Marginalized Groups Experience Serious Maternal Complications in Planned Repeat Cesareans More Often
Structural and interpersonal racism may underlie the inequities
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Researchers examining births among people with previous cesarean sections found higher rates of “severe maternal morbidity”—or serious complications that could have long-lasting effects on health—among Black and Latinx people having a planned C-section, compared to Whites.
Severe maternal morbidity (SMM), as defined by the Centers for Disease Control and Prevention, encompasses 21 unexpected outcomes of childbirth—including hysterectomy, heart attack, embolism, kidney failure, eclampsia, sepsis, anesthesia complications and more.
“There’s been increasing recognition in recent years that the U.S. has this rising rate of severe maternal morbidity, which can have a negative impact on one’s health in the future,” says Laura Attanasio, associate professor of health policy and management and lead author of the study published in JAMA Network Open. “It also can be considered a near miss for maternal mortality, or death, which is also high in the U.S. relative to other wealthy countries, though rare.”
This research takes a new focus on SMM. UMass Amherst co-authors included Dr. Sarah Goff, professor of health policy and management and a practicing pediatrician and internist, and Holly Laws, senior lecturer in psychological and brain sciences and director of methodology for the Center for Research on Families.
“Racial and ethnic disparities in SMM have been well-documented, and prior studies have identified racial and ethnic differences in birth mode after prior cesarean delivery, but the intersection of race and ethnicity, birth mode and SMM among individuals with a prior cesarean delivery has not been examined,” the paper states. “The goal of this study was to characterize the association between birth mode and SMM among individuals with a prior cesarean delivery and to examine whether this association varies by race and ethnicity.”
The research team found that severe maternal morbidity rates were similar among all racial and ethnic groups when a vaginal delivery—known as VBAC (vaginal birth after cesarean)—followed a previous cesarean. That was not the case, however, with planned repeat cesarean.
“Among White birthing people, severe maternal morbidity rates were similar for VBAC and for planned repeat cesarean,” Attanasio says. “But for Black and Latinx birthing people, planned repeat cesarean had a higher rate of severe maternal morbidity compared to VBAC.”
Among all the groups, SMM was highest for those who had an unplanned repeat cesarean—meaning they went into labor with the intention of having a vaginal birth but ended up having another cesarean. “With unplanned repeat cesarean versus VBAC, there wasn’t a difference across the racial and ethnic groups,” Attanasio says.
The research team examined 72,836 births from 2012-2021 that followed a previous cesarean using records from the Massachusetts Pregnancy to Early Life Longitudinal Data System. The self-reported racial and ethnic makeup was 56.8% White, 20.1% Latinx, 11% Black and 12.1% who identified as another race or ethnicity. The data included hospital discharge records that revealed SMM as well as other medical issues, and birth records that provided racial and ethnic data, birthplace of parents and other details.
The findings suggest a need to pinpoint and address factors that contribute to higher SMM rates among Black and Latinx individuals with planned repeat cesarean deliveries. “Future work should identify interventions to improve quality of care and promote equity for this population,” the paper states.
Attanasio says the research team controlled for factors such as medical risks that are associated with marginalized groups. She hypothesizes that “quality of clinical care can be worse for people from marginalized racial and ethnic groups, either because they’re being cared for in settings that are lower resourced and less able to provide quality care, or in some cases they could be receiving worse care in the same setting as White birthing people due to structural or interpersonal racism.”