Search

Objective: To explore population-level American Indian & Alaska Native-White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual-level risk factors. Data Sources and Study Setting: We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017. Study Design: We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native-White inequality. Data Collection/Extraction Methods: Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate. Principal Findings: After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0-34.8), 3.2 percentage points (95% CI: 1.8-4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie). Conclusions: The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low-risk Robson group 1 and those with non-cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality. KEYWORDS cesarean, health services, inequality, race, risk factors, 1 | INTRODUCTION Cesarean birth is the most common surgical procedure among reproductive-aged women in the United States (US). (1) While life-saving in certain circumstances, cesarean birth also increases the [...]

Objective: To investigate the intersection of race and economic context in treatment with hysterectomy among reproductive aged women with noncancerous gynecologic conditions. Data Sources: We combined administrative billing records of inpatient and outpatient hysterectomy procedures (N = 28 301) occurring in North Carolina between 2011 and 2014 with census data to calculate county-level hysterectomy rates. Study Design: Spatial analysis techniques examined the distribution of black and white hysterectomy rates across counties, and county-level black and white rate differences were compared across economic contexts. Data Collection/Extraction: We restricted to those of premenopausal age identifying as non-Hispanic black or white, undergoing hysterectomy for nonemergent causes (N = 28 301 procedures). Principal Findings: County-level hysterectomy rates were spatially patterned (Moran's l,P< .05) and similarly so for black and white women (LISA, P < .005). The black-white difference in hysterectomy rates was the largest in the high economic tier counties (22/10 000 person-years [PY], P < .05) and smallest in the mid and low economic tier counties (11/10 000 PY, P > .05 and 10/10 000 PY, P > .05, respectively). Conclusion: Socioeconomic context is important to understand, particularly for black-white disparities in hysterectomy. Efforts should be made to understand the causes of higher rates of hysterectomy among blacks than whites, especially in counties in the highest economic tier. KEYWORDS ecological studies, medical geography, obstetrics/gynecology, racial/ethnic differences in health care, 1 | INTRODUCTION Hysterectomy (uterus removal) has the second highest incidence of any surgical procedure among nonelderly women in the United States. (1) This procedure is one of several treatments [...]