I am interested in understanding the factors the drive cesarean section utilization, in particular access to and uptake of Vaginal Birth After Cesarean (VBAC). U.S. VBAC rates declined sharply in the 1990s and remain low at 10% of all women who have had a prior cesarean, and thus is a key driver of repeat cesarean delivery, and in turn, the rising incidence of placenta accreta in subsequent pregnancies. For my dissertation research, I will be conducting a qualitative evaluation of a shared-decision making tool that is designed to support women who desire a VBAC; the trial is being conducted in a multi-ethnic population in the SF Bay Area.
1. Gender is a key structural determinant in this situation, although I think it requires us to think somewhat differently than the readings from this week where the measurement of disparities require the "powerful" referent category. Men are of course absent from childbirth, but structural gender relations still shape the birth options that are deemed acceptable to offer women and also shape the weighing of maternal/fetal risks (to name just a few). Race is a key structural consideration in that we know that in some areas of the U.S. black women are at greater risk of cesarean section, and for these same reasons black women may have less access to facilitators of vaginal birth (hypothesized association). The health system is a key intermediary in the high cesarean rate and low access to VBAC. I felt the readings mostly discussed the health system as a protective factor against disparities, and surely this can happen with VBAC. However, when hospitals interpret national guidelines in terms of malpractice interests, when providers avoid offering VBAC even though it is recommended by ACOG--the health system itself perpetuates the disparities.
2. Socioeconomic characteristics and neighborhood effects could both restrict access to VBAC. Regarding socioeconomic characteristics early in the life course: Parental level of education and highest level of education (if the quality of education relates directly to reproductive autonomy) could inform both risk of cesarean section and motivation to have a VBAC. While in some areas well educated women who attend private hospitals have among the highest cesarean rates, these same women may have greater access to information about natural birth, an ability to find VBAC-friendly providers in their second pregnancy (which sometimes requires traveling a great distance), or these women can pay out of pocket for a home birth midwife. Regarding neighborhood characteristics: There is a shortage of midwives of color (conference communication), and thus less human resource capacity for birth care providers who will attend deliveries in the private homes of women of color. White home-birth midwives mostly are paid privately and many do not accept Medicaid due to low reimbursement. This isn't exactly a neighborhood characteristic, but I am trying to see how insurance reimbursement and provider shortage limits access to home birth for communities of color.