Hello Dear Readers! I am back after my August vacation. As we get closer and closer to the election, I am both excited to be back in the writing chair and a little nervous. I love hearing from readers and seeing your comments, the connections I’ve made through this newsletter have been a welcome warmth in what is often an isolated academic landscape.
But writing close to election time also means having to write through a lot of nonsense (no, Haitians are not eating pets. Yes, you should be worried that a presidential candidate is (once again) spouting lies and propaganda that started on Neo-Nazi websites.)
But today, I want to go back to basics in maternity care and talk about some of the research that has come out recently on cesarean rates. A study of one million births found that cesarean are overused on Black women, and given that there is a connection between cesareans and maternal mortality and that Black women have 3-4 times higher rates of maternal mortality than white women, hopefully this is finally the time to talk about over-use of cesareans.
Cesareans are overused in the US
What we know for sure: cesareans are over-utilized in the United States. Here is some data on the US maternity care in a comparative perspective. Our friends over at Evidence Based Birth offer easily accessible data and a podcast on the overuse of technology and interventions in childbirth. Jen Kamel of VBAC Facts reports on hospital policies that allow doctors to order cesareans over patient consent for any reason. The data is out there, yet too often it is ignored, and with Florida’s new law that allows doctors to perform cesareans innon-hospital medical facilities we’ll see how that data shakes out next year (ironic when midwives can’t even legally non-surgically catch babies in all birth centers around the country).
But talking about cesareans is tricky. Like polarization in the rest of US culture, talking about childbirth leads to fights, hurt feelings, and a host of misinformation.
I can’t tell you how many times I have been accused of being anti-c-section or cesarean shaming because I had my second daughter vaginally (I had a c-section with the first) or of being anti-doctor (I’m not) for bringing up the US’s high cesarean rates. Professionals who should have been able to look at the data and see the same things I did jumped to defend cesarean rates and called my research “too activist.”
People don’t trust women—I’m not even sure they like us
Why doesn’t the data convince people? I hypothesize that it stems from misogyny. People just don’t like or trust women, even other women can throw each other under the bus when we’re talking about who got childbirth “right.”
If you think I’m overreacting about the general hatred of women and want a reason to set something on fire, consider the recent case in France of Gisele Pelicot. For decades her husband drugged her without her consent so he could advertise to men to come and rape her while he videoed them doing so. The fifty men on trial right now in France, including upstanding members of their community, are one thing. But what about the hundreds or thousands over the last decades who saw these advertisements and did nothing. No one passed this on to a cop who showed up undercover and started arresting people? Why? Because violence against women, especially in a sexual capacity does not matter to far too many people. Even with video evidence, I’m betting at the end of this trial, some of those men won’t be going to jail.
It is the same thing when we talk about childbirth. People don’t trust women to make their own decisions, laws and policies that are made to control women’s bodies and choices are normalized to the point where they can’t even be questioned, and when something does go wrong, the women are blamed.
I have personally heard people suggest discredited theories like “too posh to push” blaming rising rates on women who just can’t be bothered to labor. There are so many problems with this theory, namely that major abdominal surgery that cuts through seven layers of a human body is somehow the “easy way out.” Also, shaming women for taking an easy way out is ridiculous on its face. Let me be very clear: whatever you think the easiest way out of labor is for you, take that one. I’ve done vaginal birth, I’ve done cesarean. None is easy.
Sure, there are some concerning trends of young women asking for cesareans because they want to stay “tight” for their partners. Not much makes my head fly around and start shooting fire like that one guy in castle 4 in the dark world on Zelda: A Link to the Past (you’re welcome for that super specific reference) quite like these outdated, sexist stereotypes. But this means that doctors, reproductive health and childbirth educators, and society in general needs to do better about body shaming and having honest discussion about women’s bodies. Also, this isn’t what is driving up rates.
Physician Induced Demand
What recent research confirmed is the physician induced demand (PID) theory suggests, albeit in this case, specifically through the lens of racial health disparities. Previous research also confirms that doctors are driving up cesarean rates for non-medical reasons. The factors range from defensive medicine—when doctors perform more interventions they are less likely to get sued, to economic incentives—doctors get more money.
When Medicaid started reimburses cesareans at higher rates, Medicaid recipients started having more of them. Today, more Medicaid births are cesareans. Before you ask a valid question about poverty and bad health being the reasons for cesareans (meaning it’s the factors that lead to being on Medicaid that also lead to poorer health outcomes across the board), know that that’s been studied and what came out was that if you lower cesarean reimbursements the Medicaid cesareans decrease. So, the money is the factor that changes things.
Racial Disparities
I don’t know how long it’s going to be until Black women get the health equity they deserve, but I know it’s not today. Corredor-Waldron, Curry, and Schnell (2024) bring the data to backup such big claims, but the question left is whether or not anyone is going to care. In one of his un-whitewash-able quotes, Dr. King: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Over and over this burden falls on Black women, increasingly on Latinas and Southeast Asian women as well, but that’s been the case for decades and not much has been done to change it.
We need policies that address racial health gaps. We need policies and training that address the overuse of technology and intervention in childbirth. But more than that, we need to listen to women. We need to take women and birthing people seriously when they talk about their experiences. We need to listen to Black women when they say they are living in a system that is killing them. It is that easy and that difficult.
Conclusion
I’ve recommended Dr. Blackstock’s book Legacy before, and I’m going to do it again. Her discussion on racism in medicine is important to understanding where this racial disparity comes from and why it persists. But one thing she offers that is easy to overlook is a study of the Flexner Report. When Flexner set out to change the medical profession, he didn’t just help close down all but two Black medical schools because of white supremacy. It was more than that. He took a specific model of medical and institutional supremacy paired with white supremacy based on his understanding of German attitudes towards science and empiricism.
During the time Flexner was trying to change medical school culture and doctor culture, medical educators in the field warned him that he would sacrifice patient-doctor relationship and isolate doctors from their role as community servants. Flexner won, and the medical culture he left in his wake did exactly what opponents then said it would.
After all these years, it turns out that if we want to improve health outcomes, we still have to fight Flexner. And for Black parents and their families, that moment can’t come fast enough.