-risk deliveries, Black patients aged 35 to 39 years had a lower predicted probability (by 2.7 percentage points) of giving birth via cesarean compared with their White counterparts.

CONCLUSIONS

This study uncovered a lack of medically appropriate cesarean delivery for Black patients, with low-risk Black patients at higher odds of cesarean delivery and high-risk Black patients at lower odds of cesarean than their White counterparts. The significant Black-White inequities highlight the need to address misalignment of evidence-based cesarean delivery practice in the efforts to improve maternal health equity. Quality metrics that track whether cesareans are provided when medically needed may contribute to clinical and policy efforts to prevent disproportionate maternal morbidity and mortality among Black patients.

Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections

BACKGROUND

Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections.

METHODS

We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits.

RESULTS

Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health.

CONCLUSION

Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.