Attanasio Laura B, Goff Sarah, Hardeman Rachel, Laws Holly, Srinivas Sindhu
Department of Health Promotion and Policy, University of Massachusetts Amherst, Amherst.
Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis.
JAMA Netw Open. 2025 Jun 2;8(6):e2513578. doi: 10.1001/jamanetworkopen.2025.13578.
Given that nearly one-third of US births are cesarean deliveries, subsequent births after a cesarean delivery are common. Racial and ethnic disparities in severe maternal morbidity (SMM) have been well-documented, and prior studies have identified differences in birth mode after prior cesarean delivery by race and ethnicity.
To examine variation by race and ethnicity in the association between SMM and birth mode for individuals with a prior cesarean delivery.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used Massachusetts linked birth certificate and hospital discharge data from 2012 to 2021. The analytic sample was limited to births to individuals with 1 prior cesarean delivery. Data were analyzed from August 23, 2024, to March 31, 2025.
Race and ethnicity and birth mode (vaginal birth after cesarean delivery, planned repeat cesarean delivery, and unplanned repeat cesarean delivery).
SMM was measured using Centers for Disease Control and Prevention indicators. Associations of race and ethnicity and birth mode with SMM were calculated using logistic regression, then an interaction term was added between race and ethnicity and birth mode. Models controlled for covariates.
The study population included 72 836 individuals (mean [SD] age, 32.40, [5.03] years), of whom 8022 (11.0%) were Black, 14 664 (20.1%) were Latinx, and 41 350 (56.8%) were White. Approximately one-third of individuals were born outside the US (25 119 individuals [34.5%]). In adjusted analyses, Black individuals had higher odds of SMM compared with White individuals (adjusted odds ratio [AOR], 1.60; 95% CI, 1.25-2.05). Odds of SMM were higher for unplanned repeat cesarean birth (AOR, 3.05; 95% CI, 2.23-4.18) compared with vaginal birth after cesarean delivery, and higher for planned repeat cesarean birth compared with vaginal birth after cesarean delivery (AOR, 1.57; 95% CI, 1.20-2.06). Including an interaction term identified variation in the association between birth mode and SMM by race and ethnicity. Planned repeat cesarean birth vs VBAC was associated with an increase in the likelihood of SMM of 0.56 (95% CI, 0.21-0.90) percentage points (P = .001) among Black birthing people and 0.46 (95% CI, 0.16-0.76) percentage points (P = .003) among Latinx birthing people, while among White individuals, the likelihood of SMM did not differ between planned repeat cesarean birth and VBAC.
In this cross-sectional study of births among individuals with a prior cesarean birth, patterns of SMM by birth mode varied by race and ethnicity, with elevated rates of SMM among those from marginalized racial and ethnic groups with planned cesarean births. Future work should identify interventions to improve quality of care and promote equity for this population.
鉴于美国近三分之一的分娩为剖宫产，剖宫产后的后续分娩很常见。严重孕产妇发病率（SMM）方面的种族和民族差异已有充分记录，先前的研究也已确定了不同种族和民族剖宫产后分娩方式的差异。
研究有剖宫产史的个体中，SMM与分娩方式之间的关联在种族和民族上的差异。
设计、设置和参与者：这项横断面研究使用了2012年至2021年马萨诸塞州的链接出生证明和医院出院数据。分析样本仅限于有1次剖宫产史的个体的分娩情况。数据于2024年8月23日至2025年3月31日进行分析。
种族和民族以及分娩方式（剖宫产后阴道分娩、计划再次剖宫产和非计划再次剖宫产）。
使用疾病控制和预防中心的指标来衡量SMM。通过逻辑回归计算种族和民族以及分娩方式与SMM之间的关联，然后在种族和民族与分娩方式之间添加一个交互项。模型对协变量进行了控制。
研究人群包括72836名个体（平均[标准差]年龄为[5.03]岁，32.40岁），其中8022名（11.0%）为黑人，14664名（20.1%）为拉丁裔，41350名（56.8%）为白人。约三分之一的个体在美国境外出生（25119名个体[34.5%]）。在调整分析中，与白人个体相比，黑人个体发生SMM的几率更高（调整后的优势比[AOR]为1.60；95%置信区间为1.25 - 2.05）。与剖宫产后阴道分娩相比，非计划再次剖宫产出生发生SMM的几率更高（AOR为3.05；95%置信区间为2.23 - 4.18），计划再次剖宫产出生与剖宫产后阴道分娩相比发生SMM的几率也更高（AOR为1.57；95%置信区间为1.20 - 2.06）。纳入交互项后发现，分娩方式与SMM之间的关联在种族和民族上存在差异。在黑人分娩人群中，计划再次剖宫产与剖宫产后阴道分娩相比，SMM发生可能性增加0.56（95%置信区间为0.21 - 0.90）个百分点（P = 0.001）；在拉丁裔分娩人群中增加0.46（95%置信区间为0.16 - 0.76）个百分点（P = 0.003）；而在白人个体中，计划再次剖宫产与剖宫产后阴道分娩之间SMM发生可能性没有差异。
在这项对有剖宫产史个体的分娩情况进行的横断面研究中，SMM按分娩方式的模式因种族和民族而异，在计划剖宫产的边缘化种族和民族群体中SMM发生率较高。未来的工作应确定改善该人群护理质量和促进公平的干预措施。
