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U.S. rates of cesarean section, and in particular, low-risk cesarean section (LRC) births rose dramatically across the late 1990s and early 2000s, and have since remained high. Although previous research explores how trends in LRC vary between states and across maternal characteristics, within-state heterogeneity has not yet been accounted for, nor has the extent to which maternal and county characteristics might interact to shape the likelihood of a LRC birth. Using U.S. county-level birth data for years 2008–2010 from the restricted National Vital Statistics Systems Cohort Linked Birth-Infant Death Files and the Area Health Resource Files, I conduct race-stratified multilevel analyses to explore the association between the mother’s education, the income of the county in which she gives birth, and the odds of LRC delivery. I find that regardless of race/ethnicity, less education at the individual level and lower income at the county level are associated with higher odds of LRC delivery. There are also persistent racial disparities in these relationships. Non-Hispanic black mothers have the highest overall odds of LRC delivery, yet the effect of both education and county income is greatest for non-Hispanic white mothers. The results highlight the importance of analyzing both individual resources and contextual effects of the county when assessing birthing processes, as both contribute to a mother’s access to and knowledge of natal care.

Original publication




Journal article


Population Research and Policy Review

Publication Date





117 - 135