OHSU research finds persistent racial disparities in cesarean births – OHSU News

Report on Cesarean Birth Disparities and Alignment with Sustainable Development Goals

Executive Summary

A study by Oregon Health & Science University (OHSU) researchers analyzing over 30 million births from 2012 to 2021 reveals significant racial and ethnic disparities in cesarean birth rates in the United States. Despite a slight overall decrease in cesarean procedures, the rate for Black individuals has persistently increased, widening a pre-existing gap. These findings highlight critical challenges to achieving several Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities). The research underscores that the disparity is not biological but rooted in structural racism, demanding institutional reforms aligned with SDG 16 (Peace, Justice and Strong Institutions).

Key Findings and Analysis

The retrospective observational cohort study identified concerning trends in maternal healthcare equity.

1. Overall Trend vs. Specific Disparity: While national efforts since 2014 led to a slight decrease in the overall rate of cesarean births, the rate for Black individuals, who already experienced the highest rates, continued to rise.
2. Quantified Risk Increase: After adjusting for other medical factors, the risk of a cesarean birth for Black individuals was 12% higher than for other groups in 2012, and this disparity grew to 17% higher by 2021.
3. Consistent Disparity Across Scenarios: The increased risk was observed across different birthing situations. For first-time births, the risk for Black individuals rose from 20% higher in 2012 to 23% higher in 2021. For those with a prior vaginal delivery, the risk remained consistently high at 32% in 2012 and 33% in 2021.

Implications for Sustainable Development Goal 3: Good Health and Well-being

The study’s findings directly challenge the targets of SDG 3, which aims to ensure healthy lives and promote well-being for all at all ages.

• Maternal Health Targets: The growing disparity in cesarean rates indicates a failure to provide equitable and safe maternal healthcare, undermining efforts to reduce maternal mortality and ensure universal access to sexual and reproductive health-care services.
• Quality of Care: A cesarean section is a life-saving procedure, but its overuse or inequitable application can lead to negative health outcomes. The data suggests systemic failures in providing appropriate, patient-centered obstetric care for Black individuals.
• Obstetric Inequity: These disparities are part of a larger pattern of obstetric inequity, where Black individuals face significantly higher rates of pregnancy-related death and their infants face higher risks of adverse outcomes like preterm birth.

Addressing SDG 10: Reduced Inequalities

The research provides clear evidence of health inequality within a nation, a core concern of SDG 10.

• Structural Racism as a Driver: The report explicitly attributes the disparities to structural racism and implicit bias within the healthcare system, rather than biological factors. This directly relates to SDG Target 10.3, which aims to ensure equal opportunity and reduce inequalities of outcome.
• Widening Health Gap: The increasing gap in cesarean rates between Black individuals and other groups demonstrates a worsening of inequality, contrary to the goals of SDG 10.
• Need for Inclusive Systems: Addressing this issue requires systemic changes to dismantle discriminatory practices and promote the social and health inclusion of all, as called for in SDG Target 10.2.

Recommendations for Institutional Action in Line with SDG 16

Achieving equitable maternal health outcomes requires building effective, accountable, and inclusive institutions, as outlined in SDG 16. The research suggests several key interventions.

1. Implement Quality Improvement Efforts: Hospitals and health systems must develop targeted interventions to reduce unnecessary cesarean births among the Black population and address the underlying drivers of these outcomes.
2. Address Implicit Bias: Institutions must offer ongoing education, training, and resources for clinicians to acknowledge and address the internalized stereotypes that unconsciously affect clinical decisions.
3. Systematic Case Reviews: A process of reviewing every cesarean delivery on a case-by-case basis can help clinicians identify areas for improvement in patient care and medical decision-making.
4. Diversify the Healthcare Workforce: A key structural change is to build a diverse workforce that reflects the communities being served. This requires significant investment in pipeline programs that improve access to education and career opportunities for disproportionately impacted communities.
5. Promote Upstream Interventions: Efforts should include interventions that support healthier pregnancies from the beginning, including preconception care, to mitigate risks before labor and delivery.

Analysis of SDGs, Targets, and Indicators

1. Which SDGs are addressed or connected to the issues highlighted in the article?

SDG 3: Good Health and Well-being

• The article’s primary focus is on maternal and infant health, specifically analyzing the rates and risks associated with cesarean births. It discusses obstetric care, labor management, pregnancy-related death rates, and infant health risk factors like preterm birth, all of which are central to ensuring healthy lives and promoting well-being.

SDG 10: Reduced Inequalities

• The core finding of the article is the significant and persistent racial and ethnic disparities in cesarean birth rates. The text explicitly states that these disparities “have no biological basis and are rooted in structural racism” and implicit bias within the healthcare system. This directly addresses the goal of reducing inequalities in outcomes between different social groups.

2. What specific targets under those SDGs can be identified based on the article’s content?

SDG 3: Good Health and Well-being

1. Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.
   • The article connects to this target by highlighting the broader context of obstetric inequity, stating that “Black individuals face significantly higher rates of pregnancy-related death rates.” This indicates a failure to protect the health of a specific group of mothers, which is a key aspect of reducing overall maternal mortality.
2. Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age.
   • The article relates to this target by mentioning that infants of Black individuals “are much more likely to have certain birth risk factors, such as preterm birth.” Preterm birth is a leading cause of neonatal mortality, so addressing these disparities is crucial for achieving this target.
3. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
   • The article implies a gap in “access to quality essential health-care services” for all. While access may exist, the disparity in outcomes (higher cesarean rates for Black individuals) suggests a failure in the quality and equity of care provided. The call for “patient-centered care, improved birth outcomes” and addressing implicit bias speaks directly to improving the quality of healthcare for everyone.

SDG 10: Reduced Inequalities

1. Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.
   • The research highlights a lack of equitable health outcomes for Black individuals, demonstrating a form of exclusion within the healthcare system. The article’s call to “better support Black birthing people” is a direct call for more inclusive and equitable healthcare practices.
2. Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices and promoting appropriate legislation, policies and action in this regard.
   • This target is central to the article’s conclusion. The study’s findings of increased cesarean risk for Black individuals (e.g., “risk of cesarean birth for Black individuals was 12% higher in 2012 and 17% higher in 2021”) are a clear example of an “inequality of outcome.” The article attributes this to “structural racism” and “implicit bias,” which are discriminatory practices that need to be eliminated to ensure equal opportunity for good health.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Indicators for SDG 3

• Rate of cesarean births, disaggregated by race and ethnicity: This is the primary quantitative indicator used throughout the article. The study found that while the overall rate decreased slightly, the rate for Black individuals increased. Tracking this specific indicator is crucial for measuring the quality and equity of maternal healthcare.
• Pregnancy-related death rates, disaggregated by race and ethnicity: The article explicitly mentions that “Black individuals face significantly higher rates of pregnancy-related death rates.” This directly corresponds to SDG Indicator 3.1.1 (Maternal mortality ratio) and highlights the necessity of disaggregating this data by race to measure progress in reducing disparities.
• Incidence of infant birth risk factors (e.g., preterm birth), disaggregated by race and ethnicity: The article notes that infants of Black individuals are more likely to experience “preterm birth.” This serves as an implied indicator for neonatal health and well-being, relevant to SDG Target 3.2.

Indicators for SDG 10

• Risk ratio of cesarean births for Black individuals compared to other racial and ethnic groups: The article provides specific data for this indicator, stating the risk was “12% higher in 2012 and 17% higher in 2021.” This ratio is a direct measure of the “inequality of outcome” mentioned in Target 10.3. A reduction in this ratio would indicate progress.
• Diversity of the healthcare workforce: The article implies this as an indicator by stating that “building a diverse health care workforce that reflects the communities being cared for is key” to addressing structural issues. Measuring the racial and ethnic composition of obstetrics providers could serve as an indicator of progress towards systemic change.

4. SDGs, Targets and Indicators

Source: news.ohsu.edu