Assistant Professor of Nursing Jeremy Neal has been awarded an R21 exploratory/development grant of more than $250,000 from the National Institute of Minority Health and Health Disparities to assess the differences in labor progress and care among Black and white women with low-risk pregnancies. The study, which will focus on the frequency of cesarean births among the two groups, will be the first to describe obstetric care in this way at a high-volume, academic medical center, and its findings will inform how health care providers can improve standards of care to ultimately decrease the disparity in cesarean births.
According to the Centers for Disease Control and Prevention, 31.7 percent of all deliveries in the U.S. are by cesarean birth. For low-risk pregnancies, one in four women will undergo the procedure in lieu of a vaginal birth, although vaginal birth is widely known to be the healthiest option for mother and child. Further, the disparity in primary cesarean birth rates between Black and white women with low-risk pregnancies in the United States is greater than ever before. In 2019, 30 percent of low-risk Black women experienced a cesarean birth compared to 24.7 percent of white women.
Women experiencing cesarean births are at immediate risk for severe blood loss, infection, anesthesia complications and other complications associated with major surgery. They must also contend with longer recovery times while adjusting to life with a newborn. Women who have cesarean births also have higher rates of longer-term health complications such as infertility, stillbirth, placental attachment disorders in subsequent pregnancies, and uterine rupture during future labors.
“The biggest contributor to cesarean births for first-time mothers is if their care provider deems their labor progression too slow,” said Neal, also co-director of the Vanderbilt School of Nursing postdoctoral program. “The standards for labor progression are out of sync with the physiological reality. By holding women to too fast of an expectation, we are putting them at greater risk for cesareans, unfortunately and unnecessarily.”
Neal explains that labor progression standards established in the 1950s were not updated until the early 2000s. While more recent guidelines with relaxed expectations of labor progress exist, they are not applied routinely or holistically across labor settings in the U.S. “There needs to be a shift in how providers assess labor progress and diagnose slow labor, and the criteria used need to be based on contemporary research evidence and need to be applied consistently by providers in all birth settings,” Neal said.
Neal has long been interested in safely improving labor and birth outcomes for women and babies. His attention to the decisions made in the health care world that predispose mothers and babies to adverse outcomes led him to hunt for the data that will limit unnecessary interventions during labor. During the study, Neal and his team will compare Black and white women with low-risk pregnancies with spontaneous labor onset in three areas: (1) labor progress, (2) care received during labor, and (3) indicators of provider-patient communication and decision-making quality. Neal explains that it is currently unknown why Black and white women experience such disparities in care. By looking at physiological and systemic practice issues within the same study, Neal hopes to ascertain the source of the disparity to ultimately improve birth outcomes, reduce health care costs and improve health equity among Black and white women.
The study, “Differences in Labor Progress, Care Received During Labor, and Provider-Patient Communication and Decision-Making Quality among Low-Risk Black vs. White Nulliparous Women with Spontaneous Labor Onset,” will be conducted within the Vanderbilt School of Nursing. Labor and birth data since 2017 will be retrospectively collected from Black and white women who gave birth at Vanderbilt University Medical Center following a pregnancy with spontaneous labor onset. For cross-sectional data collection, Black and white women who birthed following a low-risk pregnancy with spontaneous labor onset will be recruited during their postpartum hospitalizations and complete surveys about their satisfaction with the information they received in labor, the concordance between their preferred and experienced decision-making in labor, their perception of control in labor, and their satisfaction with their birth experiences. Labor attendant type, maternal and pregnancy characteristics, and common labor interventions will also be measured.