INSTITUTE FOR POLICY RESEARCH

Why Are Black Women More Likely to Have C-Sections Than White Women?

IPR’s Molly Schnell discusses her research on racial differences in deliveries

In the United States, Black women are three times more likely to die from a pregnancy-related cause than White women, highlighting the stark health disparities between Black and White mothers. Even wealthy Black women like Serena Williams and Beyoncé aren’t immune from these risks. In 2018, they both told Vogue that they delivered by emergency caesarean section (C-section) after experiencing pregnancy complications.

These kinds of stories point to a trend: Black women are more likely than White women to deliver their babies by C-section.

In a recent working paper, IPR economist Molly Schnell, Adriana Corredor-Waldron of North Carolina State University, and Janet Currie of Princeton University investigate the factors causing the racial difference in C-sections using a database of birth records from New Jersey from 2008 to 2017. They show that doctors, not mothers, are the reason behind the disparities. Black women were over 20% more likely to undergo a C-section—even when they preferred a vaginal birth and had the same medical risk and were treated by the same doctor in the same hospital as White women. 

Schnell spoke to IPR about her research, why doctors are performing more C-sections on Black women, and possible ways to lower the rate of unnecessary C-sections. 

What Motivated This Study?

Schnell explained that while it’s well documented that Black mothers are significantly more likely to deliver by C-section than White mothers, less is known about why. 

“In terms of the policy solutions, it really matters what the cause is,” she said. “We were interested in considering some of the hypotheses that people have previously pointed to in the literature—such as differences in maternal preferences, medical risk, or delivering clinician and hospital—and using exceptionally rich data to see whether any of these proposed explanations might account for the gap in delivery methods.”

Why Are C-sections a Cause for Concern?

C-sections are an important procedure and can save lives in some circumstances, but many argue that the rate of C-sections performed during deliveries is too high. The procedures can “lead to additional complications, both for mothers and for babies,” Schnell said. “We see that mothers are much more likely to show up to the hospital following birth with complications related to the surgical wound following discretionary C-sections.”

“Given the potential risks, we need to carefully consider when they should be used and when they shouldn't be used,” she said. 

What’s Driving the Racial Differences in C-sections? 

Data from Schnell’s study show that unscheduled C-sections, often referred to as “emergency C-sections,” are significantly less likely to happen when hospital operating rooms are busy. If an operating room is already occupied with a scheduled C-section delivery, then the rate of unscheduled C-sections falls for Black and White women, suggesting that the timing of a delivery matters. But the rate of unscheduled C-sections falls significantly more for Black mothers, so unscheduled C-sections for Black women are more discretionary than for White women. The evidence shows some doctors may have a lower threshold for performing unscheduled C-sections on Black mothers, meaning it takes less for them to opt for surgery on these patients. 

“After we came out with our IPR working paper, we talked to a number of physicians, midwives, [and] doulas—people who are on the ground, practicing in these locations,” Schnell explained. “They pointed to a number of factors that could be at play.”

Schnell says one thing they heard frequently was that doctors needed help managing how busy they were throughout their shifts. Some doctors prefer to spread deliveries out over the course of the day to better manage their patients—which can only happen by performing more C-sections, which typically take less time than a vaginal delivery.  

“We certainly can't point to one specific factor that's leading doctors to subject more low-risk Black mothers to discretionary C-sections,” she said.“But we can rule out a number of common explanations, and the discussions the study has generated have pointed to additional avenues for research and policy intervention.” 

How Does Money Factor In?

Schnell notes that research has shown that C-sections tend to rise when doctors earn more from performing a C-section compared to a vaginal birth. Although “financial incentives have been shown to be part of many doctors’ decision-making process,” she urges caution when it comes to changing the finances for deliveries. 

“In terms of policy solutions, the goal shouldn’t be to reduce C-sections universally, but rather to better target them to mothers who are medically in need of the procedure,” she argued. “If we reduce payments for C-sections, then we’d likely see a reduction in both unnecessary and necessary C-sections—which isn’t a great outcome.”

Schnell says having an advocate during birth may be one way to lower the rate of C-sections. Some randomized controlled trials (RCTs) suggest mothers are less likely to have C-sections when they have a doula, a trained professional who provides emotional and labor support during a birth. Some states are starting to change reimbursement policies for doulas and allow patients to use Medicaid to pay for them.

“We're particularly interested in how changing the role of advocates in birth could influence these findings,” Schnell said.

C-Sections and Black Maternal Health 

“Our findings are another data point in a large and troubling literature showing how the U.S. healthcare system too often leaves certain mothers and certain patients behind,” said Schnell.

In this case, we see a tendency to intervene too much instead of too little, she explains.

“Our work highlights how important it is for patients to stay informed about the different decisions involved in their medical care,” she said. “It also points to the potential value of having health advocates who can help address both the over-provision and under-provision of care.”

Molly Schell is assistant professor of economics and an IPR fellow.

Photo credit: iStock

Published: March 31, 2025.