Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates
Racial and Ethnic Differences in Utilization of Labor Management Strategies Intended to Reduce Cesarean Delivery Rates
复制标题
DOI：
10.1097/aog.0000000000002343
复制
发表时间：
2017-12-01
影响因子：
7.2
通讯作者：
Tolosa, Jorge E.
中科院分区：
文献类型：
--
作者：
Yee, Lynn M.;Costantine, Maged M.;Tolosa, Jorge E.
目的：检查剖宫产频率和适应症是否存在种族和民族差异，并评估旨在降低剖宫产率的分娩管理策略的应用是否与患者的种族和民族相关。方法：这是对多中心观察性产科队列的二次分析。训练有素的研究人员从 25 家医院提取了超过 115,000 名孕妇的孕产妇和新生儿记录（2008 年至 2011 年）。怀有单胎、非异常、顶角、活产新生儿的足月妇女被纳入两个队列：1) 未产妇 (n=35,529)； 2) 之前仅进行过阴道分娩的多产妇女 (n=39,871)。女性被分为非西班牙裔黑人、非西班牙裔白人、西班牙裔和亚洲人。使用多变量逻辑回归来评估以下结果：总体剖宫产频率、剖宫产指征以及旨在安全减少剖宫产的分娩管理策略的利用。 结果：共有 75,400 名妇女符合纳入条件，其中 47% (n=35,529) 属于未产妇队列，53% (n=39,871) 属于经产妇队列。未产妇剖宫产率为 25.8%，多产妇剖宫产率为 6.0%。对于未产妇，非西班牙裔白人、非西班牙裔黑人、亚洲人和西班牙裔女性的未经调整剖腹产率分别为 25.0%、28.3%、28.7% 和 24.0%。在未产妇中，与非西班牙裔白人女性相比，所有种族和族裔群体的剖腹产调整后赔率均较高（非西班牙裔黑人调整后赔率比 [OR] 1.47，95% CI 1.36-1.59；亚裔调整后 OR 1.26，95% CI 1.14-1.40；西班牙裔调整后 OR 1.17，95% CI 1.071.27）由于胎儿状况不可靠和难产而进行剖腹产的可能性更大。不应用有关引产失败、扩张停止、下降停止或宫颈成熟的分娩管理策略不会导致非西班牙裔黑人和西班牙裔妇女剖宫产的几率增加。与非西班牙裔白人女性相比，西班牙裔女性实际上不太可能经历选择性剖腹产（调整后 OR 0.60，95% CI 0.42-0.87）或 4 小时前因宫缩停止而剖腹产（调整后 OR 0.67，95% CI 0.49-0.92）。此外，与非西班牙裔白人女性相比，亚洲女性更有可能因胎儿状况不放心而进行剖腹产（调整后 OR 1.29，95% CI 1.09-1.53），并且在 1 分钟 Apgar 评分为 7 或更高的情况下进行剖腹产（调整后 OR 1.79，95% CI 1.07-3.00）。在既往阴道分娩的多产妇女中也发现了类似的趋势。结论：尽管剖腹产频率存在种族和民族差异，但旨在降低剖腹产率的分娩管理策略的差异化使用似乎与这些种族和民族差异无关。
OBJECTIVE: To examine whether racial and ethnic differences exist in the frequency of and indications for cesarean delivery and to assess whether application of labor management strategies intended to reduce cesarean delivery rates is associated with patient's race and ethnicity.METHODS: This is a secondary analysis of a multicenter observational obstetric cohort. Trained research personnel abstracted maternal and neonatal records of greater than 115,000 pregnant women from 25 hospitals (2008-2011). Women at term with singleton, nonanomalous, vertex, liveborn neonates were included in two cohorts: 1) nulliparous women (n=35,529); and 2) multiparous women with prior vaginal deliveries only (n=39,871). Women were grouped as non-Hispanic black, non-Hispanic white, Hispanic, and Asian. Multivariable logistic regression was used to evaluate the following outcomes: overall cesarean delivery frequency, indications for cesarean delivery, and utilization of labor management strategies intended to safely reduce cesarean delivery.RESULTS: A total of 75,400 women were eligible for inclusion, of whom 47% (n=35,529) were in the nulliparous cohort and 53% (n=39,871) were in the multiparous cohort. The frequencies of cesarean delivery were 25.8% among nulliparous women and 6.0% among multiparous women. For nulliparous women, the unadjusted cesarean delivery frequencies were 25.0%, 28.3%, 28.7%, and 24.0% for non-Hispanic white, non-Hispanic black, Asian, and Hispanic women, respectively. Among nulliparous women, the adjusted odds of cesarean delivery were higher in all racial and ethnic groups compared with non-Hispanic white women (non-Hispanic black adjusted odds ratio [OR] 1.47, 95% CI 1.36-1.59; Asian adjusted OR 1.26, 95% CI 1.14-1.40; Hispanic adjusted OR 1.17, 95% CI 1.071.27) as a result of greater odds of cesarean delivery both for nonreassuring fetal status and labor dystocia. Non-application of labor management strategies regarding failed induction, arrest of dilation, arrest of descent, or cervical ripening did not contribute to increased odds of cesarean delivery for non-Hispanic black and Hispanic women. Compared with non-Hispanic white women, Hispanic women were actually less likely to experience elective cesarean delivery (adjusted OR 0.60, 95% CI 0.42-0.87) or cesarean delivery for arrest of dilation before 4 hours (adjusted OR 0.67, 95% CI 0.49-0.92). Additionally, compared with non-Hispanic white women, Asian women were more likely to experience cesarean delivery for nonreassuring fetal status (adjusted OR 1.29, 95% CI 1.09-1.53) and to have had that cesarean delivery be performed in the setting of a 1-minute Apgar score 7 or greater (adjusted OR 1.79, 95% CI 1.07-3.00). A similar trend was seen among multiparous women with prior vaginal deliveries.CONCLUSION: Although racial and ethnic disparities exist in the frequency of cesarean delivery, differential use of labor management strategies intended to reduce the cesarean delivery rate does not appear to be associated with these racial and ethnic disparities.