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Why do Black women in the US have more C-sections than white women?
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Despite these risks – and despite what the Centers for Disease Control and Prevention (CDC), the US health protection agency, calls a “complex national problem” of Black maternal deaths – the evidence is clear. Black mothers consistently undergo caesareans more than white mothers, even in low-risk situations. And as a result, we’re more likely to suffer for longer after birth, to struggle to fully recover, or to die.

To try to understand why, I’ve been digging into the academic literature, speaking to women like Candice and Tee, and interviewing advocates leading the fight for Black maternal equality.

The short answer is simple: racism. But we need to understand the long answer too.

A history of control and profits

Some of medicine’s most impactful techniques came from repeated experiments without pain relief – including C-sections – on enslaved women in the American South.

Deirdre Cooper Owens, a professor of medical history, writes: “As much as white medical men are lauded for serving as the ‘fathers’ of American gynecology, black women, especially those who were enslaved, can arguably be called the ‘mothers’ […] because of the medical roles they played as patients, plantation nurses, and midwives.”

Despite this history, Black women’s bodies are often viewed as problematic when it comes to giving birth. Pelvic structures vary by ethnicity and even geography. But instead of teaching students to deliver babies from the wide range of body shapes in today’s multi-ethnic societies, medical books commonly treat the average white woman’s pelvis as the gold standard for vaginal delivery. Rather than learn how to support us to give birth vaginally, it’s easier to cut us open.

When the US economy depended on slavery and therefore Black reproduction to thrive, Black women were depicted as strong, perfectly capable of pushing out multiple babies and then heaving bales of cotton while carrying those babies on their shoulders. Many were even given rewards by their slave masters for giving birth – that is, providing them with more human property.

Today, the situation is reversed: treating Black women as less capable of bearing children without medical intervention suits America’s profit-driven hospitals.

“It’s about commas, it’s about money, it’s about the bottom line,” said Jennie Joseph, a British-trained midwife and founder of Commonsense Childbirth, which trains US midwives and doulas to provide hands-on assistance, emotional support and help mothers fully participate in the childbearing cycle.

Jennie Joseph founded Commonsense Childbirth to train US midwives and doulas | Jennie Joseph

The US healthcare system is run largely by a network of private corporations; it’s a system designed to prioritise the profits of stakeholders, private companies and hospitals over the health of patients. Advocates for Black maternal equality such as Joseph point out the significance of the ‘medical-industrial complex’: “It’s an entire system at play,” she told me.

This set-up produces numerous perverse incentives, resulting in a significant risk of overtreatment. And the forces pushing Black women towards caesareans have to be understood in this context – for hospitals, C-sections are a profitable business.

US hospitals charge an average of $22,646 for a C-section compared with $12,915 for a ‘normal’, uncomplicated pregnancy. While we don’t know how much each of these cost the hospitals, before they add on profit, we can get a sense from the UK’s NHS, which publishes how much it expects to pay, profit-free, for different medical procedures: $5,400 for a C-section, $4,500 for a standard vaginal delivery. Assuming base costs are about the same either side of the Atlantic, C-sections in US hospitals likely deliver around $17,000 of profit, compared with ‘just’ $8,500 for a vaginal birth.

The 2010 Affordable Care Act (ACA) meant that more Black women had medical insurance than before, but it didn’t remove the profit motive from hospitals, meaning there’s more incentive for hospitals to push women down the most profitable path, knowing their insurance company can pay. And Black women – who are less likely to be listened to when they push back against the idea of surgery – are the first people shoved down whatever road is most profitable for the system. Between 2008 and 2018, C-section rates increased for Black women, while they decreased among white women (for reasons I’ll come to).



A study from one hospital in Massachusetts looked at unscheduled C-sections. What they found was that Black babies were much more likely to be diagnosed as “in distress” than white babies.

As the academics put it, “The known subjectivity in the assessment of fetal distress using electronic fetal monitoring supports the potential of variation in decision making that results in lower thresholds for diagnosing fetal distress and recommending a cesarean among certain racial/ethnic groups.” In other words, in the high-stress context of the delivery room – likely with monitors bleeping and contractions squeezing – Black women are more likely to be pushed towards sometimes unnecessary C-sections.

The recent decrease in C-sections for white women in the US can be explained by the increase in ‘out-of-hospital’ births – at home and in birthing centres. Black women are more likely to be deemed high-risk or not healthy enough for an out-of-hospital birth, and birthing centres are often lacking in low-income communities. Also, more white women can afford the extra costs associated with these births, such as paying for a midwife or doula.

Numerous studies show access to doula care, in particular, leads to better outcomes, including lower C-section rates. But doulas aren’t covered by Medicaid, leaving Black women disproportionately out in the cold. Which is why Jennie Joseph’s school in Florida trains midwives and doulas.

[1] Url: https://www.opendemocracy.net/en/why-do-black-women-us-have-more-c-sections-white-women/