Increased Primary Cesarean Births Among People with Epilepsy: A Population-Based Cohort Study

OBJECTIVE: Pregnant people with epilepsy are at increased risk of severe maternal morbidity (SMM). Cesarean birth is a known contributor to SMM; however, the factors driving cesarean rates in this population remain poorly understood. We evaluated whether primary cesarean births were increased among nulliparous, term, singleton, vertex (NTSV) live births in people with epilepsy and whether differences were explained by sociodemographic, clinical, or hospital factors. MATERIALS AND METHODS: (ICD-10-CM) diagnosis codes were used to identify those with epilepsy, including subcategories of epilepsy (generalized, focal, and unspecified). Risk ratios (RRs) estimated the association between epilepsy subtypes and primary cesarean birth, adjusting for potential confounders. RESULTS: Of 1,550,586 NTSV births, 5,027 (0.3%) were among people with epilepsy. People with epilepsy had a higher risk of cesarean birth than people without epilepsy (32.1% versus 26.6%, RR: 1.21; 95% confidence interval [CI]: 1.16-1.25). After sequentially adjusting for sociodemographic, clinical, and hospital factors, the significant increase in cesarean birth among people with epilepsy persisted (aRR: 1.18; 95% CI: 1.13-1.23). When stratified by epilepsy type, the risk of cesarean birth was increased for people with unspecified epilepsies (aRR: 1.18; 95% CI: 1.13-1.23), which was the largest subgroup. CONCLUSIONS: The risk of NTSV cesarean birth was increased in people with epilepsy and was not explained by the measured sociodemographic, clinical, and hospital characteristics, suggesting that other unmeasured factors may be contributing. Understanding these factors is crucial for developing targeted strategies to safely reduce cesarean births and potentially improve maternal outcomes in people with epilepsy.