• An alarming new report reveals racial disparities in unnecessary C-section rates in New Jersey hospitals.
• The data show that Black women are 25% more likely to undergo a C-section than white women.
• The researchers suggest that implicit racial bias among providers may play a role in this rate and that there may be a “financial incentive” in some hospitals to fill operating rooms.
• Many factors may be responsible, experts say, and more research is needed to determine whether this disproportionate rate carries over to other states.

As racism within the healthcare system persists, a large new study reveals startling disparities in unscheduled C-sections among Black women.

A National Bureau of Economic Research (NBER) report of nearly 1 million births at 68 hospitals in New Jersey found that Black women are 25% more likely to undergo unnecessary C-sections compared to white women.

While more research is needed to determine whether these disparities are found in other states, the data point to the potential for implicit racial bias occurring in hospital delivery rooms at a provider’s discretion.

“The findings from the new study are alarming — it is concerning that these disparities exist and are so stark,” said Mark Simon, MD, chief medical officer at Ob Hospitalist Group (OBHG).

“The CDC has released data that clearly highlights national differences in C-section rates across each state, with New Jersey ranking on the high end. But this problem is not unique to New Jersey — disparities in maternal mortality, particularly along racial and socioeconomic lines, are also well-documented,” Simon told Healthline. Simon wasn’t affiliated with the research.

Why do Black women have higher rates of C-sections?

Cesarean delivery (C-section) rates have been increasing in the United States in recent years.

Many C-sections are scheduled in advance, leaving experts concerned about whether these are medically necessary.

Planned and unplanned C-sections account for roughly 1 in 3 births in the U.S., well above the 10–15% target rate recommended by the World Health Organization (WHO).

As the new research suggests, these figures include a disproportionate number of Black women. The causes for this disparity, however, is less clear.

NBER researchers suggest that more unscheduled C-sections may be occurring in Black women due to doctors who are “exercising their discretion and are more likely to conduct unnecessary C-sections on Black mothers.”

They cite in their report previous research showing that Black women are more likely to feel “pressure from a clinician to take medication to start or speed up labor and to have a C-section.”

“I do think this points to implicit bias,” Simon said. “It’s crucial that healthcare workers receive training on implicit bias to help recognize and reduce disparities in patient care. Additionally, we know a diverse clinical workforce leads to improved outcomes for Black patients. When health systems prioritize equitable outcomes for maternal patients, everyone benefits,” Simon said.

What are the risks of C-sections?

Cesarean deliveries, whether planned or unplanned, carry risks for both the birthing person and their baby. In emergency situations, however, C-sections can be lifesaving.

C-section deliveries can raise the risk of bleeding, blood clots, infection, and injury to other organs, Simon noted. “Additionally, they pose increased risks for future pregnancies, including conditions like abnormal placentation,” he added.

As NBER researchers note, Black women tend to have worse health outcomes overall than white women. However, experts point out there are underlying factors to consider that may affect the health outcomes of Black women following C-sections.

“If Black women undergo more cesarean deliveries, their exposure to associated risk increases,” Simon said. “These risks are compounded by the fact that Black women already experience higher rates of pregnancy complications and are more likely to have underlying chronic health conditions.”

Kecia Gaither, MD, MPH, double board certified OB-GYN and maternal fetal medicine specialist and director of Perinatal Services/Maternal Fetal Medicine at NYC Health + Hospitals/Lincoln in the Bronx, agreed that comorbidities often influence C-section outcomes. Gaither wasn’t involved in the new report.

“Is there a high concentration of obesity, hypertension, diabetes, substance abuse, [or] HIV?” Gaither questioned. “[It’s a] difficult question to answer.”

Multifactorial issues, such as racism, bias, poor attention to the clinical status of postoperative Black women, or the quality of the health facility, could all impact health outcomes following a C-section delivery, Gaither said.

The long-term risks of C-section delivery are not fully understood, but research has shown that short-term effects of Cesarean delivery may include:

• altered immune development
• increased risk of allergy, atopy, and asthma
• reduced intestinal gut microbiome diversity

“Cesarean sections are not benign procedures — the risk of hemorrhage, damage to the internal organs, [and] infection run high for the mother,” Gaither said.

“Babies born via cesarean may have breathing issues. Babies swim in amniotic fluid, this fluid fills the lungs. With a vaginal birth, this fluid is ‘squeezed out’ as the baby transits the birth canal. With an operative delivery, this lung fluid isn’t expressed, and it takes a while for that process to occur. As such, the baby breathes rapidly in an attempt to clear this fluid from its lungs,” she explained.

Is there a financial incentive to perform C-sections?

NBER researchers suggest there may be a financial incentive for healthcare providers to perform C-sections, thus pushing more Black women into the OR for the procedure.

“I don’t believe labor and delivery units prioritize keeping their operating rooms constantly occupied,” Simon said. “In my experience, labor and delivery staff do everything in their power to keep at least one OR open in case there is an emergency.”

Gaither was also cautious to ascribe to this theory. “I think there are many factors to consider when looking at the picture,” she said.

“Is there a high preponderance of early prenatal care [and] pre-conceptual counseling, or are patients showing up late in gestation, effectively ‘crashing and burning’ with some disease process that might have had a better outcome if caught in earlier stages?” Gaither pointed out.

“Is there a high utilization of reproductive technologies contributing to the population served? Reproductive technologies contribute to multiples (twins, triplets, quadruplets, etc.). These higher-order pregnancies increase the Cesarean section rate,” she noted.

When looking at C-section rates within hospitals, Gaither said the following factors should be considered:

• Does the population being served have insurance?
• Is the population serviced in a rural or urban setting?
• What is the mindset of the physicians servicing the population? Are they likely to perform an operative delivery so they can make a social engagement in time?
• What is the financial status of the hospital/hospitals involved?
• What impact does the environment play in the health of the populace?
• What role do bias and racism play?

Takeaway

A concerning new report shows that unnecessary C-sections are 25% more common in Black women compared to white women.

The researchers suggest that implicit racial bias could play a role, and there may be a “financial incentive” to fill operating rooms.

Experts say the reasons for this alarming disparity are multifactorial. More research is needed to determine whether the high number of C-section rates persist in other states.