RACIAL DISPARITIES IN CESAREAN BIRTH AND POSTPARTUM HEMORRHAGE: THE ROLE OF US HEALTH SYSTEM POLICIES AND PRACTICES

Abstract

Though lifesaving, cesarean birth imposes unnecessary risks when not indicated. Cesarean rates rose sharply from 1996 to 2009 alongside maternal morbidity and mortality. In response, states implemented policies to reduce unnecessary interventions. While overall cesarean rates stabilized, the Black-White disparities in cesarean birth and maternal morbidity widened. Some research implicated insurance reform in growing these disparities. This dissertation aims to:1) describe trends in Black-White disparities in postpartum hemorrhage (PPH) corresponding with cesarean birth, 2) deconstruct the factors contributing to the disparity in PPH, and 3) examine the effects of Medicaid policy reform on trends in cesarean birth and PPH. Aim 1 examines racial disparities in PPH management and severity over time. After analyzing 7.6 million hospital delivery admissions (2002–2021), results show growing cesarean disparities since the early 2010s. Black individuals experience PPH with blood transfusion or severe outcomes, especially with cesarean more often than White individuals, while being less likely to receive conservative interventions. Despite advances in care, severe PPH morbidity has not declined. Aim 2 uses 2.2 million delivery admissions (2016–2021) and applies Oaxaca-Blinder decomposition to quantify the contribution of disparate risk factors (e.g., cesarean birth) to the Black-White disparity in severe PPH. The results showed that cesarean birth accounts for up to 16% of the disparity, while anemia and delivery in predominantly Black-serving hospitals contribute up to 50%. Aim 3 uses difference-in-differences analyses of 6 million birth certificates (2009–2019) to examine the effect of Medicaid payment reform policies (e.g., nonpayment; pay-for-performance) on cesarean birth and a proxy for PPH. Despite heterogeneity across states, cesarean births increased by 0.9 percentage points (ppt) among multiparous Black individuals (95% Confidence Interval (CI): 0.4-1.4) and 1.6 ppt for first births (CI: 0.6-2.6) in nonpayment versus control states. Results for PPH were inconsistent and unreliable. This dissertation finds that insurance policies likely contributed to the growing racial disparities in cesarean birth, and the disparity in cesarean explains a substantial portion of the PPH disparity. Findings underscore the role of structural racism in obstetric outcomes, emphasizing the need for evidence-based policies to dismantle systemic barriers and foster maternal health equity.