Rural-urban and racial differences in cesarean deliveries before and during the COVID-19 pandemic in South Carolina

Unnecessary cesarean delivery increases the risk of complications for birthing people and infants. Examining the intersectionality of rural and racial disparities in low-risk cesarean delivery is necessary to improve equity in quality obstetrics care. To evaluate rural and racial/ethnic differences in Nulliparous, Term, Singleton, Vertex (NTSV) and primary cesarean delivery rates before and during the COVID-19 pandemic in South Carolina. This retrospective cohort study used birth certificates linked to all-payer hospital discharge data for South Carolina childbirths from 2018 to 2021. Multilevel logistic regressions examined differences in cesarean outcomes by rural/urban hospital location and race/ethnicity of birthing people during pre-pandemic (January 2018–February 2020) and peri-pandemic periods (March 2020–December 2021), adjusting for maternal, infant, and hospital characteristics among two low-risk pregnancy cohorts: 1) Nulliparous, Term, Singleton, Vertex (NTSV, n = 65,974) and 2) those without prior cesarean (primary, n = 167,928). Black vs. White disparities remained for NTSV cesarean in adjusted models (urban pre-pandemic aOR = 1.34, 95 %CI 1.23–1.46) but were not significantly different for primary cesarean, apart from rural settings peri-pandemic (aOR = 0.87, 95 %CI 0.79–0.96). Hispanic individuals had higher adjusted odds of NTSV cesarean only for rural settings pre-pandemic (aOR = 1.28, 95 %CI 1.05–1.56), but this disparity was not significant during the pandemic (aOR = 1.13, 95 %CI 0.93–1.37). Observed rural and racial/ethnic disparities in cesarean delivery outcomes were present before and during the COVID-19 pandemic. Strategies effective in reducing racial disparities in primary cesarean may be useful in also reducing Black vs. White NTSV cesarean disparities.