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Poster Session 2

Category: Obstetric Quality and Safety

Poster Session 2

(663) County-Level Associations Between Maternal Care Access and Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rates

Wednesday, February 11, 2026

3:30 PM - 5:00 PM

Submitting Author and Presenting Author(s)

Sebastian Z. Ramos, MD (he/him/his)

Assistant Professor
Tufts University School of Medicine
Boston, Massachusetts, United States

Coauthor(s)

ZK

Zeinab Kassem, MD

Tufts University School of Medicine
Boston, Massachusetts, United States
PH

Phinnara Has, MS

Statistician
Brown University Health BERD Core
Providence, Rhode Island, United States
SW

Stephen M. Wagner, MD

Assistant Professor
Beth Israel Deaconess Medical Center
Boston, Massachusetts, United States

Objective:
The nulliparous, term, singleton, vertex (NTSV) cesarean birth rate is a widely accepted obstetric quality metric used to assess care patterns and compare performance across hospitals and regions. Safe reduction of primary cesarean births is critical to minimizing long-term maternal morbidity. It remains unclear how regional access to obstetric care affects NTSV cesarean delivery and related outcomes. This study examines the relationship between county-level maternal care access and NTSV cesarean delivery rates.

Study Design:
This is a cross-sectional study using restricted-access CDC birth certificate data from 2019-2021. Nulliparous, vertex, singleton, non-anomalous pregnancies between 37–42 weeks were included. Counties were categorized into four levels of maternal care access: desert, low, moderate, and full access based on March of Dimes data. The primary outcome was rate of NTSV cesarean delivery. Mixed-effects logistic regression models estimated associations between maternal care access and NTSV cesarean delivery, adjusting for individual-level clinical factors and county-level social vulnerability using the CDC Social Vulnerability Index.

Results:
There were 3,441,704 births in 3,137 counties, with 3.6% occurring in maternal care deserts. Patients in maternal care deserts were younger, more likely to be Non-Hispanic White, and more likely to undergo labor induction. Operative vaginal delivery rates were 19% higher in maternal care deserts compared to full access counties (6.35% vs. 5.64%, p < 0.001). The overall NTSV cesarean rate was 25.9%. After adjusting for confounders, residing in a maternal care desert was associated with increased odds of NTSV cesarean delivery compared to full access areas (aOR 1.08, 95% CI: 1.04–1.11, p< 0.001).

Conclusion:

Geographic disparities in access to maternity care are associated with variation in NTSV cesarean delivery. These findings suggest that structural access to obstetric services may influence clinical decision-making. Further research should explore drivers of this variation and evaluate interventions to support equitable, patient-centered care.