Low-risk black women are 25% more likely to undergo C-sections than their white counterparts: that’s the concerning conclusion of a 2024 bombshell report from the National Bureau of Economic Research (NBER).
After analyzing nearly 1 million births from 68 hospitals in New Jersey between 2008 and 2017, NBER also found that low-risk black women were particularly likely to end up with C-sections during times when operating rooms were sitting empty. Some (including The New York Times, which first broke the story) have blamed financial motives and systemic racism for the disparity. But what more can this data tell us? And what can be done to reduce C-section rates for everyone, and particularly for black women whose maternal mortality rates are already disturbingly high?
Who did the research?
The NBER research was conducted by a Northwestern University researcher, a Princeton University researcher, and a North Carolina State University Economics professor. According to their curriculum vitaes, the Northwestern and North Carolina researchers originally studied under the Princeton researcher. The report was a working paper, which means it has not been peer-reviewed. However, the researchers meticulously documented their methodology.
The researchers sought to answer “the question of why Black infants are more likely to be delivered by Cesarean section (C-section) than white infants in the United States.” The researchers observed, “We use exceptionally rich administrative data covering nearly one million births in New Jersey from 2008 to 2017 to understand the causes of racial disparities in delivery method.”
New Jersey’s C-section data is representative of national data
What should our national C-section rate look like? The World Health Organization (WHO) recommends that a country’s C-section rate should not exceed 10-15%. But lest anyone wonder if racial disparities in C-sections are a uniquely New Jersey problem, the researchers also cited data from the National Vital Statistics Survey showing that 29.3% of all births by white mothers and 34% of all births by black mothers across the U.S. were via C-section in 2018. In 2023, 1 in 3 births across the country was via C-section.
Mark Simon, MD, chief medical officer at Ob Hospitalist Group (OBHG) recently told Healthline, “The CDC has released data that clearly highlights national differences in C-section rates across each state, with New Jersey ranking on the high end. But this problem is not unique to New Jersey—disparities in maternal mortality, particularly along racial and socioeconomic lines, are also well-documented.”
What did the researchers find?
A note about the language used in the NBER report is in order. ‘Unscheduled delivery’ refers to a birth in which the woman did not have a planned C-section, but planned to have a vaginal birth. The NBER report found that the unscheduled C-section rate (i.e., intended vaginal births that ended up becoming C-section births) among Black mothers in New Jersey was 21.1 percent compared to 16.9 percent among non-Hispanic white mothers. According to the report, this means that “on average, Black mothers with an unscheduled delivery are 24.8 percent more likely to have an unscheduled, or ‘emergency,’ C-section” compared to white mothers.” Shockingly, “Even when treated by the same physician in the same hospital, Black mothers with unscheduled deliveries are 20.1 percent more likely than observationally similar white mothers to deliver by C-section” (emphasis added).
“Even when treated by the same physician in the same hospital, Black mothers with unscheduled deliveries are 20.1 percent more likely than observationally similar white mothers to deliver by C-section.”
National Bureau of Economic Research
Importantly, the researchers noted that “the higher C-section rate among low-risk Black mothers is primarily driven by unscheduled C-sections,” not planned C-sections. The researchers further wrote, “Strikingly, Black mothers with unscheduled deliveries in the lowest risk quintile are 149.4 percent (p-value < 0.001) more likely to have a C-section than white mothers.”
What can be done to decrease unnecessary C sections, particularly on black women?
A key element in driving down C-section rates, especially among low-risk black women, is likely to be found in allowing normal, physiologic birth to unfold–in other words, to not “rush the process” of birth. From coast to coast, awareness is spreading of the key role midwives play in educating women before labor on what to expect, and then supporting them through labor, trusting (and verbalizing to women) that their bodies are capable of giving birth[1]. Doulas are also pivotal players in decreasing C-section rates.
From coast to coast, awareness is spreading of the key role midwives play in educating women before labor on what to expect, and then supporting them through labor, trusting (and verbalizing to women) that their bodies are capable of giving birth
States across the country would do well to sit up and take notice of the aggressive measures being taken in New Jersey to drive down C-section rates. Starting in 2018, New Jersey implemented a pilot doula program. Since 2021, New Jersey Medicaid has covered doula care, and stopped paying for elective C-sections. Also in 2021, the Nurture NJ Strategic Plan was released, recommending statewide implementation of comprehensive informed consent processes ensuring every mother understands the short-term and long-term risks of having a C-section. The Plan further recommended limiting participation in insurance networks for hospitals who don’t meet C-section target rates. Furthermore, New Jersey has established a first-in-the-nation policy of universal newborn nurse home visitation–meaning that recovering new moms needn’t figure out how to venture out to the pediatrician with their baby in tow during the vulnerable days following birth.
The bottom line
At Natural Womanhood, we understand that respect for the female body occurs on a continuum. It is illogical and inconsistent to, on the one hand, value the gift of a woman’s fertility and cycles—understanding that we ought not alter, suppress, or destroy them—but on the other hand fail to recognize the inherent wisdom of her pregnant and birthing body. Certainly, medical interventions—including emergency obstetric surgery—exist for those cases when they are vitally necessary. But as the NBER report underscores, greater discretion around the use of C-sections (and, perhaps, the interventions that are more likely to lead to them) is an urgent priority for those concerned with improving maternal health outcomes and satisfaction.
[Editor’s note: For more on the factors the 2024 NBER report found that influenced C-section rates for black women, click here.]
