Cesarean sections (C-sections) are an important part of modern obstetrical care, offering a potentially life-saving option during high-risk pregnancies. More specifically, they are an important tool under conditions where vaginal birth is deemed unsafe for the birthing person or their infant.
Despite their potential to contribute positively to birth outcomes, the rapidly mounting rate of c-sections among low risk births can have the opposite effect. Among the potential complications are those from anesthesia, blood loss, infection, the prolonged recovery period, and postpartum depression. Unfortunately, not only are we observing a rise in the rate of medically unnecessary c-sections in the United States—recent studies unveil racial disparities in the extent of this rise. As we evaluate the finding that doctors give Black women and birthing people unneeded c-sections at higher rates, we must consider the implications within the context of our nation’s dismal maternal health landscape overall.
A recent New York Times report, which pulls from the National Bureau of Economic Research’s study that examines drivers of racial disparities in c-sections, concludes that obstetricians are more likely to give Black women and birthing people unnecessary c-sections. Examining nearly a million hospital births in New Jersey, researchers found that even if a Black mother and white mother with similar medical histories saw the same physician at the same hospital, the Black mother was 20 percent more likely to have her baby via c-section. The additional c-sections were likely to happen in the absence of scheduled procedures, which suggests an underlying entanglement between racial disparities and financial incentives within the sphere of medical decision making.
This finding is particularly illuminating within our current context. The United States is among the worst high-income nations to give birth. Not only is our maternal mortality rate higher than that of similarly-positioned nations despite advances in medical technology and healthcare access, but the burden is not evenly distributed. When compared to their white counterparts, Black birthing people are three to four times more likely to die of pregnancy and childbirth related complications, with this number representing the baseline. In harder-hit regions such as New York City or Washington, D.C, this number is as large as five. While the study does not explicitly illuminate a relationship between disparities in c-section rates and racial disparities in maternal mortality, the fact of there existing similar trends calls for analysis.
In addition to thinking about what this could mean about the United States’ maternal health landscape, we should consider the specific dangers associated with heightening rates of unnecessary c-sections. Among the risks for the mother or birthing person are infection, hemorrhage or severe blood loss, injury to organs, adhesions, maternal mortality, and more. The risks for the baby include premature birth, breathing problems, low APGAR scores, and fetal injury. According to a 2006 study published in a journal of Obstetrics and Gynecology, women and birthing people are three times more likely to die during a cesarean delivery than during a vaginal birth.
We should also consider the frameworks that convene to give rise to current outcomes. In our increasingly technological world, the sphere of birthwork faces a nascent problem—the troubles of birth medicalization. In 1996, the World Health Organization called for the elimination of unnecessary technological interventions during labor. Of the 140 million births that occur each year, most do not come with unmanageable complications for the birthing person and their baby. And yet, the past few decades have seen a marked increase in unnecessary practices that initiate, accelerate, terminate, and/or regulate aspects of labor—such as oxytocin infusions and cesarean sections. Despite widespread knowledge that birth is a normal physiologic process, our current medical system treats it as a pathology that requires clinical intervention. This ultimately sets the foundation for medical professionals to treat c-sections as requirements or first-line, rather than last-resort options for those in need.
Unconscious bias is likely to play a role. When unchecked, providers’ unconscious beliefs regarding Black women and birthing people’s obstetrical hardiness, when coupled with beliefs about their imperviousness to pain, is likely to be woven into clinical interactions. What this means is that as women and birthing people are urged to give birth by c-sections at higher rates, some populations may be deemed less risky due to their perceived ability to withstand the potential complications.
Racial disparities in c-section rates are a small, yet significant piece of a much larger puzzle. As we continue working to ensure safe, dignified birthing experiences, we must continue to practice intentionality in unpacking these issues within context.
