The Unjust Disparity in C-Section Rates Among Black Women

<blockquote> <h3>Fast Facts: </h3> <ul> <li>Black women have a 53% increased risk of dying in the hospital during childbirth, independent of income level, type of insurance, or other social determinants of health. </li> <li>One of the most compelling pieces of evidence that this country’s maternal health care is steeped knee deep in racism is the rate of Cesarean section (C-section) deliveries among pregnant Black women.</li> <li>From 2018 to 2020, 35.8% of Black infants in the U.S. were born by C-section compared to the 30.9% of white infants, according to the March of Dimes, a non-profit organization focused on maternal and infant health.</li> <li>According to a study published in the January 2022 issue of <em>Obstetrics and Gynecology</em>, first-time, healthy pregnant Black and Hispanic women were 21% and 26%, respectively, more likely than white women to deliver by C-section despite being low risk and with limited medical or obstetric explanation.</li> </ul> </blockquote> <p>Pregnant women in the United States live in two different realities: being pregnant as a Black woman and being pregnant as a white woman. A Black pregnant woman may go to the same hospital with the same health history and see the exact same doctors and nurses as a white pregnant woman, and yet receive maternal care equivalent to that available in developing countries.</p> <p>This may sound like an exaggeration, but unfortunately, it’s not. The maternal mortality rate in the United States alone is one of the most compelling pieces of evidence that the American healthcare system runs on racism.</p> <p>According to the Centers for Disease Control and Prevention (CDC), in 2020 the maternal mortality rate for non-Hispanic Black women was 55.3 deaths per 100,000 live births, 2.9 times the rate for non-Hispanic white women. The higher rate of maternal mortality rate among Black women than white women is independent of education level, yearly income, insurance coverage plan, and other social determinants of health. </p> <p>The next most compelling piece of evidence that this country’s maternal health care is steeped knee deep in racism is the rate of Cesarean section (C-section) deliveries among pregnant Black women. While it’s fair to say that the rate of C-section deliveries in general are high in the United States, it’s exceptionally high among pregnant Black women compared to pregnant white women. From 2018 to 2020, 35.8% of Black infants in the U.S. were born by C-section compared to 30.9% for white infants, according to the March of Dimes, a non-profit organization focused on maternal and infant health. </p> <p>Given the glaringly uneven rates of C-sections among Black women, the obvious question on everyone’s mind is: why? But the more important question is what can be done to protect yourself from this reality?</p> <p>Read on as we dive deeper into the disparity in C-section rates in this country and how you can protect yourself if you’re giving birth – regardless of your race.</p> <h2>The rising rates of C-section deliveries is not necessarily a good thing</h2> <p>Pregnancy rarely ever goes exactly as planned. This is also true for labor and delivery, and when things go wrong while birthing your baby, having a C-section – meaning a medically necessary C-section – can mean the difference between life and death for both you and your baby. </p> <p>But therein lies the problem, the rising rate of C-sections – in most developed countries – can, in part, be attributed to them being performed when it is <em>not</em> medically necessary. For example, a pregnant woman requesting to have an elective C-section to avoid the pain of a vaginal birth. Another example, reported by Dr. Rebekah Gee, an obstetrician-gynecologist (OB-GYN) and former secretary of the Louisiana Department of Health, is that C-section rates go dramatically up at around 4 to 5 p.m. – around the time when doctors tend to want to go home. </p> <p>But these specific examples don’t explain why Black women have higher rates of C-section deliveries than white women. These examples simply explain what is causing the rising rates of C-sections in the country. </p> <p>So, where is the evidence that higher C-section rates is tied to race? </p> <h2>C-section rates are tied to race</h2> <p>Various studies have compared the birthing experiences of women of color with those of white women who had the same maternal healthcare access, insurance coverage, annual household income, education levels, and even gave birth in the same hospitals. After detailed analyses, researchers couldn’t identify a specific variable – outside of race – for higher rates of C-sections among women of different races, particularly Black women. </p> <p>“There was no benefit to being college-educated or having more money and resources, which are all of the reasons that people point to when looking at the disparities,” says Dr. Charles Chamber, an OB-GYN who was the first to identify the concept of medical racism in the 1990s. “It’s none of those things. It really points to the things we can’t measure, like racism and bias.” </p> <p>Additionally, a study published in the January 2022 issue of <em>Obstetrics and Gynecology</em> offers more insight into potentially dangerous racial disparities in C-section deliveries. The study found that in first-time live births, healthy pregnant Black and Hispanic women were 21% and 26%, respectively, more likely than white women to deliver by C-section despite being low risk and with limited medical or obstetric explanation. To add to the disparity, the higher number of C-sections appeared to increase the risk of morbidity for women of color.</p> <p>In the study, the researchers analyzed data from 5,759 pregnant women (24.3% Black, 30% Hispanic, 46.6% white). The results revealed that 1,158 of the women (20.1%) underwent C-section deliveries, 23% Black women, 22.8% Hispanic women, and 17.6% white women. Further analysis revealed that – after adjusting for confounding variables such as education, SES, and insurance coverage – Black women were 21% more likely, and Hispanic women were 26% more likely to give birth via C-section than white women.</p> <p>While the researchers did not explore the reason why Black and Hispanic women were more likely to have more C-section deliveries, data revealed that this disparity was not tied to education level, socioeconomic status (SES), or insurance coverage plan. Dr. Michelle P. Debbink, MD, PhD, assistant professor in the Department of Obstetrics and Gynecology at the University of Utah and lead author of the study hypothesized that “the difference likely stems more from differing treatment of Black or Hispanic individuals during labor.”</p> <p>The message of the study, she said, is that the healthcare system “perpetuates gaps in C-section delivery for Black and Hispanic individuals compared to white individuals” even in low-risk, first-time live births. “We do not yet know exactly what the right levers are to address this gap, but it is important that we OB-GYNs examine our practice patterns and our hospitals’ practice patterns to ensure equity for all our patients.”</p> <h2>Higher morbidities may contribute to higher C-section rates, but…</h2> <p>There’s no question that a woman’s health may lead to the need for a C-section delivery, and studies have shown that Black and Hispanic women have more comorbidities than their white counterparts. However, Dr Rebecca Delafield, PhD and assistant professor of Native Hawaiian Health at the University of Hawaii commented that, while “delivery is complex, and the causes of disparities observed are likely multifactorial [e.g., comorbidities, racism, SES, immigration status, and food choices that may influence health status], it is becoming increasingly evident that studies investigating racial/ethnic disparities in Cesarean delivery and other maternal health outcomes must look beyond maternal behavioral or medical risk factors – such as obesity or hypertension, both conditions may make C-section necessary – and consider the contribution of a broader set of factors, including societal prejudices.”</p> <p>Because the reality is, a pregnant Black woman in the United States doesn’t have the luxury of assuming that she will experience pregnancy with good outcomes, as a white woman would – which is evidenced by the high maternal mortality rate among Black women. </p> <h2>Advocate for your best maternal health care</h2> <p>Solving decades of medical racism is not going to happen overnight because, to do so, there is a need for larger, systemic, and societal changes across the healthcare industry, which takes time. </p> <p>So, in the meantime, if you’re a pregnant woman in America, you must proactively work to ensure that the right services and the right systems are in place for you to receive optimal outcomes for you and your baby. While this approach is necessary for all women, it is critical for Black women whose risk of having a C-section delivery and risk of dying in childbirth are much higher. </p> <p>With that said, here are ways you can advocate for yourself to ensure you receive the best maternal health care and a positive pregnancy outcome:</p> <p><strong>1. Optimize your health before getting pregnant. </strong>Pregnancy is very taxing on the body, and if you have a high-risk condition, like obesity, hypertension, or diabetes, your chance of a C-section delivery increases. So, get healthy before getting pregnant. That means losing weight if you’re overweight, and ensuring your hypertension, diabetes, or other health conditions are well managed before conceiving. </p> <figure> <figure><img alt="Preeclampsia disproportionately impacts pregnant Black women in the U.S. | Source: StoryMD/Pexels" src="https://cdn.storymd.com/optimized/4AwDgNSroz/thumbnail.jpg" /> <figcaption>Manage Hypertension. <em>Source: StoryMD/Pexels</em></figcaption> </figure> </figure> <p><strong>2. Choose your healthcare provider carefully. </strong>Not all doctors, nurses, midwives, etc. are created equal, and discrimination, as well as implicit and explicit biases are real contributors to a higher chance of C-sections among Black women in America. This makes it extremely important for you to assemble your maternal health care team carefully. Interview several different qualified OB/GYNs, talk to family members and friends who have had positive experiences with their healthcare provider, and choose an OB/GYN that you trust. Ask the candidate important questions such as: </p> <ul> <li>what their C-section rates are?</li> <li>what proportion of their patient population are Black women?</li> <li>how they feel about the Black maternal mortality rate?</li> </ul> <p>If the answers they provide are not satisfactory to you, then they are likely not the right doctor to oversee your maternal care. A good OB/GYN should always provide you with the best care, genuinely have your best interest at heart, and listen to your every need and want. It may sound overly dramatic but selecting the right OB/GYN can in some cases be a life-or-death decision.</p> <p><strong>3. Create and share your birth plan</strong>. Barring no unforeseen circumstances or medical emergencies (e.g., baby is in breeched position), if you have your heart set on a specific birth plan, be adamant about how you welcome your baby into to the world. Share your plan with your health care team, partner, and family. Part of the reason birth plans are so important is because you don’t want to make critical decisions in the heat of the moment. A birth plan is essentially a roadmap of your birthing preferences, and it also clearly details your personal health history so that your and your baby’s safety remain a priority. Ensure you have your plan clearly written out – such as which procedures you would consent to or which to avoid, your pain management preferences, and so on – so that your health care team can refer to them as needed. With that said, however, even with the most elaborate birth plan, sometimes no amount of planning can prevent a C-section because there are many variables that you can’t control or prepare for. </p> <p>“Your birth plan should be your megaphone, giving you the power to speak at a time when you may otherwise not be heard,” says Ms. Rachel Nance Wade, Vice-President of Marketing at a digital maternity platform company in New York City that caters to the care of Black mothers.</p> <p><strong>4. Do your research</strong>. More than ever, the health information you need to protect yourself is at your fingertips, and that includes information about C-sections. To ensure that your birthing experience is the best for you and your baby, educate yourself on all your options. Arm yourself with information about vaginal and C-section births, consult with your medical team and learn all the medical scenarios in which C-sections may be necessary for you, and speak up for yourself when things go awry. </p> <p>If you’re being told that you need an emergency C-section, ask why. Some complications are time-sensitive, and in those cases, your OB/GYN may need to act quickly to protect you and your baby, but most cases are not so urgent that you can’t ask for an explanation. You should understand everything about why a C-section is necessary before your OB/GYN proceeds.</p> <h2>More on Maternal Health Inequities</h2><ul><li><a href="https://soulivity.storymd.com/journal/wxlgo9qizw-health-equity-and-maternal-health" target="_blank">Maternal Health Inequities</a></li><li><a href="https://soulivity.storymd.com/journal/vwd727yi4w-cesarean-section" target="_blank">Cesarean Section (C-Section): What It Is and When It's Needed</a></li><li><a href="https://soulivity.storymd.com/journal/wdoqd3vf4j-prenatal-checkups" target="_blank">Prenatal Care Checkups During Pregnancy</a></li></ul>