Systemic Hospital Effects Driving Racial Disparities in Non-Elective Cesarean Delivery: Evidence from the New York Metropolitan Area

Background: Non‑Hispanic Black patients have higher non‑elective cesarean rates than Whites, but it is unclear how much of this gap is due to observable patient and hospital factors versus unmeasured structural influences. Methods: We analyzed 160,122 patients who were either Non-Hispanic Black or White using New York State Statewide Planning and Research Cooperative System (SPARCS) files for New York City and Long Island for the years 2018-2022. Racial group characteristics were compared using chi-square tests and the Oaxaca Blinder decomposition method was employed to decompose the racial disparity in cesarean surgery into explained and unexplained components. Results: Cesarean rates were 37.8 % for Non-Hispanic Black patients and 27.8 % for White patients (difference = -10.0 percentage points, p = 0.001). A small percentage of hospitals accounted for the majority of Black deliveries: 10 of the 51 hospitals accounted for 51.3 % of all Black births. Furthermore, 29.3 % of all Black deliveries occurred in facilities where White deliveries comprised <1 %. Observable factors explained only 7% (+ 0.77 percentage points; p = 0.71) of the overall gap, whereas unexplained effects accounted for 107% (-10.73; p < 0.001). Hospitals alone accounted for 40 % of the unexplained component, suggesting differential treatment within hospital driving a large share of the observed disparity in cesarian rates. Conclusions: Differential treatment by hospitals contributed almost half of the total Black/White disparity in non-elective cesarean deliveries. Interventions that standardize practice and distribute resources equitably across hospitals are essential to help close this gap.