Rachel Feltman: Imagine two pregnant women entering the same hospital to give birth. They have identical medical histories and have experienced identical pregnancies. We are seeing the same obstetrician. The only difference between the two is that one is black and the other is white. Black patients are about 20 percent more likely to have an unplanned C-section than white patients, according to a study of births in New Jersey hospitals.
This number takes into account factors such as differences in health status and access to good hospitals and doctors. Without adjusting for these variables, the number was even higher, with the researchers finding that black pregnant women were almost 25 percent more likely to have an unplanned C-section than white pregnant women.
Of course, a C-section can save lives. But with all the risks of a serious surgery, the idea that people could be unnecessarily pressured into having a Caesarean section is worrying enough. The fact that this appears to be happening disproportionately to black people is even more alarming.
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for scientific american‘s science quickly, I’m Rachel Feltman. Today I’m joined by Adriana Corredor Waldron, an assistant professor of economics at North Carolina State University and one of the authors of the research paper I mentioned.
Thank you very much for taking your valuable time today.
Adriana Corredor-Waldron: Thank you for having me.
Feltman: So, I’m interested. As someone who focuses on economics, what led you to research C-sections?
Corredor Waldron: In general, my research is interested in understanding how public policy changes and shapes health care delivery and provider behavior. But specifically in this paper, what we wanted to understand was why black infants are more likely to be delivered by cesarean section than white infants, a pattern seen across the country.
Since we have data for New Jersey, we first looked to see if we could replicate this part, this pattern, in New Jersey. And what we’ve found is that not only in the U.S. tally, but in previous studies that have suggested in different health care systems, we see the same pattern emerging in this state.
Feltman: Well, from a maternal and fetal health perspective, why is the rise in C-sections a problem?
Corredor Waldron: We want to be clear that what we want to talk about in this paper is low-risk mothers undergoing unplanned caesarean sections.
Feltman: right.
Corredor Waldron: When a high-risk mother performs a caesarean section, the baby’s life and the mother’s life are saved.
Feltman: I agree.
Corredor Waldron: But when we talk about low-risk maternal C-sections, we’re basically saying that the mother is undergoing a surgical procedure with a higher risk of complications; The same goes for the case. Mothers go in completely different directions for future pregnancies. So we are accepting low-risk mothers and doing these discretionary C-sections, but from the next birth onwards, they will probably need another surgical procedure or another C-section.
Feltman: And have you discovered anything that helps explain what is causing these disparities?
Corredor Waldron: What we have is very rich data for New Jersey from 2008 to 2017. And we can filter out what people think is causing this racial disparity. Medical risk factors at birth can be eliminated one by one. Certificates including eclampsia, previous C-section – if you have a breech baby, fit all data from 900,000 (+) births to machine learning. algorithm. Machine learning algorithms therefore learn from decisions made by healthcare providers during this period and predict the probability that a mother will require an appropriate or medically necessary C-section.
So when we say we’re controlling for observable medical risk factors for the appropriateness of a cesarean section, that’s what we’re doing, and we’re controlling for differences between blacks and whites in observable medical risk factors. Even after adjusting it, even after adjusting it to fit the hospital. What they bring to the table, and their socio-economic characteristics, what we find from this 25 percent racial disparity is that controlling for these factors only reduces the disparity to 20 percent. And this remaining 20% is accounted for. Alternatively, it is (possibly) determined by the provider’s discretion.
Feltman: So basically, if patients who are essentially identical in terms of medical history and needs, but one is a white patient and the other is black, go to the same hospital, the black patient is more likely to have a C-section. You can see that the quality is high. .
Corredor Waldron: Yes, even if you see the same doctor.
Feltman: Wow, that’s right. And what are some other ways pregnant people of color may be receiving different care than white pregnant women?
Corredor Waldron: We don’t have the data to answer exactly what drives a doctor’s decision.
Feltman: Hmm, hmm.
Corredor Waldron: What we can say is that unobserved risk factors are unlikely to be the cause. It cannot fully represent the entire picture that the physician sees at the moment he or she makes that decision.
Feltman: Hmm, hmm.
Corredor Waldron: But what we show is that if we look at what the racial disparity is when the operating room is crowded with C-section appointments versus when the operating room is empty, this racial disparity is You can see that it exists only when it is empty. .
Feltman: Hmm.
Corredor Waldron: And what we think this shows is that if Black mothers really were better candidates, and we can’t figure that out from hospital discharge records, if they were available or No matter how busy you are, you’ll find that there are gaps. , but what we’re seeing is that it’s likely not due to unobserved risk factors.
Now, whether this comes from a lack of patience on the part of the doctor, or whether it comes from a difference in communication style, or a difference in culture, or whether it comes from a doctor’s perception of risk that differs between black and white mothers. But we are not. You need enough data, or good data, to answer that part.
Feltman: So when we talk about patience, are we essentially saying that doctors are probably quicker to say, “This labor is too slow. This labor is too slow.” I recommend a C-section” to a black patient?
Corredor Waldron: That might be one possibility. Again, we can’t say from the data what exactly is going on. Another possibility is that we’ve all read the (U.S. Centers for Disease Control and Prevention’s) report on infant mortality rates for infants, or black people…
Feltman: Hmm.
Corredor Waldron: There is also evidence from previous papers that maternity wards do make a difference in how they perceive risk and how they deal with it. Therefore, some maternity wards are more reactive, waiting until complications arise and acting on them. This type of maternity ward has a low caesarean section rate, whereas a maternity ward has a high caesarean section rate, and people act proactively, such as “wanting to avoid complications,” and this type of behavior tends to increase the caesarean section rate. There is.
Again, this will require more qualitative data, such as understanding exactly how physicians make these types of decisions. But let’s say: There is evidence for both in the literature.
Feltman: Yes, so what needs to change systemically to make maternal health care more equitable?
Corredor Waldron: Well, one thing that comes to mind is promoting diversity in the healthcare workforce. So, we found some evidence that when there is concordance, that is, when the Black person’s (the mother’s) primary care physician is a Black doctor, racial disparities are reduced…
Feltman: Hmm, hmm.
Corredor Waldron: …That the racial disparity will narrow. Therefore, although not statistically significant, there is suggestive evidence that this channel may help improve these metrics.
The other is supporters. So make sure the mother has someone to support her, such as a birth doula. Unfortunately, doulas are typically not covered by insurance, despite existing evidence that they are good for mothers in terms of reducing the number of C-sections.
Feltman: Hmm.
Corredor Waldron: And this is a third party advocate for the mother, someone who has seen a lot of births and knows how things should be, right?
And the third thing, and I think this is something that regulators are trying to introduce, is value-based payments. Payment is based on patient health rather than the number of resources used, which determines how much value is added. procedure. This is because you can see the difference between when the operating room is empty and when it is busy.
Feltman: Well, basically we need to make sure that there is a financial incentive to make sure everything is done as easily and profitably as possible, rather than a financial incentive to encourage unnecessary surgery. .
Corredor Waldron: Yes, that’s right. Ultimately, protecting the health of our patients is what we value most.
Feltman: absolutely. Are you doing more research on this issue?
Corredor Waldron: I need to get this out there first (lol), but I’m also thinking, “What other decisions will be made regarding childbirth?” And one is induction. We also have the data to see if there are any patterns between races in how likely induction is to occur and what the impact is on the health of the mother and baby. It would be interesting to do so.
Feltman: wonderful. Well, thank you very much for coming on the podcast today.
Corredor Waldron: Thank you very much for the opportunity. I’m really looking forward to spreading the message.
Feltman: That’s it for today’s episode. We’ll hear on Friday how AI can help study the psychology of the dead.
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for scientific american, Rachel Feltman. See you next time!
