Cesarian sections, or C-sections, are lifesaving procedures that can come to the rescue in many situations in which the labor process puts a mother, her unborn child, or both at risk.
Like every procedure or medication, C-sections come with their risks and are ideally performed when it is assessed that these risks are a better option than the risks of labor. Unfortunately, studies keep finding that they’re being performed on women who do not need them, which means the risks are also unnecessary.
And the latest study shows how bias and racism may result in Black mothers being especially susceptible to unnecessary C-sections.
The Risk Of An Unnecessary C-Section
C-sections can come with longer and more complicated recovery times and leave scarring that can, in some cases, cause complications with future pregnancies. They can also increase the risk of blood clots and infections, according to the U.S. Department of Health & Human Services, which has set a goal of reducing the number of C-sections performed on low-risk mothers in their first pregnancy.
Their current target is to reduce these C-sections, which were being performed on about 26.3% of women in this category (low-risk and no prior births) as of 2022, by just a few percentage points, to around 23.6%.
Sometimes a C-section is planned and scheduled for various reasons in the mother’s life that may fall outside medical necessity. Still, in other cases, it results from pressure from doctors, and mothers may suffer the consequences.
When Doctors Pressure A Laboring Mom Into A Surgical Procedure
Labor can take a long time, and it’s painful, stressful, and exhausting. Moms in labor are not always in the best position to argue against a medical team and advocate for themselves, especially when they assume that the doctor’s priority is always the best medical decision.
But many moms describe being pressured into unwanted C-sections, and nurse-midwife Ann Ledbetter, writing for Scientific American, says she’s born witness to these interactions. She wrote:
“As a nurse, I remember surgeries done because the doctor ‘had a flight to catch’ or ‘didn’t want to be up all night.’ My experiences must not be unique; the timing of unplanned C-section shows that the surgery is performed at times of day that are convenient for medical staff…”
She also described what she’d seen in patient notes, such as a C-section ostensibly performed for “failure to progress” after a woman had been laboring only two hours, and others performed because the hospital did not allow VBACs (vaginal birth after c-section).
(I can attest that many hospitals will refuse to do VBACs — I even had one doctor insist to me that VBA2C didn’t exist and couldn’t be performed anywhere in the country. I found a doctor and hospital that felt otherwise, but only by traveling 1.5 hours in labor in the middle of a storm.)
Black Women Are Affected At Higher Rates
There are a lot of factors in ending up with an unnecessary C-section, including socioeconomic status. Even accounting for other factors, though, Black women are more likely to end up receiving the procedure when it’s not medically indicated. Parenting reported:
“The study, published in August 2024, gathered information from nearly 1 million births at 68 hospitals in New Jersey and found that Black mothers were 25% more likely to deliver by C-section than white mothers. Essentially, doctors are more willing to do unnecessary C-sections on Black mothers when there is the capacity to do so.”
Multiple doctors told the publication that this appears to be the result of medical racism and explicit or implicit bias. They posit that perhaps a medical team wrongly assumes a Black woman is incapable of handling labor.
Doctor Irogue Igbinosa also pointed out that before it was updated to remove bias, the metric for allowing a mother to attempt a VBAC — the vaginal birth after cesarean calculator — made Black mothers less likely to be eligible, meaning they were less likely to have the option of avoiding a c-section with a second pregnancy.
Experts Say VBAC Calculator Is Still Biased, In Fact
The VBAC calculator was updated in 2021 to remove race as a variable, but in a 2022 paper in the AMA Journal of Ethics, Nicholas Rubashkin, MD, PhD, argued against the calculator, saying:
“In fact, VBAC calculator use in the United States is laced with racism, compromises patients’ autonomy, and undermines informed consent.”
Dr. Rubashkin cites in his argument the ongoing higher maternal mortality rates for Black and Hispanic women in the U.S., and overall inequality in the U.S. affecting health conditions. He says:
“For example, neighborhood lethal policing is associated with a greater risk of hypertension and obesity in women.36 The incorporation of these 2 variables could mean that scores of Black and Hispanic women are concentrated in the lower score range.”
Disparate Treatment Equals Disparate Results
A higher rate of unnecessary C-sections can contribute to higher maternal mortality and higher rates of complications like placenta acreta that affect the mother’s ability to carry another pregnancy to term.
A procedure that leaves a mother with complications can affect the rest of her life, potentially limiting her reproductive choices in the future and even increasing the risk of needing a hysterectomy later, according to Ariadne Labs.
Overall, support seems to have the most positive effect on reducing unnecessary C-sections. The aforementioned nurse-midwife Ledbetter opines that more midwives on obstetric teams would be a good move and specifically suggests that insurance providers should require networks they cover to include midwives.
