Nearly half of all Asian and Pacific Islander mothers on Medi-Cal give birth by way of Cesarean section, a recent report found, a rate well above California’s statewide average.

“Listening to Mothers in California,” a study released in September by the National Partnership for Women and Families, showed that 45 percent of Asian and Pacific Islander (API) Medi-Cal patients delivered through C-section, compared to 33 percent of white women on Medi-Cal, and 27 percent of white women with private insurance.

The C-section rates for API women on Medi-Cal are similar to that of African-American women throughout the state — 43 percent of African-American Medi-Cal patients and 46 percent of African-American women with private insurance had C-sections instead of a vaginal delivery.

“To me that suggests that there’s not a lot of respectful care options being offered,” said Carol Sakala, director of childbirth connection programs for the National Partnership for Women and Families and one of the authors of the report, “and that shared decision making is not a process women of color are experiencing compared to white women.”

According to the study, eight percent of API women perceived unfair treatment at some point during childbirth due to their race or ethnicity, and 12 percent due to language.

The survey was only conducted in English and Spanish — and no Asian languages — so it didn’t include API participants who have limited English proficiency. These women can face even more challenges getting quality care, said Edward Tom, communications associate for Asian Health Services, an Oakland clinic operating in 14 Asian languages.

API women with limited English often struggle to communicate with providers, and may even forgo care if they can’t find a physician who speaks their language, said Tom.

Because women are often pressured by their providers to have a C-section, poor communication between patient and provider — whether because of language or cultural barriers, discrimination or patients feeling like they don’t have a voice — is one reason they happen, said Allyson Brooks, an obstetrician/gynecologist and executive medical director endowed chair of Hoag Women’s Health Institute in Newport Beach.

“In the perfect world, the decision to have a C-section is based on shared decision making,” she said. “If an individual is feeling like they don’t have a voice or that they’re not participating in a conversation or the physician isn’t participating in that two-way dialogue and there’s more of a paternalistic approach, you see the C-section rates go up.”

According to the “Listening to Mothers” report, 67 percent of API said they didn’t want medically unnecessary interventions such as C-sections during childbirth, yet 60 percent of women overall said they felt pressure to have a C-section for their first child.

The health of API women also plays a role in the high rate of C-sections, said Pamela Pimentel, a registered nurse and chief executive officer of MOMS Orange County, a nonprofit that offers healthcare coordination for low-income pregnant women.

The Vietnamese mothers that she sees in her program are typically older than the others — they tend to have their first child at 35, instead of the average age of 22, she said — which can lead to more complications during pregnancy, and eventually, a C-section. Pimentel also said that she’s seeing higher rates of diabetes among Vietnamese mothers, which then leads to higher risk of gestational diabetes and a C-section delivery.

Tom also explained that many API women on Medi-Cal have poor and infrequent prenatal care, which can lead to poor outcomes during childbirth.

While in many cases C-sections can be life saving, said Brooks, the procedure should be avoided if they aren’t medically necessary. C-sections come with increased risk of blood clots and infection on the incision site, and can lead to more pain and immobility postpartum. They can also cause problems for future pregnancies, she said, such as an increased risk for uterine rupture, which she said can have “catastrophic” consequences.

That’s why for Pimentel, educating mothers about childbirth — and their options during it — is key to helping API women reduce their numbers of unnecessary C-sections.

“For me, it’s a great travesty when a mother has a C-section and I see her a few weeks later and I ask her why she had one and she doesn’t know,” said Pimental. “I want our clients to be able to say, ‘I had a C-section because of this.’ It’s really important to know what’s happening to your body and to be empowered to ask questions.”