Why do we still use 'race' in our medical tools?: My experience with VBAC racism

Without any examination of my body, the doctor told me that I was likely “not a good candidate for a VBAC.” In shock, but not wanting to come off as an asshole, I responded “that’s interesting because my doctors at Kaiser said I’d be an excellent candidate. I’m concerned that the physicians here are generally unsupportive of VBACs and—”

“Well, we’ll let you do what you want. We won’t force you.” She cuts me off. 

Yes they will.

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VBAC stands for “Vaginal Birth After Cesarean.” Cesarean deliveries (or c-sections) are medically necessary in some circumstances, but in the U.S., birth workers (including some physicians) are concerned that medically unnecessary c-sections are occurring too often. After much thought...and a lot of reading and reflecting, I really believe my c-section was unnecessary. 

Photo of me trying to rest after being told my labor failed to progress and that the best option was to go into surgery for a c-section.

The birth of my first child was filled with mixed emotions. I’ve not shared publicly about it yet but it was traumatic. It included 38 hours of back labor, excruciating spinal pain, an epidural, dilating to 8cm (with the ultimate goal of 10cm), and an unexpected c-section. After all my preparation and that hard work during labor, I felt absolutely defeated. A c-section is a major abdominal surgery. My recovery was long and painful. Picking up my newborn, sitting up, bending over, and showering were all challenges for me in those early weeks. 

The saving grace for me was that my OBGYN said that I shouldn’t worry about a repeat c-section if I chose to have additional children because, given my history, I’m an excellent candidate for VBAC. So how did this other physician who I’d never met before get the idea that I’m not likely a good candidate just by looking at me?

Well, it seems like the US is the only country that uses ‘race’ to predict VBAC success rates or the likelihood that a woman will successfully have a VBAC. I found this nifty calculator online. 

The problem is that, baked into the VBAC calculator, there is an underlying assumption that something is biologically different about Black people’s bodies that makes us less capable at having a VBAC than other people. 

According to this calculator, a Black person has a “predicted chance of vaginal birth after cesarean” 28% lower than a white person with the same characteristics. It’s important to note that they are developing a new calculator without race and ethnicity variables. But what work—what damage—has the calculator already done? 

Screenshot of VBAC calculator. Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU), "Development of a nomogram for prediction of vaginal birth after cesarean delivery," Obstetrics and Gynecology, volume 109, pages 806-12, 2007.

We know that there are racial disparities in cesarean deliveries. People of color and especially Black birthing people are given unnecessary c-sections more often than white people. So to include race in the calculation not only normalizes the disparity, it actually perpetuates it if practitioners are using such tools to determine whether or not women are eligible to attempt to deliver vaginally. It’s a circular self-fulfilling prophecy. You give Black people more c-sections, then when they want to VBAC, you tell them the success for VBAC is less likely because you give them more c-sections — thus, resulting in more c-sections. 

The VBAC calculator can be situated in a long history of racialized medical tools. On their face, these tools “adjust for race” to support decision-making processes for physicians and other healthcare providers. However, most were developed with the premise that race tells us something about our biological makeup—or genes. It does not. But because they are designed by humans in the social world, these tools reflect the social and political inequities that determine our relative risk for disease. So, VBAC calculators tell us more about our society’s racist propensity to give Black birthing people repeat sections than it does about Black people’s ability to deliver vaginally. 

VBAC disparities have broader implications for maternal health as Black individuals are much more likely to die during and after childbirth and repeat c-sections increase the risk of death over time. One jarring example is the story of Kira Johnson who, after her second c-section was allowed to bleed internally for hours leading to her death. Her husband tells the story of how the medical staff ignored his calls for immediate attention and by the time they finally came in to help, it was too late. When Kira was finally taken in for surgery, she died immediately. 

Again, there are medical reasons to undergo a c-section. But there are also a lot of complications that can arise from repeated c-sections. None of the doctors I’ve seen so far cared to talk about any of those risks but spent a great deal of time warning me about the risk of uterine rupture if I attempt a VBAC. 

After that infuriating visit with the “you’re not a good candidate” OBGYN, I spoke to a friend of mine who is studying to become a midwife. She recommended that I ditch the OBGYNs at the clinic I was attending and instead make the midwives my primary prenatal providers. 

My first visit was fantastic. When I asked the midwife about VBAC support, she was not only supportive but enthusiastic. She checked my medical record from my first delivery to see if I had a particular type of incision. I did. 

She said “Yep! That’s all I needed to see, we’re happy to support you on your VBAC journey. What other questions do you have?” 

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We have to stop using race and other proxies for race (e.g., education, neighborhood, etc.) in these medical tools and assessments because they are more harmful than they are informative. If we’re interested in health equity as a goal, these “race adjustments” are in our way.

UCU Scholarship Essay: Never Stop Learning

Since I’ve been at UCLA, funding has been a struggle. Every year, I’ve had to apply for some grant, fellowship, or scholarship in order to pay my tuition and fees. When I was unsuccessful, I had to teach. Now, don’t get me wrong, I actually enjoy teaching. Engaging with undergrads gives me the opportunity to be a mentor and to support a younger generation in their learning processes. However, teaching is exhausting. Time-consuming. Tedious. And, to be frank, it’s not rewarded in the research world. In fact, I was advised by many mentors to teach as little as possible during my PhD program because “it’s not what gets you a job.” Of course this advice is not particularly helpful when funding options are so limited.

But, I digress.

I have one more year in my program and I wanted to really dedicate my time to my research before going into summer break. Once I return in the fall, I will start applying for postdocs so, ideally, I will get a large chunk of the dissertation completed before then.

This, of course, meant applying for money to pay tuition. I got an email about a scholarship through my credit union and decided to apply.

The application was straightforward and I only had to write an essay about the pandemic. But not just any essay. The prompt was:

How has the impact of the pandemic inspired you to “Never Stop Learning” with your own education or when educating others?

So I wrote an essay about my experiences teaching during the pandemic so I would no longer have to teach during the pandemic. The irony. Thanks so much to University Credit Union for the ability to control my time next quarter. I’m so grateful!

Here’s the essay.

The COVID-19 pandemic has changed the way students at all levels of education engage in learning. The pandemic laid bare a number of social inequities in education. Students without access to private rooms, computer equipment and stable internet are at a disadvantage in this environment. In the fall of 2020, I taught an online course for the first time. Knowing that challenges were ahead, I was inspired to use my teaching appointment to foster inclusivity, engagement, and critical thinking. In order to do that, I had to engage in my own learning process. I learned about tools for remote learning, effective pedagogy, and on a personal note, I learned about what my students actually needed from me.

Training to Never Stop Learning about Online Teaching Tools  

Once all instruction moved online, UCLA began to offer trainings and workshops for graduate student teaching assistants to learn about online tools to facilitate fruitful discussions. Because I teach primarily about race and racism, discussion is often the most important part of the course. It is where students can talk frankly about theoretical concepts they do not understand and make connections to their real lives. Given the civil unrest we experienced last year in response to police violence, I expected that there would be a lot to unpack in my classes. I participated in a workshop hosted by the UCLA Center for the Advancement of Teaching to learn about strategies to encourage active learning in a remote environment. I learned how to use special Zoom functions that allow students to anonymously submit answers to prompts. I also learned how to use online trivia software to gamify quiz questions. Additionally, I learned that incorporating simple exercises that give students time to reflect privately on their own thoughts also gives them a break from “Zoom fatigue.” Implementing the tools from this training allowed me to plan more dynamic classes and facilitate deeper discussion than expected.

Reading to Never Stop Learning about Effective Pedagogy

To prepare for teaching in the online environment, in the summer of 2020, I read Radical Hope: A Teaching Manifesto by Dr. Kevin M. Gannon which presents a humane and justice-oriented approach to teaching college students. Gannon wrote the text before the pandemic, but it has become a text that I reread to remind myself that there are more effective strategies to use education as a tool for empowerment. One strategy I found particularly useful was laying out my pedagogical approaches in the syllabus at the beginning of class. This provides an inclusive way for students to get to know me as an educator and learn a bit more about why and how I teach. I found that in the online environment this strategy helps to make the distance between us seem less severe. In fact, one student in my “Race and Ethnicity” course in the fall told me that in her four years at UCLA, she had never felt comfortable enough to attend office hours until my class. I believe this was in part due to my creating a welcoming environment based on growth and inclusion rather than memorization and punishment.

Listening to Never Stop Learning about Students’ Needs

Another way I “Never Stop Learning” is by simply listening to my students. Maintaining flexibility in the structure of class and in the assignments assured that we were being attentive to students’ personal challenges. I started every class with a wellness check-in with my students. This practice of listening to their concerns gave me the opportunity to learn about what was going on in their personal and academic lives. This knowledge allowed me to tailor each class to what the students needed. For example, students told me that breakout rooms were not effective if they were too long. Some students would turn their cameras off and disengage. But when I gave them a pointed question to discuss in groups for 5 minutes or less, we’d come back to the large group and have a fruitful discussion. In my Fall 2020 Evaluations, one student noted

Rebekah is a great TA. At the beginning of the quarter, she had split us up into groups, however, as she saw this was not working, she brought the discussion back to the whole group and we went from there. Later on, she tweaked this format a bit to better fit the class needs. […] The environment she created made it so that we felt comfortable asking questions, sharing our responses, or personal anecdotes. I would take a class Rebekah again if I had the chance.

Each academic quarter has its ebbs and flows of stress. Midterm season was especially important to listen to students’ needs. After hearing that more than 70% of my students had 3 or more midterms, I had a meeting with the lead instructor of the course to discuss how we could make the season less stressful for them. We developed a plan that involved exchanging the formal midterm exam for a short writing assignment that would help prepare the students for their final papers. My students were elated when we shared the news. Given the difficulties of the online environment, domestic and care responsibilities, non-academic employment, and a global pandemic, students appreciated that we advocated for a lighter load.

In summary, as an academic researcher, it is my job to engage in lifelong learning. Producing new knowledge requires that I read and engage often with the literature on my research topic. The pandemic has inspired me to take the same approach with teaching. Due to the uncertainty of the COVID-19 restrictions, it was important for me to never stop learning about how I could make my students’ online experience as engaging, productive, and inclusive as possible. The pandemic has hit educators and students hard, but my students have shown up every day, despite their difficult situations, ready to learn.  I owe it to them to continue to hone these new skills to contribute positively to their UCLA experience.