Unplanned Cesarean for Abnormal or Indeterminate Fetal Heart Tracing Varies Significantly by Race and Ethnicity

Introduction: The US maternity care system achieves worse outcomes for birthing people identifying as Black versus White. Assessment of fetal well-being in labor is an area of perinatal care subject to significant interobserver variability and therefore may be at particular risk of medical racism influencing care.

Methods: Statewide collaborative quality initiative data, focused on decreasing the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate, were used to conduct a retrospective cohort study to assess differences in cesarean birth for nonreassuring fetal status between birthing people identifying as Black compared with White. Generalized linear mixed modeling with hospital as a random intercept was used for multivariate analyses accounting for birthing people clustering within hospitals.

Results: Between March 1, 2020, and December 31, 2022, 69,622 births were identified, 8291 (11.9%) of which were an unplanned cesarean with a primary indication of nonreassuring fetal heart tracing (cesarean for FHT). Race and ethnicity were significantly associated with a higher risk, after controlling for covariates: compared with White birthing people, birthing people of unknown race or ethnicity had 1.23 (95% CI 1.13-1.35) and Asian Pacific Islander birthing people had 1.55 times the odds (95% CI 1.37-1.76), whereas Black birthing people had 1.71 times the odds (95% CI 1.59-1.83) of birthing via unplanned cesarean for FHT. In adjusted analysis, prepregnancy diabetes, positive COVID-19 status at admission, elevated body mass index, and birthing in the Detroit Metro area were associated with cesarean for FHT. In an unplanned subgroup analysis of births within the Detroit Metro region, Black individuals remained significantly more likely to have an unplanned cesarean for FHT (aOR 1.63, 95% CI 1.48-1.79).

Discussion: After controlling for individual and hospital-level factors, cesarean for FHT was more common among non-Hispanic Black vs non-Hispanic White birthing people in this statewide cohort of NTSV births.