Abstract
Background
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.
Objective
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.
Results
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.
Conclusion
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.
Keywords
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Article info
Publication history
Accepted:
March 8,
2023
Received in revised form:
February 26,
2023
Received:
November 5,
2022
Publication stage
In Press Accepted ManuscriptIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
