25 The surprising paradox: higher education increases the racial/ethnic disparity in cesarean delivery rates


      We aimed to evaluate the impact of maternal education on the well-documented racial/ethnic disparity in the rates of primary cesarean delivery (CD) in the US.

      Study Design

      Retrospective analysis of the CDC’s Natality Live Birth database (2016-2018). Nulliparous, singleton term births with available data for non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic Asians and Hispanics were included. Data were analyzed based on maternal education level (less than high school [< HS], high school grad [HSG], college grad [CLG] and advanced degree [AD]). We compared the prevalence of CD across different racial/ethnic groups within each education level, as well as across different education levels within each race/ethnicity, using Pearson’s chi-square test with the Bonferroni adjustment. Logistic regression was used to adjust outcomes in each education level for potential confounders: maternal age, pre-pregnancy BMI, insurance type, neonatal birth weight and fetal presentation. Results were displayed as adjusted odds ratios (aOR) and 95% confidence intervals (CI) with Whites as the reference group.


      The primary CD rate was 27.86% (788,742 of 2,831,065 births). Racial/ethnic disparities were documented across all education levels, with the highest CD rates in Blacks. Additionally, the racial/ethnic disparity increased with higher levels of education (Table 1). Figure 1 shows the differences in the aOR for CD in each racial/ethnic group across education levels, compared to Whites, illustrating that the racial/ethnic disparity is more prominent with higher education levels. For Blacks, the aOR gradually increases from 1.31 (CI 1.27-1.34) for < HS to 1.66 (CI 1.61-1.71) for AD.


      We document that race/ethnicity, as well as level of education, are essential factors impacting the risk of primary CD in the US. Surprisingly, the racial/ethnic disparity is higher as maternal education level increases. This may suggest that the disparity in CD rates is not primarily due to differences in social status. Further investigation is needed in order to elucidate the underlying causes for this paradox.
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