Why the Five & One?

Welcome to The Five & One Member Edition. Once a month, members will receive our deep, unfiltered look at the forces shaping women’s health — policy, practice, and the systems behind them. This month’s member deep dive is now live.

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When two New York Times articles link continuous fetal monitoring to unnecessary C-sections — and then connect those C-sections to rare but life-threatening complications like placenta accreta — the result is predictable. Fear. Fear of hospitals. Fear of doctors. Fear of childbirth. Fear of one piece of equipment. Fear of what might be done to women rather than for them.

The pieces resonate because women already carry a deep reservoir of skepticism about the maternity care system and C-sections. And in a moment when trust is low, and that feeling is further validated by videos of Black women in labor being ignored or dismissed, it is more than understandable.

But for Dr. Onyemaechi Anoruo, a community-based obstetrician and gynecologist who works in the trenches of modern labor and delivery, and serves as 51&’s Chief Medical Officer, the articles told an incomplete story. 

These stories are not untrue, she notes, but reductive. And oversimplified narratives carry real consequences.

“Fear is a very dangerous thing to stoke. Especially in childbirth, where trust is everything.”

What follows is a more complete picture, one that honors the valid concerns raised by journalists, while expanding the frame to include the medical realities, system failures, and human complexities that shape how labor unfolds in the United States today.

The New York Times articles taken together suggest a direct relationship: monitor → misinterpretation → unnecessary C-section → placenta accreta.

But Dr. Anoruo immediately flags what’s missing.

“Our patients are the sickest they’ve ever been,” she says. “We have the highest rates of obesity-related considerations, diabetes, hypertensive disorders in pregnancy, fetal growth restriction, autoimmune diseases, IVF pregnancies, and people giving birth at later ages — all at the same time.”

These comorbidities matter. They aren’t minor background details, they can fundamentally shape labor. They also represent the overlap with conditions that disproportionately impact women, which introduces another system gap women face.

If a patient is being induced for severe preeclampsia, diabetes, or poor fetal growth, they are being given medications designed to jump-start labor. Those medications necessarily contract the uterus, which can potentially stress the baby. Continuous monitoring doesn’t exist to replace clinical judgment; it exists because, in these cases, it’s the only tool clinicians have to understand what the baby is experiencing.

“Is the tool perfect? Absolutely not,” she says. “But it’s the only window we have into how a fetus is tolerating labor.”

The narrative that hospitals use monitoring mainly because it’s profitable or convenient erases the truth: in medically complex labors, not monitoring would be irresponsible. In many cases, it could be dangerous.

It also distorts how decisions about C-sections are actually made.

Obstetrics is not a choose-your-own-adventure story. It’s a constantly shifting evaluation of maternal vitals, cervical exams, fetal heart rate, pain patterns, bleeding, infection, and the physiology of both people in the room.

“There is no single thing that makes us recommend a C-section,” she explains. “It’s always a constellation of factors.”

Continuous monitoring may be one tile in a mosaic. It is never the whole picture.

C-section rates are increasing, but continuous monitoring is only a thin slice of why.

More comorbidities. More inductions. More medically complex pregnancies that require close surveillance.

A significant number of  people in labor at a hospital are not in spontaneous labor, they’re being induced. Labor induction in the U.S. has more than tripled over 30 years — from 9.5% in 1990 to 31.7% in 2020 (PMID: 35659796) ”Inductions can be long, slow, medically involved processes. And many indications for C-Section arise not necessarily because of induction itself, but potentially because of sequelae related to the medical comorbidities that prompted the induction.

OB/GYNs are among the highest-cost specialties for malpractice premiums of any specialty. “Fetal monitoring isn’t perfect,” she says, “but if a tracing looks bad and we do nothing, and a baby is harmed, we are held wholly responsible. That reality shapes behavior.”

“The idea that we’re doing them casually or for convenience. That’s just not the reality,” she says. Hospitals are under pressure to reduce their C-section rates (hospitals often use a benchmark rate of 23.6%) and they scrutinize their practices constantly, from induction protocols to infection rates to labor support models.

Closures of labor-and-delivery units, nursing shortages, burnout, and poor reimbursement all limit the capacity of hospitals to provide continuous one-on-one labor support, a known factor in reducing unnecessary intervention.

“Running a safe labor and delivery unit is expensive,” she says. “You need obstetricians, anesthesiologists, pediatricians, neonatologists, surgical techs, nurses, ORs. And women’s health is simply not reimbursed well.” 

The result is a perfect storm: more medically complex pregnancies, fewer resources, and a shrinking workforce.

The problem is not one device. It’s an entire interdependent system of challenges.

Is the fetal monitor perfect? No. Dr. Anoruo is one of many clinicians who believe we need a new, more precise technology.

“Fetal heart tracings can give false positives,” she explains. A monitor might suggest distress, but when the baby is born and cord blood gases are checked — the true indicator of oxygenation — everything is normal.

But here’s the nuance missing from sensational headlines:
False positives are a flaw of the device, not a sign of medical negligence or manipulation. And they are preferable to false negatives.

“You wouldn’t want us to ignore a big deceleration,” she says plainly. “Some of those decelerations are the first signs a baby is truly struggling.”

Clinicians operate in a narrow space between risk and responsibility. The fetal heart monitor is imperfect, but it is the best window they currently have.

And for many high-risk births, it can save lives.

The second NYT article goes deeper into placenta accreta, a rare but severe condition - it takes place in fewer than 1% of total US births – that becomes more likely with each C-section a woman has had, particularly if the placenta covers the cervix during the pregnancy.

In accreta, the placenta grows too deeply into the uterine wall. Delivering the baby often requires a complex, multi-specialist surgery and oftentimes a hysterectomy. The condition is dramatic, dangerous, and rising.

But here again, the narrative overshadows the deeper issue that needs attention.

Surgical Management of Placenta Accreta requires:

In a system where labor units are rapidly closing due to financial strain, many hospitals cannot deliver this high level of complex care safely.

“It’s a scary snowball,” she says. “Labor and deliveries are closing. Patients are sicker. People are losing health insurance. More women have limited or no prenatal care. And accreta detection often happens before delivery, but not always.”

When hospitals close, prenatal care disappears. When prenatal care disappears, accreta can be missed. And when accreta is missed, women walk into hospitals that aren’t prepared for the surgical catastrophe unfolding inside their bodies.

The real crisis isn’t simply the presence of C-sections or accretas. It’s the rising rates of comorbidities that contribute to increasing rates of C-sections, combined with the waning physical, human, and financial resources needed to safely manage the  complications that arise from them.

Dr. Anoruo works in a community where distrust of the healthcare system is profound, especially among Black women, whose pain is often underestimated and whose outcomes are disproportionately poor.

“When you look at the history of obstetrics in this country, especially for Black women,” she says, “it would be unusual not to have distrust.”

Black women are three times more likely than White women to die from pregnancy-related causes (a disparity confirmed across CDC, ACOG, and peer-reviewed public health data). Recent videos of Black women screaming in active labor while being ignored strike a nerve because they are not anomalies, they are visible evidence of a deeper truth many already know.

As an OB/GYN, she walks into a delivery room as both a physician and an embodiment of the system. Patients project their fears, their past traumas, and their inherited mistrust onto her. Often within minutes of meeting.

“Trust is everything,” she says. “And I have maybe ten minutes to build it.”

This is the invisible labor of birth work: the emotional, historical, cultural weight physicians must navigate alongside medical decision-making.

“You asked me what’s the biggest thing I wish patients knew,” she says. “I wish they knew we don’t take any of this lightly. But I also understand why they come in not trusting us. That’s the hardest part.”

Despite the complexity and chaos, she insists that rebuilding trust is possible and essential.

She starts every labor admission with a simple question:

“Are there any special considerations you want us to keep in mind during your birth?”

Not medical considerations. Human ones. Rituals. Naming preferences. Privacy. Triggers. Fears.

Then she asks:

“What can we do to help you feel safe?”

These questions, she believes, change everything. They anchor the experience in partnership rather than paternalism.

“Patients bring their whole history into the room,” she says. “Their anxiety, mistrust, trauma. When you acknowledge that, you open the door for real connection.”

After reading articles like the NYT pieces — frightening, binary, and lacking context — many women come to labor appointments already braced for battle.

If she could offer one piece of advice, it’s this:

Talk about your fears. Early. Before labor. Before crisis. Before urgency makes conversation impossible.

“Some people hold fears silently,” she says. “When they do, every recommendation feels impenetrable. But when you tell me, ‘I’m terrified of a C-section,’ then I can explain everything we’re doing to avoid one, what would happen if one became necessary, and how we’d keep you safe.”

Fear thrives in silence.
Trust grows in conversation.

When she zooms out, beyond individual births, beyond individual fears, Dr. Anoruo sees something bigger:

“No matter how good a surgeon you are, you’re still working in a system that doesn’t always allow you to do the best for your patients,” she says. “And that is deeply frustrating.”

This is a system that:

The enemy is not the monitor. Though redesigning monitoring is warranted.
It is not the doctor.
It is not even the C-section.

The enemy is a fragmented, under-resourced, misaligned healthcare system — and women are paying for it with fear, with trauma, and too often, with their lives.

This is the lens 51& was built around: understanding how issues connect, cascade, are experienced differently across race, ethnicity, socioeconomics, and geography. And giving women a meaningful way to shape the future of a system that so profoundly shapes them today. It’s one of the first steps to move from isolated problems to coordinated solutions.

As our interview winds down, Dr. Anoruo says something soft but resolute.

“Honestly, women deserve better. That’s the thesis of all of this.”

Better tools.
Better systems.
Better accountability.
Better access.
Better trust.
Better care.

And better stories. Ones that illuminate the complexity without collapsing it, ones that empower with knowledge, rather than terrify, and ones that center the lived experiences of the women and physicians navigating a system straining under its own contradictions.

Fear sells, yes. But fear can be inflamed irresponsibly. 

And in some cases, like with what’s happening to Black women, we need to see that fear with wide open eyes. 

But truth — full, nuanced, complicated truth — builds something far more powerful.

Trust.

And in childbirth, trust can be lifesaving.