Doctors Give Black Women Unneeded C-Sections to Fill Operating Rooms, Study Suggests

Obstetricians are more likely to give Black women unnecessary cesarean sections, putting those women at higher risk for serious complications like ruptured surgical wounds.

That’s the conclusion of a new report of nearly 1 million births in 68 hospitals in New Jersey, one of the largest studies to tackle the subject.

Even if a Black mother and a white mother with similar medical histories saw the same doctor at the same hospital, the Black mother was about 20% more likely to have her baby via C-section, the study found.

Sign up for The Morning newsletter from the New York Times

The additional operations on Black patients were more likely to happen when hospitals had no scheduled C-sections, meaning their operating rooms were sitting empty. That suggests that racial bias paired with financial incentives played a role in doctors’ decision-making, the researchers said.

How that bias creeps in is not entirely clear. Doctors may rush to perform a C-section faster for Black women, worried about the well-known racial disparities in childbirth outcomes. Black women may feel less empowered to push back against the suggestion of C-section when their labor is not progressing — or, when they do push back, they may be less likely to have their concerns taken seriously.

“Physicians may have certain beliefs about Black women,” said Janet Currie, a health economist at Princeton University and a co-author of the study. “They might not be listening to Black women as much, or be more afraid that something will go wrong.”

C-section delivery is the most common surgery in U.S. hospitals, despite years of advocacy to lessen its use. About 30% of babies in the United States are delivered this way, about double the proportion deemed appropriate by the World Health Organization. While the surgery can be lifesaving, unnecessary surgeries create a higher risk of complications for mothers, as well as higher medical bills.

In the new study, Currie and two other economists analyzed the medical records of more than 993,000 women who gave birth between 2008 and 2017. The team focused on women who came to the hospital in labor, excluding those who had scheduled C-sections.

They found that overall, Black women were 25% more likely to have C-sections than white women were. Among women who arrived healthy and who had few risk factors, the gap was even larger, with Black women more than twice as likely to be given C-sections.

Medical records could not capture everything a doctor used to make medical decisions, the researchers said. Doctors might not always write down details that made Black women better candidates for surgical delivery.

Still, the data on the capacity of the hospital’s operating rooms points to explanations that are not medically justified.

When other women were occupying operating rooms with scheduled cesarean deliveries, Black and white women had the same likelihood of being sent there for delivery.

“If Black moms are better candidates for C-section, then you should see them getting sent for C-section more even when there is limited capacity,” said Molly Schnell, an economist at Northwestern and one of the study authors.

The disparity emerged only when the operating rooms were empty. Then, 8% of healthy Black women wound up delivering by C-section compared with 4.8% of healthy white women.

“There is lots of evidence that if a hospital has a CT scan or an MRI, they like to keep it busy,” Currie said. “If you have an operating room set up to do a C-section, they like to keep that busy too.”

Dr. Ijeoma Okwandu, a practicing obstetrician with Kaiser Permanente in Atlanta who has also researched racial disparities in C-section rates, said the study was novel because it “followed the money.”

“That really is the driver of so much that happens in medicine,” she said. Private insurance plans typically pay about $17,000 for a C-section delivery and $11,500 for a vaginal birth.

Okwandu published a study in 2022 that found that Black women were more likely to be diagnosed with fetal distress during labor, leading to a C-section delivery. But that diagnosis, she said, is often subjective — and doctors may unconsciously use different thresholds for women of different races.

“Doctors know the data that shows there are worse birth outcomes for Black women, and that could play into their having lower risk tolerance,” Okwandu said. “But at the same time, they’re perpetuating another disparity in C-sections.”

The new study found that rather than preventing harm, the C-sections given to women when the operating rooms were otherwise empty led to more surgical complications. Recovery often requires more time in the hospital, and other studies have also linked the surgery to lower odds of successful breastfeeding.

A C-section, Okwandu said, “is taken as something that is common, but it’s not without risk.”

c.2024 The New York Times Company