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Soc Sci Med. Author manuscript; available in PMC 2022 November 01.
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Published in final edited form as:

Soc Sci Med. 2021 November ; 289: 114406. doi:10.1016/j.socscimed.2021.114406.

State-level structural sexism and cesarean sections in the

United States
Amanda Nagle, MPH*,
Goleen Samari, PhD, MPH, MA
Department of Population and Family Health, Mailman School of Public Health, Columbia
University, 722 W 168th St, New York, NY, 10032, USA
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Abstract
The United States (U.S.) has one of the highest cesarean rates in the world yet little research
considers structural factors, like racism and sexism, associated with the higher than recommended
cesarean rate. New research operationalizes and quantifies structural sexism across U.S. states,
which allows for consideration of how social norms and values around women and their bodies
relate to the overmedicalization of birth through cesarean sections. We obtained restricted natality
data for 2018 from the U.S. National Center for Health Statistics. In 2018, among people 15–49
years, 987,187 births fit the criteria for low-risk of cesarean section. Structural sexism scores
were derived from 6 elements covering economic, political, cultural, and physical arenas that were
totaled and standardized to create an aggregate index for each state and DC (scores range from
−1.06 to 1.4). Using multivariable logistic and multilevel mixed effects logistic regression models,
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we examined the associations between structural sexism and low-risk cesarean section for all fifty
states and the District of Columbia, controlling for relevant confounders. We found that structural
sexism in 2018 was highest in historically religious mountain states and the South. Nationally, the
low-risk cesarean rate was 25.1%. Multilevel models show that people living in states with higher
structural sexism scores were more likely to have a cesarean section (OR = 1.22, 95% CI: 1.07–
1.39). Structural sexism is related to low-risk cesarean rates in U.S., providing evidence that social
ideas and norms about women and their bodies are related to overmedicalization of birth. Health
policymakers, providers and scholars should pay attention to structural drivers, including structural
sexism, as a factor that affects overmedicalization of birth and subsequent health outcomes for
pregnant people and their infants.
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Keywords
Structural sexism; Sexism; Cesarean section; Overmedicalization; Obstetric violence

*
Corresponding author. acn2138@cumc.columbia.edu (A. Nagle).
Declaration of competing interest
None.
Credit author statement
Amanda Nagle: Conceptualization; Data curation; Formal analysis; Software; Visualization; Roles/Writing - original draft; Goleen
Samari: Methodology; Writing - review & editing; Supervising. AN conceptualized the study, conducted the analyses, and drafted the
results and original manuscript. GS guided the methodological approach, reviewed and revised the draft, and supervised the study.
Both authors contributed to the writing and approved of the final draft.
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1. Introduction
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Overmedicalization of birth is a concern in the U.S. and around the world (Kukura, 2018;
Sadler et al., 2016). Definitions of “natural” and “medical” birth vary and incorporate birth
setting, control exerted by the birthing person, and specific medical procedures (Brubaker
and Dillaway, 2009). Social science research on the medicalization of birth goes back
forty years (Brubaker and Dillaway, 2009; Clesse et al., 2018; Riessman, 1983), and recent
research has focused on interventions that are non-medically indicated or non-evidence
based, defined here as overmedicalization. These interventions include induction of labor,
routine episiotomies, use of forceps, and the excessive use of cesarean sections (C-sections)
(Borges, 2018; Kukura, 2018; Sadler et al., 2016).

C-section is one of the most common birth interventions and it is often preformed on
healthy women with little to no justification (Sadler et al., 2016). C-sections may pose
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risks to the delivering person and the neonate. They are associated with higher risks
of hemorrhage, infection, and blood clots to the delivering person than vaginal delivery
(Gregory et al., 2012), and with neonatal respiratory problems and neonatal intensive care
(NICU) admissions (Teitler et al., 2019). This study focuses on overmedicalization through
cesarean section as a subset of the medicalized birth experience.

In the United States in 2018, the overall (includes first and second) C-section rate was 32%
(J. Martin et al., 2019). This is higher than the overall rate of 28% in OECD countries in
2017. However, rates in OECD countries have also been increasing, up from 20% in 2000
(OECD, 2019). In the U.S., improvements in neonatal and infant morbidity and mortality
were seen in the initial rise of C-sections, but C-sections have not continued to demonstrate
an improvement in infant health since 2006 (Teitler et al., 2019). The WHO considers 10%–
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15% to be ideal C-section rate as maternal and infant mortality improvements are seen when
rates are below 10%, but not above (World Health Organization, 2015).

Recent research has explored why these rates around the world have increased and
remained so high, focusing on factors including medical conditions (Chu et al., 2007;
Main et al., 2011), sociodemographic characteristics of patients (Gould et al., 2010), patient
preferences (McCourt et al., 2007), facility practices and provider preferences (Bates,
1994). However, much of this work is focused on individual preferences and interpersonal
dynamics and few studies consider macro or structural factors. Researchers from the
fields of feminism, midwifery, sociology, and medicine have found that technological
developments, sociological, cultural, political, and professional factors have contributed to
medicalized birth as generalized in U.S. society. Accordingly, it has been recommended that
medicalization and population C-section rates be examined at the macro level and through
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structural factors. (Clesse et al., 2018).

1.1. Structural factors and obstetric violence

The literature on obstetric violence provides an important framework for how structural
factors may be at play and how societal values drive up medicalization of birth, and in
particular, C-section rates. The term “obstetric violence” was first formally defined in
Venezuela as “the appropriation of women’s body and reproductive processes by health

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personnel, which is expressed by a dehumanizing treatment, an abuse of medicalization

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and pathologizing of natural processes, resulting in a loss of autonomy and ability to

decide freely about their bodies and sexuality, negatively impacting their quality of life”
(Sadler et al., 2016). This definition includes delays in providing care, denial of pain
medication, overly restrictive birthing position requirements, unconsented episiotomy, and
unconsented caesarean section. Obstetric violence is also a consequence of structural
violence (Miltenburg et al., 2018; Sadler et al., 2016). Miltenburg et al. (2018) views
violence towards women in health facilities as a consequence of women’s lives not being
valued by social, economic, and political structures. Violence against women stems from
structural gender inequity (Jewkes and Penn-Kekana, 2015), and obstetric violence is in fact
one of the most invisible forms of violence against women (Sadler et al., 2016). Patriarchal
views that devalue reproductive labor and pathologize birth are cultural attitudes about
women’s bodies that have been linked to overmedicalization of birth (Kukura, 2018).
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While there is no estimate of the prevalence of obstetric violence in the U.S. (Kukura,
2018), women report forced or coerced cesarean sections, forced or coerced episiotomies,
unconsented medical procedures, sexual violation, physical constraint, and disrespect
(Borges, 2018; Kukura, 2018). The high rate of C-section in the U.S. is due in part to
force and coercion from medical staff (Kukura, 2018; Morris and Robinson, 2017). In
2013, a study of people who had recently given birth found that 25% who had experienced
induction of labor or a caesarean section reported being pressured by their care provider to
consent to treatment (Kukura, 2018). Overmedicalization is also due, in part, to C-sections
that are recommended by health care providers for reasons other than medical necessity
and are consented to by patients. Physician community norms, financial incentives, medical
technology, physician personal religious and personal ideology on fetal protection, and
avoidance of malpractice suits influence physicians’ recommendations for C-sections (Bates,
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1994). Finally, there is evidence that some pregnant people prefer and request C-sections
(McCourt et al., 2007). These decisions and ideas about birth should also be understood to
be influenced by social norms about women’s bodies, since birthing people can internalize
gender in ways that affect birth behavior (K. Martin, 2003).

1.2. Structural sexism and overmedicalized birth

Social norms about women are often rooted in sexism or systematic gender inequality which
can be perpetrated by individuals and institutions without awareness or intent (Swim and
Cohen, 1997). Following the structural racism literature, new research on structural sexism
defines and operationalizes systematic gender inequality in power and resources at the
macro, meso, and micro levels (Homan, 2019). This multilevel approach aligns with the
socioecological model by considering the societies in which women live, their experiences
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interacting with others in their communities, providers, and families, and their individual
attitudes and physiological processes. Gender and sexism operate at the micro or individual
level through mechanisms like internalized sexism. The meso level of structural sexism
is often characterized by discriminatory or stigmatizing interactions between individuals.
At the macro level, sexism is institutional discrimination and systemic power imbalance
(Homan, 2019).

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Sexism at the macro level is conceptualized as gender inequality in power and resources
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favoring men within political, economic, and cultural institutions (Homan, 2019). Thus,
structural sexism is measured through the gender differences in power and resources within
various aspects of life, including legislative representation, earnings, etc. In the aggregate,
this captures gender inequities. Exposure to sexism at the macro level is associated with
more chronic conditions, worse self-rated health, and worse physical functioning (Homan,
2019). Macro-level gender equity has generally been found to be related to better health
in men and women (King et al., 2020). These findings align with prior social determinants
of health research which has found that structural and institutional discrimination towards
lesbian, gay, and bisexual Americans, towards Black Americans, and towards ethnic
minorities is associated with worse health outcomes (Hatzenbuehler, 2017). Furthermore, the
feminist discourse on rising cesarean rates centers on its relation to patriarchally structured
society (Lee and Kirkman, 2008). By providing a means of operationalizing patriarchal
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social systems and given the connection to other poor health outcomes, structural sexism
could be a relevant driver of overmedicalization of birth since it is linked to social views and
norms of women and their bodies.

Health system factors also play a role in overmedicalization of birth, particularly

through cesarean deliveries. Medical workforce shortages and maldistribution may lead to
overmedicalization of birth, including cesarean sections and inductions of labor (Mincer,
2017). Additionally, lack of access to nearby hospital based obstetric care can result in an
increase non-indicated cesarean sections (National Advisory Committee on Rural Health
and Human Services, 2020). There is evidence that health systems are not indifferent to
financial incentives, and the likelihood of receiving a C-section has been found to be related
to expected hospital fee reimbursement (Hoxha et al., 2017). These systemic factors can be
viewed as part of a patriarchal society that does not value women’s reproductive processes,
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as these factors can be linked to a lack of public investment in obstetric care and health
insurance for women of reproductive age (National Advisory Committee on Rural Health
and Human Services, 2020).

When women, their bodies, and reproductive labor are not valued, laboring people are
vulnerable to being deprioritized during the birth process. Physicians’ preferences, such
as for quicker schedulable deliveries, and risks, such as for a malpractice suit, are often
prioritized over the desires and best interests of women (Bates, 1994; Morris and Robinson,
2017). As discussed in relation to obstetric violence, coercion by medical providers to obtain
consent for a cesarian, or preforming one without consent, is a form of controlling women
and their bodies. The power relationship between medical staff and laboring people can
be one of hegemonic dominance that mirrors the male dominance of society (Jewkes and
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Penn-Kekana, 2015). Conflict between patients and providers around birth medicalization
can arise from physicians not respecting women’s choices and decision-making capacity,
and over valuing their own opinion of what labor and delivery should look like (Kukura,
2018). The socialization of women to be agreeable may also push women themselves to
acquiesce to medical interventions when they are proposed by medical staff, even when they
prefer nonintervention (K. Martin, 2003). Finally, societal values that prioritize fetal health
over the rights and health of mothers may impact the protocols of hospitals and physicians to
favor medical interventions during birth, despite risks to the health of the delivering person

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or their preferences (Bates, 1994). Thus, greater structural sexism may be linked to coerced
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and noncoerced overmedicalization of birth and higher rates of C-section.

Despite a growing literature on structural determinants of health, to date, there are

no empirical studies that examine the relationship between structural sexism and
overmedicalization of birth in the United States. The present study addresses this gap. In
this study, we use national vital statistics data to examine the associations between state
level structural sexism and C-sections for birthing people residing in the United States.
We hypothesize that greater structural sexism is associated with greater rates of C-sections
across states.

2. Methods
2.1. Data
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We obtained restricted limited geography natality data for 2018 from the U.S. National
Center for Health Statistics. These data include comprehensive birth certificate information
from all deliveries in the United States in 2018 as well as information on the state identifiers
for all births. The analysis includes low risk C-sections because certain health conditions
and a history of C-section are linked with C-section on current birth. A low-risk C-section
is defined by the Department of Health and Human Services as a cesarean delivery among
term (37 or more completed weeks), singleton, vertex (head first) births to women giving
birth for the first time (J. Martin et al., 2019). The natality data was subset accordingly
and second births, multiple births, non-vertex births, and premature births were removed.
Records with missing data for the covariates (age, payment type, education level, and race
ethnicity) were also excluded. Of the 3,791,712 births recorded in the U. S. in 2018, 988,678
were singleton, vertex presentation, first births and had non-missing demographic and
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payment type and state of birth information. For comparability with estimates about women
of reproductive age, births to individuals below 15 years of age and above 49 were excluded,
resulting in 987,187 births included in the analysis. This research was determined exempt
from human subjects review because it used aggregate data with de-identified information
that is available upon request.

2.2. Measures
2.2.1. Independent—State-level structural sexism is adapted from Homan (2019) and
the macro level structural sexism measure that considers economic, political, cultural, and
physical policies related to gender inequities. Table 1 lists each element of the structural
sexism score, the source of the data, and the year the data represents.
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The structural sexism measure used in this study is based on the Homan (2019) measure,
using publicly available data. Therefore, one measure varies from the original index:
wage and salary income is used instead of weekly wages. The measure was also updated
to represent 2018 where possible. When 2018 data was unavailable, for religiosity and
reproductive health, the closest available year was used (2014 and 2017 respectively).

For the economic estimates based on American Community Survey, individual responses
were aggregated utilizing annual survey weights to account for complex sampling. State

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values for other measures were available as percentages. Each element of the structural
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sexism score was then standardized, where the mean of the element was calculated and
subtracted from the raw value of each state, resulting in measures with mean of zero.
Standardization allowed for the aggregation of the index elements without giving more
weight to any individual measure. Then all measures were summed to create one structural
sexism score for each state where a higher score represents more structural sexism in the
state. Structural sexism scores for U.S states and DC in 2018 range from −1.06 to 1.4, with a
mean of 0. Table 2 shows summary statistics for the overall structural sexism scores and the
individual measures of the score.

For each measure, a higher value indicates more sexism. Fig. 1 shows the structural sexism
score for each state and DC. Structural sexism is highest in historically religious mountain
states (Utah, and Wyoming), and the South (Oklahoma, Arkansas, Mississippi, Kentucky,
Alabama, and West Virginia).
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2.3. Covariates
Covariates are patient characteristics including age, race and ethnicity, payment type, and
education level achieved. Age is measured as a continuous numeric variable. Race and
ethnicity were measured using the standard Office of Management and Budget categories,
and combined by the National Center for Health Statistics to create a single variable.
Education level was collapsed into 5 categories-no high school diploma, high school
graduate or GED, some college or an associate’s degree, a bachelor’s degree, or a graduate
degree. Payment type is categorized as Medicaid, private insurance, self-pay, or some other
payment type. Race and ethnicity have been found in prior research to be associated with
C-section, particularly for Black women (Davis, 2019; Taylor, 2020). Education level and
payment type are used as proxies for socio-economic status, which has been found to
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be related to C-section rate (Gould et al., 2010). Payment type also has impacts apart
from being a socio-economic status proxy because payment type can influence how much
hospitals can expect to be reimbursed for treatments and procedures, establishing financial
incentives to preform procedures or not to preform them (Hoxha et al., 2017). At the state
level, state urbanicity, operationalized as the percent of the population living in rural areas,
is included as a covariate in this model to control for rural/urban access to obstetric services
issues that may also be related to cesarean section.

2.4. Dependent
The dependent variable under study is whether or not a cesarean section was the method of
delivery. This is an indirect measure of overmedicaization of birth, as this study does not
involve detailed medical records and does not attempt to evaluate the medical necessity for
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the C-section. The measure is used to compare medicalization across states to understand
community influences on medicalization rates.

2.5. Analysis
Descriptive statistics were calculated for all variables. Multivariable logistic regression
models estimate associations between structural sexism and low risk C-sections, while
accounting for relevant covariates. Multivariable, multi-level mixed effects logistic

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regression models estimate associations between low-risk C-sections at level one and state
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level structural sexism at level two, while controlling for relevant covariates. Random
intercepts and slopes for states were included in the multilevel models to account for the
variation across states and state level predictors that may cause states to differ in the effects
of structural sexism. Data cleaning and variable creation were conducted in SAS University
edition. Adapted SAS code from the National Bureau of Economic Research was used to
read the natality data into SAS (Roth, 2017). All subsequent analyses were conducted in
Stata v16 with the binary outcome of C-section.

3. Results
Of the 987,187 low-risk births in the United States in 2018, 247,358 (25.06%) were
delivered by C-section. The majority of birthing people at low-risk of C-section in 2018
identified as white (54%), and 22% identified as Hispanic and 13% as Black (Table 3). Most
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were between 25 and 34 years old (52%), and over 50% had completed some college or
received a college degree. Private insurance (56%) followed by Medicaid (36%) are the most
common payment types.

Rates of C-section vary significantly across these demographic groups (Table 4). Black
women have the highest rate of C-section with 29% of Black birthing people having
C-sections. Patients who self-pay for their labor and delivery care have the lowest rates
of C-section. Rates of C-section increase for each age category, with those 45–49 years of
age having the highest rate at 67%.

Multivariate logistic regression show that structural sexism has a significant positive
relationship with C-section (OR = 1.19, p < 0.001), controlling for age, race and ethnicity,
education level, and payment type (Table 5). For every one-point increase in the structural
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sexism score of pregnant person’s state, they are 19% more likely to receive a C-section,
controlling for confounders.

To account for clustering of observations within states, multilevel models used state
residence to group observations at the second level (Table 6). A model with only C-section
at level one and state at the second level resulted in a statistically significant intraclass
correlation (ICC), demonstrating the appropriateness of a multilevel model. The inclusion of
random slopes for states is supported as the standard deviation of random slopes for states
(0.0668) is just less than twice its standard error (0.0381), suggesting significant state level
variation. In the multilevel model, structural sexism was positively associated with C-section
(OR = 1.22, p < 0.01). An increase of one point of structural sexism is associated with
a 22% increase in odds of C-section. Cross level interactions between race and structural
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sexism were not significant and are not included in the final model. The interaction between
state urbanicity and structural sexism was also not significant and not included in the final
model.

4. Discussion
This study shows a relationship between structural sexism and cesarean sections for birthing
people in the United States. Prior research has shown that structural sexism is associated

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with chronic conditions, worse self-rated health, and worse physical functioning (Homan,
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2019). Early literature on the medicalization of birth focused on the subjective experiences
of birthing people (Davis-Floyd, 1992) and evolved to include interpersonal dynamics with
providers and variations in medical or nonmedical birth settings (Brubaker and Dillaway,
2009). This study expands on such research by layering in and quantifying the macro
structural dynamics and showing a relationship between structural sexism and C-sections,
a measure of overmedicalization of birth. There are important differences in gender equity
across states with implications for overmedicalization of birth, a marker of structural and
obstetric violence.

Providing support for the primary hypothesis, structural sexism is associated with higher
C-section frequency across states. This finding fits with the theoretical framing of
overmedicalization as a symptom of structural violence and sexism towards women and
the devaluation of reproductive labor and processes (Sadler et al., 2016). Results also
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confirm historic theories around birth processes that emphasize incorporation of macro-
social factors as a component of increasing medicalization (Riessman, 1983; Rothman,
1989; Simonds et al., 2007). This study connects structural sexism conceptually and
quantitatively to the high C-section rate in the United States. While the study does not
quantify the prevalence of obstetric violence directly, it connects a root cause of obstetric
violence, sexism, to overmedicalization in the United States. This is an important addition
to the literature because few quantitative studies based in the U.S. have attempted to study
overmedicalization or apply theories of obstetric violence (Kukura, 2018). Our findings
provide further evidence that obstetric violence and overmedicalization arise not only from
individual perceptions (Davis-Floyd, 1992) and interpersonal sexism, but are shaped by
structural drivers. Clinicians and scholars who work to prevent overmedicalization of birth
should consider these structural pathways.
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This study also further demonstrates the utility of structural sexism as a measure in relation
to health outcomes. Gender inequities are often discussed at the micro and meso, or
interpersonal, levels, with less focus on the impact of macro gender-based inequities on
health outcomes. While this body of work finds that gendered interpersonal power dynamics
are relevant to overmedicalization of birth (Baker et al., 2005), this study leverages an
important measure of structural sexism to show macro drivers of C-section rates. This study
also advances the literature on cesarean sections by focusing on community and structural
factors in relation to C-sections. Considering past research on births in the US and around
the world, many other studies examine individual experiences of birth (Davis-Floyd, 1992;
Dillaway and Brubaker, 2008; Lobel and DeLuca, 2007) and cover associations between
individual factors like race, wealthy or income, pregnancy health, or obesity and C-section
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(Chu et al., 2007; Gould et al., 2010; McCourt et al., 2007). Some studies look at health
facility factors (Bates, 1994). One study discusses community factors, but it does not
include any variables in the analysis that quantify or categorize the community level factors
(Leone et al., 2008). This study confirms theoretical work that situates birthing people in
communities with patriarchal systems (Lee and Kirkman, 2008; Simonds et al., 2007) and
extends this previous individual level focused work to empirically show that birthing people
in the United States are subject to systems shaped by structural gender inequities.

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While this study is the first to consider structural sexism and C-sections in the United
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States, there are some limitations. Studying only low cesarean risk pregnancies leaves out
many pregnancies and cesarean deliveries. While pregnancies to people who have already
have cesarean deliveries have a different set of risks and dominant medical practices, repeat
C-sections are also potential overmedicalization worth studying. Additionally, this research
did not involve accessing detailed medical records, and as such, definitions of low-risk and
high-risk are broad categories corresponding to Health and Human Services and the Joint
Commission’s National Quality Core Measures definitions (Osterman and Martin, 2014).
These definitions are general and may not be clinically meaningful. There are many labor
complications that necessitate cesarean section, even in low-risk pregnancies. Accordingly,
the analysis could not comprehensively control for medical necessity of low-risk cesareans
and does not label all low-risk c-sections overmedicalizations. Rather, the study takes a
comparative approach to understand social influences on rates of medicalization across
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communities. This indirect measure is a limitation of this study. This study also examined
important associations between the exposure and outcomes, but in the absence of a quasi-
experimental design, these associations are not necessarily causal and women and providers
can select into states based on unobserved factors. Finally, white women and Black,
Indigenous, women of color do not experience overmedicalization equally, nor do they
experience sexism in the same ways. Structural racism has been theoretically linked to the
heightened C-section rates for black women (Taylor, 2020). In this study, the interactions
between race and structural sexism were not significant, but race is not a measure of
racism. Given the significantly higher C-section rates among Black women, future research
should consider the intersectional dynamics between structural racism and sexism in shaping
overmedicalization of birth.

Future research should also explore associations between structural sexism and other
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medicalization of birth, including episiotomies, induction of labor and vaginal birth after
cesarean (VBAC). Routine episiotomy is no longer routine, and restricted use is related
to better health outcomes (Sadler et al., 2016). The VBAC procedure is becoming more
common (J. Martin et al., 2019) in the U.S and continued cesareans may not be as necessary
or assumed as best care in the future. This study calculates structural sexism at the state
level, but more localized geographies such as cities or counties should also be investigated as
they may differently represent the communities and societies in which women live. Studies
should also consider structural sexism over time, beyond one year, and how changes over
time shape birth outcomes, overmedicalization, and C-section rates.

The National Institute of Child Health and Human Development, the Society for Maternal-
Fetal Medicine, and the American College of Obstetricians and Gynecologists acknowledge
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that overmedicalization of birth is an ongoing risk for pregnant people (Spong et al., 2012).
This study demonstrates that the current climate of structural gender inequities and sexism
in the United States may hinder any efforts to reduce overmedicalization and C-section
rates. This work contributes to prior research on structural measures and health outcomes by
demonstrating that higher state level structural sexism is related to higher C-section rates in
the U.S., evidence that larger structural and societal ideas about women and their bodies are
related to overmedicalization of birth in the US. The trends described in this study suggest

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that social and economic policies that are inequitable for men and women have medical and
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public health implications for pregnant people and infants.

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statement/en/.
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Fig. 1.
Structural sexism in US states and DC, 2018.
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Table 1

Elements of state-level structural sexism.

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Dimension Measure Data Source Year

Economic Ratio of men’s to women’s labor force participation a 2018

American Community Survey
Ratio of men’s to women’s wage and salary income a 2018
American Community Survey
Ratio of women’s to men’s poverty rate (percent below the federal poverty a 2018
line American Community Survey

Political Percent of state legislature seats occupied by men Center for American Women and 2018
Politics
Cultural Percent of state population composed of religious conservatives Pew Research Center 2014
(Evangelical Protestant or LDS)
Physical/ Percent of women who live in a county without an abortion provider Guttmacher Institute 2017
Reproductive

Note.
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a
American Community Survey data was obtained from the University of Minnesota IPUMS.
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Table 2

Summary statistics, structural sexism score among U.S. States and DC (n = 51), 2018
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Mean Std. Dev Min Max

Structural Sexism Score (standardized) 0 0.55 −1.06 1.4

Ratio score measures (pre-standardization)
Ratio men’s to women’s earnings 1.66 0.15 1.31 2.23
Ratio men’s to women’s labor force participation 1.16 0.04 1.03 1.25
Ratio women’s to men’s poverty 1.2 0.07 1.08 1.57
Percent score measures (pre-standardization)
Percent of State Legislature men .74 .08 .60 .89
Percent religious conservatives .28 .12 .10 .62
Percent of women living in a county without an abortion provider .46 .26 0 .96
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Table 3

Characteristics of Persons having Singleton, First Birth, Cephalic Births, 2018 U.S. Vital Statistics Birth
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Records.

Characteristic Total N overall

Age
15–19 years 119797 12.1%
20–24 years 279046 28.3%
25–29 years 285643 28.9%
30–34 years 217230 22.0%
35–39 years 72953 7.4%
40–44 years 11654 1.2%
45–49 years 864 0.1%
Race/Ethnicity
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Non-Hispanic White 531382 53.8%

Non-Hispanic Black 6126024 12.8%
Non-Hispanic Asian 77540 7.9%
Hispanic 220762 22.4%
Non-Hispanic more than one race and other races 31483 3.2%
Education Level
No high school diploma 100223 10.2%
High school graduate or GED 241626 24.5%
Some college credit, or associate degree 265945 26.9%
Bachelor’s degree (BA, AB, BS) 236246 23.9%
Graduate degree 143147 14.5%
Payer Type
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Medicaid 361526 36.6%

Private 548453 55.6%
Self-pay 36961 3.7%
Other 40247 4.1%
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Table 4

Characteristics of Persons having Singleton, First Birth, Cephalic Births, 2018 U.S. Vital Statistics Birth
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Records.

Characteristic Total N Cesarean (%)

Age ***
15–19 years 119797 19264 16.1%
20–24 years 279046 59599 21.4%
25–29 years 285643 71541 25.0%
30–34 years 217230 62684 28.9%
35–39 years 72953 27755 38.0%
40–44 years 11654 5937 50.9%
45–49 years 864 578 66.9%

Race/Ethnicity ***
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Non-Hispanic White 531382 128105 24.1%

Non-Hispanic Black 6126024 36998 26.3%
Non-Hispanic Asian 77540 20823 20.8%
Hispanic 220762 54093 24.5%
Non-Hispanic other races and more than one race 31483 7339 23.2%

Education Level ***

No high school diploma 100223 20002 20.0%
High school graduate or GED 241626 57727 23.9%
Some college credit or associated degree 265945 69867 26.3%
Bachelor’s degree (BA, AB, BS) 236246 61558 26.1%
Graduate degree 143147 38204 26.7%
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Payer Type ***

Medicaid 361526 128105 24.0%
Private 548453 36998 26.3%
Self-pay 36961 20823 21.7%
Other 40247 54093 24.1%

Notes:
***
p < 0.001 according to χ2 tests.
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Table 5

Logistic regression models of cesarean section for registered births to people ages 15 to 49, 2018 U.S. Vital
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statistics birth records.

Cesarean Section

Key Variables OR SE

Structural sexism 1.19*** 0.0057

Age 1.08*** 0.0005

Race/ethnicity (Ref = non-Hispanic white)

Non-Hispanic Black 1.47*** 0.0074

Non-Hispanic Asian 1.06*** 0.0090

Hispanic 1.18*** 0.0064

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Non-Hispanic other races and more than one race 1.11*** 0.014

Payment type (Ref = Medicaid)

Private 0.92*** 0.0062

Self-Pay 0.70*** 0.0138

Other 0.81*** 0.0130

Education (Ref = No high school diploma)

High school graduate or GED 1.05*** 0.0095

Some college credit or associate degree 1.01 0.0098

Bachelor’s degree 0.80*** 0.0109

Graduate Degree 0.72*** 0.0121

Observations 987187
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Notes:
***
p < 0.001.
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Table 6

Multilevel logistic regression models of cesarean section for registered births to people ages 15 to 49, 2018
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U.S. Vital statistics birth records.

Cesarean section

Key Variables OR SE

Structural sexism 1.22** 0.0640

State urbanicity 1.01 0.0023
Age 1.08*** 00005

Race/ethnicity (Ref = non-Hispanic white)

Non-Hispanic Black 1.40*** 0.0076

Non-Hispanic Asian 1.08*** 0.0092

Hispanic 1.18*** 0.0068

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Non-Hispanic other races and more than one race 1.17*** 0.0142

Payment type (Ref = Medicaid)

Private 0.94*** 0.0063

Self-pay 0.70*** 0.0139

Other 0.84*** 0.0131

Education (Ref = No high school diploma)

High school graduate or GED 1.05*** 0.0096

Some college credit or associate degree 1.02 0.0098

Bachelor’s degree 0.80*** 0.0110

Graduate Degree 0.71*** 0.0121

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Observations 987,187
Variance at Level 1 (Individual Level) .0110
Variance at Level 2 (Structural Sexism Score) .0653

Notes:
*
p < 0.05
***
p < 0.01
***
p < 0.001.
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