Maternal education and racial/ethnic disparities in nulliparous, term, singleton, vertex cesarean deliveries in the United States

Temporal trends in peripartum hysterectomy among individuals with a previous cesarean delivery by race/ethnicity in the United States: A population-based cohort study

OBJECTIVES

Rates of severe maternal morbidity have highlighted persistent and growing racial disparities in the United States (US). We aimed to contrast temporal trends in peripartum hysterectomy by race/ethnicity and quantify the contribution of changes in maternal and obstetric factors to temporal variations in hysterectomy rates.

METHODS

We conducted a population-based, retrospective study of 5,739,569 US residents with a previous cesarean delivery, using National Vital Statistics System's Natality Files (2011-2021). Individuals were stratified by self-identified race/ethnicity and classified into four periods based on year of delivery. Temporal changes in hysterectomy rates were estimated using odds ratios (ORs) and 95% confidence intervals (CIs). We used sequential logistic regression models to quantify the contribution of maternal and obstetric factors to temporal variations in hysterectomy rates.

RESULTS

Over the study period, the peripartum hysterectomy rate increased from 1.23 (2011-2013) to 1.44 (2019-2021) per 1,000 deliveries (OR 2019-2021 vs. 2011-2013 = 1.17, 95% CI 1.10 to 1.25). Hysterectomy rates varied by race/ethnicity with the highest rates among Native Hawaiian and Other Pacific Islander (NHOPI; 2.73 per 1,000 deliveries) and American Indian or Alaskan Native (AIAN; 2.67 per 1,000 deliveries) populations in 2019-2021. Unadjusted models showed a temporal increase in hysterectomy rates among AIAN (2011-2013 rate = 1.43 per 1,000 deliveries; OR 2019-2021 vs. 2011-2013 = 1.87, 95% CI 1.02 to 3.45) and White (2011-2013 rate = 1.13 per 1,000 deliveries; OR 2019-2021 vs. 2011-2013 = 1.21, 95% CI 1.11 to 1.33) populations. Adjustment ranged from having no effect among NHOPI individuals to explaining 14.0% of the observed 21.0% increase in hysterectomy rates among White individuals.

CONCLUSION

Nationally, racial disparities in peripartum hysterectomy are evident. Between 2011-2021, the rate of hysterectomy increased; however, this increase was confined to AIAN and White individuals.

Skin-To-Skin Contact During Cesarean Birth in the United States over the Last Decade

PURPOSE

To assess skin-to-skin contact during cesarean birth, including incidence and maternal characteristics.

STUDY DESIGN AND METHODS

A cross-sectional, retrospective study using survey methods was conducted. Women who had a cesarean birth within the last 10 years prior to January 2022 were recruited via social media. Descriptive statistics, chi square, and binary logistic regression analyses were calculated.

RESULTS

There were 2,327 participants, of which 29.7% experienced skin-to-skin contact during their cesarean birth. This was reported to be less often than desired. Significant associations were found among skin-to-skin contact during cesarean birth and planned cesarean birth, previous cesarean birth, maternal age, level of education, and birth region. Previous vaginal birth and race were not significantly associated with skin-to-skin contact during cesarean birth. Most (93.65%) respondents identified as White. Barriers to skin-to-skin contact during cesarean birth may be birth region, unplanned or emergency cesarean births, younger age, lacking a college degree, and lack of previous cesarean births.

CLINICAL IMPLICATIONS

There are differences in incidence and access to skin-to-skin contact during cesarean birth. Our findings emphasize the continued need to address disparities in care, increase maternal health care equity, and make skin-to-skin contact during cesarean birth available for all women who desire it.

Neurodevelopmental outcome of low-risk moderate to late preterm infants at 18 months

Background

Of the 15 million preterm births that occur worldwide each year, approximately 80% occur between 32 and 36 + 6 weeks gestational age (GA) and are defined as moderate to late preterm (MLP) infants. This percentage substantiates a need for a better understanding of the neurodevelopmental outcome of this group.

Aim

To describe neurodevelopmental outcome at 18 months in a cohort of healthy low-risk MLP infants admitted to the neonatal unit at birth and to compare the neurodevelopmental outcome to that of a healthy term-born infant group.

Study design and method

This single-centre observational study compared the neurodevelopmental outcome of healthy MLP infants to a group of healthy term control (TC) infants recruited during the same period using the Griffith's III assessment at 18 months.

Results

Seventy-five MLP infants and 92 TC infants were included. MLP infants scored significantly lower in the subscales: Eye-hand coordination (C), Personal, Social and Emotional Development (D), Gross Motor Development (E) and General Developmental (GD) (p < 0.001 for each) and Foundations of Learning (A), (p = 0.004) in comparison to the TC infant group with Cohen's d effect sizes ranging from 0.460 to 0.665. There was no statistically significant difference in mean scores achieved in subscale B: Language and Communication between groups (p = 0.107).

Conclusion

MLP infants are at risk of suboptimal neurodevelopmental outcomes. Greater surveillance of the neurodevelopmental trajectory of this group of at-risk preterm infants is required.

Effect of the COVID-19 pandemic on racial disparities in postpartum visits at a Texas level IV maternal center

Background

The primary aim of our study was to determine the attendance of postpartum visits stratified by race and if the COVID-19 pandemic affected racial disparities in postpartum visit attendance.

Methods

We searched our labor and delivery records from July 1, 2019 to December 31, 2019 and from July 1, 2020 to December 31, 2020 and included patients who delivered liveborn infants. The final analysis was restricted to patients who identified as White or Caucasian only, Black or African American only, or Hispanic. We then performed joint tests on the logistic regression with an interaction term of race and year of delivery to determine the final model.

Results

The odds ratio of Black or African American and Hispanic patients attending a postpartum visit was 0.589 (95% CI 0.456, 0.760; P < .001) and 0.836 (95% CI 0.676, 1.034; P = 0.099), respectively, compared to White or Caucasian patients. The interaction term of race and year of delivery was not statistically significant.

Conclusion

Black or African American patients at our hospital had a clinically and statistically significant lower utilization of postpartum visits compared to White or Caucasian patients and this disparity was not exacerbated by the COVID-19 pandemic.

Disparities by race/ethnicity in unplanned cesarean birth among healthy nulliparas: a secondary analysis of the nuMoM2b dataset

BACKGROUND

Racial disparities exist in maternal morbidity and mortality, with most of these events occurring in healthy pregnant people. A known driver of these outcomes is unplanned cesarean birth. Less understood is to what extent maternal presenting race/ethnicity is associated with unplanned cesarean birth in healthy laboring people, and if there are differences by race/ethnicity in intrapartum decision-making prior to cesarean birth.

METHODS

This secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) dataset involved nulliparas with no significant health complications at pregnancy onset who had a trial of labor at ≥ 37 weeks with a singleton, non-anomalous fetus in cephalic presentation (N = 5,095). Logistic regression models were used to examine associations between participant-identified presenting race/ethnicity and unplanned cesarean birth. Participant-identified presenting race/ethnicity was used to capture the influence of racism on participant's healthcare experiences.

RESULTS

Unplanned cesarean birth occurred in 19.6% of labors. Rates were significantly higher among Black- (24.1%) and Hispanic- (24.7%) compared to white-presenting participants (17.4%). In adjusted models, white participants had 0.57 (97.5% CI [0.45-0.73], p < 0.001) lower odds of unplanned cesarean birth compared to Black-presenting participants, while Hispanic-presenting had similar odds as Black-presenting people. The primary indication for cesarean birth among Black- and Hispanic- compared to white-presenting people was non-reassuring fetal heart rate in the setting of spontaneous labor onset.

CONCLUSIONS

Among healthy nulliparas with a trial of labor, white-presenting compared to Black or Hispanic-presenting race/ethnicity was associated with decreased odds of unplanned cesarean birth, even after adjustment for pertinent clinical factors. Future research and interventions should consider how healthcare providers' perception of maternal race/ethnicity may bias care decisions, leading to increased use of surgical birth in low-risk laboring people and racial disparities in birth outcomes.

Factors Contributing to Rapidly Increasing Rates of Caesarean Section in Andhra Pradesh, India: A Case-Control Study

Introduction In some obstetric situations, a caesarean section (CS) can be a crucial, life-saving treatment for both the mother and the infant. Nonetheless, unnecessary CS can raise the risk of morbidity for both. The present study was conducted to study the factors associated with CS delivery and to study the patterns of utilization of health facilities by pregnant women in the state of Andhra Pradesh in India. Materials and methods A community-based case-control study was done in Mangalagiri mandal, Guntur district, Andhra Pradesh, India in 2022. A total of 268 mothers (134 CS and 134 normal vaginal childbirth) who delivered between 2019 to 2022 with at least one biological child less than three years of age were studied. The data was collected using a structured questionnaire. Robson's 10-Group Classification was used to differentiate the type of deliveries of the participants. A p-value less than 0.05 was considered to be significant. Results The mean age of the 268 women studied was 25.49±3.73 years. We found that 47 of the 82 (57.3%) women who went to government healthcare facilities and 87 of the 181 (48.1%) women who went to private healthcare facilities had a CS. Of the total CS studied, approximately 83.5% were emergency CSs. All four mothers who had twins had undergone CS. All women with oblique or transverse fetal lie underwent CS irrespective of parity. On multivariate analysis, participants' education status less than or equal to 10th standard was positively associated with CS and identification of complications in the third trimester by healthcare provider was significantly protective for CS. Conclusion CS rate reduction necessitates a multi-faceted strategy that includes a variety of programming initiatives. Audits of CS performed as part of health programs and other creative monitoring techniques can be useful tools for assessing the standard of maternity care, particularly emergency CS.

Disparities in Incidences of Cesarean Section Among Women With Gestational Diabetes Mellitus in the United States

Background In this study, we explored the interaction between women's race/ethnicity and insurance type and determined how these interactions affect the incidences of cesarean section (CS) among women with gestational diabetes mellitus (GDM). Methodology We utilized the National Inpatient Sample (NIS) database from January 2000 to September 2015 to conduct a retrospective analysis of all GDM-associated hospitalizations. We then explored the interaction between race/ethnicity and insurance types and determined how these interactions affect the incidences of CS among GDM patients, controlling for traditional risk factors for CS and patients' sociodemographics. Subsequently, we determined the risk of primary postpartum hemorrhage (PPH) in the CS group and a propensity score-matched control group who had vaginal deliveries. Results There were 932,431 deliveries diagnosed with GDM in the NIS database from January 2000 to September 2015. The mean age of the study population was 30.6 ± 5.9 years, 44.5% were white, 14.0% were black, and 26.7% were Hispanic. The CS rate was 40.5%. After controlling for covariates, women who utilized private insurance had the highest CS rate across the different races/ethnicities; white (odds ratio (OR) = 1.21 (1.17-1.25)) blacks (OR = 1.33 (1.26-1.41)), and Hispanic (OR = 1.12 (1.06-1.18)). CS patients were less likely to develop PPH compared to their matched controls with vaginal deliveries (OR = 0.67 (0.63-0.71)). Conclusions Private insurance is associated with higher incidences of CS among women with GDM, irrespective of race/ethnicity.