Monday, July 20, 2009

Sarasota Public Hospital Board Meeting, and Maternal Request Cesareans

At today's monthly Sarasota Public Hospital Board meeting, I requested an address with the board during the public commentary section of their agenda. As Sarasota Memorial is a tax-funded hospital, this is a right that anyone in our community has. I was given five minutes to speak. Five minutes was not enough, and there was much I wasn't able to say--but I left each board member with 146 pages of evidence to digest, and I hope that they do. The following is the agenda I used to quickly try and paint the broad picture.

What is the problem?
  • I represent a body of consumers that is concerned with the notably high c-section rates at Sarasota Memorial Hospital.
  • SMH's c-section rates are between 41.3-44%, depending on research vs. consumer data.
  • Best evidence (WHO) supports rates of 15% or less. I understand ACOG's viewpoint that this is an arbitrary number, and agree that hospitals should take a patient-centered approach rather than striving for a certain rate; however, it remains true that as c-section rates rise, so do maternal mortality and preterm birth rates, NICU admissions and health care costs.
How does Sarasota Memorial Hospital compare?
  • Sarasota County has the 4th highest rate in Florida.
  • Florida has the 2nd highest rate in the United States.
  • SMH has a real opportunity to implement protocols that will reduce these numbers and prove tremendous cost savings and improved outcomes.
Why is this a problem?
  • Evidence (included in binder) consistently shows that maternal / fetal / infant risks far outweigh benefits at this rate.
  • My biggest concern is the risk to future pregnancies / placental issues, as this directly correlates to the VBAC access problem.
  • Cost to taxpayers--C-sections cost twice as much as vaginal births; in Sarasota, taxpayers are hurt doubly - by paying for medicaid funded c-sections, and because SMH is a tax-funded hospital.
  • Cost to hospital--1/3 of c-sections are repeat c-sections, and repeat c-section babies are twice as likely to go to the NICU, at a high overhead to SMH; 1/2 of these babies are covered by medicaid, increased stay and risk of infection reduces reimbursement to hospital
  • Cost to patients--Insurance companies are beginning to refuse coverage to those with prior sections; if patients can't get coverage for repeat sections, AND can't get VBAC access, they find themselves in a true health crisis.
How can we improve?
  • Revise induction protocols. 44% of first time moms who are induced wind up with c-sections, as opposed to 8% of moms who go into spontaneous labor. Verify cervical ripening prior to induction. No induction prior to 39 weeks. Revise oxytocin infusion protocol to reduce intensity and frequency of inductions.
  • Require mandatory prenatal counseling on risks of elective c-sections (including benefits of full-term babies and natural hormone release).
  • Implement voluntary audit system / commitment of OB community (launch 1-5 year initiative, etc.).
  • Support TOLAC / VBAC wherever and whenever possible (i.e. w/ OB hospitalist to remain with laboring patients, careful attention to effects of pitocin on VBAC patients, etc.).
  • Reduce patient to nurse ratio for improved continuity of care.
  • It has been done: the Institute for Healthcare Improvement Strategic Partners Program trains hospitals to implement guidelines regarding induction and elective c-section prior to 39 weeks. 60 hospitals have joined. One such hospital reduced NICU admission by 46% in just three months.
What are the benefits of improvement?
  • SMH has the opportunity to be a model community at the forefront of evidence-based maternity care.
  • With the new bldg, allow for induction-free / drug-free labor support, including intermittent fetal monitoring, freedom of movement, increased continuity of care, and doula programs.
  • By allowing and encouraging spontaneous labor, you will send a message that you support the natural process of hormonal release that stimulates bonding and increases the rate of and the chance for successful breastfeeding.
  • If you implement these protocols and reduce c-section rates, you will see tremendous cost savings to the hospital, the taxpayer, and the patient.
  • A mother-friendly hospital is an attraction for potential new families.
  • Reducing c-section rates will result in fewer pre-term babies.
  • Reducing c-section rates will result in better birth outcomes, more satisfied mothers, support of initial bonding, and, I would argue, a reduction in postpartum depression.
When I was finished sharing this information with the board, Dr. Washington Hill, M.D., FACOG, the Director of Maternal-Fetal Medicine at SMH, presented an overview entitled Sarasota Memorial Hospital Births: Cesarean Delivery, Vaginal Birth after Cesarean Delivery, and Induction of Labor. His presentation was thorough and explanatory, defining commonly used terms, showing trends in c-section and VBAC rates, and siting tort reform as a necessary component to reversing this trend. On his list of 'Maternal Factors Responsible for the Increased Cesarean Delivery Rate,' Dr. Hill includes 'increased number of women choosing primary elective cesarean delivery and/or induction of labor (maternal request).' He and his colleagues have made a conscious decision to offer patients the choice of an induction or cesarean section, though he maintains that they are not performed unnecessarily prior to 39 weeks.

While I do not have specific physician diagnosis breakdowns for the c-sections performed at Sarasota Memorial Hospital, in Florida as a whole, maternal request was not listed among the top ten diagnoses for c-sections (AHCA 2006). If women are the ones driving up the c-section rates, their 'choice' is not being given as the reason for surgery.

Among physician diagnoses, there is a difference between the designation 'Elective Primary Cesarean Section' (EPCS) and 'Cesarean Delivery on Maternal Request' (CDMR):

Elective Primary Cesarean Section (EPCS): A planned first or “primary” cesarean section in a healthy woman for the birth of a baby when there is no medical, fetal, or obstetric reason for the surgery. May be influenced by non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability, insurance coverage, liability fears, hospital economics, efficiency, convenience, and reimbursement rates, as well as other factors not listed. (American College of Nurse-Midwives, Position Statement: Elective Primary Cesarean Section & Citizens for Midwifery, News Release: “Patient Choice” Cesareans Almost Non-Existent)

Maternal Request Cesarean Section / Cesarean Delivery on Maternal Request (CDMR): A subcategory of elective primary cesarean sections. A planned (before labor begins) first or “primary” cesarean initiated by the mother with the understanding that there is no medical, obstetrical, or fetal indication requiring cesarean delivery, and after a through review of the risks and benefits of cesarean delivery vs. vaginal birth by the obstetrician, the woman’s decision is to have a planned cesarean section. The primary decision maker for a CDMR is the woman. (National Institute of Health (NIH) Cesarean Conference definition, March 2006 & Childbirth Connection, Listening to Mothers II Survey)

Necessary Criteria for Maternal Request Cesarean Section:
1 : The request for the cesarean and the scheduling of the cesarean must have been made prior to the onset of labor.
2 : The request for the cesarean must have been initiated by the mother.
3 : The mother must have the understanding that there is NO medical, obstetrical, or fetal indication requiring a cesarean delivery.
4 : The obstetrician must personally review and assure the mother’s understanding of the risks and benefits of elective cesarean surgery vs. planned vaginal birth.
5 : The woman is the primary decision maker.

In national data compiled by The Childbirth Connection's Listening to Mothers Survey, 98% of women who gave birth by c-section believed there was a medically necessary reason for doing so.

As the Hospital Board meeting adjourned, Dr. Hill and his staff informed me of a new policy they are adopting involving elective induction and augmentation 'bundles.' The Insitute for Healthcare Improvement defines 'bundles' as groups of evidence-based interventions related to a disease or care process that, when executed together, result in better outcomes than when implemented individually. Components of the bundle, or elements that must be considered when administering oxytocin, include ensuring that gestational age is at least 39 weeks, monitoring fetal heart rate, pelvic assessment and monitoring and management of hyperstimulation.

I am hopeful that careful consideration of this and other protocol revisions aimed at lowering cesarean section rates at Sarasota Memorial Hospital are successful. In every clinical study I've read where rates have improved, the common denominator was voluntary commitment on the part of the obstetric community. Our obstetricians must be united in a desire to show the will and leadership necessary to reduce induction and c-section rates, thereby improving outcomes and saving our taxpayers, our hospitals, and our patients money.


  1. Great job! Here's hoping that they will take your presentation to heart and implement the necessary changes.

  2. Wow are incredible!!! What a beautiful and thorough presentation you gave. I appreciate your work on this SO much--you are inspiring.

  3. WOW! You know, at one point in my life it was a dream to do the work you are doing! I am so happy that you are following your passion, Laura. This work is so incredibly needed. You are on a noble and valuable path. You never cease to awe me, mama! Hugs and kisses for all the good work you do!

  4. Missing from Induction Bundle Protocol:

    Requiring Adequate Cervical Ripeness/ Bishops Score to be eligble for induction of labor:

    and eliminating the use of cytotec/ misoprostol for induction of labor, which should be part of the plan to reduce hysperstimulation of the uterus.

  5. Good job.

    It is true that the studies show women believe there is medical reason for their c-sections. Women are not clambering for higher risk major surgery as an alternative to birth. If women express fear of birth, that is normal, and this normal fear should be met with appropriate education, not an offer of major surgery! Especially because the physicians have so many incentives to do them.

    There needs to be third party informed consent for these so called 'maternal request' c-sections, because there are significant incentives for the physicians to subtly and not so subtly encourage these c-sections. C-sections limit liability exposure, are conveniently schedulable so they do not interfere with office hours, and take less time and pay better than vaginal births.

    It is very beneficial to a physician practice to have a high c-section rate. It is very unhealthy for women to have a high c-section rate. There is a conflict of interests, and the women are not the ones with the power to decide in most cases.

  6. Great work Laura! I am so glad the Board got to hear this. It must eventually sink in...

  7. You are doing such important work! Thank you. Beautifully presented. You are an inspiration ...making it happen

  8. Laura, thank you for presenting to the Sarasota Memorial Hospital Board; our public hospital. I have 32 years of neonatal intensive care unit (NICU) experience as a R.N., and have frequently admitted infants to the NICU after a scheduled cesarean delivery, most often due to respiratory issues. Many times the infant requires a septic work up to determine the cause of their breathing problem. Depending on the neonatologist or pediatrician, after the infant's blood is drawn and a chest x-ray is obtained, IV antibiotics are initiated for 48-72 hours. The infant's response to the antibiotics is monitored by repeat blood work. A venipuncture does cause pain to the infant, who may not receive anything for the painful procedure. Infants may not be able to go home with the mother after her 48 hour stay on the mother baby unit (MBU), and frequently the mother's are not prepared for this separation, however brief. A 3 day NICU stay is several thousand dollars. If a ventilator or oxygen is required, the cost is higher. A mother may consider and request a cesarean delivery because she has received limited education regarding the benefits of a full term delivery or she has misinterpretated information about the risks or lack of risks of an elective scheduled cesarean section. Many times the NICU scenario can be eliminated by the mother waiting for signs of spontaneous labor. By reducing the admission to the NICU, the family (and the healthcare system) has less financial burden, reduced family/maternal stress and a more positive bonding experience. Changing the attitudes and behaviors of the hospital board, medical community and the public require continued education and dedication. I know we all want a healthy full term infant to be discharged from the hospital in the arms of their mother without complications to mom or baby. Thanks again, Pauline

  9. This is so impressive and Pauline's comments are enlightening and terribly disturbing, when you think of how all of that could be prevented. My understanding is that NICUs are major money-makers for hospitals, however. So I'm not sure that reducing NICU admissions and NICU procedures is a compelling one to the hospital board (though it should of course be compelling in terms of health outcomes and the wellbeing of the people they serve.) I don't know exactly how the costs/charges work and who the winners are, financially speaking. Perkins "The Medical Delivery Business" may have answers. It's a great book if you haven't seen it already.

    Again, this is so fantastic and I think it could be a model for other ICAN Chapters and mother-friendly care advocates. Great work!

  10. Cheryl Ross Hollifield, CNMJuly 24, 2009 at 7:25 AM

    Great Job Laura! You know that and important part of the change could be midwives practicing midwifery in the hospital setting - a mammoth challenge in itself! Thanks for all you do!