Racial and Ethnic Disparities in Cesarean Birth Trends in the United States

Importance: Inequity by race and ethnicity persists in obstetric practice. A comprehensive comparison of the rates of cesarean birth by race and ethnicity in the United States is essential to target quality improvement efforts. Objective: To evaluate the trends in national cesarean birth rates stratified by race and ethnicity as well as parity from 2012 to 2021 and to describe any racial and ethnic disparities. Design, Setting, and Participants: This was a retrospective observational cohort study of birth data from the National Vital Statistics System. Inclusion criteria were singleton, nonanomalous, full-term gestation (37 weeks and 0 days to 42 weeks and 0 days) births with vertex presentation. Trends in the proportions of cesarean births from 2012 to 2021 among nulliparous individuals, multiparous individuals without prior a cesarean birth, and multiparous individals with prior a cesarean birth were graphically examined. Data were analyzed from March 27, 2024, to July 13, 2025. Exposure: Race and ethnicity, self-reported as American Indian or Alaska Native, Asian, Hispanic, non-Hispanic Black, and non-Hispanic White. Main Outcomes and Measures: Main outcomes were cesarean birth rates among nulliparous individuals and multiparous individuals with or without a prior cesarean birth. Cesarean birth rates among self-reported racial and ethnic groups were compared in 2021 relative to 2012 using risk ratios (RRs). Further, the association of racial and ethnic groups with cesarean deliveries was examined using multivariable Poisson regression analyses adjusting for maternal age, education, insurance, prepregnancy body mass index, diabetes (preexisting and gestational), hypertension (chronic and gestational), birth weight, and gestational age and reported as adjusted RRs (ARRs). Results: In total, 30 014 020 births were included (mean SD maternal age, 28.6 5.8 years). For non-Hispanic Black individuals, the adjusted risk of cesarean birth was higher compared with individuals from other racial and ethnic groups; this disparity increased from 2012 to 2021 (2012 ARR, 1.12 95% CI, 1.11-1.13; 2021 ARR, 1.17 95% CI, 1.14-1.20). This finding persisted among nulliparous (2012 ARR, 1.20 95% CI, 1.17-1.24; 2021 ARR, 1.23 95% CI, 1.19-1.27) and multiparous individuals without a prior cesarean birth (2012 ARR, 1.32 95% CI, 1.20-1.45; 2021 ARR, 1.33 95% CI, 1.24-1.43). Conclusions and Relevance: In this cohort study of births in the United States from 2012 to 2021, the rate of overall cesarean births decreased slightly over the study period. However, racial and ethnic disparities persisted, with increasing risk of primary cesarean births among non-Hispanic Black individuals compared with individuals from other racial and ethnic groups. Quality improvement efforts to reduce unnecessary cesarean births should address this inequity and the structural racism that drives it.