Lauren Hoehn-Velasco

Background Racial and ethnic disparities in cesarean rates in the United States are well documented. This study investigated whether cesarean inequities persist in midwife‐led birth center care, including for individuals with the lowest medical risk. Methods National registry records of 174,230 childbearing people enrolled in care in 115 midwifery‐led birth center practices between 2007 and 2022 were analyzed for primary cesarean rates and indications by race and ethnicity. The lowest medical risk subsample ( n = 70,521) was analyzed for independent drivers of cesarean birth. Results Primary cesarean rates among nulliparas (15.5%) and multiparas (5.7%) were low for all enrollees. Among nulliparas in the lowest‐risk subsample, non‐Latinx Black (aOR = 1.37; 95% CI, 1.15–1.63), Latinx (aOR = 1.51; 95% CI, 1.32–1.73), and Asian participants (aOR = 1.48; 95% CI, 1.19–1.85) remained at higher risk for primary cesarean than White participants. Among multiparas, only Black participants experienced a higher primary cesarean risk (aOR = 1.49; 95% CI, 1.02–2.18). Intrapartum transfers from birth centers were equivalent or lower for Black (14.0%, p = 0.345) and Latinx (12.7%, p < 0.001) enrollees. Black participants experienced a higher proportion of primary cesareans attributed to non‐reassuring fetal status, regardless of risk factors. Place of admission was a stronger predictor of primary cesarean than race or ethnicity. Conclusions Place of first admission in labor was the strongest predictor of cesarean. Racism as a chronic stressor and a determinant of clinical decision‐making reduces choice in birth settings and may increase cesarean rates. Research on components of birth settings that drive inequitable outcomes is warranted.