Original Research Original ResearchDoc head & section head both text are the same. please check|Articles in Press, 100927

Racial Bias in Cesarean Decision-Making



      Continuous external fetal monitoring showing category II fetal heart tracing is a frequent indication for cesarean birth in the United States, despite its somewhat subjective interpretation. Black patients have higher rates of cesarean birth, as well as higher rates for this indication. Racial bias in clinical decision-making has been demonstrated throughout medicine, including in obstetrics.


      We sought to examine if racial bias is present in providers’ decisions about cesarean birth due to category II fetal heart tracings.

      Study Design

      We constructed an online survey study consisting of two clinical scenarios of patients in labor with category II tracings. Patient race was randomized to Black and White; vignettes were otherwise identical. Participants had the option to continue with labor or proceed with cesarean birth at three decision points in each scenario. Participants reported their own demographics anonymously. This survey was distributed to obstetric providers via email, listserv, and social media. Data were analyzed using chi-square tests at each decision point in the overall sample and in subgroup analyses by various participant demographics.


      A total of 726 participants contributed to the study. We did not find significant racial bias in cesarean decision-making overall. However, in a scenario of a patient with prior cesarean birth, Fisher's exact test showed providers < 40 years old (n=322, p= 0.01) and those with < 10 years of experience (n=239, p= 0.050) opted for cesarean birth in Black patients more frequently than for White patients at the first decision point. As labor progressed in this scenario, rates of cesarean birth equalized across patient race.


      Younger providers and those with fewer years clinical experience demonstrated racial bias in cesarean decision-making at the first decision point early in labor. Providers did not show racial bias as labor progressed, nor in the scenario without prior cesarean birth. This bias may result from provider training with the Maternal Fetal Medicine Unit Network's Vaginal Birth After Cesarean calculator, developed in 2007 and widely used to estimate the probability of successful vaginal birth after cesarean. This calculator used race as a predictive factor until it was removed in June 2021. Future studies should investigate if this bias persists following this change, while also focusing on interventions to address these findings.


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