Yee Lynn M, Costantine Maged M, Rice Madeline Murguia, Bailit Jennifer, Reddy Uma M, Wapner Ronald J, Varner Michael W, Thorp John M, Caritis Steve N, Prasad Mona, Tita Alan T N, Sorokin Yoram, Rouse Dwight J, Blackwell Sean C, Tolosa Jorge E
Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, University of Texas Medical Branch, Galveston, Texas, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, Columbia University, New York, New York, the University of Utah Health Sciences Center, Salt Lake City, Utah, the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, the University of Pittsburgh, Pittsburgh, Pennsylvania, The Ohio State University, Columbus, Ohio, the University of Alabama at Birmingham, Birmingham, Alabama, Wayne State University, Detroit, Michigan, Brown University, Providence, Rhode Island, the University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas, and Oregon Health & Science University, Portland, Oregon; and the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.
Obstet Gynecol. 2017 Dec;130(6):1285-1294. doi: 10.1097/AOG.0000000000002343.
To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity.
This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008-2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery.
A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36-1.59; Asian adjusted OR 1.26, 95% CI 1.14-1.40; Hispanic adjusted OR 1.17, 95% CI 1.07-1.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Nonapplication of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or cervical ripening did not contribute to increased odds of cesarean delivery for non-Hispanic black and Hispanic women. Compared with non-Hispanic white women, Hispanic women were actually less likely to experience elective cesarean delivery (adjusted OR 0.60, 95% CI 0.42-0.87) or cesarean delivery for arrest of dilation before 4 hours (adjusted OR 0.67, 95% CI 0.49-0.92). Additionally, compared with non-Hispanic white women, Asian women were more likely to experience cesarean delivery for nonreassuring fetal status (adjusted OR 1.29, 95% CI 1.09-1.53) and to have had that cesarean delivery be performed in the setting of a 1-minute Apgar score 7 or greater (adjusted OR 1.79, 95% CI 1.07-3.00). A similar trend was seen among multiparous women with prior vaginal deliveries.
Although racial and ethnic disparities exist in the frequency of cesarean delivery, differential use of labor management strategies intended to reduce the cesarean delivery rate does not appear to be associated with these racial and ethnic disparities.
探讨剖宫产的频率及指征是否存在种族和民族差异，并评估旨在降低剖宫产率的分娩管理策略的应用是否与患者的种族和民族相关。
这是一项对多中心观察性产科队列的二次分析。经过培训的研究人员提取了25家医院（2008 - 2011年）超过115,000名孕妇的母婴记录。足月单胎、无畸形、头位、活产新生儿的妇女被纳入两个队列：1）初产妇（n = 35,529）；2）仅既往有阴道分娩史的经产妇（n = 39,871）。妇女被分为非西班牙裔黑人、非西班牙裔白人、西班牙裔和亚裔。多变量逻辑回归用于评估以下结果：总体剖宫产频率、剖宫产指征以及旨在安全降低剖宫产率的分娩管理策略的使用情况。
共有75,400名妇女符合纳入标准，其中47%（n = 35,529）在初产妇队列中，53%（n = 39,871）在经产妇队列中。初产妇的剖宫产频率为25.8%，经产妇为6.0%。对于初产妇，非西班牙裔白人、非西班牙裔黑人、亚裔和西班牙裔妇女未经调整的剖宫产频率分别为25.0%、28.3%、28.7%和24.0%。在初产妇中，与非西班牙裔白人妇女相比，所有种族和民族群体剖宫产的调整后优势比均更高（非西班牙裔黑人调整优势比[OR]1.47，95%CI 1.36 - 1.59；亚裔调整OR 1.26，95%CI 1.14 - 1.40；西班牙裔调整OR 1.17，95%CI 1.07 - 1.27），原因是胎儿状况不佳和产程难产导致剖宫产的可能性更大。对于非西班牙裔黑人和西班牙裔妇女，在引产失败、宫口扩张停滞、胎头下降停滞或宫颈成熟方面未应用分娩管理策略并未导致剖宫产几率增加。与非西班牙裔白人妇女相比，西班牙裔妇女实际上进行择期剖宫产（调整OR 0.60，95%CI 0.42 - 0.87）或在4小时前因宫口扩张停滞进行剖宫产（调整OR 0.67，95%CI 0.49 - 0.92）的可能性更小。此外，与非西班牙裔白人妇女相比，亚裔妇女因胎儿状况不佳进行剖宫产（调整OR 1.29，95%CI 1.09 - 1.53）以及在1分钟Apgar评分≥7的情况下进行剖宫产（调整OR 1.79，95%CI 1.07 - 3.00）的可能性更大。在仅有既往阴道分娩史的经产妇中也观察到了类似趋势。
虽然剖宫产频率存在种族和民族差异，但旨在降低剖宫产率的分娩管理策略的差异使用似乎与这些种族和民族差异无关。
