Monday, June 8, 2009

Florida Ranks 2nd Nationally for C-Sections

An article in today's Sun-Sentinel reveals that the most recent AHCA data (from July 2007 through June 2008) shows Florida ranking second in cesarean section rates, just behind New Jersey. Florida rates are now 39%, far exceeding the national average of 31.8%. Using the researchers data from 2007, Sarasota County ranks 4th of all reporting counties in Florida, delivering over 41% of our babies surgically. The consumer data from the same year puts this number at an even higher 44%, almost tripling the World Health Organization recommended 15%.

In sharp contrast, the most recently available Licensed Midwives Annual Report, collected from 34 practicing Florida Licensed Midwives in 2006, reveals a C-section rate of just 6.3% (92 surgeries out of 1454 births).

Something isn't adding up.

The Sun-Sentinel article, as do many other writings on the subject, cites "medical malpractice fears" as a big part of the problem. "Obstetricians and hospitals in litigious South Florida order C-sections for any irregularity before or during labor," doctors and researchers said. "Doctors contend they are under pressure to deliver surgically. If they don't and something goes wrong, they are sued." Yet based on my own research during the McGlades trial appeal, I have yet to discover a single medical malpractice suit awarded to a client of a Florida Licensed Midwife.

So midwives aren't getting sued, yet they aren't performing the high volume of C-sections that many obstetricians credit as their saving grace from malpractice litigation. What is at the root of this anomaly?

I understand that the current C-section rates take into account those high-risk women and pregnancies that actually require them, and once again, I cannot extend enough gratitude to the obstetricians that skillfully and appropriately perform this surgery. Yet according to the World Health Organization, as well as recent research supporting its recommendation, the best outcomes for mothers and babies are congruent with cesarean section rates of 5% to 10%. High-risk hospitals (such as Sarasota Memorial, the only provider of obstetrical services and Level III neonatal intensive care in Sarasota County) have the best outcomes with C-section rates of 15% or less. The combined evidence I've seen over the last five years, including the most recent issue of Obstetrics and Gynecology, indicates that cesarean rates above 15% are simply medically irresponsible, and are directly contributing to the high maternal mortality rates in our country (1 in 4800).

According to research from the Childbirth Connection, the following seven evidence-based factors are contributing to the rising C-section rates in America:

1 :: Low priority of enhancing women’s own abilities to give birth.
2 :: Side effects of common labor interventions.
3 :: Refusal to offer the informed choice of vaginal birth.
4 :: Casual attitudes about surgery and C-sections in particular.
5 :: Limited awareness of harms that are more likely with C-sections.
6 :: Providers’ fears of malpractice claims and lawsuits.
7 :: Incentives to practice in a manner that is efficient for providers.

It seems to me that perhaps the root of the malpractice anomaly lies within the patient's basic rights to informed consent and refusal. An excerpt from The Florida Patient's Bill of Rights:

"A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient, in which case the information must be given to the patient's guardian or a person designated as the patient's representative. A patient has the right to refuse this information.
A patient has the right to refuse any treatment based on information required by this paragraph, except as otherwise provided by law."

Improving American birth culture and reducing egregious C-section rates absolutely must be the result of a combined effort among legislators, policy makers, public health officials, hospitals, maternity care providers, and us, the consumers, who have the right and responsibility to the best evidence and information about our maternity care choices.

1 comment:

  1. Nice post. It's encouraging that THERE ARE places that have tackled this problem successfully. The will must be there, but there is a way. Coalition for Improvement of Maternity Services annual conference always has presenters from Mother-Friendly hospitals. Tallahassee's small community hospital and a hospital in Minnesota stickout as having really tackled the issue and successfully reduced c-section rates. The hospitals have to get on the providers to make it happen though. They have to stop inductions. Tallahassee made the doctors get someone from L&D to confirm cervical ripeness before they were allowed to induce. No ripe cervix, no induction. Reduced the rates a lot, taking all those failed inductions out of the mix.

    We also need a national healthcare system- this is tough problem to fix with no national group overseeing or holding providers or hospitals accountable. Everyone can point the finger at someone else. And providers are free to pressure women with incomplete information, since there is no national standard or mandate for what constitutes informed consent on a particular issue. Women will always do what is best for the baby, so if you present c-section in that way, they will do what they have to. It's way too easy to pressure a pregnant women into over interventive medical care- all you have to say is it's best for the baby and they will consent.

    Our maternal mortality rates are rising and we have no way of even tracking how many deaths occur nationally, or why they occur. There is no way to improve if we do not even know why the women are dying in childbirth! With no standard death certificate or place to report these deaths, the rates have been going up ten years and we are not sure why. What we are doing in birth in the USA is dangerous, but what part is dangerous no one knows exactly. But we do know that when the interventions go up, and the deaths and complications go up. That tells us something.

    Continuity of care is a piece of it as well. In Sweden, the midwife monitors labor and the birth, basically acting as labor nurse and midwife. This means responsibility for outcome is in one person's hands. This instead of it being split between one nervous nurse who has no power to act if things take a turn, and one doctor who is off site and relying on a phone report to assess the labor. When you split the birth into one on labor, one on birth, and divide responsibility, everyone gets over intervetive because everyone is out of touch and afraid of missing something. I think Sweden's low c-section rate, and licensed midwives low rates, are due to the continuity of care in labor and birth.

    This c-section rate is a systemic problem on so many levels. And women are the ones paying the price.