Introduction Cesarean delivery accounts for nearly one-third of U.S. births and is associated with substantial maternal morbidity and health care costs. Persistent racial disparities have been documented, yet the structural factors contributing to these differences remain incompletely understood. The extent to which insurance coverage shapes racial disparities in cesarean delivery remains unclear.

Objective To evaluate the independent and interactive associations of race/ethnicity and insurance coverage with cesarean delivery in the United States.

Methods Population-based retrospective cohort study using singleton live births recorded in the United States Vital Statistics Natality files from 2014 to 2024. Multivariable logistic regression was used to estimate the independent effects of race/ethnicity and insurance status on cesarean delivery, including interaction terms to test effect modification, using national birth certificate data. Models were adjusted for maternal demographics, clinical factors, and temporal covariates. Adjusted odds ratios, predicted probabilities, and absolute risk differences were derived from post-estimation marginal effects. The main outcome measure was cesarean delivery (yes vs no).

Results Among 41,543,568 deliveries from 2014 to 2024, 13,312,221 (32.0%) were cesarean deliveries. After adjustment, both race and ethnicity and insurance status were independently associated with cesarean delivery. Compared with non-Hispanic White women, non-Hispanic Black women had higher odds of cesarean delivery (odds ratio [OR], 1.22; 95% CI, 1.22–1.23). Relative to uninsured women, those with private insurance had 59% higher odds of cesarean delivery (OR, 1.59; 95% CI, 1.58–1.60). Significant interaction effects were observed, indicating that insurance coverage modified racial and ethnic differences in cesarean delivery. Non-Hispanic Black women had the highest predicted probabilities across all insurance categories, with the largest absolute disparities observed among uninsured women.

Conclusion Racial and ethnic differences in cesarean delivery persist in the United States and are modified by insurance coverage, suggesting that coverage-related differences may contribute to inequities in obstetric care.

The authors have declared no competing interest.

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The NCHS natality files are de identified and publicly available. Consequently, this study is considered non human subjects research and did not require institutional review board approval or informed consent.

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The data used in this study are publicly available from the National Center of Health Statistics (NCHS). Data can be assessed at: https://www.cdc.gov/nchs/index.html For additional information regarding data access, researchers may contact the NCHS National Vital Statistics System at: nvsscdc.gov The CDC serves as the non-author institutional point of contact and maintains long term data availability.