Interesting charts. One thing that might need to be clarified, is the tendency of hospitals to under-report what could be considered negatives...for instance, in Richmond Virginia, there is a hospital with a nearly 50% c/s rate...granted the majority of clients are low income, but I lived in Southside for 20 years, and tried to encourage both self-education and homebirth...and midwifery...That is the best ticket out of these bad stats, I would think...:)
Here is a link to the VA obstricians comparison chart...http://www.vhi.org/ob_report_results_phys.asp Note that some of the docs have nearly a 50% c/s rate, and the ones with the lowest rate, are often the best docs, cuz they know how to avoid surgery(unneeded)! Dr. Naved Jafri in Hampton, (I have worked with him before) is a case in point. He lets the dads help catch the baby, encourages waterlabor(hospitals didn't allow birth in water) and was more like a midwife than a doc...But his "rating" is not as high as the ones who cut more, so I suspect the VDOH's criteria on what is "good' care is a little skewed, wouldn't you? Great work, keep up the good work...

Also, you might want to check with Ina May Gaskin. She might have some insight on the Maternal mortality stats, since she specialises in that..(as part of the Safe Motherhood Initiative)

I think the biggest factor here is the tendancy for women in the South to be more submissive to authority in general. Its the Southern-Belle theory. Etiquette prohibits them from questioning a doctor's orders.

Be very careful when making such broad, sweeping generalizations, Bethany. Stereotypes are a flawed resource in reasoning.

I think the biggest factor here is the tendancy for women in the South to be more submissive to authority in general. Its the Southern-Belle theory. Etiquette prohibits them from questioning a doctor's orders.

right! And women in the northeast get cut because they're pushy and want to schedule their births around their jobs, and west coast women get cut because they want a tummy tuck at the same time. It's the "ballbusting new Englander" and "vapid Hollywood babe" theories!

Are you kidding? Because I am and I hope you are too.

This might be more broad than what you want, but what about breastfeeding rates? That should be easy to find, although I suspect it anti-correlates with the poverty rate.

Two other statistics which are interesting, but probably tricky to find, are epidural rate and doula rate. I'd guess the latter is strongly anti-correlated with the poverty rate.

What about education levels? Or is that tied closely enough to the poverty rate that it's not an additional bit of useful information?

Oh! What about average age of the mother?

The statement about questioning docs in the south, she is right. In the south you don't question your docs if you do you are a radical. I do question my doc but man, I have had run ins left and right about it and I am seen as NOT the norm. I talk with many women and they simply don't question them because that is just how it is. Sad.

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If there is a connection, it's interesting that Alaska, which has plenty of poverty, is so low on c/secs, but maybe that's a function of low population and few hospitals.

<<I think the biggest factor here is the tendancy for women in the South to be more submissive to authority in general. Its the Southern-Belle theory. Etiquette prohibits them from questioning a doctor's orders.

right! And women in the northeast get cut because they're pushy and want to schedule their births around their jobs, and west coast women get cut because they want a tummy tuck at the same time. It's the "ballbusting new Englander" and "vapid Hollywood babe" theories!

Are you kidding? Because I am and I hope you are too.>>

FWIW, I don't think we should be blaming women...Courtroom Mama this is what I'm guessing you're getting at here.

However, I do think that cultural constructs contribute to how we make decisions regarding childbirth...and if our cultural construct is to be more submissive to authority, as it is in the South for white women (I will stick with white women since I am one and that is what I am most familiar with, and won't presume to speak for other groups), I would argue that has an effect on whether that specific group of women would tend to question/challenge their doctors and thus would tend to impact the rates of ________. Living in TX, I can say that I am a radical in my area, having had a homebirth and questioning my doctors at every step of the way. My friends will do all the research, but if it comes down to their doctor telling them something, they *have* to trust the doctor, even if they know what he is telling them flies in the face of everything they know. I dunno, maybe it's not southern belle culture, maybe it's just plain doctor worship...but there *is* plenty of southern belle culture still around, which is quite noticeable for me since I'm not really Southern (although I've been here most of my life). I thought an interview I saw with Reese Witherspoon was interesting one time..it was on late night. The host (can't remember who) mentioned Reese is from Missouri (generally considered the south or midwest) and somehow medicine came up. She said something like yeah, the people at home don't get it...they figure if you get sick you go to the doctor, they don't get this not trusting western medicine stuff. That's the first time it hit me, that maybe I feel like more of a wierdo than I otherwise would just by virtue of where I live.

That being said, I really think we have to be careful not to blame the women for their cultural construct...it is what it is (just as it is anywhere else) and the medical authority needs to be even more over the top in trying *not* to be overbearing in cultures where challenging their opinion is not only not the norm, but anti-etiquette. And that is definitely not the case, there are many bullies in white coats in our area. Blaming the women for southern belle culture causing c/secs is the same as blaming the western/California women for too posh to push c/secs...there might be a few cases of it but really it's overblown and it's doctors' lack of disclosure and pressure that acts to coerce the women...it's just that for these particular women their cultural construct makes it easier to succumb to authority (versus a tummy tuck), but it sure doesn't excuse the bully...if anything the bully is equally or more guilty in this situation than in a situation where the woman is more likely to stand up for herself.

Or, thinking "out loud" and beginning to see a pattern here, it seems that doctors who want to coerce c/sections will use the cultural construct of women to encourage one. If the woman lives in California, let's encourage her by giving her a tummy tuck...if the woman lives in the south, let's appeal to her sense of respect for authority and etiquette...if she lives in New York let's appeal to her desire to schedule. (Although I would say that these motivations can be true of women in any other area, and not true of women in those areas, as well....there are lots of women here in TX who schedule their births to plan their work and/or social schedules, for example.) And then they blame the women for wanting it for these reasons, when they actually used their suggestibility to these things (due often to their culture or personal values) to coerce a section.

I do think culture has some bearing on it. The western states have lower rates ...that could be fewer hospitals, more miles to a hospital, but the western culture also tends to be more independent (as a general rule) as well...the pioneer spirit and all (I know, I know, a generalization). I say this with some confidence because the only eastern state with a low rate approaching the western states is Vermont ("live free or die"...this stuck me even before I hit the comments section). Based on that, I can't imagine that culture doesn't impact it somehow. Probably other explanations for it as well, but all these things ultimately interact...race, culture, education, socio-economic status, etc. It is an overgeneralization to say "southern belle culture = more submissive = higher c/sec rates," but I don't think we should dismiss it out of hand either...just as long as we're placing the blame (if we have to) where it lies, with the medical professionals who are coercing these moms and not with the moms themselves.

I am *not* sure that southern belle culture applies to non-white people in the South...I think there are other factors that influence their rates (the discussion yesterday was a great case that racism impacts how they are treated, correct?) But I think it goes to say that my comments on bullying / coercion by doctors applies here as well...it may not be southern belle culture that impacts these women's outcomes...it might be overt racism instead. Still, the medpro's fault, not the woman's...and if race or class or level of education or culture or anything else is an issue that would prevent a woman from getting the best possible care then to me the doctor needs to spend more time with these women, showing them how to educate themselves, making what resources they can available, not less. More time laying out risks/benefits, less time coercing.

But I think I get what you're saying too, Courtroom Mama, let's not make over simplifications and over generalizations because they do not really help fix the issue? Yet I guess the point I'm making is that I don't think we can completely rule out cultural constructs and their potential impact on these stats either. I don't think we can simplify it down to one thing, be it race, poverty, education, culture, sexism, etc...it all combines to impact the rates. I'm guessing you're in agreement here...it was the oversimplification inherent in the original statement that prompted your response?

I think I hijacked the real meaning of the post...it was c/secs and prematurity rates...and it is interesting how closely they correlate, and race does seem to be juxtaposed in there as well, continuing the conversation from yesterday. So could be that whatever is causing the higher c/sec rates in the south is contributing to the racial disparity in outcomes (be it racism, culture, poverty, education levels, or more likely a combo of all of this).

Whew, I never submit a short post...maybe one of these days. Hope I haven't offended anyone...it wasn't the intent...but is a probability. I've read this about 5x and do need to get back to work, so please do accept my apologies in advance if I said something that sounds wacky.

Anne,

Yes, my comment was a cheeky way of saying that we shouldn't oversimplify like that. Really, the number of women who are inheritors (inheritrixes? inheritrices?) of the "Southern Belle" construct are actually very few. This particular stereotype has a connotation of rich white women, who certainly don't constitute the majority.

However, there is a kernel of truth. From my perspective, it's less about "culture" and more about gender socialization (i.e. hierarchy). The "Southern Belle" thing as just a manifestation of gender subordination of rich white women, where a lot of other cultural stereotypes are avatars of gender subordination (one that comes to mind from Latino culture is the "madre sufrida," the long-suffering mother who sacrifices herself for her husband and family). Women's subordinate status doesn't just apply to their interactions with men, it also applies in their interactions with people in other positions of power. So, there's a doctor/patient power imbalance in every medical situation, but perhaps men might be more empowered to challenge the imbalance because of their relative position of privilege. Taking it a step further, I feel like the crisis of maternity care as it is is caused by the fact that, on some level, we’re still not totally comfortable with the fact that women (particularly pregnant women) are full, autonomous individuals. The one common denominator is that (pretty much) everyone who needs maternity care is a woman. Interestingly, the other places where we have "crises" are in drug treatment and mental health – two other populations that are devalued and dehumanized.

So yeah, culture probably has something to do with it, but it’s intersectional, right? “Southern Belle” fails to account for probably the majority of women. So maybe some women are “too polite to fight” (the converse of too posh to push?), but some women are poor and told that they will have to pay out of pocket or be denied care if they don’t go along with medical advice, and lots of other socialization factors... I think that if we're really trying to figure out the factors that make women vulnerable to unnecessary medical intervention, we have to look a lot deeper than that, and look at things like healthcare delivery systems, medicolegal factors, onset of prenatal care, attitude toward women's autonomy, history of involuntary medical procedures (a BIG problem in the South and Puerto Rico)... I agree with you 100% that we should avoid blaming women, so instead of saying "these women are pushover Southern Belles constrained by their etiquette" it may be more useful to say "these areas tend to punish women for transgressing gender norms," and coercive medical practices are just one form of punishment.

I think that if I could have any statistic in the world for this, I'd want to see indexes of socioeconomic inequality and gender inequality. Not 100% sure how the latter would be measured (maybe participation of women in public office and the workplace, or women's earning power relative to men?), but I'm sure some sociologist has already created such a measure. A side note about those western states: they were the first to introduce women's suffrage, some even before the passage of the 19th Amendment. Maybe that could be seen as valuing equality and actively working toward dismantling gender hierarchy? Just musing...

I wasn't trying to say that EVERY woman down here who has a c-section does so because she's a mint-julep-sipping-rich-white woman. However, there is a tendancy in the South, where I've had ALL my babies, including my last VBA3C, to not make waves and not question authority. I'm not blaming women for their c-sections. I've just giving a guess as to ONE influencing aspect in what has become a horrible trend in medicine.

Courtroom Mama (can I call you CRM?), thanks for your thoughtful response. It would make a great post (wink wink). I liked Jill's post from today as a take off on it...you do have a way with words.

Interesting comments on "Southern belle syndrome." However, when I think of Southern belles, I think of Scarlett O'Hara -- sweet and pretty and polite on the outside, but tough as nails on the inside and as hard-headed as they come. Who ever told Katie Scarlett what to do?? While there is an emphasis on politeness and manners and "not making waves" in our culture, there is also a stubborn, independent streak as well. How much of each a woman is depends on her personality and upbringing (nature + nurture) -- just like in every other area of the country. I would see Southern women as being more likely to "passively resist," rather than vocally ("impolitely") object -- for instance, just not showing up for an induction.

But really, who knows?

I'm just writing this as a middle-class white woman who was born and raised in the South, albeit with Yankee parents, so I may have missed out on some nuances of Southern culture, just as I missed out on being raised to eat okra, chitlins, black-eyed peas and corn-bread, and I cannot stand tea -- sweet or unsweet. :-)