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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: Obstet Gynecol. 2023 May 1;141(5):1024. doi: 10.1097/AOG.0000000000005158

Racial and Ethnic Disparities in Primary Cesarean Birth and Adverse Outcomes Among Low-Risk Nulliparous People

Suzan L Carmichael 1, Jonathan Snowden 2
PMCID: PMC10069716  NIHMSID: NIHMS1879362  PMID: 37103537

In the November 2022 issue, Fishel Bartal et al1 examine racial and ethnic disparities in primary cesarean birth and composite adverse maternal and neonatal outcomes among low-risk nulliparous term births. The study used U.S. vital statistics data and makes some interesting observations about disparities in risk of primary cesarean. Maternal morbidity was examined as a secondary outcome and represented by a composite of intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy. The article does not acknowledge the severe limitations of the validity of these data or consider this bias might serve as a potential alternative explanation for the findings. Vital statistics data have notoriously poor reporting of these outcomes.2,3 For example, in a study of California births, we found that compared to International Classification of Diseases codes in hospital discharge records, the sensitivity was 0.08 for transfusion and 0.25 for unplanned hysterectomy.3 A study of Massachusetts births reported sensitivities of 0.12 and 0.51 for these respective outcomes, 0.20 for admission to the ICU and 0.26 for uterine rupture.2

We desperately need better large-scale population-based data on maternal health to move research and practice forward. Using invalid data simply because better data are not available will not help and may even produce misleading findings.4 We appreciate on-going calls for improved data, which could be achieved in various ways, from facilitating availability of vital statistics data linked with hospital discharge data (which, although also imperfect, have much more complete and detailed information on maternal morbidities than vital statistics data)5 to investing in national registries.6 The time has come to improve our data systems. Meanwhile, it is imperative to acknowledge current data limitations and thoughtfully consider their potential impact when reporting and interpreting research findings.

Footnotes

Financial Disclosure

Suzan L. Carmichael disclosed that money was paid to their institution from the NIH. Jonathan Snowden disclosed that money was paid to him from PCORI, and money was paid to his institution from Oregon Health Authority and the NIH (NIDDK, NINR).

Contributor Information

Suzan L. Carmichael, Departments of Pediatrics and Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, CA.

Jonathan Snowden, School of Public Health, Oregon Health & Science University-Portland State University, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR.

REFERENCES

  • 1.Fishel Bartal M, Chen HY, Mendez-Figueroa H, Wagner SM, Chauhan SSP. Racial and ethnic disparities in primary cesarean birth and adverse outcomes among low-risk nulliparous people. Obstet Gynecol 2022;140:842–52. doi: 10.1097/AOG.0000000000004953 [DOI] [PubMed] [Google Scholar]
  • 2.Luke B, Brown MB, Liu CL, Diop H, Stern JE. Validation of severe maternal morbidity on the US certificate of live birth. Epidemiology 2018;29:e31–e32. doi: 10.1097/EDE.0000000000000828 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Snowden JM, Lyndon A, Kan P, El Ayadi A, Main E, Carmichael SL. Severe maternal morbidity: A comparison of definitions and data sources. Am J Epidemiol 2021;190:1890–97. doi: 10.1093/aje/kwab077 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Grimes DA. Epidemiologic research using administrative databases: garbage in, garbage out. Obstet Gynecol 2010;116:1018–9. doi: 10.1097/AOG.0b013e3181f98300 [DOI] [PubMed] [Google Scholar]
  • 5.Carmichael SL, Abrams B, El Ayadi A, et al. Ways forward in preventing severe maternal morbidity and maternal health inequities: conceptual frameworks, definitions, and data, from a population health perspective. Womens Health Issues 2022;32:213–18. doi: 10.1016/j.whi.2021.11.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Federspiel JJ, Kucirka LM, Mallampati DP, Wheeler SM, Menard MK, Hughes BL, Quist-Nelson J, Meng ML. For better care we need better data: towards a national obstetrics registry. Am J Obstet Gynecol MFM 2023. Jan;5(1):100787. doi: 10.1016/j.ajogmf.2022.100787 [DOI] [PMC free article] [PubMed] [Google Scholar]

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