June 16, 2022 -- When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, SC.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection -– on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist  at the Icahn School of Medicine at Mount Sinai in New York City.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be -- were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the Unites States every year, composing over 31% of all births in 2020, according to the CDC.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of white women. Black women are also about three times more likely to die of pregnancy-related causes than white women.

Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

"When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Glazer says.

Clinical Discretion Leads to Biased Judgement Calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in white women.  Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among white women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Glazer says. “Once you adjust for all these measures, pre-pregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown.  Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

 “Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, DC.  The cost of a cesarean delivery averages about $17,000, compared to about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery, but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system; if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for white women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine in Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decision making, and that by standardizing practices we could address these differences -- people were somewhat resistant at first,” Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3 to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine in Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

Kimberly B. Glazer, PhD, MPH, perinatal epidemiologist, Icahn School of Medicine, Mount Sinai in New York City.

Rebecca Hamm, MD, MSCE, assistant professor of obstetrics and gynecology, Perelman School of Medicine, University of Pennsylvania.

Jamila Taylor, PhD, MPA, director of health care reform and a senior fellow, The Century Foundation, Washington, DC.

Camille Clare, MD, MPH, chair, American College of Obstetricians and Gynecologists district II (New York).

Natalie Hernandez, PhD, MPH, assistant professor and executive director, Center for Maternal Health Equity, Morehouse School of Medicine, Atlanta.

Cleveland Clinic: "C-Section vs. Natural Birth: What Expectant Moms Need to Know."

National Center for Health Statistics: "Births – Method of Delivery."

Centers for Disease Control and Prevention: "Maternal Mortality Rates in the United States, 2020."

World Health Organization: "WHO Statement on Caesarean Section Rates."

National Partnership for Women & Families: "Black Women’s Maternal Health."

Paediatric and Perinatal Epidemiology: "Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates."

Maternal and Child Health Journal: "Double Disadvantage in Delivery Hospital for Black and Hispanic Women and High-Risk Infants."

The Journal of Law, Medicine & Ethics: "Structural Racism and Maternal Health Among Black Women."

Nature: "Stunted microbiota and opportunistic pathogen colonization in caesarean-section birth."

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