Abstract
Currently, stark maternal health disparities persist in the U.S. Pregnancy outcomes are subject to substantial racial/ethnic disparities including maternal morbidity and mortality. According to the Centers for Disease Control and Prevention (CDC), pregnancy-related deaths are three times higher among Black women compared to White women (CDC, 2024a). This dissertation emerges at a critical time of increasing awareness and policy development focused on addressing maternal health disparities. This dissertation explores associations between race/ethnicity and cesarean delivery among pregnant women admitted for labor and delivery services in the U.S. As a major surgical intervention, unnecessary cesarean delivery increases the risks of adverse patient outcomes (Frappalo et al., 2023). Lowering the rate of unnecessary cesarean deliveries is both a national and global health priority. The U.S. Department of Health’s Healthy People 2023 campaign aims to reduce cesarean deliveries for low-risk, nulliparous (first birth) patients to 23.6 percent by 2030 (Frappalo et al., 2023). This dissertation draws on the Social Ecological Model and Andersen’s Behavioral Model of Health Services Use as its theoretical foundation. This mixed methods study used a multivariate cross-sectional design, controlling for confounding effects of patient and clinical factors characteristics for quantitative analysis. Data for Aim 1 and Aim 2 were sourced from the 2019 Natality (NIS) Public Use File. The NIS comprises a sampling frame of 95 percent of all U.S. hospital inpatient stays data based on discharge records from the State Inpatient Databases (SID). This dataset was supplemented by urban/rural classification data from National Center for Health Statistics (NCHS) and income data from the American Community Survey (ACS). The first study aim analysis was conducted using logistic regression to identify patient and clinical factors characteristics that contribute to the likelihood of a cesarean (C-section) delivery among all births that occurred in 2019. The analysis revealed that Black women (OR 1.36; CI 95% 1.34, 139) have the highest odds of an Nulliparous Term Singleton Vertex (NTSV) cesarean delivery. NTSV cesarean or C-section births refer to “live babies born at or beyond 37.0 weeks gestation to women in their first pregnancy, that are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions) via cesarean birth.” (California Maternal Quality Care Collaborative, n.d.). NTSV C-section and the likelihood of an NTSV C-section increases with increasing age, Body Mass Index (BMI) and weight gain. The opposite effect is observed, as education and income increase: the adjusted odds ratio decreases. Notable risk factors which increase the likelihood of an NTSV C-section include pre-pregnancy diabetes (OR 2.30; CI 95%, 2.16, 2.42) and receiving antibiotics during labor and delivery (OR 2.44; CI 95% 2.42, 2.47). For Aim 2, Fairlie decomposition analysis was conducted to understand the extent to which individual-level and clinical factors contribute to differences among Black patients and White NTSV C-section rates. The Fairlie decomposition analysis revealed a total disparity of six percentage points in C-section rates between White and Black women. Of this disparity, 21 percent is explained by differences in observed characteristics, while the remaining 79 percent is attributable to unobserved characteristics. Specific observed characteristics which largely contribute to this disparity are: maternal age (30.4%), exposure to antibiotics during labor and delivery (8.0%), and BMI (7.0%). Among Black and White women with a high BMI (< 25), the total explained percentage increases to 35 percent. Specific observed characteristics which largely contributed to this disparity are: maternal age (52.9%), exposure to antibiotics during labor and delivery (15.0%) and payment method (11.1%). For Aim 3, qualitative data about the birthing experience was obtained from a series of focus group discussions with patients and providers. Findings from the qualitative study align with existing research indicating that effective patient-provider communication, culturally competent care and physician well-being improve maternal health outcomes. Patients who had continuous care from a trusted provider or doula reported higher satisfaction and lower stress levels. Conversely, those who experienced fragmented care and dismissive provider interactions reported feeling isolated and anxious during labor.