In its latest effort to end its unscientific use of race and ethnicity as biological variables, the University of Maryland Medical System will stop considering race when helping individuals who have given birth via cesarean section decide if they should get a C-section for subsequent births.
Medical institutions use several factors to decide if repeated C-sections are necessary for those who have undergone them before, including a tool called the VBAC, or Vaginal Birth After Cesarean, calculator. The calculator uses a number of health variables to recommend whether a person should give birth vaginally after having previously had a C-section, which is considered risky due to the possibility of the patient’s C-section scar reopening during the birth.
The calculator counts race as a factor and is more likely to recommend Hispanic women and Black women have another C-section, due to a historic belief that the shapes of Black and Hispanic women’s pelvises are less conducive to healthy vaginal births. Although UMMS said that the calculator was used infrequently across its hospitals, the system has now eliminated its use completely.
It will be replaced by a new tool called the VBAC 2.0 that was released in early 2021, not only removing race as a factor but adding a new question about the patient’s history with hypertension. The new calculator has been endorsed by the American College of Obstetricians and Gynecologists.
“(This) is exactly what we need to be doing,” said Joseph Wright, UMMS’s vice president and chief health equity officer. “We need to not rely on an inappropriate use of a social construct, like race and ethnicity, and rely on scientific variables, clinical variables like hypertension.”
Though there is no nationwide data about how many pregnant people of color have been unnecessarily directed to receive a C-section over the years due to the calculator’s algorithm, data has shown that race is a major factor in whether or not the VBAC calculator advises an individual to go forward with a vaginal birth.
A study completed at Boston Medical Center between 2017 and 2018 showed that 44% of Black woman received an unfavorable score in the VBAC when race was included, but that number plummeted to 12% when it wasn’t. For Hispanic women, the numbers dropped from 45% to only 10%. Additionally, according to the Centers for Disease Control and Prevention, rates of vaginal births after C-sections for white patients outpaced rates for Hispanic and Black patients.
UMMS did not have data available regarding disparities within its own hospitals, but “there is no reason for me to expect that we are somehow different than what’s going on across the country,” Wright said.
Unnecessary C-sections are dangerous for the same reason any unnecessary surgery is — such procedures can lead to complications, and Black people are already three times as likely than white people to die from pregnancy-related causes.
The old version of the calculator is still the nationwide standard, according to Wright, but the new version is picking up steam nationwide.
Eliminating race as a factor in birthing decisions is the second major step the hospital system, Maryland’s largest, has made to eliminate the use of race and ethnicity information when making clinical decisions. Towards the end of 2021, UMMS decided to stop using race to diagnose kidney disease, a practice that leads to Black people often being under-diagnosed for the illness and being unable to receive life-saving treatment.
According to Wright, this is just the beginning of a deep dive into the system’s clinical practices surrounding race. The two changes the hospital system has already made were “low-hanging fruit,” Wright said — obvious cases of race being incorrectly used as a biological variable.
“I will not be at all surprised (if), as we do this deeper dive and reexamination, that we will discover many other (examples), some that may be subtle examples, of where race and ethnicity are inappropriately used as biological proxies,” he said. “These are not one-off actions. This is part of a larger journey.”