title: Race, Insurance Status, and Nulliparous, Term, Singleton, Vertex Cesarean Indication: A Case Study of a New England Tertiary Hospital.
abstract: The current U.S. cesarean section rate (32.2%) is recognized as too high in light of its negative health impacts on women and infants. Efforts are underway in several states and individual hospitals to lower the rate of cesarean section among low-risk women, defined as nulliparous (first birth), term (≥37 weeks gestation), singleton (one baby), vertex (head down presentation; NTSV).
  
  
  
  We conducted a case study of one hospital's experience with NTSV cesarean sections to see whether race and insurance status affect the probability of cesarean indication. Many cesarean indications are ambiguous, and biases may seep into decisions with ambiguous diagnoses.
  
  
  
  We conducted a retrospective chart review of women who had NTSV cesarean sections at a tertiary care hospital in an urban New England city between June 2013 and November 2013. We analyzed the data using multinomial logistic regression to examine the marginal effect of race and health insurance status on the predicted probability for NTSV cesarean indication.
  
  
  
  We find that Black and Hispanic women have a lower predicted probability of having a cesarean section for cephalopelvic disproportion than do White women and that women with private health insurance have a lower predicted probability of having a cesarean section for nonreassuring fetal heart rate and for a clinical indication than do women without private health insurance.
  
  
  
  We suggest biases may seep into clinicians' decisions to perform an NTSV cesarean section. Hospital quality improvement efforts are aided by an examination of sociodemographic factors that influence clinician decision making in the specific hospital being studied.
authors.affiliation: Department of Sociology, Texas A&M University, College Station, Texas. Electronic address: theresa.morris@tamu.edu.
authors.forename: Theresa
authors.initials: T
authors.lastname: Morris
authors.affiliation: Student Outreach and Support Department, MIT, Cambridge, Massachusetts.
authors.forename: Olivia
authors.initials: O
authors.lastname: Meredith
authors.affiliation: Tiger Foundation, New York, New York.
authors.forename: Mia
authors.initials: M
authors.lastname: Schulman
authors.affiliation: Department of Pediatrics, California Maternal Quality Care Collaborative at Stanford University, Palo Alto, California.
authors.forename: Christine H
authors.initials: CH
authors.lastname: Morton
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data*; D002585:Cesarean Section / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D006630:Hispanic or Latino / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data*; D016015:Logistic Models; D015999:Multivariate Analysis; D009511:New England / Q000453:epidemiology; D010298:Parity; D011247:Pregnancy; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D014505:Urban Population; D044465:White People / Q000706:statistics & numerical data*; D055815:Young Adult