Cesarean sections are increasing worldwide. Currently about 21 percent of all births are C-sections, up from 7 percent in 1990. And that number is expected to grow to 29 percent by 2030, according to the World Health Organization (WHO).
But who exactly gets a C-section isn't always equal. From 2018 to 2020, 35.8 percent of Black infants in the U.S. were born by cesarean, compared to 30.9 percent of white infants, according to the March of Dimes, a nonprofit organization focused on maternal and infant health.
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While C-sections can be lifesaving procedures, they also pose a significant risk for both birthing parents and babies. Women who had cesareans experienced ruptured uteruses, unplanned hysterectomies and ICU admissions more frequently than women who had vaginal births, according to a May 2015 report from the Centers for Disease Control and Prevention (CDC).
This trend is troubling to many health experts, considering the pregnancy-related mortality rate is already three times higher for Black women than white women, according to a September 2019 CDC report.
People have taken to Twitter to speak about personal losses of Black mothers in their lives due to cesarean section complications, expressing how different things would be if their friends were listened to in delivery rooms.
In April 2020, a woman named Amber tweeted: "Can't wait to write a tell-all about my experience during my last two trimesters dealing with incompetent doctors…" Five days later, one of her followers shared that Amber died during her C-section.
Amber's story is not the first of its kind, and numerous stories like hers can be found on Twitter under the search "C-section Black women."
The big question on everyone's minds is "Why?"
A Note on Language
Here at LIVESTRONG.com we consider both sex and gender to be spectrums, and as such, we make deliberate choices about the language we use. Throughout this article we're using the terms for birthing parents used by the primary sources for the sake of accuracy.
The concept of medical racism was first identified in the 1990s, ob-gyn Charis Chambers, MD, a pediatric and adolescent gynecologist, tells LIVESTRONG.com. Dr Chambers's resident research project focused on the disparities in cesarean sections among Black women.
Once researchers identified higher mortality rates among Black birthing parents, they started to dig deeper for an explanation. Various studies compared the birthing experiences of women of color with those of white women who had the same access, insurance coverage, yearly income and educational levels and even gave birth in the same hospitals, according to Dr. Chambers.
Even after in-depth analyses — including a May 1999 study in the Journal of the National Medical Association and a March 2004 report in Birth — researchers couldn't determine what accounts for higher rates of C-sections or delivery-related deaths among people of different races.
"You should pick your doctor like your life depends on it, and unfortunately, in some cases, it does."
"There was no benefit to being college-educated or having more money and resources, which are all of the reasons that people point to," Dr. Chambers says. "It's none of those things. It really points to the things we can't measure, like racism and bias."
The lack of answers remains decades later. In a May 2015 study in the American Journal of Public Health, researchers weren't able to find a direct explanation for why C-section rates were higher among women identified as African American in administrative data from 255 hospitals in California.
The researchers stressed the need for more attention to be paid to patient-level factors that have not been measured, including provider-physician interactions and patient preferences.
It's important to note that some C-sections are necessary, and some birthing parents may prefer to deliver via cesarean. The problem is when neither of those things is true.
How to Advocate for Your Best Care
Decades of medical racism serve as a reminder that there is a need for larger, systemic, societal changes across the health care industry, which takes time. In the meantime, there are some ways you can protect yourself if you're giving birth, even though the responsibility shouldn't solely fall on you.
To arm you with the information you need to become an empowered patient, several Black ob-gyns shared tips here about how you can advocate for the best care while pregnant and during delivery.
Consider Your Options
Start by thinking through your own priorities and/or sitting down with your partner to discuss what's most important, including your ideal birthing process and prenatal care, prior to meeting with doctors, says Diana Wilson, MD, an ob-gyn at Morehouse School of Medicine.
Deciding the type of birth you want can be difficult, and you should remember even the best birth plans don't always go the way you want them to. But knowing what you truly want may help you find the perfect doctor for you.
That might look like a less traditional birthing experience, such as:
- Visiting a midwifery center: These facilities aren't part of a hospital or doctor's office, but midwives and/or ob-gyns assist during the birthing process.
- Having a home birth: Delivering at home is typically monitored by a midwife.
- Working with a doula: Doulas are trained supporters rather than health care professionals who aid parents through the birthing process and other related experiences.
If you choose a midwifery center, Dr. Wilson recommends interviewing different midwives and asking how they work with physicians. If you end up needing to go to a hospital, for example, "does the midwife have privileges there?" she suggests asking. "If the doctor does have to do a C-section, does the midwife assist the physician?"
You'll also want to talk to potential midwives and ob-gyns about the safest option for you. Midwifery centers and home births are not without their own risks, even if they sound more appealing to you. For example, an August 2020 study in the American Journal of Obstetrics and Gynecology found 13 out of every 10,000 midwife-attended home births resulted in infant death, compared to 6 per every 10,000 hospital births.
Find a Doctor Who Is a Good Fit
"Interview several different ob-gyn physicians. Also, talk to family members and friends who have had positive, good experiences with their ob-gyn physicians," Dr. Wilson says.
Once you've chosen a doctor and are under their care, here are some red flags to look out for, according to Dr. Chambers:
- Bad reputation with other patients
- Unanswered questions
- Minimization of your concerns
- Lack of trust in the patient-doctor relationship
If there are certain things that bother you, speak up. "There is no trophy for being most-liked patient," Dr. Chambers says. "You need to push back, and good doctors want you to feel good with their plan. Good doctors want you to understand what the next step is."
Patients can be scared to push back, she adds, but when it comes to your health, a fear of asking questions can be potentially dangerous.
"You want to choose a provider who listens to you," Dr. Wilson says. "You have to be heard, and it has to be a good relationship. It's OK to start off with one provider and then decide to switch."
You may also want to look for a doctor with diverse patients. "You want to choose a physician who is well-versed in African American women," Dr. Wilson says. "Most of all, you want to choose a physician who is passionate about giving good health care to all women."
You can ask doctors for their C-section rates to determine if their rates are higher than usual, Dr. Wilson says, and even ask how they feel about the Black maternal mortality rate, Dr. Chambers suggests. If they don't have an answer that's satisfactory to you, then they may not be the right fit for you.
"You should pick your doctor like your life depends on it," Dr. Chambers says, "and unfortunately, in some cases, it does."
Do Your Research
To do what's best for you and your family, you'll likely need to educate yourself on whichever options interest you, Dr. Chambers says. You may find the best way to do this is by consulting with medical professionals you trust.
Dr. Chambers also suggests gaining more insight by reading informational texts, including pamphlets at your ob-gyn's office. "Read anything you can get your hands on [in your doctor's office]," she says, "especially if you don't know much about labor and delivery."
Any additional materials you read should come from trusted sources.
Start With These Credible Resources
Speak Up if Your Care Team Is Pushing a C-Section
If the process doesn't go smoothly when you're in the delivery room, you and your loved ones can speak up in the hospital, as well.
"There are reasons things change," Dr. Wilson says, "such as if we think you should have a C-section because of what we see."
If you're being told you need to have an emergency C-section, Dr. Wilson says it is absolutely OK to ask why. Some complications are time-sensitive, and in those cases, doctors may act quickly to protect you, she says.
"Often, we need to do this for your baby. We need to do this because labor is not safe," Dr. Chambers says. "It's hard to counsel in an emergency where the more time you spend counseling, the less life you have."
A rushed, emergency C-section most often has to do with the fetus's health, Dr. Chambers says. In situations where there is a lack of blood circulation to the fetus, it leaves very little time for doctors to explain the issue before performing a C-section.
Other issues that result in emergency C-sections include a fetus or parent in distress, a fetus being in an abnormal position, problems with the placenta and more, according to the Mayo Clinic.
If it is not urgent, ask for a list of reasons your doctor recommends a C-section and weigh your options, Dr. Chambers says. You should understand everything about why a C-section is necessary if it's not an emergency.
You can ask for another hour to decide, depending on the circumstances, but Dr. Chambers warns everyone's situation is different. Your doctor should communicate the risks in order for you to make the best decision for yourself.
- WHO: "Caesarean section rates continue to rise, amid growing inequalities in access"
- March of Dimes: "Total cesarean deliveries by race: United States, 2018-2020 Average"
- Center for American Progress: "Eliminating Racial Disparities in Maternal and Infant Mortality"
- CDC: "Maternal Morbidity for Vaginal and Cesarean Deliveries"
- CDC: "Racial/Ethnic Disparities in Pregnancy-Related Deaths"
- American Public Health Association: "Factors Associated With Increased Cesarean Risk Among African American Women"
- ACOG: "Planned Home Birth"
- American Journal of Obstetrics & Gynecology: "Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant"
- American Journal of Obstetrics & Gynecology:"Neonatal outcomes of births in freestanding birth centers and hospitals in the United States"
- Mayo Clinic: "C-Section"
- The Journal of Reproductive Medicine: "Maternal mortality in the U.S. Department of Defense, 1993-1998"
- Birth: "Effects of maternal characteristics on cesarean delivery rates among U.S. Department of Defense healthcare beneficiaries, 1996-2002"
- Journal of the National Medical Association: "Predictors of cesarean section delivery among college-educated black and white women, Davidson County, Tennessee, 1990-1994"
Is this an emergency? If you are experiencing serious medical symptoms, please see the National Library of Medicine’s list of signs you need emergency medical attention or call 911.