Factors associated with increased cesarean risk among African American women: Evidence from California, 2010

Objectives: We studied if both observed and unobserved maternal health in African American women in hospitals or communities were associated with cesarean delivery of infants. Methods: We examined the relationship between African American race and cesarean delivery among 493 433 women discharged from 255 Californian hospitals in 2010 using administrative data; we adjusted for patient comorbidities and maternal, fetal, and placental risk factors, as well as clustering of patients within hospitals. Results: Cesarean rates were significantly higher overall for African American women than other women (unadjusted rate 36.8% vs 32.7%), as were both elective and emergency primary cesarean rates. Elevated risks persisted after risk adjustment (odds ratio generally >1.27), but the prevalence of particular risk factors varied. Although African American women were clustered in some hospitals, the proportion of African Americans among all women delivering in a hospital was not related to its overall cesarean rate. Conclusions: To address the higher likelihood of elective cesarean delivery, attention needs to be given to currently unmeasured patient-level health factors, to the quality of provider-physician interactions, as well as to patient preferences.