AL-OSTAD ET AL., 2015

MULTIPLE STATES

Retrospective Cohort Study

All Births from Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) database 1998–2008

Total: N = 5,338,995

Black: n (%) = 9.7% of 5,337,424 without sepsis, 17.8% of 1571 with sepsis

Comparison group: all deliveries without a sepsis diagnosis

1. Incidence rate and mortality rate of maternal sepsis

2. Associated risk factors for developing maternal sepsis during pregnancy, L&D, and postpartum

Multivariate logistic regression

Being over 35, Black, having lower income, and smoking were associated with developing sepsis

After adjusting, Black women were 20% more likely to develop sepsis than White women (OR = 1.20 95% CI 1.02–1.41) p = 0.026

Black women were also 72% more likely to experience sepsis-related deaths than White women

SMM

Maternal mortality

BLACK ET AL., 2021

MULTIPLE STATES

Retrospective Cohort Study

All delivery hospitalizations with a live birth in 2016 from MarketScan Commercial Claims and Encounters & Medicaid databases

Total: N = 165,444 live births

Total Black: n (%) = 20,284 (30.5%) of Medicaid users (only available for Medicaid users)

1. Risk of hospital readmission after delivery and SMM

SMM definition: Occurrence of one or more of 21 indicators/ potentially life-threatening maternal conditions/ complications

Multivariable logistic regression

Black Medicaid users had higher rates of readmission after delivery compared to non-Hispanic White Medicaid users (OR = 1.22; 95% CI = 1.06–1.42)

SMM

Medicaid

BLACK ET AL., 2022

Retrospective Cohort Study

All women with a live inpatient birth in 2016 from MarketScan Commercial Claims and Encounters

Total: N = 170,760 (commercial), 219,670 Medicaid)

Total Black: n (%) = 72,856 (34.1%) among Medicaid group, commercial unknown

1. SMM which was defined as the occurrence of one or more of 21 indicators/ potentially life-threatening maternal conditions/ complications

Multivariate logistic regression

Black mothers, and women with multifetal gestation, and those who delivered by cesarean had significantly more prevalence of SMM

Black mothers had the highest incidence of SMM compared to other races among patients with Medicaid insurance

SMM

Medicaid

COLLINS ET AL., 2021

OHIO

Qualitative, Phenomenological

(interviews)

Total: N = 25 Black women that were enrolled in a program providing a PSP (similar to doulas)

Nature and characteristics of Black women's interactions with medical providers during childbirth when they were accompanied by a PSP and what shaped those experiences

Thematic analysis (not named, but described)

Positive experiences: having a responsive and helpful care team having birth plans respected

Negative experiences: feeling disrespected, ignored or invisible, feeling pressured or rushed, disrespect of the PSP

Responsive care team

Respect of birth plans

Disrespect of patient

Disrespect of PSP

Feeling ignored or invisible

Feeling pressured

Feeling rushed

CREANGA ET AL., 2014

MULTIPLE STATES

Cross-Sectional Study

Used Healthcare Cost and Utilization Project's State Inpatient Database (SID) data from 7 states, 2008–2011 to examine 15 delivery-related indicators

SID data were linked with AHA data from 6/7 of the states to obtain hospital characteristics

Total: N = 4,456,426 delivery hospitalizations;

1021 White-serving, 56 Black-serving, and 530 Hispanic-serving hospitals

Total Black: n (%) = White-serving hospitals = 9.9% Black mothers; Black-serving hospitals = 66.4% Black mothers; Hispanic-serving hospitals = 6.2% Black mothers

1. Rates of the selected delivery-related indicators

Delivery-related indicator rates

Poisson regression models

The most prevalent delivery-related indicators were complicated vaginal delivery, complicated cesarean delivery, obstetric trauma

Overall lower performance of Black-serving hospitals on delivery-related indicators and higher rates of complications for either method of delivery among Black women when compared to White women in adjusted models

Higher risk of complicated deliveries regardless of method

Higher rates of indicators among Black women

Low rates of obstetric trauma in Black- and Hispanic-serving hospitals

DAVIS, 2019

MULTIPLE STATES

Ethnography/ Case studies with a Black feminist approach

Total: N = 17

Total Black: n (%) = 3 Black mothers (cases)

To demonstrate the presence and effects of obstetric racism through various stories of Black births. Specifically: (1) to frame obstetric racism in the literature on adverse birth outcomes;

(2) to describe the methodological approach of the study;

(3) to present 3 case studies of Black women's medical encounters to elucidate the concept of obstetric racism;

(4) to explore the role of birth workers who seek to intervene and decrease women's obstetric racist encounters

Interviews with cases

Interviews with birth workers

Analysis not described (though a type of narrative analysis of interview data seems to be present)

Participants birth plans, including the attendants and support persons at birth, the place and method of delivery were all undermined; 2/3 participants' birth plans were changed due to circumstances out of their control

Black women were subjected to unwanted cesarean, drugs (pitocin and epidurals), and NICU stays (even when they could not be justified clearly)

“[…] when Black women express

wanting to have control over their births, 'some nurses and doctors, regardless of the medical

professionals’ race, punish Black moms. It is like they don’t deserve to have the kind of birth they want.”

Birth workers (doulas and midwives) help women maintain bodily autonomy and planning a birth on one's own terms

Neglect

Lack of information

Dismissiveness

Disrespect

Interventions without explanation

DAYMUDE ET AL., 2022

RURAL GEORGIA

Mixed-Methods Study

Quantitative: The study used data from the Georgia Department of Public Health Online Analytical Statistical Information System (OASIS), regional household income data from the US Census Bureau, Provider and LDU information from the Georgia Maternal and Infant Health Research Group, and patient data from Emory's MCH linked vital records data repository

Qualitative: Study used newspaper articles and Georgia's OBGYN society reports from 2011 to 2016

30 rural LDUs in Georgia

Total Black (%) = 30.2–34.5% of Black women per Primary Care Service Area (PCSA); 31.9–41.9% of Black birthing patients per LDU

To explore what factors may be associated with rural hospital LDU closures in Georgia from 2012 to 2016

Quantitative:

OR, 95% CI; Cochran-Mantel-Haentzel

Qualitative: Content and thematic analysis

Quantitative:

Odds of having a Black female resident (15–44) and Black women were 7% and 46% higher, respectively, for PCSAs containing LDUs that subsequently closed compared to PCSAs with LDUs that remained open. After controlling for payor group, LDUs that eventually closed had 34% higher odds of having Black patients than LDUs that remained open

Qualitative:

LDU closures attributed to:

(1) Costly obstetric services receiving inadequate reimbursement

(2) Refusal to expand Medicaid and budget cuts to rural hospitals under the ACA

Birth Volume:

Lower for PCSAs with LDUs that closed (313) compared to PCSAs with LDUs that remained open in 2011(365, p = 0.49)

Location of delivery:

The nearest birth hospitals to LDUs that closed had higher median annual birth volumes (773.5) than the nearest birth hospitals to LDUs that remained open (327) (p = 0 0.06)

Black women may have been more reliant on the LDUs that closed or were less able to access care in the LDUs that remained open, thus experiencing disproportionate impact of the closing LDUs

LDUs that remained open had a greater influx of patients from neighboring regions compared to LDUs that closed

DEICHEN HANSEN ET AL., 2021

FLORIDA

Cross-Sectional Qualitative Pilot Study

Total: N = 11 Black women

Total Black: n (%) = 11 (100)

1. Prenatal practices

2. Birthing experiences

Thematic Analysis

Theme 1: Decision-Making Strategies for Employing Alternative Prenatal Care and Birthing Practices—7 women decided to use alternative birthing practices (i.e., de-emphasizing more common obstetric trends and requiring less invasive procedures or interventions)

5/11 women reported using midwifery at some point in their pregnancies, 4/11 indicated a preference for OOH midwife or doula-supported births, and 2/11 had OOH births

Women's preferences for OOH births were due to concerns about a lack of control over epidurals, cesarean deliveries, and pain management during long hospital deliveries

Theme 2: Accessing Formal Resources for Pregnancy and Childbirth -

Participants expressed the need for resources and educational opportunities (i.e., birthing and breastfeeding classes) offered after business hours and inclusive of Black women and working mothers due to a lack of accessibility and inclusivity, and race-concordance with instructors in existing resources

Theme 3: Seeking Advice from Other Black Women with Similar Perspectives on Birthing and Parenting –

At least 50% of the participants stated that their decisions were influenced by their mothers, grandmothers, other influential women in their partner's families as well as other trusted Black women in their community with whom they had built bonds over time. Participants also found parenting groups on social media useful to learn and explore alternative care options

Theme 4: Being Confident in One’s Decisions –

Both formal and informal sources of information helped the women feel more confident and empowered in their birthing decisions

Decision-making strategies for employing alternative prenatal care and birthing practices

Accessing formal resources for pregnancy and childbirth

Seeking advice from other Black women with similar perspectives on birthing and parenting

Being confident in one’s decisions

DRASSINOWER ET AL., 2014

Cross-Sectional Study

Total: N = 1009 vertex-vertex twin pregnancies

Total Black: n (%) = 274 (27.2%)

1. Unplanned cesarean in the trial of labor group

2. Maternal outcomes:

– PPH

– Blood transfusion

– Intensive care unit admission

– Repeat laparotomy

– Maternal death

3. Neonatal outcomes (not reported here)

Multivariate logistic regression

Black women (n = 22, 8%) were the least likely to have an elective cesarean compared to White women (OR = 0.5; 95% CI, 0.3–0.8)

Similar rates of preterm delivery between 32 and 36 weeks across ethnicities, with an overall rate of 58.5% (White 60.3%, Black 56.7%, Hispanic 58.3%, Asian 51.7%, and other 50%, p = 0.26)

SMM

Maternal mortality

Method of delivery

GROBMAN ET AL., 2015

Cohort Study

25 medical centers of NICHD MFMU Network assembled an observational obstetric cohort (i.e., Assessment of Perinatal EXcellence (APEX) study)

Total: N = 109,208

Total Black: n (%) = 27,291 (25%)

1. Frequency of adverse outcomes during or after L&D

2. Association between types of obstetric care provided (e.g., episiotomy) and race and ethnicity

Multivariable logistic regression

Non-Hispanic Black, Hispanic, and Asian women had significantly greater odds of experiencing a severe PPH or peripartum infection than non-Hispanic White women

Non-Hispanic White women, Asian women had significantly higher odds of laceration, while non-Hispanic Black women had significantly lower odds of laceration although no longer significant after adjusting for differences in patient characteristics

Black women were significantly less likely to have labor inductions, vaginal deliveries, and episiotomies

SMM

Postpartum complications

Method of delivery

HAYWORTH ET AL., 2020

STATE UNKNOWN

Case Report

Electronic medical record

Total: N = 1 Back patient

Report on treatment of PPCM during L&D

Tests which confirmed the PPCM diagnosis and led to a cardiology consult:

– Blood pressure monitoring

– Heart rate monitoring

– Preeclampsia blood panel

– Computed tomography scan

– Chest X-ray

Labor induction and vacuum assisted delivery of healthy baby but patient then experienced a series of complications leading to the implantation of a permanent left ventricular assist device (LVAD)

Before implant:

Patient wanted to breastfeed so the cardiology team collaborated with obstetrics, pediatrics, and a lactation consultant to determine which medications were safe and develop a nursing plan to support breastfeeding, mother-baby bonding, fundal massage

Patient was discharged home with devices to monitor and prevent sudden death. Home health care visits and frequent follow-up in the Heart Failure clinic were arranged

A need for additional training, and interdisciplinary collaboration of highly specialized providers

KATHAWA ET AL., 2022

MULTIPLE STATES

Qualitative Study

Total: N = 8 doulas of color

Total Black: n (%) = 4 (50%)

Conceptualization of the influence of racial and ethnic identities on birth work within the context of racial disparities in birth outcomes among doulas of color

Content analysis of interview data

Four major themes:

(1) Relationship with the medical system—Sub-themes: agency in L&D, preference for race concordant providers due to distrust of White providers, generational trauma

(2) Role of identity in the doula’s work -

Sub-themes: less dismissal of validity of challenges due to similar lived experiences, awareness of the necessity for culturally appropriate care to eradicate disparities, birth work passed down to generations, higher likelihood of having successful unmedicated vaginal delivery

(3) Class and the accessibility of the natural birth movement –

Sub-themes: financial barriers to accessing doula support, financial barriers access doula training and certification, feeling called to serve people who cannot afford care, feeling like the help with White clients

(4) Divisions within the natural birth movement –

Sub-themes: divisions between professional and community doulas, cultural appropriation and White people capitalizing on the natural birthing movement resulting in leaving out the people who invented the movement while privileged people with a lesser need benefit

Relationship with the medical system

Role of identity in the doula’s work

Role of class

Divisions within the birth movement

KOZHIMANNIL ET AL., 2014

MULTIPLE STATES

Retrospective Cohort Study

Used linked hospital discharge and birth certificate data for the uncomplicated term (> 37–0/7 weeks’ gestation) births between 1995–2009 in California, Missouri, and Pennsylvania

Total: N = 7,296,363 full-term, uncomplicated pregnancies;

232,189 early-term nonindicated deliveries

Total Black: n (%) = 17,020 (7.3%) full-term, uncomplicated pregnancies; 5,977 (5.5%) early-term nonindicated cesarean

1. Association between early term nonindicated birth (initiated by induction or cesarean)

2. Prolonged length of stay and infant respiratory distress

Survival analysis using multivariable Cox proportional hazards models

Black women had substantially higher rates of nonindicated cesarean birth without labor (HR, 1.29; 95% CI, 1.27- 1.32) compared with non-Hispanic White women, after controlling for other risk factors

Minority racial/ ethnic status was associated with higher rates of early-term nonindicated cesarean without labor, whereas non-Hispanic White women had comparatively higher rates of early-term nonindicated induction

Racial/ethnic minority women had substantially lower rates of early term nonindicated labor induction than did non-Hispanic White women

Nonindicated cesarean without labor

Method of delivery

LIESE ET AL., 2022

ILLINOIS

An innovation from the field of midwifery, Melanated Group Midwifery Care (MGMC)

*MGMC is part of a randomized control trial in which it is compared to traditional perinatal care in Chicago, IL

As described by MCMG

N/A

MGMG has 4 evidence-based strategies:

(1) Racial concordance between Black midwives and patients,

(2) Group prenatal care,

(3) Nurse navigation, and

(4) One year of in-home postpartum doula support

Midwifery-led perinatal care model

Promotion of engagement in one’s own care

Positive provider–client interactions

MISSAL ET AL., 2016

MINNESOTA

Qualitative Study: Ethno-nursing

Total: N = 12 Somali immigrant mothers who had delivered a healthy child in the 3 years prior to data collection

Immigrant Somali mothers’ childbirth experiences in Minnesota

Leininger’s four-phase ethno-nursing data analysis of interview data

11/12 participants had normal spontaneous deliveries; 1/12 had a cesarean delivery

Six major themes:

(1) Limitations of Support due to Separation from Family—Support from Somali community (known and unknown)

(2) Importance of Cultural and Religious Practices –

Muslim call to prayer first thing baby hears

(3) Desired Relationships with Nurses -

Desire for communication with nurses

(4) Fear of Cesarean – Belief that cesarean = God’s punishment; avoiding hospitals at onset of labor due to belief going in would lead to automatic cesarean

(5) Value of Education –

Desire to educate themselves to better their lives and serve their communities

(6) Views on Postpartum Blues/Depression – Postpartum experience in Somalia less stressful then in US

Social support

Physical, emotional, and educational support from nurses

Cesareans done for financial benefit of physician

Lack of understanding of the need for cesareans

Depression believed to be a sign of weakness

Lack of assistance form nurses

Need for information about available resources for postpartum depression

OGUNWOLE ET AL., 2020

Viewpoint paper

1. Describe emerging data concerning racial disparities (and the related pathways for those disparities) in birth outcomes during the COVID-19 pandemic

2. Highlight how community-based doula services can disrupt the mechanisms leading to such disparities in COVID-19-related birth outcomes by proposing strategies for integrating doulas into health care teams and normalize recognizing them as essential health care workers

N/A

Racism places residents of predominantly Black counties at higher risk of COVID-19 infection and chronic diseases

Because benefits of community doulas have not been deemed essential in hospital L&D settings, COVID-19 restrictions forced some women to choose between an often-unqualified partner/family member and their doula

Healthcare systems should invest into and partner with community-based programs to promote health equity

Hospital policies should reflect doulas’ designation as essential health care workers

Educate obstetric providers about the role of doulas, to enable partnerships that can improve birth outcomes

PRATER ET AL., 2020

MISSOURI

Cross-Sectional Study

Affinia Healthcare is a federally qualified health center serving historically marginalized populations

Total: N = 97, including Myanmar (n = 5), Afghanistan (n = 4),

Nepal (n = 1)

Total Black: n (%) = 49 (51%), including

Democratic Republic of Congo (n = 6), Somalia (n = 1)

1. Perceived discrimination measured with the 7-question Discrimination in the Medical Setting (DMS) survey

2. Association between race and perceived discrimination, quality of care, trust of healthcare providers, and perceived control over medical choices relating to prenatal care and delivery

DMS scores

Multivariate logistic regression

Black women reported higher rates of ever feeling not listened to (20% vs 7%, p = 0.049)

Black women reported higher rates of perceived discrimination (31% vs 11%, aOR 3.9 [1.2–12.1], p < 0.05), lower control over health choices (84% vs 98%, aOR 0.1 [0.0–0.8], p < 0.05), and were more likely to perceive lack of respect (12% vs 2%, p = 0.045) compared to other women or color

Higher rates of experienced discrimination compared to other women of color

Healthcare decision-making

Trust

SALEM ET AL., 2011

MINNESOTA

Prospective Cohort Study

A review of the medical records of all Somali women delivering at a single tertiary center between Nov 1994-Dec 2007

Total N = 106 Somali immigrants

1. Compare the cumulative incidence rate of a second child as well as the number of deliveries between the two modes of delivery (vaginal vs cesarean)

2. Total number of children a woman delivered

Cox proportional hazards models

Poisson regression

68 (64%) had a vaginal delivery (Group 1); 38 (36%) had a cesarean (Group 2)

Somali women who had an initial vaginal delivery were 1.56 times (95% CI, 0.94–2.57; p = 0.08) more likely to have a subsequent delivery compared to women who had an initial cesarean section

No statistically significant association between the number of subsequent deliveries and the initial mode of delivery (rate ratio for vaginal vs cesarean = 1.35: 95% CI, 0.92–2.01: p = 0.09) when followed longitudinally over extended periods of time

Need for counseling Somali women about the potential delay in a second live birth after cesarean

Frank dialogue between physicians and Somali women

Building trust and cultural competency through well guided counseling

Addressing Somali women’s concerns to ease transition into US healthcare system

SPERLICH ET AL., 2017

MICHIGAN

Cross-Sectional Study

A secondary analysis of data from interview responses and medical chart data collected during the NIH's STACY study ("Stress and the Childbearing Year")—a prospective, longitudinal study

Total: N = 634

Total Black: n (%) = 208 (32.8%)

To answer the following questions:

1. Do White and Black women endorse feeling safest giving birth outside of a hospital at different rates?

2. Do women who feel safest giving birth out-of-hospital differ from women who feel safest giving birth in a hospital based on other sociodemographic indicators such as age, income, education, insurance status, or living arrangements?

Logistic regression

Similar rates of feeling safest delivering in out-of-hospital settings Black (11.5%) and White (13.1%)

80/634 (12.6%) of participants said they would feel safest delivering in out-of-hospital setting including birth centers, home or other

Significant variables associated with feeling safest delivering out-of-hospital were poverty ($15,000 annual income) and having an educational level above high school e.g., having a master’s degree but low income

The disproportionately higher number of planned out-of-hospital births among White women in the US is not due to feelings about the safety of delivering out-of-hospital but more likely differential access to and knowledge of such services

SPERLICH ET AL., 2019

MICHIGAN

Cross-Sectional Study

A secondary analysis of data from interview responses and medical chart data collected during the NIH's STACY study (“Stress and the Childbearing Year”) – a prospective, longitudinal study

Total N = 645 completed late pregnancy interviews

564 completed six-week postpartum interviews

Total Black: n (%) = 214 (33.2%) completed late pregnancy interviews and 170 (30.1%) completed six-week postpartum interviews

1. Rates of preferring midwives over doctors

2. Rates of using midwives

2. Rates of doula familiarity

3. Midwife preference

4. Doula care familiarity

5. Sociodemographic predictors of midwife use

Multivariate logistic regression

34.8% of Black women preferred midwives compared to 23.7% of White women

Black women were attended by midwives 29.4% of their births (67.7% by physicians), compared to white women who had midwives available 18.5% of their birth

36.8% of Black women had knowledge about doulas compared to 85.7% of White women; though a similar rate of women from both race groups said they would consider a doula (61.6% White; 61.5% Black)

No statistical significance with race and midwifery preference

Lower educational levels were associated with preferring a midwife (33.9% of those with less than high school education preferred midwives compared to 23.7% of those with higher than high school education)

TAYLOR ET AL., 2022

LOUISIANA

Retrospective Cohort Study

All patients who delivered at Woman's Hospital in Baton Rouge, LA between Oct 2015 and Sept 2020

Total N = 30,674

Total Black: n (%) = 11,513 (37.5%)

1. Rates of PPH by demographics

2. Predictive values for PPH by race

3. Cesarean delivery and risk of PPH

4. Previous cesarean delivery risk of PPH

Multivariable logistic regression

Those who were obese, Black, Medicaid-eligible, and who did not have a previous cesarean delivery were more likely to experience PPH (p < 0.001)

Black women had greater odds of PPH (aOR = 1.23; 95% CI = 1.10–1.38)) compared to White women; among those who had a cesarean, this association was slightly greater (aOR = 1.29; 95%CI = 1.13, 1.15)

Having a cesarean was the greatest predictor of PPH, with OR 8.80 (95% CI = 7.73–10.01) compared to those who delivered vaginally. Having a previous cesarean resulted in decreased odds of PPH in subsequent c-sections (aOR = 0.38; 95% CI = 0.32–0.44)

SMM

Pregnancy complications

Association of Black race to risk of disease

No mention of racism

THOMAS ET AL., 2023

NEW YORK

Quasi-experimental matched cohort design

Total N = 2,412 (603 participated in the By-My-Side doula program intervention; 1,809 who did not)

*Matched using Natality Data

Total Black: n (%) = 1,936 (80.2%)

484 (participated in By-My-Side program);

1,452 (did not participate)

1. Preterm birth

2. Low birthweight

3. Cesarean birth by groups

4. Location of birth

5. Mode of delivery

Conditional and multivariable logistic regression

Intervention group had significantly lower rates of preterm birth (5.6% vs. 11.9%, p < 0.0001) and low birthweight (5.8% vs. 9.7%, p = 0.003) compared to control group, and significantly higher rates of giving birth outside of a hospital

3.2% of By-My-Side participants used a birthing facility compared to 0.3% of non-participants (p < 0.0001), and 2.3% of By-My-Side participants gave birth at home compared to 0.8% of non-participants (p < 0.0001)

Adjusted analyses confirmed lower odds of preterm birth (aOR = 0.43; 95% CI = 0.29–0.63) and low birthweight (aOR = 0.57; 95% CI = 0.38–0.84) among intervention group compared to control group

No statistically significant associations between the intervention and primary cesarean deliveries

Women who participated in the program had decreased odds of preterm birth, low birthweight, and safe out of hospital deliveries compared to the control group who did not use doula services

THORNTON, 2018

Diagnostic Test Accuracy Study

Author describes the challenges with using a VBAC calculator

1. Birth setting

2. Race

No methods are used or described

VBAC calculator has been predominantly tested and validated at academic hospitals; rates of primary and repeat cesarean vary greatly by setting

VBAC calculator only includes indicators from the woman giving birth, not the institutional or provider factors (e.g., guidance/advice, credentials, preferences, call schedules, patient volumes) and fails to address a woman's motivation for seeking a VBAC (which has previously been associated with success)

Though no biological indicators for differences by race, the calculator accounts for the fact that just being a woman of color in the US decreases odds of successful VBAC. This frame fails to address the differences between physiological and social indicators and thus, sustains narratives that social disadvantage is a neutral biological fact like age or height

"Of course, racism has real health consequences, but if we restrict women's options based (in part) on known health disparities, we risk recreating them."

THORNTON, 2023

Systematic Review

Synthesizing recent US studies exploring the VBAC calculator

1. Calculator development

2. Review of studies

3. Barriers and race

Narrative synthesis (not described)

Original development of the tool considered several risk factors, including Black/Hispanic race/ethnicity despite lack of biological predictors; systematic use of this tool could result in Black/Hispanic women being counseled against labor/vaginal birth, which is problematic given the higher rate of morbidity from cesarean delivery that many Black/Hispanic patients experience

Some studies reveal underestimation of success for VBAC among Hispanic and White individuals compared to Black individuals

One study demonstrated that Black parents were 3 times more likely to desire LAC compared with White parents; 70% of Black parents in the same study rated the difficulty of finding LAC care demonstrating the significant restriction of access to LAC for black families

Need for research including large numbers of low scoring and racially minoritized patients in order to evaluate the effect of removing race on the VBAC calculator performance

VEDAM ET AL., 2018

Scale Development

The study team created a scale to estimate midwife integration in hospital settings, then assessed the scale for validation and effect measures using the Delphi method

MISS

1. MISS scores and birth outcomes including (rates of spontaneous vaginal birth, exclusive breastfeeding, cesarean delivery, induction, VBAC, preterm birth, low birth weight, and neonatal mortality)

2. MISS scores by race/state (including state midwife density and consumer access to midwives across birth settings (hospitals, home, birth centers)

Spearmen's Rho correlation Coefficient

Higher MISS scores and improved access to midwives in all settings were associated with significantly higher rates of spontaneous vaginal delivery, VBAC, and breastfeeding at birth and six months; and significantly lower rates of cesarean, preterm birth, and low birthweight

MISS scores, access to midwives, and density of midwives were significantly lower in states with a higher proportion of Black births (rs = -0.37, p = 0.007; rs = -0.375, p = 0.007; and rs = -0.298, p = 0.04, respectively)

MISS scores did not significantly explain disparities in cesarean delivery and low birthweight

VYAS ET AL

2019

Text and Opinion

Described the issues with incorporating race/ethnicity into VBAC calculations despite limited evidence of its impact on cesarean delivery and trial labor

Narrative of the history of the VBAC predictor tool with explanations for the various factors that go into the tool's calculation

N/A

There is limited evidence that race/ethnicity impacts VBAC success (the author points to historically racist and anecdotal theories such as pelvic anatomy differences or suitability for vaginal birth). There are concerns with including race/ethnicity in the current models (i.e., ignoring the obvious sociopolitical mechanisms that intercede race and VBAC success; risking the continuance of these outcomes by systemizing the disparities)

No biological plausibility for differences by race

"Moreover, using

incidence data to justify race-based correction is a circular

argument: since the observational data reflected a snapshot in time, it is unsurprising that it revealed racial and ethnic disparities that are known to exist."

WYCKOFF ET AL., 2020

FLORIDA

Retrospective Cohort Study

Total: N = 201 patients attempting a VBAC delivery at a single birth center

Total Black: n (%) = 58 (28.8%)

1. VBAC prediction vs. actual occurrence

2. Prediction success by race

Exact binomial test

Study population had higher success in vaginal delivery than predicted from VBAC calculator

VBAC calculator had better prediction success in Black populations compared to White and Hispanic populations

Need to use VBAC calculator with caution

Discussion about VBAC with patient should happen well before L&D