Cesarean Delivery Rates in the United States

About a third of all infants delivered in the U.S. are delivered via a cesarean section, as opposed to a vaginal birth. This is much lower than the “necessary” rate of c-sections, as the World Health Organization reports this value to be closer to 10-15%.1 This is troubling, as a vaginal birth is considered the safer option for a healthy pregnancy. So why are there so many c-sections being performed if they are not necessary and not the safer option?

There are ongoing debates as to why the rate of cesarean deliveries continues to rise, but the most probable answer includes a combination of several factors. Increased maternal age and increased numbers of multiple births both play a role in this.2 Unfortunately, there are much more cynical reasons that could be behind this. Doctors are paid substantially higher for c-sections than they are for natural births. Additionally, c-sections typically take a lot less time than a vaginal birth. One concerned mother who was forced to have a cesarean delivery after her doctors denied her the chance to discuss other birth options, stated that she gave birth right around the holidays and she could tell everyone was itching to go home.3 Did her doctors perform an unnecessary, and possibly more harmful procedure, with a longer recovery time in order to ensure they made it home earlier for the holidays? This is a truly unsettling and disturbing thought, but it may just be reality.

It is also critical to note that the aforementioned mother who was coerced into a cesarean delivery is a black woman. During 2019-2021, the number of cesarean deliveries that were performed on infants in the U.S. was reported, along with the races of these infants, and there was a clear disparity. 36.2% of the cesarean deliveries were black infants, 31.4% of the cesarean deliveries were hispanic infants, and 30.8% of the cesarean deliveries were white infants.4 This disparity cannot be taken nightly. Not when giving birth is one of the hardest and most prominent experiences a woman will have in their lifetime. At the very least, every woman deserves to be heard and respected, especially by those who took an oath to help and not harm.

Edited by: Nana Osaki

Graphic Designed by: Shanzeh Sheikh

References

1. Emily Oster, W. S. M. C. (2019, October 17). Why the C-section rate is so high. The Atlantic. Retrieved March 24, 2023, from https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/

2. Highest C-section rates by country. BellyBelly. (2022, August 3). Retrieved March 24, 2023, from https://www.bellybelly.com.au/birth/highest-c-section-rates-by-country/

3. WebMD. (2022, June 16). More black mothers deliver by cesarean, not always by choice. WebMD. Retrieved March 24, 2023, from https://www.webmd.com/baby/news/20220616/more-black-mothers-deliver-by-cesarean-not-always-by-choice

4. MarchofDimes. (n.d.). Total cesarean deliveries by maternal race/ethnicity: United States, 2019-2021 average. March of Dimes | PeriStats. Retrieved March 24, 2023, from https://www.marchofdimes.org/peristats/data?reg=99&top=8&stop=356&lev=1&slev=1&obj=1

Removing the Barriers to Infertility Care

While the decision to get pregnant and have a child is a decision that is often carefully thought over, for some that option is taken away. Infertility affects millions of people of reproductive age, with some estimates suggesting that between 48 million couples and 186 million individuals are affected globally (WHO). The causes for this condition vary, with most being traced back to abnormalities in sperm, the ovaries, uterus, fallopian tubes, and the endocrine system.

However, there are a variety of options for those looking for treatment. These treatments can depend on multiple factors, including the cause, how long an individual has been infertile, age, as well as personal preferences. One treatment is the use of assisted reproductive technology, with the most common technique being in vitro fertilization (IVF). IVF involves “stimulating and retrieving multiple mature eggs, fertilizing them with sperm in a dish in a lab, and implanting the embryos in the uterus several days after fertilization” (Mayo Clinic). Other options include artificial insemination, in which sperm is transferred directly into someone’s uterus, and ovulation induction, where hormone medication is used to stimulate the ovaries to produce multiple mature follicles and ova.

Despite these different options for infertility care, limited information, high costs, and stigma, put this care out of reach for many, especially those in marginalized communities. One of the greatest obstacles to obtaining infertility care is the high out-of-pocket cost. Combined with the limited number of private insurance and public programs that covers infertility services, this economic barrier denies many the opportunity for infertility treatment. In fact, the median cost of a single IVF cycle in the United States is $19,200 (WHO). This hefty price tag is one that only those of high economic standing can afford, with one study finding that women without insurance coverage were three-times more likely to discontinue treatment after their first cycle because of the high price (Bronwyn Bedrick et al.).

Racial disparities in access to infertiliy care is well-documented within the United States. For example, while black women of reproductive age are 80% more likely to report they’re infertile compared to white women, they are actually 20% less likely to receive infertility care (Ada C. Dieke et al.). Furthermore, Hispanic and American Indian/Alaska Native non-Hispanic women have shown below average rates of infertility care use (Ada C. Dieke et al.). Part of the reason for these disparities could be the way IVF and other infertility care is marketed. As most people believe that IVF is something only the rich and white do, minorities are less likely to seek out these treatments. However, the root of the problem lies in our healthcare system: the high costs of care and lack of insurance coverage.

These barriers don’t have to exist. With better information given to the general public, more people can learn about the options they have for infertility care. More importantly, at the very least, we need to fight to have infertility care covered by insurance. Removing these drastic economic barriers will allow more people to gain access to this vital treatment. Being able to have a child is a basic human right and it’s the responsibility of those involved in reproductive and fertility care, including physicians and policymakers, to be aware of and address these barriers.

Edited by: Nana Osaki

Graphic Designed by: Alejandra Gonzalez-Acosta

References

1. https://reproductiverights.org/wp-content/uploads/2020/02/64785006_Infertility-and-IVF-Access-in-the-U.S.-Fact-Sheet_2.5.2020_Final.pdf

2. https://www.who.int/news-room/fact-sheets/detail/infertility

3. https://www.mayoclinic.org/diseases-conditions/infertility/diagnosis-treatment/drc-20354322

4. Bronwyn Bedrick et al., Factors Associated with Early In Vitro Fertilization Treatment Discontinuation (July 2019), 112 FERTILITY & STERILITY 105 (July 2019), https://www.fertstert. org/article/S0015-0282(19)30250-X/fulltext.

5. Ada C. Dieke et al., Disparities in Assisted Reproductive Technology Utilization by Race and Ethnicity, United States, 2014: A Commentary, 26 J. WOMEN’S HEALTH 605 (2017), https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5548290/ (hereinafter Dieke, Disparities)

The Injustices Within the Black Maternal Mortality Epidemic

Despite Black Americans making up 13.6% of the U.S. population, the maternal mortality rate for non-Hispanic/Latina Black women in 2020 was 55.3 deaths per 100,000 live births—almost three times more than that for non-Hispanic/Latina White women [1]. Unfortunately, during the COVID-19 pandemic, the Black maternal mortality rate increased to 68.9 deaths per 100,000 live births in 2021, a much larger mortality rate increase than for non-Hispanic/Latina White women [2]. As a Black woman who wants to have children someday, these statistics terrify me, and I believe that we should not be complacent in accepting this disproportionate mortality rate as the norm. More needs to be done to address the social determinants of health that lead to racial disparities in maternal healthcare, and more needs to be done to protect Black mothers.

Researchers have found that disparities such as lack of access to care, poor health insurance coverage, socioeconomic inequalities, racism, discrimination, and chronic stress contribute to worsening maternal health outcomes [3]. Health insurance coverage before and throughout pregnancy allows mothers to have better access to prenatal care, which includes physical exams, discussions on the health of the mother and the fetus, weight checks, breast checks, and blood tests [3, 4]. Access to this care is essential in reducing the risk of pregnancy complications, but people of color, specifically Black Americans, experience differences in health insurance coverage and more barriers to healthcare, especially in rural populations that are typically medically underserved [3]. The structure and finance of the U.S. healthcare system have been shaped by racial discrimination since the Jim Crow era (1875-1968) [5]. For instance, when the Hospital Survey and Construction Act was passed in 1946, states were allowed to build healthcare facilities that were racially separate and unequal. Additionally, federal programs to provide care to the poor were not supported by many state governments, and even today, inequalities under the Affordable Care Act exist in insurance coverage, financing care, and quality of care [5].

Concerning mortality rates, the leading causes of maternal death for Black women were the gestational high blood pressure disorders pre-eclampsia and eclampsia and a form of heart failure called postpartum cardiomyopathy. Black women were five times more likely than White women to die from these illnesses, and they were also two times more likely to die of severe bleeding or blood vessel blockages during and after pregnancy [6]. Therefore, frequent access to adequate care and better health insurance coverage is necessary to bridge the gap of the disparities that burden and kill pregnant Black women in our country.

Though a lack of access to adequate healthcare negatively contributes to poor maternal health, the combination of socioeconomic inequalities, systemic and structural racism, and discrimination against Black mothers are reported to be the primary factors of poor maternal health outcomes [3]. A survey on race and health that was conducted in 2020 and included over 800 Black participants found that most Black adults felt that the American healthcare system discriminates against people according to their race; this same survey reported that 37% of Black mothers were mistreated due to their race when receiving healthcare for themselves or a relative [7].

Other inequalities, especially those exacerbated by the COVID-19 pandemic, have disproportionately affected the Black community and Black mothers. For example, it is widely known that poverty disproportionately affects communities of color, especially with affordable housing, public transportation, access to healthy food, and quality of education. Research has shown that the chronic stress associated with this poverty has contributed to racial maternal health disparities [8]. Overall, these inequalities contribute to the problems we are seeing in Black maternal healthcare and show that America, specifically the U.S. healthcare system, needs to do better in providing care and listening to Black women.

One way that Black maternal health outcomes can be improved is through more government support in increasing access to maternal healthcare. In June 2022, the Biden Administration published the Blueprint for Addressing the Maternal Health Crisis. This document describes how federal agencies need to prioritize increased health insurance coverage, data collection and research, a larger and more diverse prenatal workforce, and other incentives to improve maternal health [3]. Additionally, the Health Resources and Services Administration has allotted over $300 million for states to strengthen maternal and infant health, and the Office of the Assistant Secretary for Health has invested over $8 million into initiatives to reduce maternal deaths and health complications that hurt people of color and people living in rural areas [3].

Only time will tell if these initiatives can decrease the overall maternal mortality rate and decrease the number of Black women who die every year due to pregnancy-related issues. The maternal mortality rate being three times higher for Black women than it is for White women should not be viewed as just another statistic or number on a piece of paper. This epidemic is scary, preventable, and unacceptable, and it highlights the injustice that Black women constantly face in healthcare settings. I am tired of seeing this disparity grow bigger and bigger every year, and I hope that one day, I will live in a country where I do not have to worry about Black women being pushed aside, disregarded, and ignored by our healthcare system.

Edited by: Sanjana Anand

Graphic Designed by: Natalie Chou

References

1. Hoyert, D. L. (2022, February 23). Maternal mortality rates in the United States, 2020. Centers for Disease Control and Prevention. Retrieved March 3, 2023, from https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm#Suggested_citation

2. United States Government Accountability Office. (2022, October). Maternal health: Outcomes worsened and disparities persisted during the pandemic. GAO Report to Congressional Addressees. Retrieved March 4, 2023, from https://www.gao.gov/assets/gao-23-105871.pdf

3. Hill, L., Artiga, S., & Ranji, U. (2022, November 1). Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. Retrieved March 3, 2023, from https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-maternal-and-infant-health-current-status-and-efforts-to-address-them/#:~:text=Research%20has%20documented%20that%20social,of%20mortality%20among%20Black%20infants

4. National Institutes of Health. (2017, January 31). What is prenatal care and why is it important? Eunice Kennedy Shriver National Institute of Child Health and Human Development. Retrieved March 3, 2023, from https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/prenatal-care#:~:text=Prenatal%20visits%20to%20a%20health,tests%2C%20such%20as%20ultrasound%20exams

5. Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US health care policy. Health Affairs, 41(2), 187–194. https://doi.org/10.1377/hlthaff.2021.01466

6. PRB. (2021, December 6). Black women over three times more likely to die in pregnancy, postpartum than white women, new research finds. PRB.org. Retrieved March 3, 2023, from https://www.prb.org/resources/black-women-over-three-times-more-likely-to-die-in-pregnancy-postpartum-than-white-women-new-research-finds/

7. Hamel, L., Lopes, L., Muñana, C., Artiga, S., & Brodie, M. (2020, October 13). KFF/The undefeated survey on race and health. KFF. Retrieved March 3, 2023, from https://www.kff.org/racial-equity-and-health-policy/report/kff-the-undefeated-survey-on-race-and-health/

8. National Partnership for Women & Families. (2018, April). Black women's maternal health: A multifaceted approach to addressing persistent and dire health disparities. National Partnership for Women & Families. Retrieved March 3, 2023, from https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html