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.