This is the first story in a two-part series. Read the second story here.
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When Jennifer Sloan-Ziegler became pregnant with her first child in 2020, she knew she wanted to experience her inauguration into motherhood with a natural birth.
For her, that meant giving birth in the hospital with no induction and no epidural — a plan she says her obstetrician was at first amenable to. But as her due date approached, Sloan-Ziegler says her OB began limiting her options, leading to what many birth professionals call the “cascade of interventions” — where one medical decision has unintended consequences that lead to more procedures, sometimes including a C-section.
After undergoing a series of medical interventions she didn’t want, Sloan-Ziegler ended up with a cesarean due to “failure to progress,” according to the medical records from her birth. She had no problems with blood pressure, and no signs of infection or fetal distress — but she didn’t feel she had the choice to say no.
Sloan-Ziegler, from Ridgeland and now 37, is one of more than 3,300 first-time mothers at low risk for a C-section who wound up with the surgery anyway in 2020 in Mississippi. The state has the highest rate of overall C-sections and of those performed on first-time moms — nearly a third of whom end up in surgery for their first delivery.
To date, this is the first known reporting on low-risk C-sections at hospitals in Mississippi — one of the most dangerous places to give birth in the U.S. The C-sections investigated here are those that occur in first-time moms who are at least 37 weeks pregnant and delivering a single baby in the head-down position. These cesareans, referred to in the medical world as NTSV — which stands for nulliparous, term, singleton, vertex — are described by the Centers for Medicare and Medicaid Services and other federal agencies as “low-risk cesareans.”
Despite national pressure to reduce these types of C-sections, Mississippi’s rate has stayed high across the last decade — peaking at 32.5% in 2018, according to data obtained from the Mississippi State Health Department. While the state’s overall prevalence of these surgeries is high, it’s the extreme variation across otherwise similar hospitals that shows the layers of a complex problem, experts say.
“C-section rates vary so widely at the hospital level, such that a person’s biggest risk factor for getting a C-section isn’t her personal preferences or [medical] needs,” said Dr. Neel Shah, an OB-GYN and chief medical officer at Maven Clinic, a virtual clinic for women focused on reducing barriers to maternal health care, whose medical research has focused on preventing unnecessary C-sections. “It’s which door she walks through.”
At one Mississippi Delta hospital, more than half — a staggering 56.1% — of first-time, low-risk moms gave birth by C-section in 2016 at then-Merit Health Northwest in Clarksdale.
New management of the hospital told Mississippi Today and The Fuller Project they could not speak to the use of these C-sections under former management, but are committed to staying in line with the state average. They said they have hired a midwife and are working to hire a doula to achieve their goal.
Though they can be life-saving, much of the growing research suggests that C-sections are overused. The major abdominal surgery has immediate and long-term risks, including infection, hemorrhage and future placenta problems. And the more of these surgeries a woman has, the riskier they are due to repeated irritation of scar tissue. C-sections are also correlated with increased maternal mortality — an important consideration in the state with one of the highest maternal mortality rates in the U.S.
Many patients report the surgery stripped them of their autonomy — and often, feeling coerced out of fear for their baby’s wellbeing. For first-time moms like Sloan-Ziegler, anxiety and vulnerability can be particularly high amid the unknowns of giving birth.
“What do you do when someone says this is dangerous for your child?” she asked.
Surgical birth was a rocky introduction into motherhood that had resounding effects on Sloan-Ziegler’s well-being. She suffered severe postpartum depression, made worse by chronic pain and immobility after the surgery — side effects that she couldn’t get health professionals to take seriously, she says.
“I would tell my husband, ‘Everybody would be better off if I wasn’t alive,’” she said. “I would curl up into the smallest ball possible and put myself in a corner and just cry.”
Mississippi Today and The Fuller Project made multiple attempts to contact Sloan-Ziegler’s doctor, who did not respond to questions.
To be sure, a low-risk delivery doesn’t mean no risk — emergencies and complications can and do arise in this group of first-time moms. Not all C-sections that occur in this population are synonymous with “medically unnecessary,” experts warn, since first-time moms may still have other risk factors like diabetes or hypertension.
But Sloan-Ziegler — and many others, particularly women of color — didn’t have any high-risk factors, but had the surgery anyway. The surgery itself poses major risks, including blood clots, uterine rupture, organ injury, and prolonged delivery recovery. More than two-thirds of all pregnancy-related deaths in Mississippi from 2017 to 2019 had a C-section delivery in common, according to the state’s maternal mortality data.
“You’re taking away some of the risk factors,” with first-time moms who had a straightforward pregnancy without complications, like Sloan-Ziegler, explained Jill Alliman, a certified nurse midwife who serves on the board of directors of the American Association of Birth Centers. “I wouldn’t call it low-risk C-sections — although it sometimes is — but I would call it lower-risk.”
The World Health Organization recommends an overall C-section rate of 10 to 15%. But, as C-section rates increase beyond that, the health benefits to mom and baby start to plateau, research shows — a marker of diminishing returns, says Robbie Davis-Floyd, a reproductive anthropologist whose research focuses on the hospital model of childbirth.
“Below 10%, you’re having women die of lack of cesareans,” Davis-Floyd said. “But when you get well above 15%, you’re having some women die of the overuse of cesareans.”
The problem isn’t unique to Mississippi — but it is worse in Mississippi. Across the country, C-sections have been on the rise for decades, going from 17% of all births in 1980 to 32% in 2023. The rise in the surgery coincides with the introduction and widespread use of electronic fetal monitoring, which experts say points to providers’ increasing reliance on technology, and an aversion to what used to be considered normal risk in birth — without improved outcomes. In Mississippi – where the number is 39% – the problem becomes more complicated, with poverty, provider shortages and lack of access to health care playing significant parts, as well as a history of racial bias baked into the obstetrics system.
Though the trend is clear — and worrisome to many experts — why it’s happening is less clear.
Some overlapping factors contribute to the rising rates, like older and more overweight pregnant patients in the U.S. — both of which can cause complications that often lead to a C-section. But those commonalities don’t fully explain the problem, much less the persistent racial disparities.
Studies show that Black women are more likely to deliver by C-section, even when controlling for factors like health conditions and access — meaning that if a Black and a white woman give birth at the same hospital with the same pre-existing conditions, prenatal care and health insurance, the Black woman is more likely to have an unwanted C-section.
This means that provider preference and bias seep into decision-making, according to the American College of Obstetrics and Gynecology, or ACOG, which issued a rare consensus statement about the “significant concern that cesarean delivery is overused” in 2014.
In Mississippi, the state with the largest Black population per capita, a lack of health care access contributes to health inequities that raise C-section risk. Rurality, barebones state health infrastructure and high rates of uninsured people have led to vast obstetrics deserts and there’s a pervasive stigma that the high use of Medicaid health insurance means patients are inherently unhealthy. That contributes to the assumption that more invasive care is necessary, according to research.
Until 2021, a common delivery screening algorithm incorrectly used race as a predictive factor — citing Black women as less likely to have “successful” vaginal birth — which for years, unduly steered providers’ decision-making, according to ACOG.
Cost is also a factor. The fact that hospitals can claim back more money from insurers for a C-section than for a vaginal birth may indirectly influence health systems’ reliance on the surgery, especially where poverty pervades and hospitals are hanging on by a thread.
So the surgeries persist, in part because of their ubiquity in the first place.
Once a woman has a first-time cesarean, her odds of having a repeat cesarean are significantly increased, making it difficult to exit the cycle. For every 100 moms who have a first-time C-section in the U.S., 85 will have another.
The adage “once a C-section, always a C-section,” remains largely true in Southeastern states where culture, alongside a lack of resources and providers, make VBACs, or vaginal birth after cesarean, a rarity.
“Ninety-five percent of solving a really hard problem is defining it correctly. And I think C-sections have often been framed too narrowly,” Shah, the OB-GYN and Harvard assistant professor, said.
He added that many clinicians see the surgery decision as clear-cut — patients either need one or they don’t — but it should be a more nuanced process.
“The right number is not zero. And that’s actually the whole challenge because for everything else in health care, the target is zero. You want zero mortality and zero infection.”
For C-sections, even low-risk ones, the target isn’t zero, he says.
“But it’s certainly not 32% in most cases.”
‘We’ve designed the system backwards’: Hospitals with the highest rates
Despite increasing pressure from federal agencies to decrease C-sections, Mississippi and others have been slow to adapt.
In 2020, the U.S. Health and Human Services agency first made low-risk C-section reduction goals public, citing their correlation to maternal mortality. Although dying as a direct result of the surgery is rare, and the nation’s messy maternal mortality data make a direct link difficult to suss out, C-sections have been shown to increase severe illness and raise the risk of mortality more than other factors in the U.S. Across the globe, the correlation varies. Low- and middle-income countries see more complications, but also a higher need — “overuse and underuse of cesarean section coexist,” according to the WHO.
Research around C-section overuse is still growing and adapting to the relatively new trends. When it comes to maternal mortality and C-sections, the U.S. has the highest rates and racial disparities for both among developed nations. Research shows a correlation between the two, which means that more women die when C-section rates are higher, with ACOG calling increased C-sections among women of color “a contributing factor to maternal morbidity and mortality.” But that doesn’t necessarily prove the high rate of C-sections is causing more deaths — at least in part because the risk factors that make a C-section more likely, as well as complications arising from the surgery itself, also increase the risks of maternal death.
However, the federal government has been clear that the correlation is enough evidence to reduce what they say is an overreliance on the procedure. The Biden Administration gave the national reduction goals some regulatory teeth by empowering the Centers for Medicare and Medicaid Services to collect and publish hospitals’ low-risk C-section rates starting in 2025 — intended to incentivize C-section reduction and promote “birthing friendly hospitals.”
Mississippi has slightly reduced its low-risk C-section average amid the federal pressure — from 31.8% in 2014 to 30.7% in 2022, according to health department data. But it is still well above the national average of 26.3%. Moreover, several Mississippi hospitals stick out for stubbornly high use of the procedure. Despite some similarities, these hospitals are scattered across the state and serve different patient populations. Their hospital management also responded differently as to why their rates are high — echoing national variation among hospitals.
Nearly half — 46.7% — of women at low risk for a C-section received one anyway at South Sunflower County Hospital in Indianola between 2014 and 2022, the highest in the state for that time period.
Officials at the hospital did not respond to any of Mississippi Today and The Fuller Project’s questions for the story.
Markedia Perryman, 31, is still dealing with complications from a C-section there four years ago — which resulted in an infection and a month-long hospital stay after delivery. She’ll need to have another surgery this year to remove a hernia that developed from muscle weakness following her surgery.
“People say having a C-section is easier than pushing — it’s not. After what I went through, it’s definitely not. I suggest when you can, have your baby like God wanted you to have them,” she said.
Though she originally wanted to have more than one child, she changed her mind after her C-section and its resulting complications.
Perryman says she had only labored for four hours when the doctor changed course for surgery.
“I was dilating …” Perryman said. “I guess I wasn’t dilating fast enough for them.”
The medical records from her birth, contrary to standards for delivery records, show no progress of labor notes or measurements of fetal vitals on the day of delivery. The records list two indications for Perryman’s surgery — “arrest of labor” and “nonreassuring fetal heart tones” — the two most common reasons for C-sections in first-time moms in the U.S.
South Sunflower administrators did not answer questions about Perryman’s experience.
South Sunflower Hospital is the only birthing hospital in Sunflower County, one of the poorest counties in the state and nation. In 2022, 89% of the mothers who gave birth there were on Medicaid.
Perryman, who is Black, says she was never told anything about her daughter’s heart rate, nor do her medical records indicate any specifics about the heart tones’ measurements. Experts say it’s not uncommon for the indication to coincide with provider biases.
“Non-reassuring fetal status is one of the reasons to perform a cesarean delivery, and it has been identified by multiple researchers as being prone to subjective interpretation and even bias,” explained Alliman, a certified nurse midwife who serves on the board of directors of the American Association of Birth Centers. “Black women have cesareans for non-reassuring fetal status at two times the rate for other groups, even among the lowest-risk patients.”
After a week-long stay at South Sunflower, Perryman was transferred two hours away to the University of Mississippi Medical Center for a higher level of care due to an infection in the surgical site. She stayed there for a month and, as a result, wasn’t able to breastfeed or bond with her daughter in the first few weeks postpartum.
“I was really mad, depressed,” she said. “When I got home, me being away from my daughter for so long, when I tried to hold her … she wouldn’t do nothing but cry. That hurt me. She didn’t know me because she wasn’t around me, that hurt me a lot.”
And in her community, she’s far from being an outlier.
Perryman, others in the Black community, and researchers have long known what the federal government and regulators are just catching up to. “It’s like it’s a trend, I’m going to be honest,” Perryman said. “People my age and under — the majority of their babies have been delivered by C-section.”
Across the U.S. and in Mississippi, low-risk C-sections are performed on Black women more than any other group — even when accounting for health conditions.
But importantly, the problem isn’t unique to the Delta. St. Dominic’s and Merit Health Woman’s Hospitals — two Jackson-area hospitals that together deliver more than 2,500 babies annually — averaged 45.1% and 43.2% over the same time period.
Officials with St. Dominic’s declined to answer specific questions about the prevalence of low-risk C-sections at its hospital. Jeremy Tinnerello, market president of the hospital, said he recognizes this measure as “an opportunity for improvement” in an emailed statement to Mississippi Today.
A spokesperson for Merit Health says they closely monitor the number of low-risk C-sections at Merit Health Woman’s in Flowood and Merit Health Central in Jackson — both of which ranked in the top 10 hospitals in the state with highest rates for this measure between 2014 and 2022 — and began initiatives in the last few years to lower them.
She did not say what specific initiatives Woman’s has implemented, though their use of these C-sections has decreased since 2014.
Some hospitals landed among the highest rates due to large variation — a few years with very high use and others with lower use. That’s true for George Regional Hospital in Lucedale, which had a rate of 48.8% in 2015. Its average rate over the nine-year period was 40.3%.
Fluctuation from year to year makes sense — especially for smaller hospitals.
“There’s nothing predictable — that’s for sure,” said Dr. Jay Pinkerton, the only OB-GYN at George Regional. “There’s months with 15 deliveries and months where you do 35. On average, you’re seeing about four primary C-sections a month. So, if you did one more or one less, you affected your percentages by 10, 15, 20%.”
Pinkerton moved to Mississippi with his wife in 2011 to reopen the labor and delivery unit at the George County hospital. The pair left their life at a large academic medical center in Cleveland, Ohio, for a warmer climate and the satisfaction of serving a tight-knit community where Pinkerton says he’s delivered every kid he sees trick-or-treating on Halloween night.
A small department has its benefits and drawbacks. Pinkerton says not having the staff and resources to do successful emergency surgeries means he’s had to shift the way he weighs risk-benefit equations. Often, that takes the form of opting for planned C-sections rather than waiting it out.
“If I’m going to need to do a C-section, I’m going to have to make the decision earlier. In Cleveland (Ohio), I had one of the best NICUs in the country, right down the hallway from me. I could wait until the last second on a tracing [of the fetal heart rate] to say, ‘Well, it’s not coming out this way, we’re going to have to do an emergency C-section.’”
In Lucedale, however, Pinkerton is about an hour away from the nearest NICU in the state, and bringing in hospital staff for an emergency C-section can be harder than for a planned C-section.
These decisions are not easy for doctors, he said.
“If you had a crystal ball, it would be easy. But we don’t,” he said. “So those are the decisions I have to make on a daily basis, and these are some of the challenges we face not having a big, academic center (nearby).”
Mississippi’s rurality and provider shortages do play a part in its high C-section rates — overall and among low-risk women. Still, other rural, small hometown hospitals similar to George Regional don’t perform nearly as many low-risk C-sections.
A hospital’s approach to C-sections largely comes down to the provider — and how risk-averse he or she wants to be.
Individual practice style is one of the key factors in high first-time C-section rates, according to research. But importantly, experts say, that means that if the hospital culture changes, C-section reduction also follows. “Doctors want to do the right thing, but most doctors don’t know their own C-section rate,” Shah, the Harvard OB-GYN, said.
“We’ve designed the [obstetrics] system backwards where everybody gets a surgeon, but not everybody gets support, like from a doula,” he said. “You can hurt people in two ways in health care: by doing too little too late, which everybody understands — and also by doing too much, too soon, which is a harder one to wrap your mind around.”
National research shows the large increase in C-sections over the past few decades in America is not due to mothers requesting the surgery.
“In all cases it’s been around 1%,” said Gene Declercq, a professor at Boston University School of Public Health and author of multiple studies on the issue. “It happens, but it’s not driving the primary cesarean rate.”
After “failure to progress,” the second most common reason for a first-time cesarean is “non-reassuring fetal heart tones,” which experts agree is highly subjective.
One study found that when four obstetricians reviewed 50 fetal heart tracings, they agreed with each other in less than a quarter of the cases. When looking at those exact records again two months later, the same obstetricians interpreted 21% of the tracings differently.
Most medical research focused on investigating C-sections includes hard-to-miss financial implications. C-section deliveries cost nearly twice as much as vaginal births on average — which can also influence culture, Shah says. Labor and delivery units are expensive to run, too, which is why they’re usually the first to shutter when a hospital is struggling.
“The labor floor is actually the most intensive treatment environment of the whole hospital for the healthiest people,” Shah said. “If you take 99% of American women and you put them in an ICU and surround them by surgeons, what do you think is going to happen?”
This series is the result of a collaborative reporting partnership between Mississippi Today and The Fuller Project.
Mississippi Today, winner of the 2023 Pulitzer Prize for Local Reporting, is the state’s flagship nonprofit newsroom whose mission is to hold the powerful accountable and equip Mississippians with the news and information they need to understand and engage with their state.
The Fuller Project is an award-winning global nonprofit newsroom dedicated to reporting on issues that affect women. The Fuller Project encourages you to follow them and sign up to learn more.
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