Sarasota Health News on MHC in 21st Century

Florida's high c-section rates, midwifery among topics of Sarasota conference seeking to improve community's maternal healthcare

by David Gulliver (Sarasota Health News)

When Jennifer Petroskey was planning for the birth of her third child, she hoped she would be able to have a natural delivery. Her twins, born four years earlier, had to be delivered by Cesarean section.

Her doctor, however, ruled out the natural birth, following a widely-held view among obstetricians: “Once a c-section, always a c-section.” Her doctor cited the potential for complications -- primarily, uterine rupture, resulting from pressure where her uterus had healed.

“I was basically told that this was how it was going to be,” the North Port mother said, “although I wanted the experience of a vaginal birth.”

Petroskey’s experience is the norm, and illustrates a significant trend in how babies are delivered. C-sections accounted for 38.2 percent of all births in Florida in 2008 -- up almost 50 percent from the rate in 2000 and the second-highest rate in the country.

It also highlights how rifts can develop between women, their doctors and other providers of maternal health care. In this case, obstetricians are following their profession’s guidelines for minimizing risk, while more women are embracing the trend of less invasive medical care.

Those are the issues behind a conference Sunday in Sarasota, titled “Maternal Health Care in the 21st Century: Sarasota and Beyond.”

---

The conference was born out of a presentation by Laura Gilkey, who delivered her two children at her Sarasota home with the aid of midwives. She is vice president of the Florida Friends of Midwives.

In July, she spoke before the Sarasota Memorial Hospital Board, laying out a slew of statistics in her six-minute talk -- such as Florida’s high c-section rate, studies showing higher neonatal ICU (or NICU) admissions and death rates for babies delivered by c-section, and that c-sections cost nearly twice as much as a vaginal birth.

In Florida, a c-section cost about $14,458, compared to about $7,533 for a vaginal birth, according to the most recent state figures. With more than 40 percent of c-sections being performed on Medicaid or charity cases, the trend also has implications for both the state’s Medicaid spending and Sarasota County’s hospital tax, Gilkey said.

She called on Sarasota Memorial to take steps to lower its c-section rate -- in 2008, it was 41.7 percent, ranking 22nd among the 115 Florida hospitals delivering babies, and about 10 points higher than the 2000 rate.

“Our medical model is not as great as everyone thinks it is,” Gilkey said in a later interview.

She summarized her points in a letter published in the Sarasota Herald-Tribune. It caught the eye of Sonia Pressman Fuentes, a longtime women’s rights activist, who said she was amazed at the findings. Pressman Fuentes, a member of the local National Organization for Women chapter, pulled together support for the conference.

The conference’s purpose, Gilkey said, is to provide better education about childbirth risks and about the full spectrum of maternal healthcare.

“If we move toward a collaborative model, doctors and women working together based on risk levels, our VBAC would rise, there would be fewer pre-term babies, NICU admission would decline and our overall health barometer would rise,” she said.

Panelists include Jennifer Highland, executive director of the Healthy Start Coalition of Sarasota; Ina May Gaskin, a national expert on midwifery; Florida Rep. Keith Fitzgerald, who serves on a House health care planning committee; and Dr. Washington Hill, medical director of labor and delivery and director of maternal-fetal medicine at Sarasota Memorial and a nationally-known expert in his field. Vice-Mayor Kelly Kirschner is the moderator.

At the July hospital board meeting, Hill said it was more important to look at the end result. “When I was a medical student in 1965, we all looked at c-section delivery rates,” he said. “I think now what we look at is the quality of that patient and the quality of that outcome.”

“There is no single c-section delivery rate that can be said to be ideal or correct for either the physician or the hospital or the county or the state,” he said.

But the rise of Cesarean section deliveries demonstrates what happens when some of the most powerful trends in medicine interact.

---

In 1990, the U.S. Dept. of Health and Human Services set a national goal of reducing c-sections to 15 percent of births. After some initial gains, rates have steadily risen to a national average of about 32 percent. In some Florida hospitals, c-sections account for more than half of all births.

In his talk to the hospital board, Hill pointed to a number of reasons behind the trend.

There are more mothers over age 35, who tend to develop more complications. More mothers of all ages are obese, another complication. More women are concerned about preserving their pelvic floor. Some women elect c-sections for convenience and for a desire to have a “perfect” baby.

And hospitals are trying to respect patients’ decisions. “We’ve made a decision at this hospital that if a patient is well counseled and says she wants a primary elective cesarean delivery or induction, then she can have that done,” Hill said.

One of the most important factors, he said, is fear of a malpractice suit. “The physicians themselves say very clearly that malpractice litigation concerns and the risk of litigation is going to increase their decision to do a cesarean delivery,” Hill told the board.

C-sections are quicker and more predictable, less prone to sudden or unforeseen complications, obstetricians say.

And as more patients and doctors opt for the surgical deliveries, it starts a cycle. If a woman who delivered by c-section is having another baby, her doctor is likely to recommend another c-section. National studies show about 90 percent of women who deliver a baby after a c-section do so by another c-section.
---

Jennifer Petroskey’s four-year-old twins, Alex and Kailin, are happy, healthy kids now. But at birth, one was in breech position, the other transverse, indicating a c-section was the safest course.

Six-month old Jackson presented no such problems, but her obstetrician insisted on a c-section, saying the risk were too great. Petroskey likes and respects her doctor, so she agreed.

“I wasn’t really given a choice. I was told that was what was going to happen,” she said.

The doctor’s advice reflected the evolution of the field’s position on vaginal birth after Cesarean, or VBAC. The long-held dictum was challenged in the 1980s and doctors again began accepting the procedure, with it peaking in the late 1990s.

But the studies reaffirmed the initial position, and doctors again shied away from VBAC. In Sarasota, Dr. Michael Shroder is one of the small handful of obstetricians will perform the deliveries.

He understands his colleagues’ reluctance about the VBAC. "There is a real risk of complications,” said Shroder, who, like Hill, is a member of the First Physicians Group practice.

The potential problems include uterine rupture, hysterectomy, blood clots, infection, maternal mortality. Uterine rupture, tear in the wall of the organ, occurs in about 1 percent of VBACs, but of that 1 percent, few are catastrophic ruptures and can be treated easily.

He cited a Dec. 2004 study in the New England Journal of Medicine, which examined nearly 34,000 cases of mothers carrying a single baby and who had a previous c-section. About half had another c-section, while half had a traditional labor and delivery.

In the labor and delivery group, there were 124 uterine ruptures, about 0.7 percent, and 12 cases of where the infant suffered complications from a lack of oxygen during delivery. There was no difference in maternal death rate.
Overall, the researchers found a 1 in 2,000 chance of of an adverse complications for the infant. Echoing the authors, Shroder termed it a "a small but significantly higher risk."

But, he notes, in some cases there are “significant benefits." In addition to avoiding a longer hospital stay, the major advantage is avoiding another scar in the uterus, which could complicate a future pregnancy. Those complications include placenta previa (separating and bleeding), or placenta accreta (intruding into the muscle of the uterus.)

He bases his decisions on the patient’s history -- has the patient had more than one previous c-section, or if the c-section was other than a low transverse incision -- and on the presence of other conditions, like placenta previa, that would indicate a c-section.

And it depends largely on the patient’s plans. A c-section might be indicated for 40-year-old woman planning no future pregnancies. “A 20-year-old who plans two more children has a lot to gain from a VBAC," he said.

“It’s incumbent on me to look at the facts and risks and benefits and help the patient make a informed decision.”

In addition to potential complications and liability, he said, some obstetricians avoid VBAC because of hospital policies. Sarasota Memorial’s policy, which he said is common, requires the obstetrician to be present for entire labor, a major time commitment that can take them away from other patients.

That reluctance of doctors and hospitals may send women to midwives, generally more accepting of the mother’s wishes. But that raises some concerns for doctors.

---

“Having a baby at home is a risk. Having a baby at a birthing center is a risk,” Hill said. “If they have a decline of the fetal heart rate, by the time the baby gets here it could be a catastrophe.”

But he also sees the value of midwives in maternal health care, noting the non-profit Genesis Newtown Medical Group’s team approach to reducing fetal death rate, premature births and low birthweight babies. It employs community volunteers, midwives and an obstetrician to provide prenatal care for the low-income community.

Similar programs have a track record of success. In 2002, Florida Hospital Waterman, in Lake County, noted an alarming trend: More and more pregnant women were showing up in its emergency room, some about to deliver, with no prenatal care.

It meant complicated, often premature births, and longer hospital stays for both mother and child. It meant financial losses for the hospital, because most of the mothers were uninsured. Meanwhile, obstetricians were leaving the county, over the rising cost of malpractice insurance -- to some extent because of the more precarious deliveries.

The hospital met with Lake County officials and together they developed a strategy to hire four midwives and two OB/GYNS midwives to provide prenatal care. The midwives also care for the mothers in the early stages of labor.

The result: in 2007-08, the program handled some 700 deliveries and saved the hospital an estimated $1 million.

Lake County saw its Cesarean delivers drop from almost 51 percent in 2006 to 36 percent in 2008, a 14-point drop -- double the reduction of the next-best Florida hospital over that time, and only 11 hospitals reduces Cesarean deliveries by 2 percentage points or more.

County officials attributed the improvements to the work of the midwives. “If you didn’t have a team program that saw the uninsured in the community, what you would have is the patients reporting to the ER with no prenatal care,” said Donna Gregory, a Lake County Health Department administrator, in an interview this spring.

The Sarasota conference planners say they hope to foster similar partnerships and more unified maternal care with the best possible outcomes.

“There are many pieces needed to make this happen -- licensed midwives, hospitals, the community, government. Each piece has some work to do,” Hill said.

“The licensed midwives need to communicate better with the doctors. We need to communicate better with the licensed midwives. We all need to work together. If we don’t communicate with each other, the whole thing breaks down.”

“We should do whatever we can in the community to have a healthy mother and a healthy baby,” he said.

---

The conference is free and open to the public, and will be at 3 p.m. Sunday, Nov. 1., at the Hyatt Regency of Sarasota. Call 915-8115 for more information.