ABSTRACT
Background
Asian birthing people have the second highest rates of cesarean birth (CB), lowest rates of community (home and birth center), and midwife‐attended births compared to other racial and ethnic groups in the United States.
Methods
The American Association of Birth Centers Perinatal Data Registry (PDR) was used to abstract socio‐demographic and clinical data. Logistic regression analyses identified the drivers of cesarean birth among Asian birthing people in the overall and community birth eligible samples.
Results
Between 2007 and 2021, 2983 people self‐identified as Asian within the PDR. The Asian sample had a lower percentage of birth center births and a higher percentage of hospital births, CB, gestational diabetes, and postpartum hemorrhage compared to the overall sample. The cesarean rate in the Asian sample was 12.4%. Asian multiparous birthing people were at 1.5 greater odds of CB compared to White multiparous birthing people (OR = 1.54; 95% CI, 1.19–2.03; p < 0.01). Asians in the community birth eligible group had higher odds of CB compared to their White counterparts (OR = 1.54; 95% CI, 1.23–1.93; p < 0.01). Asian and White multiparous birthing people admitted to the hospital from the community birth eligible group had five times higher odds of CB compared to the total sample of Asian and White multiparous birthing people (OR = 5.18; 95% CI, 3.77–7.12; p < 0.01).
Discussion
There were lower rates of CB among Asians who birthed in PDR user sites compared to the national average. Future research is needed in community birth outcomes among different Asian ethnicities and Asian birthing people's perspective on community birth.
Keywords: Asian, birth outcomes, cesarean, perinatal inequities, pregnancy
1. Introduction
There are currently 18 million Asians and Asian Americans (Asians) in the United States (US). Single‐race, non‐Hispanic Asians are the fastest‐growing racial group in the US [1], and the Asian population in the US is projected to double by 2060 [2]. Though Asian communities in the US are growing, Asian birthing people consist of only 7% of the total births in the US [3]. Research studies that have included Asian birthing people have demonstrated perinatal health inequities, not only compared to other races, but also among Asian ethnicities. While Black birthing people have the highest rates of cesarean birth in the US, Asian birthing people have the second‐highest rate of cesarean birth compared to other races [4]. An analysis of birth registry data in one US state found that Filipino and Indian birthing people had the highest rates of cesarean birth compared to other Asian ethnicities [5]. In addition to poor cesarean birth outcomes, Asian birthing people have the highest rates of gestational diabetes (15.8%) compared to other races and ethnicities [4]. Other research indicates higher than average rates of postpartum hemorrhage and Hepatitis B in Asian birthing people [6, 7, 8, 9].
Birth center and midwifery care models have demonstrated a lower likelihood of cesarean birth and improved perinatal outcomes [10, 11, 12]. However, Asian birthing people are often not choosing community birth. Compared to non‐Hispanic Black, Hispanic, American Indian, Pacific Islander, and White birthing people, Asians have the lowest rates of out‐of‐hospital birth and are the lowest utilizers of midwifery care [4, 13]. Asian birthing people also have the highest rate of intrapartum transfer from birth center to hospital compared to their Black, Hispanic, and White counterparts [14]. In 2021, 8.9% of all Asian births in the US were attended by either a Certified Nurse‐Midwife or Certified Midwife, compared to the national average of 10.7% [4].
Research demonstrates the benefits of culturally and racially concordant care in perinatal care [15, 16, 17], however the number of Asian midwives in the US is small. The 2023 American Midwifery Certification Board Demographic report cites that 1.9% of Certified Nurse‐Midwives and Certified Midwives identify as Asian [18]. There is a dearth of research on the utilization of community birth among this population, defined as birthing at home, in a birth center, or other locations outside of the hospital. There are currently no studies on the birthing outcomes of Asian service users of birth center care in the US. Therefore, the purpose of the study is to describe clinical and sociodemographic outcomes of Asian birthing people and to use logistic regression to understand the drivers of cesarean birth in Asian families who birthed at US birthing centers and hospitals who participate in the American Association of Birth Centers (AABC) Perinatal Data Registry (PDR).
2. Methods
Data from the AABC Perinatal Data Registry was analyzed to complete a secondary data analysis on outcomes between 2007 and 2021 from individuals who identified as Asian. The PDR contains 900 perinatal health‐related variables that have been tested for reliability and validity [19]. There are 115 user sites across the US that contribute to the PDR. The PDR is under exempt status with the New England Institutional Review Board [20].
Descriptive statistics for frequencies were completed. Variables were stratified by the total Asian sample, Asian community birth eligible groups and the total sample which consisted of self‐identified American Indian, Asian, non‐Hispanic Black, Hispanic, Mixed, Native Hawaiian/Pacific Islander, and non‐Hispanic White birthing people. The “community birth eligible” category includes those at low risk for pregnancy complications defined as greater than 36.6 weeks gestation, vertex, singleton, and excluding several medical, antenatal and intrapartum conditions that have been outlined in a previous manuscript that utilized the PDR [21]. Additionally, birthing people in the “community birth eligible” sample were free from medical and antenatal risk factors (Table 1), that would preclude them from having a baby in a US birth center based on criteria set by the Commission for Accreditation of Birth Centers [21]. Select sociodemographic variables included: maternal age, multiparity, BMI (underweight < 18, normal 18–24.9, overweight 25–29.9, obese > 30), years of education, marital status (married), insurance type (Medicaid or private). Birth place was reported by intended place of birth, admission place of birth and actual place of birth. Clinical variables that were measured were: cesarean birth (either primary or repeat), postpartum hemorrhage (> 1000 mL), diabetes (pregestational or gestational diabetes), and hypertension (diagnosed prenatally or intrapartum). Reasons for cesarean birth were also reported and include arrest of labor (1st and 2nd stages), non‐reassuring fetal status, malpresentation, abruption/previa, chorioamnionitis, suspected macrosomia, and failed induction. Logistic regression analyses were performed to evaluate the odds of cesarean birth for nulliparous and multiparous Asian birthing people in the total sample and in the community birth eligible category. In this analysis, we controlled for diabetes, hypertension, hypertension, substance use, smoking, marital status, years of education, maternal age, BMI, parity, insurance type; these variables were selected based on similar studies utilizing the PDR examining cesarean birth rates [14, 22].
TABLE 1.
Risk factors that disqualify a birthing person from the “community birth eligible” category.
| Risk category | Conditions |
|---|---|
| Previous medical history | Smoking, chronic hypertension, preexistent diabetes, type 1 diabetes, class II–IV heart disease, substance abuse, thrombophilia, bicornate uterus |
| Previous pregnancy history | Previous cesarean birth |
| Pregnancy complications | Abruption or previa, childhood seizure disorder, gestational diabetes, gestational hypertension, herpes simplex virus, intrauterine fetal demise, intrauterine growth restriction, macrosomia (estimated fetal weight > 4500 g), malpresentation, multiple gestation, nonreassuring fetal testing, preeclampsia, severe preeclampsia, preterm labor 32–37 weeks, very preterm < 32 weeks, preterm rupture of membranes, postterm, > 42 weeks and 0 days, sensitization with antibody, “other”—for example, chronic hypertension, seizures, cerclage, cholestasis, oligohydramnios, low lying placenta |
| Intrapartum complications | Intrauterine growth restriction, nonreassuring fetal testing, preeclampsia, prelabor ruptures of membranes at term, postdates > 42 weeks, gestational diabetes |
Source: Adapted from Jolles et al. (2017) [21].
3. Results
3.1. Sociodemographic and Clinical Outcomes
The demographic characteristics of the total sample of 2983 Asian people registered in the AABC PDR are reported in Table 2; 48.2% were multiparous and the average maternal age was 30 years old. The majority had private insurance (59.5%), and 20% had Medicaid for insurance. The majority of the sample had a BMI between 18 and 24.9. The average years of education were more than 15 years, with a majority having at least a college degree (65.8%). Most were married (87%). The community birth‐eligible sample had similar demographics to the total (Table 2).
TABLE 2.
Select demographics of total and community birth eligible Asian birthing people and total sample.
| Characteristics | Total sample (n) | Total Asian sample | Community birth eligible |
|---|---|---|---|
| All sample demographics | 100 (2983) | 100 (1306) | |
| Multiparous | 57.1 (89,487) | 48.2 (1439) | 46.7 (610) |
| Insurance | |||
| Private | 53.5 (83845) | 59.5 (1774) | 61 (797) |
| Medicaid | 27.4 (42,941) | 20.1 (599) | 17.4 (227) |
| Other public | 4.7 (7366) | 4.8 (142) | 4.7 (61) |
| Other payment | 14.4 (22,568) | 15.7 (468) | 16.9 (221) |
| Married | 75.0 (117,540) | 84.2 (2513) | 86.7 (1132) |
| Maternal age a | 29.0 | 30.7 | 30.5 |
| BMI | |||
| < 18 | 3.7 (5799) | 7.0 (209) | 5.8 (76) |
| 18–24.9 | 82.5 (2461) | 85.1 (1111) | |
| 25–29.9 | 8.5 (13,321) | 5.4 (162) | 5.3 (69) |
| > 30 | 12.0 (18,806) | 5.1 (151) | 3.8 (50) |
| Years of education a | 14.6 years | 15.7 years | 15.9 years |
Data are expressed as mean ± standard deviation or n%.
Asian birthing people who were community birth eligible had higher rates of intention to give birth in a birth center (85%), admission to a birth center (83.3%), and completion of the birth in a birth center (69.9%) as compared to the total Asian sample and the overall sample (Table 3). Intention to, admission for, and having a home birth rates in the total and community birth categories were similar (Table 3). There was a 21% difference between the percentage of the total Asian sample intending to have a hospital birth (20.1%) and those that actually had a hospital birth (41.3%). Similarly, 11.9% of Asian birthing people intended to have a hospital birth in the community eligible group, and ultimately, 26.2% had a hospital birth.
TABLE 3.
Intended, admitted, and actual birth place of total and community birth eligible Asian birthing people and total sample.
| Characteristics | Total sample (n) | Total Asian sample | Community birth eligible |
|---|---|---|---|
| Intended birth place | |||
| Birth center | 78.3 (122,002) | 76.7 (2272.6) | 85.0 (1110) |
| Home | 3.2 (4986) | 3.2 (94.8) | 3.1 (41) |
| Hospital | 20.1 (615.6) | 11.9 (155) | |
| Admission birth place | |||
| Birth center | 66 (76,006) | 65.4 (1435.5) | 83.3 (1088) |
| Home | 3.6 (4146) | 3.8 (83.4) | 4.1 (54) |
| Hospital | 29.3 (33,742) | 29.6 (649.7) | 12.6 (165) |
| Actual birth place | |||
| Birth center | 56.8 (65,377) | 54 (1186.9) | 69.9 (913) |
| Home | 3.7 (4259) | 3.8 (83.5) | 3.8 (50) |
| Hospital | 38.4 (44,199) | 41.3 (907.8) | 26.2 (342) |
Asian birthing people (7.2%) and Asian people in the community birth eligible group (8.0%) had higher rates of postpartum hemorrhage compared to the total sample (5.9%) (see Table 4). The rate of diabetes in pregnancy in the total Asian sample was 6.6% compared to 3.0% in the community birth eligible category and 3.7% in the total sample. Asian birthing people in the community birth eligible group had lower rates of preterm birth (0.6%) and prenatal/intrapartum hypertension (0.4%) compared to the total sample and the total Asian sample.
TABLE 4.
Clinical outcomes of total and community birth eligible Asian birthing people and total sample.
| Characteristics | Total sample (n) | Total Asian sample | Community birth eligible |
|---|---|---|---|
| Postpartum hemorrhage | 5.9% (6793) | 7.2% (159) | 8.0% (104) |
| Diabetes | 3.7% (5799) | 6.6% (198) | 3.0% (39) |
| Preterm birth | 4.2% (5798) | 4.7% (125) | 0.6% (8) |
| Prenatal/IP hypertension | 3.4% (2821) | 2.5% (76) | 0.4% (5) |
| Cesarean—primary or repeat | 9.8% (11,237) | 12.4% (271) | 7.6% (99) |
| Arrest of labor (1st stage) | 24.3% (2349) | 26.0% (64) | 27.3 (27) |
| Arrest of labor (2nd stage) | 18.4% (1779) | 24.0% (59) | 33.3 (33) |
| Non‐reassuring fetal status | 26.8% (2590) | 26.0% (64) | 27.3 (27) |
| Malpresentation | 18.5% (1788) | 14.6% (35) | 9.1 (9) |
| Abruption/previa | 2.0% (193) | 1.6% (4) | 0.0 |
| Chorioamnionitis | 1.1% (1194) | 1.6% (4) | 2.0 (2) |
| Suspected macrosomia | 0.6% (58) | 0.0 | 0.0 |
| Failed induction | 0.2% (19) | 0.0 | 0.0 |
The rate of cesarean birth was higher in the total Asian sample (12.4%) compared to the overall sample. Asian birthing people in the community birth eligible sample had lower rates of cesarean birth (7.6%) compared to the total sample. Asian birthing people in the community birth eligible group had a higher percentage of cesarean births due to arrest of labor in both 1st (27.3%) and 2nd (33.3%) stages, non‐reassuring fetal status (27.3%) and chorioamnionitis (2%), compared to the overall and total Asian samples. In the total Asian sample, there was a higher percentage of those that had a cesarean birth due to arrest in 1st (26%) and 2nd (24%) stages of labor, compared to the total sample.
3.2. Logistic Regression on Cesarean Birth
Outcomes in Table 5 describe the likelihood of cesarean birth in Asian birthing people compared to non‐Hispanic White birthing people in the total, community birth eligible group and in the community birth eligible group who were admitted to the hospital. The total sample of Asian birthing people had 1.4 higher odds of cesarean birth compared to non‐Hispanic White birthing people, adjusting for sociodemographic and clinical factors (aOR = 1.354; 95% CI, 1.197–1.532; p < 0.01). Similarly, in the community birth eligible sample, Asian birthing people had 1.5 higher adjusted odds of cesarean birth compared to their White, non‐Hispanic counterparts in the community birth eligible sample (aOR = 1.522; 95% CI, 1.218–1.848; p < 0.01). In the total sample, both Asian nulliparous (aOR = 1.258; 95% CI, 1.091–1.450; p < 0.01) and multiparous (aOR = 1.539; 95% CI, 1.180–2.007; p < 0.01) birthing people had higher adjusted odds of cesarean birth compared to non‐Hispanic White nulliparous and multiparous birthing people. Both Asian and White birthing people in the community birth eligible group who were admitted to the hospital had 2.5 higher adjusted odds of cesarean births compared to the total Asian and White sample (OR = 2.530; 95% CI, 2.014–3.179; p < 0.01). Asian and White nulliparous birthing people in the community birth eligible category who were admitted to the hospital had 2.2 higher adjusted odds of cesarean birth compared to the total Asian and White nulliparous birthing people (OR = 1.26; 95% CI, 1.09–1.46; p < 0.01). Asian and White multiparous birthing people who were admitted to the hospital from the community birth eligible category had 5.2 higher adjusted odds of cesarean births compared to the total sample of Asian and White multiparous birthing people (OR = 5.18; 95% CI, 3.77–7.12; p < 0.01).
TABLE 5.
Unadjusted and adjusted odds ratio (OR) and 95% CI for Cesarean birth in Asian birthing people compared to non‐Hispanic White birthing people.
| Variable | Cesarean unadjusted | Cesarean adjusted a | Adjusted a nulliparous | Adjusted a multiparous | ||||
|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | |
| Total | 1.452 (1.279, 1.649) | 0.000* | 1.354 (1.197, 1.532) | 0.000* | 1.258 (1.091, 1.450) | 0.002* | 1.539 (1.180, 2.007) | 0.001* |
| Community birth eligible | 1.835 (1.469, 2.291) | 0.000* | 1.522 (1.218, 1.901) | 0.000* | 1.480 (1.185, 1.848) | 0.001* | 1.740 (0.874, 3.465) | 0.115 |
| Admission place—hospital | 2.233 (1.802, 2.767) | 0.000* | 2.530 (2.014, 3.179) | 0.000* | 2.152 (1.722, 2.689) | 0.000* | 5.164 (3.734, 7.142) | 0.000* |
Logistic regression was used to analyze findings and controlled for the following variables: any diabetes, hypertension, prenatal/IP hypertension, substance use, smoking, marital status, Education in years, age in years, BMI, parity, insurance type. *p < 0.01.
4. Discussion
This study is a descriptive analysis of data from 2983 Asian birthing people whose outcomes are recorded in the American Association of Birth Center's Perinatal Data Registry from 2007 to 2020. Antenatal and perinatal outcomes described in this study reflect similar national data that have been reported in other studies [4]. Our study found inequities in perinatal outcomes such as cesarean birth (CB), gestational diabetes, and postpartum hemorrhage, affirming findings that have been previously reported [23, 24]. National data indicates that 33.5% of Asian birthing people had CBs in 2022, and approximately 29.2% of these individuals belonged to a low‐risk category [4]. We found that births recorded in the PDR were associated with CB rates that are less than half the national rate, with a total cesarean rate of 12.4% and 7.6% in the community birth eligible category. The difference between the national rate and our study findings may be due to factors such as birth setting, model of care, and selection bias related to patient preference to avoid interventions. PDR data is collected from majority midwifery‐led practices and birth centers. Though data is collected from both midwives and obstetricians, provider type and model of care may contribute to the lower rates of CB observed. This correlates with multiple studies demonstrating lower CB rates among birthing people receiving midwifery and birth center care [25, 26].
Shifting birth setting may be one potential way to decrease the risk of CB within Asian communities. There was an increase of 18.4% in birth center utilization among Asians in the US between 2019 (0.50%) and 2020 (0.59%) [13]. If this trend continues, more diverse communities may achieve greater access to birth outside of the hospital. Our findings align with results from a survey conducted among California residents, where 25% of Asian birthing people stated they would consider using free‐standing birth centers over hospitals for future pregnancies [27]. However, there is a lack of data on the use of birth centers versus hospital births among Asian, and our results highlight a need for further research on decision making and access to community settings for Asian birthing people. There is a particular need for qualitative research on why Asian birthing people are not choosing and/or facing barriers to accessing birth centers.
There were five times higher odds of cesarean birth among Asian and non‐Hispanic White multiparous birthing people in the low‐risk category who elected hospital birth. This also demonstrates that birth setting was an independent driver for cesarean birth in our sample. This is a similar finding to a secondary analysis with PDR data that found that multiparous birthing people who elected hospitalization had five times greater odds of CB as compared to multiparous birthing people electing birth center admission [14].
A cross‐sectional analysis of US birth certificate data on the Robson categories for cesarean birth found that Asians had the highest rates of cesarean birth due to breech for nulliparous birthing people (Robson 6) and admission to hospital without labor (Robson 2b) [7]. In this analysis, the highest number of cesarean births contributing to the total number of Asian cesarean births were from multiparous birthing people in spontaneous labor, excluding those who had a previous cesarean birth (Robson 3) [7]. This aligns with our findings in this study where multiparous birthing people in the community birth eligible category who were admitted to the hospital had higher odds of cesarean birth compared to those who were not.
Poor communication and lack of shared decision‐making may be factors in electing CB. Research has demonstrated racial inequities in experiences of care as noted in the Listening to Mothers in California survey, where among those on Medi‐Cal (California's public insurance), Asian and Pacific Islander birthing people were three times more likely to report being treated unfairly [27]. Additionally, an analysis of the ARRIVE trial found that compared to other races, nulliparous Asians who were medically low‐risk were the least likely to participate in elective induction of labor, decline induction due to family and friends objections, and the most likely to provide the reason for declining induction as preferring to be expectantly managed [28]. Given the evidence on poor communication and preference for vaginal birth, it will be important to examine the influence of factors such as racism, cultural and ethnic differences, insurance type, immigration status, provider bias, and health literacy on Asian birth outcomes.
4.1. Strengths and Limitations
The study is the first analysis of Asian birthing people using data from the PDR. We analyzed retrospective data from 2007 to 2021, which provided a large sample over time. Asian birthing people were compared with non‐Hispanic White birthing people in this study due to the fact that White, non‐Hispanic people were the largest sample and had the best outcomes compared to other racial groups in the PDR. The PDR does not have disaggregated Asian ethnicities nor nativity of the birthing person. Given the wide variation of ethnicities within the category of Asian birthing people, it is difficult to know how much ethnicity and nativity may have influenced the findings. Therefore, it will be necessary going forward to disaggregate data on Asian and Asian Americans [29, 30, 31]. As the AABC's PDR is composed of midwifery‐led care units, there may be sampling bias or self‐selection, which cannot be calculated. As a result, findings from this study may not be generalizable beyond midwifery‐led models of care.
5. Conclusion
This is the first study examining pregnancy and birth outcomes among Asian communities using the AABC's Perinatal Data Registry. Findings from this study highlight the perinatal outcomes and inequities in multiparous and nulliparous cesarean birth among Asian birthing people who are medically low‐risk. Further research is needed to disaggregate and evaluate perinatal outcomes data within the US. Asian community, with a focus on cesarean birth rates. Future studies are needed to explore the low utilization of midwifery and birth center care, as well as experiences of care among Asians. This study contributes to the dearth of literature on Asian birthing people's outcomes and demonstrates the urgent need to address midwifery and birth center access for Asian communities in the US.
5.1. Reflexivity
The authors acknowledge the importance of one's lived experience and positionality and therefore wish to share it here. AG is a Korean American midwife researcher. DK is an Asian American MD student who has been inspired by her immigrant single mother's experience. AN is a biracial Asian American working as a microbiologist whose parents immigrated from Vietnam. DS is a Asian Indian PhD candidate and former architect in India. DJ is a White non‐Hispanic nurse‐midwife, researcher, and educator.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
This study was funded by the AABC Foundation Research Grant. We are grateful for the work of Susan Stapleton and Jennifer Wright in managing the PDR and for Lauren Hoehn‐Velasco's contribution in data analysis.
Funding: This study was funded by the AABC Foundation Research Grant.
Data Availability Statement
The data that support the findings of this study are available from American Association of Birth Centers. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of American Association of Birth Centers.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from American Association of Birth Centers. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of American Association of Birth Centers.