Physician characteristics and implicit bias in disparate rates of primary cesarean delivery in Black vs. non-Black patients

Abstract Background Black patients experience a higher chance of cesarean delivery (5–19% increased incidence over white patients) and reductions in low-risk cesarean deliveries in white patients have surpassed reductions among Black patients. The reasons driving this health care disparity are largely unknown. Here, we assess physician demographic characteristics and a measure of implicit bias in relation to primary cesarean delivery in Black vs. non-Black patients as possible contributing reasons for disparate rates of cesarean delivery by patient race. Methods This is a retrospective study of patients delivered at term at a single safety-net hospital. Demographics of the attending physician responsible for the delivery, including physician gender, race, years in practice, type of training, and physicians' results of an Implicit Association Test were compared to determine associations between provider factors on mode of delivery (cesarean or vaginal) by maternal race (Black vs. non-Black). Multinomial regression analysis was used to model primary cesarean delivery rates in Black compared to non-Black patients. Results In 4,847 singleton, term deliveries without a prior cesarean delivery, we found a significant difference in mode of delivery (cesarean or vaginal delivery) by race in the sample, with higher cesarean delivery rates in Black patients (21.3%) compared to non-Black patients (12.9%) (P < 0.001). Ten of 22 physicians (47.6%) responded to a request to share implicit association test results. Multinomial regression demonstrated higher rate of cesarean delivery in Black vs. non-Black patients that persisted for all physician attributes: gender (aOR 0.53, 0.20–1.38 95% CI), race and ethnicity (aOR 1.01, 0.94–1.09 95% CI), years in practice (aOR 0.71, 0.25-2.00 95% CI), training type (aOR1.05 0.84–1.32 95% CI), and measure of implicit bias (aOR 0.99, 0.82–1.19 95% CI). Conclusion We did not find that higher primary cesarean delivery in Black vs. non-Black patients were related to physician characteristics or implicit association test results.