As recently reported by The New York Times, the key takeaway from the 2024 National Bureau of Economic Research (NBER) report on C-section rates in New Jersey hospitals was that factors other than medical necessity appear to drive C-section rates for black women, especially low-risk black women. While some have speculated that financial incentives may be at play (since the operating room is the major “moneymaker” for the hospital), evidence suggests that other factors may be more influential.
[Editor’s note: For the first part in this two-part series on the 2024 NBER report, click here.]
What role do empty operating rooms play in unnecessary C-sections?
The NBER researchers found that whether or not operating rooms were empty played a significant role in whether or not women, particularly low-risk black women, ended up with a C-section. “When there is no scheduled C-section at the time of an unscheduled delivery [the operating room is empty], 4.8 percent of non-Hispanic white mothers with unscheduled births in the lowest risk quintile have a C-section compared to 8.0 percent of Black mothers, leading to a racial gap of 67.9 percent (p-value < 0.001). When there is a scheduled C-section, meaning that the operating room is occupied, the white rate for the lowest risk births falls to 1.6 percent and the Black rate falls to effectively zero, reducing the gap to an insignificant -69.9 percent (p-value = 0.412).”
The researchers spelled out, “the racial disparity shrinks when the costs of ordering an unscheduled C-section are higher due to the unscheduled delivery taking place at the same time as a scheduled C-section. This finding is consistent with doctors being more willing to do unnecessary C-sections on Black mothers when there is the capacity to do so,” in other words, when the operating room is empty.
The researchers spelled out, “the racial disparity shrinks when the costs of ordering an unscheduled C-section are higher due to the unscheduled delivery taking place at the same time as a scheduled C-section. This finding is consistent with doctors being more willing to do unnecessary C-sections on Black mothers when there is the capacity to do so,” in other words, when the operating room is empty.
Provider preference as a rationale for unnecessary C-sections?
The NBER researchers pointed to past research suggesting that women with the exact same risk factors may have lower or higher likelihood of having a C-section based on what hospital, medical practice, or provider they choose. Overall, the researchers wrote, “The results point to the importance of provider discretion and suggest that many doctors simply set a lower threshold for performing unscheduled C-sections on Black mothers.”
The time crunch element and unnecessary C-sections
Dr. Tamika Cross, a black OB/GYN interviewed in a film segment by a Houston FOX affiliate for her reaction to the NBER report, observed: “Besides the fact of the obvious… black women in particular being treated differently than other races, I think sometimes it’s a time thing… kind of rushing the process, [with physicians saying or thinking] ‘We have things to do, we gotta rush and get back to the clinic.’”
“I vowed to myself I would never have another birth in a hospital”
The concept of “rushing the process” of birth came up in an interview with a black mother during the same FOX segment. With her third child, Millie Rucker was pressured to undergo a C-section. “When I was pregnant with my 5 year-old son… they were basically rushing me, saying that my son wasn’t turning when they needed him to, that I wasn’t dilating in the amount of time that I guess they needed me to. I told them I would literally get up and walk out and go home and have my child if they tried to force me to do that. A few hours later, I gave birth to a healthy almost-10 pound baby boy. After that I vowed to myself that I would never have another birth in a hospital.” 2 years ago, Millie had a water birth in a birth center.
Hundreds of comments on the Youtube video of the FOX segment echoed these women’s experiences. Chillingly, one commenter wrote “Every black woman I know has had a C-section.”
Hundreds of comments on the Youtube video of the FOX segment echoed these women’s experiences. Chillingly, one commenter wrote “Every black woman I know has had a C-section.”
Failure to listen to black women
OB/GYN Dr. Tamika Cross cited systemic racism and racial bias as drivers of C-sections, saying that many providers believe black women won’t speak up for themselves. Nurse Tequila Russell further stated, “They figure we don’t have the advocates. They figure we don’t have the literacy and we won’t speak up for ourselves, we won’t be heard.” A 2022 research study found that black women were more likely than white women to report feeling “pressure from a clinician to take medication to start or speed up labor and to have a C-section.”
Tequila Russell, a nurse with 12 years of experience and a mother of six, was another black woman interviewed for the FOX segment. Her oldest is 23 years old, and her youngest children are 15-year-old twins. She reported similar experiences to Millie, saying “I did feel pressured to have C-sections. I’ve had 3 C-sections and 2 VBACs (vaginal birth after Cesarean), which I had to force and advocate for, to the point that my OB/GYN was irate with me… demanding that I not [have a VBAC].” Her first C-section was for “failure to progress,” which she attributes to the epidural being so strong that she could not feel anything, making it difficult to push. “That’s not fair for a birthing mom to not be able to feel her birthing process… so of course it’s a failure to progress.”
Are high C-section rates contributing to high rates of maternal mortality among black women?
The stakes are high to ensure C-sections are only done when medically necessary because they have real health implications, including effects on future pregnancies. Infection (whether a surgical wound infection, endometritis, or a urinary tract infection from the catheter), hemorrhage, blood clots, and injury to other organs are possible short-term complications of C-sections. C-sections can also lead to placenta problems in future pregnancies. Abnormal placentation is connected to preeclampsia, intrauterine growth restriction (baby not growing properly), preterm birth, stillbirth and more.
Dr. Simon of OBHG also told Healthline, “If Black women undergo more cesarean deliveries, their exposure to associated risk increases. These risks are compounded by the fact that Black women already experience higher rates of pregnancy complications and are more likely to have underlying chronic health conditions.”
Underlying health conditions and C-section risks
Underlying health conditions, ranging from high blood pressure, obesity, heart disease, diabetes, and more, are predictive of increased C-section complications. Since black women are more likely to have underlying health conditions than white women are, C-sections may actually be riskier for them. As we previously explained, vaginal birth or VBAC may be most important for black women with obesity and other health conditions.
Underlying health conditions, ranging from high blood pressure, obesity, heart disease, diabetes, and more, are predictive of increased C-section complications. Since black women are more likely to have underlying health conditions than white women are, C-sections may actually be riskier for them.
Fear of black maternal mortality might play a role
Black women are 6x more likely to die of pregnancy-related complications than white women, and their babies are 3x more likely to die in their first year of life compared to their white counterparts. Yet, paradoxically, black women may be pushed towards dangerous C-sections due to provider awareness of their higher maternal mortality rates. A Princeton press release quoted Janet Currie, a health economist at Princeton University and a co-author of the study: “Physicians may have certain beliefs about Black women. They might not be listening to Black women as much, or be more afraid that something will go wrong” during the vaginal birth process. This may lead to a desire to “control” the birth process in a (misguided) attempt to mitigate the risks.
Weighing the benefits and risks
There’s no doubt that medically necessary C-sections are truly life-saving procedures. But even medically necessary surgeries still come with risks. In cases of medical necessity, the benefits are judged to clearly outweigh the risks. Reducing racial disparities and driving down maternal mortality rates necessitate greater discretion about when C-sections are medically necessary vs. not.
Additional Reading:
