Comment on “Racial and Ethnic Disparities in Cesarean Birth Trends in the United States”

Cesarean delivery (CD) can be lifesaving when medically indicated. But when it is performed without clear necessity, it is associated with increased maternal morbidity and death. In the United States, structural inequity has an impact on maternal obstetric outcomes. Non-Hispanic black and American Indian and Alaska Native individuals have the highest rates of maternal death, and those who are non-Hispanic black and Hispanic experience higher rates of morbidity related to CD. In response to an increasing cesarean birth rate, professional obstetric organizations have issued labor management guidance to reduce the rate of primary cesarean births. However, efforts to reduce this rate have been narrow in scope and involve low-risk populations. Understanding the ideal cesarean rate is difficult, too, with rates ranging from 7% to 70% across institutions in the United States. The Centers for Disease Control and Prevention aimed for a cesarean birth rate for nulliparous, term singleton vertex pregnancies of 23.9% in its Healthy People 2020 objectives and 23.6% in its Healthy People 2030. The aim of this study was to examine the trends in cesarean birth rates in the United States and how these trends differ by race and ethnicity. This was a retrospective, observational cohort study, using birth and infant death data from the National Vital Statistics System between 2012 and 2021. Included were singleton, nonanomalous, term pregnancies with a vertex presentation. Excluded were individuals whose parity and prior cesarean birth history were unknown. The primary outcome was cesarean birth, with race and ethnicity as the independent variables of interest. Study individuals self-identified as American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic black, and non-Hispanic white. They were further categorized based on parity: nulliparous, multiparous without a prior cesarean birth, and multiparous with a prior cesarean birth. A total of 30,014,020 births were included in the analysis. Of these, 27.3% were cesarean births. For all 3 parity groups, the rate of cesarean birth decreased over the time period [risk ratio (RR), 0.99; 95% CI, 0.99-0.99; P =0.02] and the rate of vaginal birth after cesarean (VBAC) increased. Non-Hispanic black individuals were more likely to undergo CD, compared with Asian or Pacific Islanders and Hispanics (30.9% vs. 28.0% vs. 27.6%, respectively). From 2012 to 2021, cesarean birth rates declined among non-Hispanic white individuals from 27.4% to 26.0% (RR, 0.87; 95% CI, 0.85-0.89). A similar decline was observed among Hispanic individuals, Asian or Pacific Islanders, and non-Hispanic black individuals. No significant change was observed among American Indian or Alaska Natives. In 2012, there was a significantly higher risk of cesarean birth among non-Hispanic black individuals (aRR, 1.12; 95% CI, 1.11-1.13) and Asian or Pacific Islanders (aRR, 1.11; 95% CI, 1.07-1.16). In 2021, the cesarean birth rate remained similarly higher among Asian or Pacific Islanders (aRR, 1.10; 95% CI, 1.05-1.16) and increased among non-Hispanic black individuals (aRR, 1.17; 95% CI, 1.14-1.20). When stratified by parity, the adjusted risk of cesarean birth for non-Hispanic black nulliparous individuals rose from 1.20 (95% CI, 1.17-1.24) in 2012 to 1.23 (95% CI, 1.19-1.27) in 2021. Among multiparous individuals without a prior cesarean birth, the disparity also increased with an aRR of 1.32 (95% CI, 1.20-1.45) in 2012 and 1.33 (95% CI, 1.24-1.43) in 2021. Among multiparous individuals with a prior cesarean birth, a slight difference was observed in 2012, but no differences were observed in 2021. In conclusion, while overall cesarean birth rates declined from 2012 to 2021, non-Hispanic black individuals consistently had higher risks of primary cesarean delivery. This disparity widened from 2012 to 2021. (Summarized from Boller MJ, Garg B, Baker HA, et al. Racial and ethnic disparities in cesarean birth trends in the United States. JAMA Netw Open . 2025;8(11):e2544078. doi:10.1001/jamanetworkopen.2025.44078).