Failure to Progress: The binational problem of repeat cesarean deliveries among Mexican migrant women in California

Background: Rates of primary cesarean delivery are of concern worldwide. While low rates suggest inadequate access to emergency obstetric services, high rates (above 15%) are considered by the WHO to be excessive. US rates are some of the highest worldwide- close to 30%. Among US Hispanic women, primary cesarean rates are lower (22%), yet repeat cesarean rates are highest of all ethnic groups (90%). Some have suggested that this increased repeat rate may be attributed to the ‘Hispanic paradox', in which migrant women of Hispanic origin, initially healthier in terms of birth outcomes upon arrival to the US, over time adopt the cultural lifestyle risks more prevalent in the US. We sought to examine the validity of this claim for Mexican-origin women. In particular, we examined cesarean history and medical records access for Mexican migrant women who might otherwise be eligible for a vaginal birth after cesarean (VBAC). Medical records documenting previous cesarean incision is mandatory in California, as a vertical uterine incision, although rare (and often not visible on the outside) could rupture during labor with serious adverse consequences, and prohibits attempted VBAC.

Methods: We selected 3 safety net clinics in two California counties with large Mexican migrant populations (Sonoma and Monterey County), that had VBAC available under Medi-Cal. Chart review was completed for all entering prenatal patients between August, 2003 and February, 2004 to determine: previous deliveries and location, cesarean delivery details, age, ethnicity, birthplace, and whether or not medical records had been requested for previous cesareans and if obtained. Analysis was restricted to Hispanic women with previous birth histories.

Results: 634 charts with complete data were abstracted (96%) with 355 Hispanic women with previous birth history identified. 33% had a previous cesarean. Women with cesarean were not significantly older than women with vaginal birth histories (62% <30years, vs 69%), and had not been in the US for longer. Over half (54%) of women with cesarean histories also had previous vaginal birth histories and women with cesarean deliveries in Mexico (43%) did not have Mexican medical records requested or received. 74% of women with cesarean histories, had only one cesarean and would otherwise be eligible for VBAC, pending confirmation of uterine incision type.

Conclusions: Mexican migrant women in California are at risk for repeat cesarean despite young age and previous vaginal birth history. Limited medical records access prevents Mexican women in the US from attempting VBAC.