Social Causes for Cesarean?

One of the courses I am taking this semester is about determinants of health.  We look at things both within the individual, and within the environment, and how they interact to affect health. A very interesting topic, and very challenging to integrate the research on a topic into a three page essay. But integrate I must.

For the next paper, I’ve decided to look at race and ethnicity and its effects on cesarean.  I know enough epidemiology to know that when you adjust for risk factors African American and Latina American women are more likely to give birth via cesarean than their Caucasian American neighbors. It isn’t a small increase either – check out this study which is pretty representative of the epidemiology all over:

What the adjusted odds ratio means is that when we control for all the things that we know affect having a cesarean (like social or medical risks), we end up with this number.  In the case of African American women, that number is 1.54 – so an African American woman with no risk factors for cesarean is 54% more likely to give birth via cesarean than a Caucasian American woman with no risk factors in the next room.

Does this surprise you?

What about the result that African American women have a 2.19 adjusted odds ratio of having a cesarean for non reassuring fetal heart tracings. This means that if two women are in labor in rooms right next to each other (this was data from one hospital system), the African American woman has more than twice the risk of being told she has non-reassuring fetal heart tracings and that she needs a cesarean than the Caucasian American woman in the next room.  Does this seem biologically possible to you?

There are potential social factors that cannot be adjusted for – for example, are Caucasian American women and African American women likely to use different practitioners for their care – and therefore the choice of practitioner is affecting the rate of cesarean?

Another idea is the effect of racism on the actual health of the woman – do the effects of racism and the chronic stress of that racism reduce the capacity of an African American woman’s body to handle the additional stress of labor?

Or is it more obvious than that? Are our healers and care institutions still making decisions based on racism – deciding African American women are either too lazy, too unhealthy, too unfit, too complaining, too controlling, too loud, too sexual, too poor, too proud…. (you get the idea) to give birth naturally and so the decision to cesarean is made faster, easier, with less compelling data?

I don’t know what the answer is. I don’t think I’ll find it in the literature, but if I do I’ll let you know.  In the mean time, consider what your advocacy group for physiological childbirth looks like – and if the increased cesarean risk for racial minorities is something your advocacy group speaks against.