As technology advances encourage improvements in maternal healthcare, the number of Cesarean sections has risen significantly. According to the World Health Organization, C-section rates worldwide have increased from approximately 7% in 1990 to about 21% currently [1]. With this dramatic rise, WHO predicts that 29% of all births will be via C-section by 2030. A Cesarean section is an abdominal procedure that involves an incision in the uterus to deliver a child surgically instead of vaginally [2]. The surgery is invasive and hence requires planning. This planning ranges from the type of medications used during the birth to post-partum care for the child and the mother - such as, NICU admittance for birthing complications for the infant or post-operative care for the mother in case of complications regarding blood loss and blood pressure fluxtuations - and other surgical support. Non-medical and personal planning is also necessary, such as who will be in the operating room, what day will the C-section be scheduled and at which hospital, when can the mother begin breastfeeding, etc. Due to the extensive nature of such planning, individuals with more financial resources will have more access to the procedure, making scheduled C-sections a luxury. Meanwhile, for working class womxn and womxn of color, making C-sections more rare. They simply do not have the time nor funds to spare in order to schedule a C-section. In the situation that they need an emergency C-section due to high risk pregnancies, often complicated by the environments of impoverished neighborhoods and demographics, their local hospitals will not carry the resources necessary for substantial care. Thus, as C-section rates increase, one can also observe the subsequent rise of inequity surrounding them. This inequity can be found right around us, in New York City, as seen through varying C-section rates in each of the city’s boroughs, that differ in demographics such as ethnicity and socioeconomic class.

When comparing income, the Bronx has the highest percentage of people living in poverty. As of 2019, the poverty line for a family of four was $25,926; 29.5% make less than $20,000 [3-4]. This borough also has a lower number of specialized hospitals; the Bronx houses seven specialized hospitals while Manhattan houses thirteen. Specialized hospitals require more funding and resources, something for which low-income communities are unable to pay without aid from the state. Therefore, specialized, well-funded hospitals like the New York Presbyterian health system and NYU Langone are in wealthier areas: the Financial District and Rose Hill respectively. In these areas, many patients are more likely to have private insurance. On a national level, hospitals lose money to Medicare and Medicaid. In 2015, Avalere health found that 63.9% of hospitals lost money on Medicare. Private insurance partially covers this loss. Hence, in order to support these specialized hospitals, private insurance is a must in order to support patients with Medicare and Medicaid. Columbia Presbyterian, which is affiliated with the well-endowed Columbia University, is one such hospital that accepts a wide range of private insurance companies in addition to Medicare and Medicaid. The hospital accepts coverage from over 60 insurance companies [5]. It is also one of the largest and oldest hospitals in the United States, with 20,000 employees and just under 3,000 beds [6]. The New York Presbyterian healthcare system is the result of a merger between The New York Hospital and The Presbyterian Hospital, resulting in the collaboration between Ivy League institutions Columbia University and Cornell University. Housed in Manhattan, the hospital serves not only the borough but surrounding areas such as the Bronx.

Surveying the issue geographically, one can conclude that hospitals with birth wards in the Bronx experience more stress due to the higher population that they have to serve. Hospitals in the Bronx tend to be overfilled as the 7 hospitals of the borough serve approximately 1.4 million people, while Manhattan has 6 more hospitals to serve only 0.2 million more patients [8]. Bronx hospitals also faced issues with understaffing and lack of resources in face of COVID-19 [9]. However, before COVID, Bronx hospitals perpetually faced issues with overfilling due to the fact that they serve more people with fewer hospital resources available. The resource disparity between both boroughs is evident through the maternal morbidity rate. In Manhattan, the severe maternal morbidity rate is 745, the second lowest of the five boroughs (Staten Island being the lowest and Brooklyn being the highest) which parallels their significantly larger and better access to medical-resources [7]. Considering borough size and population, the Bronx has disproportionately fewer hospitals, ergo it also has fewer options in terms of maternal medical centers per person. The Bronx is 42.27 square miles and home to 1.425 million people according to the U.S. 2020 Census [10]. There are only seven specialized hospitals to serve patients throughout the borough, which is double the size of Manhattan; While, Manhattan is 22.82 square miles, home to 1.632 million individuals, and houses thirteen hospitals [11]. The discrepancy is quite evident. Not only do women in the Bronx have to seek out the few medical centers that specialize in maternal healthcare (resources for C-section complications due to hospitals being more generalized to suit the larger population size), but they also have a lesser number of hospitals from which to choose. They also have to travel farther distances to receive Cesarean sections, which contributes to ongoing inequities concerning socioeconomic class.

A comparison of two hospitals, one in Manhattan and the other in the Bronx, offers a unique insight into this inequity. New York Presbyterian Hospital-Columbia Presbyterian Center in Manhattan performs the highest number of C-sections in the city of New York: C-sections there make up 41.8% of births while vaginal births make up 58.2% [12]. Meanwhile, the BronxCare Hospital Center, which is part of a broader health system, and is one of the busiest medical centers in New York City, typically has 40.5% of its deliveries as C-sections and 59.5% as vaginal births [13]. Although the data shows that C-section and vaginal birth rates are similar, it is important to consider that Manhattan has thirteen hospitals that specialize in maternal healthcare while the Bronx has seven. This comparison is startling, given that Columbia Presbyterian is one of thirteen hospitals in Manhattan. BronxCare is one of seven hospitals in the Bronx. Hospitals such as Weill Cornell Medical Center, NYU Langone, and New York Presbyterian- Allen Hospital are likely to provide the same amount of resources to patients as Columbia Presbyterian. Weill Cornell, for example, provides care in high risk pregnancies such as preterm birth, multiples, and placenta complications. The hospital is also well-known for their Ultrasound Services Unit [14]. Therefore, it is evident that patients in Manhattan have more access to not only maternal care but also hospitals with reputable maternal care units. Because there are only seven specializing hospitals in the Bronx, the borough is likely to experience scarcity in resources, leaving patients with limited options for care and fewer resources. However, more access to maternal care might also raise the price of C-sections. In Manhattan, the median price for a C-section is $21,706 [15]. No data is available for the Bronx, which speaks volumes. It may show either that not enough data from C-sections could be gathered to obtain a median or that the price varies so greatly that an accurate median could not be calculated. In fact, there is about a $41,000 dollar range between the 25th and 99th percentiles of C-section costs in the Bronx, which is similar to Manhattan. Yet, Manhattan has a median cost.

In conjunction with income, race is also a factor in this complex problem of C-section inequity. 85.3% of Bronx residents are Black and/or Hispanic. 46.8% of Manhattan residents are white while only 38.4% are Black and/or Hispanic. It is important to observe that most maternal healthcare institutions are centered around Manhattan, the whitest borough. Notably, the majority of people in the Bronx are individuals of color, and 29.5% of residents earn less than $20,000 annually [16]. That is, hospitals are less numerous and less equipped in areas where people are unable to pay. Across the United States, “people of color are more likely to be uninsured” [17]. While Medicare assists them, “they may lose coverage at the end of their 60-day post-partum coverage period.” Other barries to healthcare include, but are not limited to, racial discrimination, language barriers, and hospitals’ lack of knowledge regarding how to distinguish symptoms in people of color. The New York State Task Force on Maternal Mortality and Disparate Racial Outcomes reports that between 2012-2014, “the top five causes of pregnancy-related deaths were embolism (24%), hemorrhage (16%), infection (16%), cardiomyopathy (12%) and hypertensive disorders (7%).” For womxn of color, these complications often go unnoticed because symptoms present differently. Furthermore, the taskforce reports that “65% of the pregnancy-related deaths occurred within a week of the end of pregnancy” [18]. This statistic could be the result of medical neglect due to racial discrimination. Also, there is the possibility that because womxn of color often experience higher rates of poverty, they cannot afford to stay in hospitals for observation concerning complications.

Most working class womxn, often womxn of color, rely on some form of medical assistance. Therefore, they need to find medical institutions that take Medicare or Medicaid. The best care is often offered at private, for-profit hospitals due to the funds available. The average hospital stay costs $11,700 even with Medicare [19]. When a working-class woman makes $20,000 annually, paying $11,700 is impossible. In addition, working mothers are more likely to choose vaginal births over C-sections due to the shorter recovery time associated with this form of birth. Typically, C-sections require a hospital stay of at least two to four days [20]. Meanwhile, vaginal births only require one to two days. C-sections are major surgical procedures, and given work circumstances such as minimum-wage jobs with little to no healthcare benefits or few provided sick days, recovery time/sick leave is a privilege. Womxn need at least six weeks to recover from a C-section, time that women who depend on work income lack. Given the interdependency of race and socioeconomic class observed in the New York City boroughs of Manhattan and the Bronx, there needs to be reform in the healthcare system where all mothers receive optimal care despite financial, geographical, or racial status. This speaks to a wider problem of how race and socioeconomic class together correlate with this C-section inequity not only in New York City, but in other metropolitan areas with similarly diverse demographics.

References:
1. World Health Organization. (n.d.). Caesarean section rates continue to rise, amid growing inequalities in access. World Health Organization. Retrieved May 3, 2022, from https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growin g-inequalities-in-access
2. Mayo Foundation for Medical Education and Research. (2020, June 12). C-section. Mayo Clinic. Retrieved May 3, 2022, from https://www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655
3. Statement: Poverty declined in New York City for fifth straight year but census data fails to capture devastating economic impact of covid-19. Community Service Society of New York. (n.d.). Retrieved May 3, 2022, from https://www.cssny.org/news/entry/statement-poverty-declined-in-new-york-city-for-fifth-straight- year-but-cen
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