Racial disparities found in severe maternal morbidity after cesarean delivery

Racial disparities found in severe maternal morbidity after cesarean delivery | Image Credit: © strigana - © strigana - stock.adobe.com.

Severe maternal morbidity (SMM) patterns differ based on race and ethnicity among patients with a prior cesarean delivery, according to a recent study published in JAMA Network Open.¹

Racial and ethnic differences in SMM

Over 50,000 US birthing individuals are impacted by SMM annually, with a 1.6-fold increased rate reported in Black patients and 1.2-fold in Hispanic patients vs their White counterparts.² Cesarean delivery, which is also more common in Black patients, has been linked to higher SMM rates.¹ A vaginal birth after cesarean delivery (VBAC) is often used to reduce morbidity in subsequent births.

“Prior studies have identified racial and ethnic differences in birth mode after prior cesarean delivery, but the intersection of race and ethnicity, birth mode, and SMM among individuals with a prior cesarean delivery has not been examined,” wrote investigators.

Assessing live births

The cross-sectional study was conducted to determine the link between birth mode and SMM based on race and ethnicity in patients with prior cesarean delivery. Participants included women aged at least 18 years with a singleton live birth from 34- to 42-weeks’ gestation and a prior cesarean delivery.

Exclusion criteria included a contraindication to vaginal delivery and a newborn with a congenital anomaly. SMM was reported as a binary variable using International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes.

Birth mode and demographics

Labor after cesarean delivery (LAC) and birth mode after prior cesarean birth were reported as independent variables. Variables from the birth certificate and diagnosis and procedure codes were used to identify LAC. Categories for birth mode included VBAC, planned repeat cesarean birth, and unplanned repeat cesarean birth.

Race and ethnicity were also reported as key variables. Categories of race and ethnicity included non-Hispanic Black, Hispanic, non-Hispanic White, and non-Hispanic other race. Age, education, insurance type, US birth, parity, gestational age, prepregnancy body mass index, and year of birth were reported as covariates.

Delivery characteristics

There were 72,836 patients aged a mean 32.40 years included in the final analysis. Of patients, 11% were Black, 20.1% Hispanic, 56.8% White, and 12.1% another race or ethnicity. The most common age category was 30 to 34 years, followed by 35 to 39 years and 25 to 29 years.

Birth outside the United States was reported in 34.5% of patients, a college degree or higher in 47.8%, and private insurance in 49.7%. Sixty nine percent underwent planned cesarean birth, 30.9% LAC, 20.4% VBAC, and 10.6% unplanned cesarean delivery. An SMM was reported in 0.8%, increasing to 1.9% when including blood transfusion.

SMM rates and comorbidity scores

Patients with planned repeat cesarean birth had an average obstetric comorbidity index score of 5.75, vs 4.93 for VBAC and 6.81 for unplanned repeat cesarean birth. For patients with LAC, the mean score was 5.57. Increased scores were reported among Black and Hispanic patients in each birth mode category.

An unplanned repeat cesarean birth was reported in 15.3%, 11.5%, and 9.1% of Black, Hispanic, and White individuals, respectively. SMM rates among these populations were 1.5%, 0.9%, and 0.6%, respectively, highlighting a reduction among White patients.

Key findings and birth outcomes

When including 3-category birth mode and race and ethnicity as independent variables, an adjusted odds ratio (aOR) of 1.60 for SMM was reported among Black patients vs White patients. In those with planned and unplanned repeat cesarean delivery vs VBAC, the aORs were 1.57 and 3.05, respectively.

Variations in the link between birth mode and SMM also varied by delivery. SMM rates 1.06%, 0.80%, and 0.59% for Black, Hispanic, and White patients, respectively with planned repeat cesarean birth. This highlighted the impact of race and ethnicity on SMM patterns in patients with a prior cesarean delivery.

“Identifying factors contributing to higher SMM rates among Black and Latinx birthing people with planned repeat cesarean delivery is necessary to improve care quality and to promote equity,” wrote investigators.

References

1. Attanasio LB, Goff S, Hardeman R, Laws H, Srinivas S. Severe maternal morbidity by race and ethnicity and birth mode among individuals with a prior cesarean birth. JAMA Netw Open. 2025;8(6):e2513578. doi:10.1001/jamanetworkopen.2025.13578
2. Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015.Obstet Gynecol. 2018;132(5):1158-1166. doi:10.1097/AOG.0000000000002937