Early Elective Delivery Disparities between Non-Hispanic Black and White Women after Statewide Policy Implementation

Published:December 19, 2017DOI:



      In 2011, Oregon implemented a policy that reduced the state's rate of early (before 39 weeks' gestation) elective (without medical need) births.


      This analysis measured differential policy effects by race, examining whether Oregon's policy was associated with changes in non-Hispanic Black–White disparities in early elective cesarean and labor induction.


      We used Oregon birth certificate data, defining prepolicy (2008–2010) and postpolicy (2012–2014) periods, including non-Hispanic Black and White women who gave birth during these periods (n = 121,272). We used longitudinal spline models to assess policy impacts by race and probability models to measure policy-associated changes in Black–White disparities.


      We found that the prepolicy Black–White differences in early elective cesarean (6.1% vs. 4.3%) were eliminated after policy implementation (2.8% vs. 2.5%); adjusted models show decreases in the odds of elective early cesarean among Black women after the policy change (adjusted odds ratio, 0.47; 95% confidence interval, 0.22–1.00; p = .050) and among White women (adjusted odds ratio, 0.79; 95% confidence interval, 0.67–0.93; p = .006). Adjusted probability models indicated that policy implementation resulted in a 1.75-percentage point narrowing (p = .011) in the Black–White disparity in early elective cesarean. Early elective induction also decreased, from 4.9% and 4.7% for non-Hispanic Black and non-Hispanic White women to 3.8% and 2.5%, respectively; the policy was not associated with a statistically significant change in disparities.


      A statewide policy reduced racial disparities in early elective cesarean, but not early elective induction. Attention to differential policy effects by race may reveal changes in disparities, even when that is not the intended focus of the policy.
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        • Abdus S.
        • Mistry K.B.
        • Selden T.M.
        Racial and ethnic disparities in services and the Patient Protection and Affordable Care Act.
        American Journal of Public Health. 2015; 105: S668-675
        • Attanasio L.
        • Kozhimannil K.B.
        Patient-reported communication quality and perceived discrimination in maternity care.
        Medical Care. 2015; 53: 863-871
        • Baumeister L.
        • Marchi K.
        • Pearl M.
        • Williams R.
        • Braveman P.
        The validity of information on “race” and “Hispanic ethnicity” in California birth certificate data.
        Health Services Research. 2000; 35: 869-883
        • Bryant A.S.
        • Worjoloh A.
        • Caughey A.B.
        • Washington A.E.
        Racial/ethnic disparities in obstetric outcomes and care: Prevalence and determinants.
        American Journal of Obstetrics and Gynecology. 2010; 202: 335-343
        • Callaghan W.M.
        • Creanga A.
        • Kuklina E.V.
        Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.
        Obstetrics and Gynecology. 2012; 120: 1
        • Caughey A.B.
        • Cahill A.G.
        • Guise J.M.
        • Rouse D.J.
        Consensus statement: Safe prevention of the primary cesarean delivery.
        Obstetrics and Gynecology. 2014; 123: 693-711
        • Caughey A.B.
        • Nicholson J.M.
        • Cheng Y.W.
        • Lyell D.J.
        • Washington A.E.
        Induction of labor and cesarean delivery by gestational age.
        American Journal of Obstetrics and Gynecology. 2006; 195: 700-705
        • Clark S.L.
        • Frye D.R.
        • Meyers J.A.
        Reduction in elective delivery at < 39 weeks of gestation: Comparative effectiveness of 3 different approaches to change and the impact on newborn intensive care admissions and stillbirths.
        American Journal of Obstetrics and Gynecology. 2010; 203: 449.e1-449.e6
        • Creanga A.A.
        • Bateman B.T.
        • Mhyre J.M.
        • Kuklina E.
        • Shilkrut A.
        • Callaghan W.M.
        Performance of racial and ethnic minority-serving hospitals on delivery-related indicators.
        American Journal of Obstetrics and Gynecology. 2014; 211: 647.e1-647.e16
        • Donovan E.F.
        • Lannon C.
        • Bailit J.
        • Rose B.
        • Iams J.D.
        • Byczkowski T.
        A statewide initiative to reduce inappropriate scheduled births at 36 (0/7)-38 (6/7) weeks’ gestation.
        American Journal of Obstetrics and Gynecology. 2010; 202: 243.e1-243.e8
        • Ehrenthal D.B.
        • Hoffman M.K.
        • Jiang X.
        • Ostrum G.
        Neonatal outcomes after implementation of guidelines limiting elective delivery before 39 weeks of gestation.
        Obstetrics and Gynecology. 2011; 118: 1047-1055
        • Eichelberger K.Y.
        • Doll K.
        • Ekpo G.E.
        • Zerden M.L.
        Black Lives Matter: Claiming a space for evidence-based outrage in obstetrics and gynecology.
        American Journal of Public Health. 2016; 106: 1771-1772
        • Elder T.E.
        • Goddeeris J.H.
        • Haider S.J.
        • Paneth N.
        The changing character of the black-white infant mortality gap, 1983-2004.
        American Journal of Public Health. 2014; 104: S105-S111
        • Fowler T.T.
        • Schiff J.
        • Applegate M.S.
        • Griffith K.
        • Fairbrother G.L.
        Early elective deliveries accounted for nearly 9 percent of births paid for by Medicaid.
        Health Affairs. 2014; 33: 2170-2178
        • Frohlich K.L.
        • Potvin L.
        Transcending the known in public health practice: The inequality paradox: The population approach and vulnerable populations.
        American Journal of Public Health. 2008; 98: 216-221
        • Grobman W.A.
        • Bailit J.L.
        • Rice M.M.
        • Wapner R.J.
        • Reddy U.M.
        • Thorp Jr., J.M.
        • the Eunice Kennedy Shriver National Institute of Child Health and Human Development NICHD) Maternal-Fetal Medicine Units (MFMU) Network
        Racial and ethnic disparities in maternal morbidity and obstetric care.
        Obstetrics and Gynecology. 2015; 125: 1460-1467
        • Hardeman R.R.
        • Medina E.M.
        • Kozhimannil K.B.
        Structural racism and supporting Black lives: The role of health professionals.
        New England Journal of Medicine. 2016; 375: 2113-2115
        • Huesch M.
        • Doctor J.N.
        Factors associated with increased cesarean risk among African American women: Evidence from California, 2010.
        American Journal of Public Health. 2015; 105: 956-962
        • Howell E.
        • Egorova N.
        • Balbierz A.
        • Zeitlin J.
        • Hebert P.L.
        Black-white differences in severe maternal morbidity and site of care.
        American Journal of Obstetrics and Gynecology. 2016; 214: 122.e1-122.e7
        • Howell E.A.
        • Egorova N.N.
        • Balbierz A.
        • Zeitlin J.
        • Hebert P.L.
        Site of delivery contribution to black-white severe maternal morbidity disparity.
        American Journal of Obstetrics and Gynecology. 2016; 215: 143-152
        • Jou J.
        • Kozhimannil K.B.
        • Johnson P.J.
        • Sakala C.
        Patient-perceived pressure from clinicians for labor induction and cesarean delivery: A population-based survey of U.S. women.
        Health Services Research. 2015; 50: 961-981
        • Kozhimannil K.B.
        • Karaca-Mandic P.
        • Blauer-Peterson C.
        • Shah N.
        • Snowden J.M.
        Uptake and utilization of practice guidelines in US hospitals: The case of routine episiotomy.
        Joint Commission Journal on Quality and Patient Safety. 2017; 43: 41-48
        • Kozhimannil K.B.
        • Macheras M.
        • Lorch S.
        Trends in childbirth before 39 weeks’ gestation without medical indication.
        Medical Care. 2014; 52: 649-657
        • Lain S.J.
        • Hadfield R.M.
        • Raynes-Greenow C.H.
        • Ford J.B.
        • Mealing N.M.
        • Algert C.S.
        • Roberts C.L.
        Quality of data in perinatal population health databases: A systematic review.
        Medical Care. 2012; 50: e7-e20
        • Lorenc T.
        • Petticrew M.
        • Welch V.
        • Tugwell P.
        What types of interventions generate inequalities? Evidence from systematic reviews.
        Journal of Epidemiology and Community Health. 2013; 67: 190-193
        • Lu M.C.
        • Halfon N.
        Racial and ethnic disparities in birth outcomes: A life-course perspective.
        Maternal and Child Health Journal. 2003; 7: 13-30
        • Main E.K.
        New perinatal quality measures from the National Quality Forum, the Joint Commission and the Leapfrog Group.
        Current Opinion in Obstetrics and Gynecology. 2009; 21: 532-540
        • Martin J.A.
        • Hamilton B.E.
        • Osterman M.J.K.
        Births in the United States, 2014.
        NCHS Data Brief. 2015; 216: 1-8
        • Martin J.A.
        • Wilson E.C.
        • Osterman M.J.K.
        • Saadi E.W.
        • Sutton S.R.
        • Hamilton B.E.
        Assessing the quality of medical and health data from the 2003 birth certificate revision: Results from two states.
        National Vital Statistics Reports. 2013; 62: 1-19
        • Muoto I.
        • Luck J.
        • Yoon J.
        • Bernell S.
        • Snowden J.M.
        Oregon's coordinated care organizations increased timely prenatal care initiation and decreased disparities.
        Health Affairs (Millwood). 2016; 35: 1625-1632
        • Nazroo J.Y.
        The structuring of ethnic inequalities in health: Economic position, racial discrimination, and racism.
        American Journal of Public Health. 2003; 93: 277-284
        • Oshiro B.T.
        • Henry E.
        • Wilson J.
        • Branch D.
        • Varner M.W.
        Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system.
        Obstetrics and Gynecology. 2009; 113: 804-811
        • Parikh L.I.
        • Reddy U.M.
        • Männistö T.
        • Mendola P.
        • Sjaarda L.
        • Laughon S.K.
        Neonatal outcomes in early term birth.
        American Journal of Obstetrics and Gynecology. 2014; 211: 265.e1-265.e11
        • Purnell T.S.
        • Calhoun E.A.
        • Golden S.H.
        • Halladay J.R.
        • Krok-Schoen J.L.
        • Appelhans B.M.
        • Cooper L.A.
        Achieving health equity: Closing the gaps in health care disparities, interventions, and research.
        Health Affairs (Millwood). 2016; 35: 1410-1415
        • Sengupta S.
        • Carrion V.
        • Shelton J.
        • Wynn R.J.
        • Ryan R.M.
        • Singhal K.
        • Lakshminrusimha S.
        Adverse neonatal outcomes associated with early-term birth.
        JAMA Pediatrics. 2013; 167: 1053-1059
      1. Smedley B.D. Stith A.Y. Nelson A.R. Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press, Washington, DC2003
        • Snowden J.M.
        • Muoto I.
        • Darney B.G.
        • Quigley B.
        • Tomlinson M.W.
        • Neilson D.
        • Caughey A.B.
        Oregon’s hard-stop policy limiting elective early-term deliveries: Association with obstetric procedure use and health outcomes.
        Obstetrics and Gynecology. 2016; 128: 1389-1396
        • The Joint Commission
        Specifications manual for Joint Commission National Quality Measures.
        2013 (Available:) (Accessed: April 6, 2017)
        • Tita A.T.
        • Landon M.B.
        • Spong C.Y.
        • Lai Y.
        • Leveno K.J.
        • Varner M.W.
        • Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network
        Timing of elective repeat cesarean delivery at term and neonatal outcomes.
        New England Journal of Medicine. 2009; 360: 111-120


      Katy B. Kozhimannil, PhD, MPA, is Associate Professor in the Division of Health Policy and Management at the University of Minnesota. She conducts research to inform the development, implementation, and evaluation of health policy that affects women, families, and communities.


      Ifeoma Muoto, PhD, is a Postgraduate Administrative Fellow at Kaiser Permanente Southern California. Her focus areas include strategy, process improvement, and health systems development, to promote population health.


      Blair G. Darney, PhD, MPH, is a health services researcher affiliated with the Oregon Health & Science University Department of Obstetrics and Gynecology and Instituto Nacional de Salud Publica (Cuernavaca, Mexico). Her research interests include maternal morbidity and mortality, contraception, and abortion.


      Aaron B. Caughey, MD, PhD, is Professor/Chair, Department of Obstetrics and Gynecology at Oregon Health and Science University School of Medicine. He utilizes clinical epidemiology, health economics, health policy, and the decision sciences to examine obstetric care and outcomes.


      Jonathan M. Snowden, PhD, is Assistant Professor in the Oregon Health and Science University /Portland State University School of Public Health. He is an epidemiologist and health services researcher focusing on analytical methods to study and mitigate sexual/reproductive health disparities.