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Why do Black women in the US have more C-sections than white women?

Black women in the US have the highest risk of dying in childbirth. Dangerous and unnecessary caesareans have a lot to do with this. What’s going on?

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Joni Hess
13 July 2021, 7.00am
Candice had a hysterectomy at the age of 29, after two C-sections
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Candice. All rights reserved

A hysterectomy – the removal of a woman’s reproductive organs – is more likely to happen to women in later life, after their childbearing years, or if they’re facing a serious medical condition. It’s a rare procedure for women under 30 who are beginning to start their families. Yet, following the birth of her two children by caesarean section (C-section) Candice had a hysterectomy at only 29 years old.

Tee, also a mother of two, described the recovery period after her first C-section as “horrible”. “When I came home from the hospital, everything kind of fell apart. My husband worked during the day, so we were home alone a lot. Eventually, one of my staples burst open and the pain was excruciating. I couldn't walk. I was crying all the time,” she said.

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Tee feels she was pressured into having a second C-section | R. Ray Robinson

Candice and Tee believe their experience of becoming mothers would have been less traumatic if they weren’t Black. And they may well be right: Black women have the highest rate of pregnancy-related death in the US, with Alaska Native and American Indian women close behind. And that’s before we talk about the women who are left disabled, with chronic pain, traumatised or in need of serious surgery.

One factor driving these disparities is the extensive use of C-sections in the US. In 1970, the rate was a mere 5%. By 2019, it had risen to more than 30%. The increase hasn’t led to an improvement in outcomes. And the overall figure hides a racial disparity: the rate of C-sections for Black women is higher (35.9%) than for white women (30.7%).

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C-sections can be necessary for a high-risk pregnancy, such as having twins. However, there is substantial evidence to show that the procedure is overused at alarming rates, exposing more mothers to what can be dangerous surgery.

My own twins were delivered by C-section on Christmas Eve 2019, nine weeks before their due date. Despite developing a cough afterwards, which made me feel like my incision was being ripped apart, I don’t regret how my children were brought into this world – especially after giving birth to a stillborn child earlier that year.

In 1970, the rate of C-sections in the US was a mere 5%. By 2019, it was more than 30%

For many women, C-sections are seen as the ‘safer’ option, as it was in my own case. But research shows that C-sections pose a much greater risk to the mother than vaginal deliveries, with potential problems including damage to the bladder, infection, heart attack or kidney failure. Women are twice as likely to experience a severe haemorrhage following a C-section compared with a vaginal birth. Bleeding out after giving birth is one of the leading causes of childbearing related death.

Uterine scarring is another risk that has risen over recent years – something Candice knows all about. This scarring can cause chronic pain, abnormal bleeding and may require surgical removal before subsequent pregnancies. Typically, they lead to subsequent C-sections, which increase these risks every time.

Despite these risks – and despite what the Centers for Disease Control and Prevention (CDC), the US health protection agency, calls a “complex national problem” of Black maternal deaths – the evidence is clear. Black mothers consistently undergo caesareans more than white mothers, even in low-risk situations. And as a result, we’re more likely to suffer for longer after birth, to struggle to fully recover, or to die.

To try to understand why, I’ve been digging into the academic literature, speaking to women like Candice and Tee, and interviewing advocates leading the fight for Black maternal equality.

The short answer is simple: racism. But we need to understand the long answer too.

A history of control and profits

Some of medicine’s most impactful techniques came from repeated experiments without pain relief – including C-sections – on enslaved women in the American South.

Deirdre Cooper Owens, a professor of medical history, writes: “As much as white medical men are lauded for serving as the ‘fathers’ of American gynecology, black women, especially those who were enslaved, can arguably be called the ‘mothers’ […] because of the medical roles they played as patients, plantation nurses, and midwives.”

Despite this history, Black women’s bodies are often viewed as problematic when it comes to giving birth. Pelvic structures vary by ethnicity and even geography. But instead of teaching students to deliver babies from the wide range of body shapes in today’s multi-ethnic societies, medical books commonly treat the average white woman’s pelvis as the gold standard for vaginal delivery. Rather than learn how to support us to give birth vaginally, it’s easier to cut us open.

When the US economy depended on slavery and therefore Black reproduction to thrive, Black women were depicted as strong, perfectly capable of pushing out multiple babies and then heaving bales of cotton while carrying those babies on their shoulders. Many were even given rewards by their slave masters for giving birth – that is, providing them with more human property.

Today, the situation is reversed: treating Black women as less capable of bearing children without medical intervention suits America’s profit-driven hospitals.

“It’s about commas, it’s about money, it’s about the bottom line,” said Jennie Joseph, a British-trained midwife and founder of Commonsense Childbirth, which trains US midwives and doulas to provide hands-on assistance, emotional support and help mothers fully participate in the childbearing cycle.

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Jennie Joseph founded Commonsense Childbirth to train US midwives and doulas | Jennie Joseph

The US healthcare system is run largely by a network of private corporations; it’s a system designed to prioritise the profits of stakeholders, private companies and hospitals over the health of patients. Advocates for Black maternal equality such as Joseph point out the significance of the ‘medical-industrial complex’: “It’s an entire system at play,” she told me.

This set-up produces numerous perverse incentives, resulting in a significant risk of overtreatment. And the forces pushing Black women towards caesareans have to be understood in this context – for hospitals, C-sections are a profitable business.

US hospitals charge an average of $22,646 for a C-section compared with $12,915 for a ‘normal’, uncomplicated pregnancy. While we don’t know how much each of these cost the hospitals, before they add on profit, we can get a sense from the UK’s NHS, which publishes how much it expects to pay, profit-free, for different medical procedures: $5,400 for a C-section, $4,500 for a standard vaginal delivery. Assuming base costs are about the same either side of the Atlantic, C-sections in US hospitals likely deliver around $17,000 of profit, compared with ‘just’ $8,500 for a vaginal birth.

The 2010 Affordable Care Act (ACA) meant that more Black women had medical insurance than before, but it didn’t remove the profit motive from hospitals, meaning there’s more incentive for hospitals to push women down the most profitable path, knowing their insurance company can pay. And Black women – who are less likely to be listened to when they push back against the idea of surgery – are the first people shoved down whatever road is most profitable for the system. Between 2008 and 2018, C-section rates increased for Black women, while they decreased among white women (for reasons I’ll come to).

A study from one hospital in Massachusetts looked at unscheduled C-sections. What they found was that Black babies were much more likely to be diagnosed as “in distress” than white babies.

As the academics put it, “The known subjectivity in the assessment of fetal distress using electronic fetal monitoring supports the potential of variation in decision making that results in lower thresholds for diagnosing fetal distress and recommending a cesarean among certain racial/ethnic groups.” In other words, in the high-stress context of the delivery room – likely with monitors bleeping and contractions squeezing – Black women are more likely to be pushed towards sometimes unnecessary C-sections.

The recent decrease in C-sections for white women in the US can be explained by the increase in ‘out-of-hospital’ births – at home and in birthing centres. Black women are more likely to be deemed high-risk or not healthy enough for an out-of-hospital birth, and birthing centres are often lacking in low-income communities. Also, more white women can afford the extra costs associated with these births, such as paying for a midwife or doula.

Numerous studies show access to doula care, in particular, leads to better outcomes, including lower C-section rates. But doulas aren’t covered by Medicaid, leaving Black women disproportionately out in the cold. Which is why Jennie Joseph’s school in Florida trains midwives and doulas.

Black women are more likely to be denied a vaginal birth if they have previously had a C-section

Joseph understands one of the main reasons why Black women suffer and die more in childbirth. “What was really putting [Black women] in more jeopardy was not being listened to, not being heard, not being acknowledged,” she told me.

One common example of this is that Black women are more likely to be denied a vaginal birth if they have previously had a C-section. Vaginal births after caesarean delivery (VBACs) result in decreased deaths and a decrease in the overall caesarean rate, yet Black women are less likely to be offered the option of a VBAC and are often actively discouraged by physicians.

When Tee was pregnant with her second child, her doctor quickly scheduled her for a C-section, even though it wasn’t what she wanted. She was told that since she’d already “been cut”, a natural birth would be damaging to her body.

Candice’s second delivery left her with regrets she’s still trying to come to terms with. “I asked [the doctor] months before if we could do a VBAC. But she shut me down and terrified me and my husband, saying there’s a high chance my baby and I wouldn’t make it. So we agreed to do a repeat C-section.”

Three weeks before the scheduled surgery, she ended up in hospital, already in advanced labour, and was offered the VBAC she had initially wanted. But Candice replayed her doctor’s words from months earlier about the potential harm to her and her baby – and she opted for the C-section. “To this day, I wish I’d been brave enough to do it,” she said. “Afterwards, I stayed in the hospital for two days. I was in a lot of pain and told them I didn’t think I was ready to leave, but they discharged me anyway. A day later, I was back in the ER with an infected incision.”

Days after Tee was discharged from hospital, some of her stitches reopened. When she returned, she was blamed for “doing too much”, despite being the sole caregiver for her baby.

In returning to hospital, both women represent another trend. Compared with white women, Black women have an 80% greater risk of postpartum readmission and are more likely to suffer from life-threatening conditions in the weeks following delivery – often because they’ve had a C-section.

And that means Black women also suffer more from the US’s general lack of postnatal care.

In the UK, there are systems to ensure mothers are recovering after the birth. The day after discharge, a community midwife will visit, followed by a minimum of two home visits in the following weeks. The mother’s physical and emotional needs are assessed. Moms in America, however, are discharged when their insurance coverage ends, and the earliest they come into contact with a healthcare professional is typically six weeks later – if they can make it to the appointment. Heart problems, which can develop during pregnancy, are responsible for most deaths within those six weeks.

Blame the mother

With more than 20 years experience in midwifery, Joseph can list common themes among the Black women she’s served. Among them: a copious amount of self-blame, which mirrors the blame imposed on them by healthcare providers. Candice believes that if she had drunk more water throughout her pregnancy, had a healthier diet and progressed faster through labour, a C-section would have been less likely. Her doctor added to this game of ‘blame-the-mother’ by telling her she was too “petite” and “tightly built”.

On a grander scale, this blame extends to a society that ignores social determinants of health while telling Black women, for example, that they are too heavy or too mature in age to have a normal pregnancy. Blame is always an easy way to divert attention from the actual systemic problems that adversely affect Black people.

Blame is a smokescreen for healthcare systems to continue authoritarian and discriminatory practices towards Black women, whose bodies and voices simply aren’t valued compared to their white counterparts.

A decade before scarring led to the removal of her uterus, Candice (then aged 19) feared something may have been wrong as she was prepped with an epidural before her surgery. But she was too scared to say anything. Lying on the operating table, when she should have been numb, she experienced immense pain immediately after her baby was pulled from her body. “I screamed and yelled ‘I can feel it!’, and they put a mask over my face. I went to sleep and woke up in the recovery room. They were not kind to me at all and never even explained what happened.”

The joy of a newborn’s face often blurs the trauma of childbirth, so much so that many women push it behind them and never tell their stories. But as awareness of these inequities grows, Black women’s voices can no longer be ignored.

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