Estimating Educational Differences in Low-Risk Cesarean Section Delivery: A Multilevel Modeling Approach
U.S. rates of cesarean section, and in particular, low-risk cesarean section (LRC) births rose dramatically across the late 1990s and early 2000s, and have since remained high. Although previous research explores how trends in LRC vary between states and across maternal characteristics, within-state heterogeneity has not yet been accounted for, nor has the extent to which maternal and county characteristics might interact to shape the likelihood of a LRC birth. Using U.S. county-level birth data for years 2008–2010 from the restricted National Vital Statistics Systems Cohort Linked Birth-Infant Death Files and the Area Health Resource Files, I conduct race-stratified multilevel analyses to explore the association between the mother’s education, the income of the county in which she gives birth, and the odds of LRC delivery. I find that regardless of race/ethnicity, less education at the individual level and lower income at the county level are associated with higher odds of LRC delivery. There are also persistent racial disparities in these relationships. Non-Hispanic black mothers have the highest overall odds of LRC delivery, yet the effect of both education and county income is greatest for non-Hispanic white mothers. The results highlight the importance of analyzing both individual resources and contextual effects of the county when assessing birthing processes, as both contribute to a mother’s access to and knowledge of natal care.
KeywordsUnited States C-sections Fertility Education Contextual effects BID files AHRF
I thank the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)-funded University of Colorado Population Center (Award Number P2C HD066613) for development, administrative, and computing support; the National Association for Public Health Statistics and Information Systems and the National Vital Statistics Systems for providing data access; and Ryan K. Masters and Richard G. Rogers for guidance on analyses and manuscript preparation. This manuscript also benefitted from comments and discussion from the Population Health Working group at the University of Colorado Boulder. The content is solely the responsibility of the author and does not necessarily represent the official views of the NICHD, the National Institutes, NAPHSIS, or the NVSS. A previous version of this manuscript was presented at the Population Association of America annual meeting in Chicago, IL, April 27–29, 2017.
- Area Health Resources Files (AHRF) 2015–2016. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Rockville, MD.Google Scholar
- Bernstein, P.S. (2005). Complications of Cesarean Deliveries. Medscape PN 04-2-910-809.Google Scholar
- Bridges, K. (2011). Reproducing race: An ethnography of pregnancy as a site of racialization. Berkeley: University of California Press.Google Scholar
- Clark, C. (2016). What’s Behind San Diego County’s Alarmingly High C-Section Rates? KPBS. Retrieved from http://www.kpbs.org/news/2016/apr/28/whats-behind-san-diego-countys-alarmingly-high-c-s/.
- Gálvez, A. (2011). Patient citizens, immigrant mothers: Mexican women, public prenatal care, and the birth weight paradox. New Jersey: Rutgers University Press.Google Scholar
- Gibbons, L., Belizán, J. M., Lauer, J. A., Betrán, A. P., Merialdi, M., & Althabe, F. (2010). The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Report, 30, 1–31.Google Scholar
- Haelle, Tara. (2016). Your Biggest C-Section Risk May be Your Hospital. Consumer Reports. Retrieved from http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/.
- Hamilton, B., Martin, J., Osterman, M., Curtin, S., & Matthews, T. J. (2015). Births: Final Data for 2014. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 65(3), 1–14.Google Scholar
- Lake, N. (2012, November–December). Labor, Interrupted. Harvard Magazine. Retrieved from http://harvardmagazine.com/2012/11/labor-interrupted.
- Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the black-white gap in birth outcomes: A life-course approach. Ethnicity & Disease, 20, S2.Google Scholar
- Meit, M., Knudson, A., Gilbert, T., Yu, A. T. C., Tanenbaum, E., Ormson, E., et al. (2014). The 2014 update of the rural-urban chartbook. Bethesda: Rural Health Reform Policy Research Center.Google Scholar
- Morris, T. (2016). Cut it out: The C-section epidemic in America. New York: NYU Press.Google Scholar
- National Center for Health Statistics [NCHS]. [Linked Births Infant Deaths] [2007–2013], as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.Google Scholar
- Osterman, M. J., & Martin, J. A. (2014). Trends in low-risk cesarean delivery in the United States, 1990-2013. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 63(6), 1–16.Google Scholar
- Rehavi, M. M., & Johnson, E. M. (2013). Physicians Treating Physicians: Information and Incentives in Childbirth. NBER Working Paper 19242.Google Scholar
- Roberts, D. E. (1999). Killing the black body: Race, reproduction, and the meaning of liberty. New York: Vintage Books.Google Scholar
- Rosenberg, T. (2016). Reducing Unnecessary C-Section Births. The New York Times. Retrieved from http://opinionator.blogs.nytimes.com/2016/01/19/arsdarian-cutting-the-number-of-c-section-births/?_r=0.
- Spong, C. Y., Berghella, V., Wenstrom, K. D., Mercer, B. M., & Saade, G. R. (2012). Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop. Obstetrics and Gynecology, 120(5), 1181.Google Scholar
- U.S. Census Bureau [Census]. Metropolitan and Micropolitan Statistical Areas (2007–2013). Retrieved from http://www.census.gov/population/metro/data/.
- US Department of Health and Human Services, Office of Disease Prevention and Health Promotion [HHS]. (2010). Healthy people 2020.Google Scholar