Journal of Perinatology (2012) 32, 260264

r 2012 Nature America, Inc. All rights reserved. 0743-8346/12

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ORIGINAL ARTICLE

Racial and ethnic differences in the prevalence of placenta previa

LH Kim1, AB Caughey2, JC Laguardia3 and GJ Escobar3
1

Department of Obstetrics, Gynecology & Reproductive, Sciences, University of California, San Francisco, CA, USA; 2Department of
Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA and 3The Kaiser Permanente Division of Research,
Oakland, CA, USA

Objective: The objective of this study is to determine the prevalence

of placenta previa among different racial and ethnic groups.

Study Design: We conducted a retrospective cohort study to examine the

prevalence of placenta previa among five major racial and ethnic groups:
African American, Asian, Caucasian, Hispanic and Native American.
We included all deliveries X20 weeks gestation from a large northern
Californian Health Maintenance Organization from 19952006.
A multivariable logistic regression model was used to control for potential
confounders.
Result: Of the 394 083 deliveries in our cohort, 1580 (0.40%) were
complicated by placenta previa. The prevalence of placenta previa was: Asian
0.64%, Native American 0.60%, African American 0.44%, Caucasian 0.36%,
Hispanic 0.34% and unknown 0.31% (P<0.001). In our multivariable logistic
regression model, only Asians (odds ratio (OR) 1.73, 95% confidence intervals
(CI) 1.531.95) and African Americans (OR 1.43, 95% CI 1.191.72) were at
increased risk for having placenta previa, compared with Caucasians.
Conclusion: Asian women have the highest prevalence of placenta previa.
Journal of Perinatology (2012) 32, 260264; doi:10.1038/jp.2011.86;
published online 30 June 2011
Keywords: placenta previa; race and ethnicity; risk factors

Introduction
Placenta previa, in which the placenta completely or partially
covers the cervix, complicates approximately four out of every
1000 pregnancies.1 The presence of a placenta previa requires a
cesarean delivery and is potentially life-threatening, with
significantly associated maternal and neonatal morbidity related
to maternal hemorrhage and preterm birth.26 It also increases
the risk of placenta accreta, especially in the setting of prior
cesarean delivery.7
Correspondence: Dr LH Kim, Department of Obstetrics, Gynecology & Reproductive Sciences,
University of California, 505 Parnassus, Room 1495B, Box 0132, San Francisco, CA 941430132, USA.
E-mail: kimlh@obgyn.ucsf.edu
Received 10 January 2011; revised 27 April 2011; accepted 25 May 2011; published online
30 June 2011

Known risk factors for placenta previa include advancing

maternal age, multiparity, assisted reproductive technology,
multiple gestation, prior cesarean delivery, prior abortion and
tobacco use.813 However, there is conflicting data regarding
whether specific racial or ethnic groups are associated with an
increased risk for placenta previa and the biologic plausibility
of such an association is unclear. Several studies have found an
increased risk of placenta previa among Asian women compared
with Caucasian women,1416 and among African-American and/or
other minority women pooled into a mixed group than for
Caucasian women.2,8,13,16 18 In contrast, other studies failed to
show a relationship between maternal race and placenta
previa.8,9,11,19 23 The two largest studies to date on race and
placenta previa were population-based retrospective cohort studies
with data derived from US national databases, and although
both agreed that Asian women had a higher risk of placenta
previa compared with Caucasian women, they reached
opposite conclusions regarding African-American women.15,16
(See Appendix 1, Supplementary Information, for a summary of
the literature.)
Given these discrepancies in the literature regarding the
relationship between maternal race and placenta previa, we sought
to determine the prevalence of placenta previa stratified by race
and ethnicity, using a large northern Californian Health
Maintenance Organization birth cohort from 1995 to 2006, and to
identify whether any of the five major racial and ethnic groups
studied (African American, Asian, Caucasian, Hispanic and Native
American) were associated with an increased risk of placenta previa.
Methods
We conducted a retrospective cohort study of all women who
delivered from 1995 to 2006 at Kaiser Permanente of northern
California, a large Health Maintenance Organization. We included
all deliveries X20 weeks gestation and compared the
characteristics of women with pregnancies complicated by placenta
previa to those without placenta previa. The Kaiser Permanente
Institutional Review Board approved this study. We analyzed all
data using Stata statistical software version 7.1 (StataCorp, College
Station, TX, USA).

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261

We defined placenta previa as the complete or partial

covering of the cervix by the placenta. First, we identified women
with placenta previa by ICD-9 code and included them in the
study if they had a cesarean delivery. Second, a board certified
obstetrician, who was blinded to the race and ethnicity of the
patients, personally confirmed the diagnosis of placenta previa by
individual chart review. We considered the diagnosis of placenta
previa to be correct if there was a follow-up third trimester
ultrasound showing persistent placenta previa and/or written
documentation in the hospital chart confirming the presence
of placenta previa at the time of cesarean delivery. In order to
confirm that Kaiser Permanente did not underreport the diagnosis
of placenta previa, we also conducted a chart review of a random
selection of 240 cesarean deliveries that did not have an ICD-9 code
for placenta previa.
Patients self-reported their racial and ethnic identification
and we abstracted the data from the Kaiser Permanente Northern
California electronic records. We categorized race and ethnicity
into five major groups: African American, Asian, Caucasian,
Hispanic and Native American. If a patient did not report a racial
or ethnic group, or if a particular racial or ethnic group did not
fall into one of these five major categories, we listed it as
unknown.
We compared the prevalence of placenta previa for each
of these five major racial and ethnic groups using the Pearson
w2-test. We also stratified the prevalence of placenta previa among
women with twin pregnancies and among women with a history
of cesarean delivery by racial/ethnic categories using the Pearson
w2-test. We further examined the prevalence of placenta previa
by maternal age from 17 to 45 years using the Pearson w2-test.
In order to estimate the unadjusted and adjusted odds ratios
(OR) of having a pregnancy complicated by placenta
previa with 95% confidence intervals (CI), we performed
both bivariate and multivariable logistic regression analyses.
In the multivariable model, we controlled for maternal
race/ethnicity (reference group was Caucasian), maternal age
(reference age of 2029), multiple gestation (reference group
was singleton gestation) and prior cesarean delivery (reference
group was no history of cesarean).

Results
We included 394 083 deliveries in our cohort for the period of
1995-2006. Of these deliveries, we confirmed that 1580 pregnancies
were complicated by placenta previa with an overall prevalence
of 0.40% (Table 1). The overall cesarean delivery rate among the
entire cohort was 20.8%, and all women with a placenta previa
underwent a cesarean delivery. Table 1 shows comparisons of
characteristics between the major racial/ethnic groups, as well as
for the entire cohort.
From a random chart review of 240 cesarean deliveries
without an ICD-9 code for placenta previa, we found that there
were no cases of unreported placenta previa. The upper confidence
for 0% with a sample size of 240 is four cases. Assuming there
were four cases of a missed diagnosis of placenta previa,
the sensitivity of a placenta previa diagnosis in this study is
99.70% (95% CI 99.3599.90%), and the specificity is 99.77%
(95% CI 99.7699.79%).
We also compared the following characteristics of the
1580 women with placenta previa to the 392 503 women
without placenta previa (see Appendix 2, Supplementary
Information, for a summary of this comparison). Both groups
of women were racially diverse. Among the women with a
placenta previa compared with no previa, 8.6 versus 7.9% were
African American, 27.6 versus 17.3% Asian, 38.6 versus
43.4% Caucasian, 9.8 versus 11.7% Hispanic, 0.6 versus 0.4% Native
American and 14.8 versus 19.3% unknown (P<0.001).
Women with a placenta previa were older compared with their
non-previa counterparts, with a mean age of 33.55.4 s.d. versus
29.46.0 s.d. More women with a placenta previa had a history of
cesarean delivery, compared with women without previa, 21.5
versus 11.2% (P<0.001). Also, more women with a placenta
previa compared with no previa had a current multiple gestation,
4.9 versus 3.0% (P<0.001).
The percent prevalence of placenta previa by race and ethnicity
were as follows: African American 0.44%, Asian 0.64%, Caucasian
0.36%, Hispanic 0.34%, Native American 0.60% and unknown
0.31% (P<0.001). We further stratified our data by maternal age
group categories. As expected, we found a universal rise in the
prevalence of placenta previa by increasing maternal age for each

Table 1 Demographics by race and ethnicity

N (%)a
Mean ages.d.
Prior cesarean N (%)b
Multiple gestation N (%)b
Placenta previa N (%)b
a
b

African American

Asian

Caucasian

Hispanic

Native American

Unknown

Total cohort

30 951 (7.9)
27.66.6
4123 (13.3)
1208 (3.9)
136 (0.44)

68 333 (17.3)
30.75.4
7120 (10.4)
1675 (2.5)
437 (0.64)

171 168 (43.4)

29.76.0
18 456 (10.8)
6055 (3.5)
610 (0.36)

46 170 (11.7)
28.16.0
5869 (12.7)
1064 (2.3)
155 (0.34)

1489 (0.4)
28.75.9
177 (11.9)
49 (3.3)
9 (0.60)

75 972 (19.3)
28.56.1
8424 (11.1)
1956 (2.6)
233 (0.31)

394 083 (100)

29.46.1
44 169 (11.2)
12 007 (3.0)
1580 (0.40)

Percents calculated based on total cohort.

Percents calculated based on the N for each column.
Journal of Perinatology

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262

of the major racial/ethnic groups. We also stratified our cohort by

multiple gestation and history of cesarean delivery (Figure 1).
With respect to twins, we found that there were no cases of placenta
previa among African-American women (0/1170, P 0.021),
whereas Asian women had the highest prevalence of previa in twins
of 1.37% (22/1609, P<0.001). Asian women again had the highest
prevalence of placenta previa, 1.1% (79/7120, P<0.001), among
women with a prior cesarean delivery.
Increasing maternal age was associated with progressively
higher rates of placenta previa (Figure 2). When compared with a
baseline age group of 2029 years, women older than a threshold
of 30 years had progressively higher significant OR of a pregnancy
complicated by placenta previa, whereas the opposite was true for
women under 20 years old (Table 2).
In our multivariable logistic regression model, only Asians
(OR 1.73, P<0.001) and African Americans (OR 1.43, P<0.001)

Figure 1 Prevalence of placenta previa by race and ethnicity. Prevalence

of placenta previa stratified by maternal race/ethnicity among women with
twin pregnancies and a history of prior cesarean delivery, Kaiser Permanente
of Northern California birth record data, 19952006.

had a significant adjusted OR for having placenta previa,

compared with Caucasians when controlling for the confounders
of maternal age, multiple gestation and prior cesarean delivery
(Table 2). We calculated the area under the receiver operator
characteristic (AUROC, or c-statistic) to depict model
discrimination (a c-statistic 0.5 shows that results are completely
random, whereas a c-statistic 1.0 indicates perfect
discrimination). The c-statistic of our multivariable model is 0.69.
To test the goodness-of-fit between observed and expected outcomes
in our multivariable model, we used the HosmerLemeshow
technique (a P-value >0.005 is consistent with no significant
difference between the observed and expected values, meaning that
the model fit is acceptable, with a higher P-value indicating a
better goodness-of-fit). The HosmerLemeshow corresponding
P-value for our model is 0.49.
We also calculated the relative contribution of each variable in
the logistic regression model to the odds of having a placenta
previa and found that maternal age had the greatest contribution
(75.2%), followed by maternal race/ethnicity (13.2%), history of
cesarean delivery (10.3%) and current multiple gestation (1.3%).
To assess differences in neonatal outcome by race and ethnicity
among the cohort of women with a placenta previa, we calculated
the rates of preterm delivery <37 weeks, as well as composite
neonatal morbidity (consisting of respiratory distress syndrome,
necrotizing enterocolitis, intraventricular hemorrhage and/or
sepsis). The percent of women with a placenta previa, who
experienced preterm delivery <37 weeks for each race and ethnicity
were: African American 39%, Asian 47%, Caucasian 46%, Hispanic
35%, Native American 78% and unknown 55% (P<0.001).
The percent of women by race and ethnicity with a placenta previa,
who had at least one of the components of our composite neonatal

Table 2 Risk of placenta previa

Figure 2 Prevalence of placenta previa by maternal age. Prevalence of placenta

previa stratified by maternal age, Kaiser Permanente of Northern California birth
record data, 19952006. The prevalence of placenta previa for the entire cohort
(N 394 083) is 0.4%. Women over the age of 30 years have an increasingly
higher rate of placenta previa above that of the baseline cohort.
Journal of Perinatology

Category

ORa

95% CI

aORb

95% CI

African-American
Asian
Hispanic
Native American
Unknown race
Prior cesarean
Multiple gestation
Age <20
Age 3039
Age >40

1.10
1.83
0.77
1.51
0.73
2.18
1.49
0.09
2.07
3.39

0.921.31
1.642.04
0.680.88
0.782.92
0.630.84
1.932.46
1.211.85
0.050.18
1.872.29
2.933.91

1.43
1.73
1.10
1.88
0.93
1.73
1.45
0.21
2.56
5.48

1.191.72
1.531.95
0.951.27
0.973.64
0.791.09
1.531.95
1.161.83
0.110.41
2.262.90
4.626.52

Abbreviations: OR, odds ratio; CI, confidence interval.

a
Unadjusted OR.
b
Adjusted OR; controlled for maternal race/ethnicity, prior cesarean delivery, multiple
gestation and maternal age. Multivariable logistic regression model area under receiver
operator curve (c-statistic) 0.6927 and HosmerLemeshow corresponding
P-value 0.488.

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morbidity were: African American 10%, Asian 8%, Caucasian 14%,

Hispanic 9%, Native American 33% and unknown 11%
(P 0.011).
Discussion
Our large retrospective cohort study that included 1580 women
with placenta previa shows that Asian women, followed by
African-American women, had a higher prevalence of placenta
previa than Caucasian women. When controlling for potential
confounders such as maternal age, multiple gestation and prior
cesarean delivery, Asian and African-American women were still
significantly more likely to have a pregnancy complicated by
placenta previa, compared with Caucasian women.
Novel to the literature on placenta previa, we report differences
in neonatal outcomes by race and ethnicity. Interestingly, African
Americans with a placenta previa had lower rates of preterm
delivery than Caucasians or Asians. This is in contrast to the
fact that African Americans have higher preterm delivery rates
overall, compared with other racial/ethnic groups.24 In our study,
African-American women with placenta previa also had less
neonatal morbidity than their Caucasian and Asian counterparts.
Native Americans had the highest rates of preterm delivery and
poor neonatal outcomes among the women with placenta previa.
Our study highlights the need for more research in health
disparities with special attention to Native Americans as a high-risk
population.
The relationship we found between Asian race and increased
risk of placenta previa is consistent with three prior studies.1416
Taylor et al.14 conducted a smaller casecontrol study
of 810 women with placenta previa, using the Washington State
birth certificate data, but only reported data on Asian and
Caucasian women and showed a lower overall prevalence
of placenta previa (3.3/1000), compared with our study (4/1000).
The studies by Yang et al.15 and Shen et al.16 were larger
retrospective cohort studies using the US national-linked
birth/infant mortality database and the National Inpatient Sample,
respectively. However, the Yang et al.15 study was limited by
the absence of a Hispanic ethnic category, and their results differed
from ours in that they showed African-American women had a
lower frequency of placenta previa (3.0/1000) then Caucasian
women (3.3/1000), compared with our study which found
African-American women had a higher frequency of placenta
previa (4.4/1000) compared with Caucasian women (3.6/1000).
Although the Shen et al.16 study did include Hispanic women,
as did our study, they reported that African-American women
were at a higher risk of placenta previa then Asian women, in
contrast to our result that Asian women had the highest risk of
placenta previa followed by African-American women. Furthermore,
the overall lower prevalence of placenta previa in the Taylor et al.14
and Yang et al.15 studies suggest that the information they

derived from birth certificate data may have underreported

placenta previa.
The relationship between race and ethnicity and the
development of placenta previa is poorly understood. The
pathophysiology of placenta previa may be multifactorial
and explained by a combination of genetic, cultural and
socioeconomic factors. One proposed mechanism of placenta previa
is abnormal placentation due to prior endometrial or myometrial
damage such as in the setting of a previous cesarean delivery,
myomectomy or abortion. Other proposed theories include
the failure of normal placental migration away from the cervical
os during gestation, poor uteroplacental perfusion as seen with
tobacco use and increased placental surface area as in the
setting of multiple gestation.14 Research is needed to elucidate the
genetic and non-genetic reasons why Asian and African-American
women are at an increased risk of placenta previa.
One of the strengths of our study is its large size, with a
sufficiently diverse population to be able to detect significant
differences in the prevalence of placenta previa by racial and
ethnic subgroups. The validity of our data is strong in that each
diagnosis of placenta previa was confirmed with a chart review by
a board certified obstetrician who was blinded to race and ethnicity,
and that the random chart review of cesarean deliveries without
a placenta previa ICD-9 code did not reveal any cases of unreported
placenta previa. An additional strength of our study is that we had
adequate medical information to control for important confounders
such as prior cesarean delivery, maternal age and multiple gestation.
Our study is also unique in that we differentiated between
the major racial and ethnic groups, whereas numerous previous
studies either grouped Asian and African-American women together
in an umbrella minority group,2,17,23 or combined non-Caucasian
non-African-American women into one category.8,11,13,18,21,22
Other studies failed to include a separate category for Asian17 or
Hispanic women,15 or had limited comparisons of only Asian
and Caucasian women, but not African-American or Hispanic
women.14 (See Appendix 1, Supplementary Information, for a
summary of the literature).
Asian Americans are a heterogeneous group with significant
differences in perinatal outcomes.25 However, because we lacked
information on the country of origin among Asians in our cohort,
we were unable to assess whether the associated risk of placenta
previa varied by sub-categories of Asian country of origin. We were
also limited in our data analysis by a lack of information regarding
parity, history of spontaneous and/or induced abortion and tobacco
use, all of which have been identified as risk factors for placenta
previa.9,1113 We were therefore unable to control for these
potential confounders in our logistic regression model. Despite this,
the c-statistic of our multivariable model (0.69) is relatively high,
given the limitations of our predictors. Furthermore, we were
limited by the inability to demonstrate causality due to the
retrospective cohort study design.
Journal of Perinatology

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264

In conclusion, we found that Asian women, followed by

African-American women, have a significantly increased risk of
pregnancy complicated by placenta previa, compared with
Caucasian women. Based on these results, we suggest that
clinicians should have a higher index of suspicion for placenta
previa in these racial groups and must exclude its presence with
detailed antenatal ultrasound evaluation. Furthermore, these
results may help inform future research of possible genetic and
health disparities-related contributions to the etiology of placenta
previa (Supplementary Information).
Conflict of interest
The authors declare no conflict of interest.
Acknowledgment
This study was supported by Kaiser Foundation Research Institute Community
Benefits Grant.

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