Racial and ethnic differences in indications for repeat cesarean following labor after cesarean

Objective Among those with a prior cesarean, Black individuals are more likely to have labor after cesarean compared to White individuals, but have lower rates of vaginal birth after cesarean following labor. However, little is known about indications for cesarean among these patients. We examined whether indication for unplanned cesarean delivery varied by race and ethnicity among individuals with one prior cesarean. Study Design Using linked Massachusetts birth certificate and hospital discharge data (2012–2022), we identified individuals with one prior cesarean who labored and subsequently had an unplanned cesarean. Indications were categorized as nonreassuring fetal status, labor dystocia/arrest, or other. A multilevel multinomial logit model assessed associations between race and ethnicity and cesarean indication, adjusting for covariates. Results Overall, 41% had cesarean for nonreassuring fetal status, 16% for labor dystocia/arrest, and 43% for other indications. Nonreassuring fetal status was the indication for 59% of Black patients versus 36% of White patients. In adjusted analyses, Black individuals had a 42% higher relative risk of having a cesarean for an indication of nonreassuring fetal status, compared to White individuals and compared to having a cesarean for an indication of labor arrest/dystocia (Relative Risk Ratio [RRR] 1.42, 95% Confidence Interval [CI]: 1.14-1.76). Black and Latinx individuals had a lower relative risk of having a cesarean for other indication, compared to White individuals and compared to cesarean for an indication of labor arrest/dystocia. Conclusions Racial and ethnic differences exist in indications for unplanned cesarean after labor among those with one prior cesarean, mirroring disparities reported for primary cesarean indications.