Beneath the Incision: Variation in Low-Risk Cesareans Among Asian and Pacific Islander Subgroups in the United States

Abstract

Background: Quality initiatives aim to reduce primary cesarean rates in pregnancies with low clinical risk. These cesarean rates vary significantly by race-ethnicity in the United States. This study analyzes differences in low-risk primary cesareans between Asian/Pacific Islander (API) individuals and other pan-ethnic groups and among API subgroups in the United States.

Methods: We used data on all recorded births in the United States from 2010 to 2020 to analyze primary cesareans in the lowest risk NTSV (nulliparous, term, singleton, vertex) and MTSV (multiparous, term, singleton, vertex) pregnancies by race-ethnicity. We used logistic regression to compare API births with births among other pan-ethnic groups (N = 22,212,076) and to analyze variation across API subgroups (N = 1,663,167).

Results: API births had lower risk-adjusted odds of a primary cesarean than most other pan-ethnic groups. Among API subgroups, Indian and some Pacific Islander groups had higher adjusted odds of a primary cesarean, whereas Chinese, Korean, Filipino, and, especially, Japanese groups had lower odds. Foreign-born API birthing people had higher odds than U.S.-born API birthing people (NTSV odds ratio [OR] = 1.17, 95% confidence interval [CI] [1.16, 1.19], and MTSV OR = 1.11, 95% CI [1.10, 1.13]).

Conclusions: Although odds of a low-risk primary cesarean were slightly lower in API births than in births among most other pan-ethnic groups, this concealed significant variation among API subgroups and between foreign-born and U.S.-born API birthing people. These disparities suggest inequities in access to quality care and possible discrimination against some API groups, leading to unnecessary overtreatment. Efforts to reduce disparities should recognize differences across subgroups and potential barriers to culturally appropriate care.