Rachel Feltman: Imagine two pregnant women going into labor at the same hospital. They have the same medical histories and have had the same pregnancies. They are seeing the same obstetrician. The only difference between them is that one is Black and the other is white. According to a study of births in New Jersey hospitals, black patients were about 20 percent more likely to have an unscheduled C-section than white patients.
That number takes into account factors such as differences in health status or access to good hospitals and doctors. Without controlling for these variables, the number is even higher, with the researchers finding that black pregnant women are nearly 25 percent more likely to have an unscheduled C-section than white women.
C-sections can, of course, save lives. But they also carry all the risks of major surgery, so the fact that people could be pressured into having unnecessary C-sections is quite worrying. That this seems to happen disproportionately to black people is even more troubling.
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In fact American scientific‘s fast science I’m Rachel Feltman. Join us today Adriana Corredor-WaldronAssistant Professor of Economics at NC State University and one of the authors working paper I mentioned
Thank you so much for taking the time to speak with us today.
Adriana Corredor-Waldron: Thank you for being me.
Feltman: So I’m curious: you know, as someone who focuses on economics, what made you want to study C-sections?
Corridor-Waldron: In my research, I am generally interested in understanding how public policy changes or shapes health care and provider behavior. But specifically for this article, what we wanted to understand is why black babies are more likely to be delivered by C-section than white babies, and this is a pattern that you see in the United States.
We have data for New Jersey, so the first thing we checked is whether we can replicate this part of this pattern in New Jersey. And what we find is that even the US aggregates, but also the previous research suggested in different health systems, we can see the same pattern emerging for this situation.
Feltman: Mm, and why is the increase in C-sections worrisome, you know, from a maternal and fetal health perspective?
Corridor-Waldron: I want to clarify this article, what we are talking about: low-risk moms getting an unscheduled C-section…
Feltman: right
Corridor-Waldron: Caesarean section among high-risk mothers can save the life of the baby and the mother.
Feltman: Absolutely, yes.
Corridor-Waldron: But when we talk about C-sections among low-risk moms, we’re basically saying that moms are getting a surgical procedure that has a higher risk of complications, but that’s going to be put in the case of a C-section as well. mothers on a completely different path for future pregnancies. So we’re taking low-risk moms and then we’re making these discretionary determinations, and after the next delivery they’re very likely going to need another surgical procedure or another C-section.
Feltman: And have you found anything that helps explain what causes these differences?
Corridor-Waldron: The data from New Jersey is very rich from 2008 to 2017. And we are able to rule out what people might think is driving this racial disparity: we can rule out individual medical risk factors from birth. certificates that include eclampsia, prior C-section, if any—there is a booth presentation, and we adjust all of these data to one (over) 900,000 births. machine learning algorithm. So the machine learning algorithm is learning from the decisions the provider is making during that time period and predicts the probability that the mother will need the right c-section or the doctor that is needed.
So that’s what we do when we say that we control for an observable medical risk factor for eligibility to have a C-section, so even after adjusting for black-white differences in observable medical risk factors, even after adjusting for hospitalization. that they delivered and this-their socio-economic characteristic, what we find comes from that 25% racial aspect, controlling for these factors, the range is reduced to only 20 percent. And that remaining 20 percent is explained, or (more likely) driven by the provider’s discretion.
Feltman: So if you had patients who were basically the same in terms of their medical history and their needs, but one was a white patient and the other was a black patient, if they went to the same hospital, you found that the black patient was more likely to get a C-section. .
Corridor-Waldron: Yes, and even if they see the same doctor.
Feltman: Wow, yes. And what are some other ways that pregnant people of color receive different attention than their white counterparts?
Corridor-Waldron: We do not have the data to answer exactly what influences the doctor’s decision.
Feltman: Mm-hmm.
Corridor-Waldron: What we can say is that it is likely not due to unseen risk factors. We do not fully show the whole picture that the doctor is seeing at the time of making that decision.
Feltman: Mm-hmm.
Corridor-Waldron: But what we show is if we look at what happened to the racial gap when the operating room is occupied with a scheduled C-section and it’s empty, what you find is that this racial gap is only there when the operating room is empty. .
Feltman: Hmm
Corridor-Waldron: And what we think that’s showing is that if black mothers were better candidates—and we’re not going to be able to get that through medical discharge records—we should see that there’s a gap, if it’s empty or if it’s busy. , but what we’re seeing is that it’s likely not due to unseen risk factors.
Now, whether this is due to a lack of patience on the part of the doctor, a difference in communication styles and culture, or the doctor’s perception of risk, that it is different for black or white mothers, but we don’t. have enough data – or the right data to answer that part.
Feltman: So when we talk about patience, are we basically saying that maybe the doctors are faster, you know, “This show is going too slow; Would I recommend a C-section,” for a black patient?
Corridor-Waldron: That could be an option. Again, we can’t tell from the data what exactly is going on. Another possibility could be that we’re all reading (Centers for Disease Control and Prevention) reports on infant mortality-or Black infant mortality…
Feltman: Hmm
Corridor-Waldron: And in the previous works we also know how the maternity departments perceive risk and how they act; therefore, there are some maternity wards that are more reactive – for example, they wait until there is a complication, and then they act on it – and those types of maternity wards have a lower Cesarean rate compared to maternity wards that are more proactive – for example, “I want to avoid a complication”—and this type of behavior tends to result in a larger C-section.
So, again, for that, we would need more qualitative data, such as how doctors make these kinds of decisions. But let’s put it this way: literature has proof of both.
Feltman: Yes, so what needs to change systematically to make maternal health more equitable?
Corridor-Waldron: Yes, what comes to mind is promoting diversity in the medical profession. So we find some evidence that the racial gap narrows when there is concordance, namely when the Black (mother’s) physician assistant is a Black physician….
Feltman: Mm-hmm.
Corridor-Waldron: … that the racial gap is narrowing. Therefore, there is suggestive evidence, although not statistically significant, that this channel can help us improve these indicators.
Another is advocates, so make sure moms have an advocate, like a birth doula. Unfortunately, although the available evidence shows that doulas are good for mothers in reducing C-sections, doulas are not usually covered by insurance.
Feltman: Hmm
Corridor-Waldron: And this is a third person, who will stand up for the mother, who has seen many births and knows how things should be, right?
And the third, which is something that the regulators are trying to implement, I think, is value-based payments, where the payment is not based on the number of resources used, but on the health of the patient, how much value we’ve added with this. the procedure And that’s because we’re seeing a discrepancy between when the operating room is empty and when it’s occupied.
Feltman: Yeah, so basically making sure there’s no financial incentive to promote unnecessary surgeries, but rather a financial incentive to make sure everything is being done as easily and as helpfully as possible.
Corridor-Waldron: Yes, exactly. In the end, taking care of the patient’s health is what matters to us.
Feltman: Absolutely. Are you doing more research on this question?
Corridor-Waldron: First of all, we have to publish this (laughs), but we’re also thinking: “Okay, what other decisions are made about childbirth?”. And one is inductions. We also have the data, so it would be interesting to see if there is any pattern between the races to achieve induction and what the consequences are for the health of the mother and the child.
Feltman: Terrible Well, thanks so much for coming on the podcast today.
Corridor-Waldron: Thank you very much for the opportunity. I am very eager to spread the message.
Feltman: That’s all for today’s episode. We’ll be back on Friday to hear how the mind can help us study the psychology of the dead.
Fast Science produced by me, Rachel Feltman, along with Fonda Mwangi, Kelso Harper, Madison Goldberg and Jeff DelViscio. Shayna Posses and Aaron Shattuck check out our show. Our theme music was composed by Dominic Smith. subscribe American scientific for more up-to-date and in-depth science news.
In fact american scientific this is Rachel Feltman. See you next time!
