Racial and Ethnic Differences in Unplanned Cesarean Birth Among Women Veterans Receiving VA Maternity Care

Background: Cesarean birth is associated with higher maternal morbidity and mortality than vaginal birth. Unplanned cesarean births, which occur after labor onset, reflect intrapartum decision-making and care processes that may vary across clinical settings. Prior research has demonstrated racial and ethnic disparities in unplanned cesarean birth in civilian populations, but these patterns have not been well characterized among women Veterans. Such disparities may extend to Veterans receiving maternity care through the Department of Veterans Affairs (VA) Community Care Network (CCN). This study examined racial and ethnic differences in unplanned cesarean birth among Veterans receiving obstetric care in the VA CCN. Methods: We conducted a retrospective cohort study of 314 nulliparous Veterans with singleton, term deliveries through the VA CCN between 2016 and 2021 who completed both prenatal and postpartum telephone-based surveys. Planned cesarean births were excluded. Poisson regression with robust variance estimation was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for unplanned cesarean birth by race/ethnicity. Results: The overall rate of unplanned cesarean birth was 26.4%. Compared with White Veterans, non-Hispanic Black Veterans had a 75% higher risk of unplanned cesarean birth (RR 1.75, 95% CI: 1.14–2.68), which persisted after adjustment for clinical risk factors (adjusted RR aRR 1.59, 95% CI: 1.04–2.42). Non-Hispanic Veterans identifying as other races also had higher adjusted risk (aRR 1.83, 95% CI: 1.04–3.21). Hispanic Veterans had a similar risk of unplanned cesarean birth compared with White Veterans (aRR 0.97, 95% CI: 0.54–1.77). Conclusions: Non-Hispanic Black and other race Veterans experienced higher risk of unplanned cesarean birth than White Veterans after adjustment for key clinical risk factors. These findings suggest that differences in labor management, care processes, or delivery contexts within the CCN may contribute to observed disparities. Further research is needed to examine quality, decision-making, and equity across CCN-affiliated maternity care settings.