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FL C-sections driven by culture?

By Dave Gulliver and Carol Gentry
9/21/2010 © Health News Florida

A report from California last week found a statistically significant link between high rates for cesarean-section births and the for-profit status of hospitals. Health News Florida ran a similar analysis and found no such association.
 

Our analysis of the 116 Florida hospitals that delivered babies in 2009, both in overall rates and in rates of c-sections where there were no medical complications, found similar results in non-profits and for-profits. See complete list.

The overall rate statewide of around 39 percent, about seven percentage points above the national average, shows differences tend to be geographic. That didn't come as news to Tampa OB-GYN Robert Yelverton, a member of the Florida Perinatal Collaborative.

"We know it's higher in hospitals below (Interstate) 4, in general," he said. "We’re attempting to find funding to study that."

That suggests a demographic difference linked to the culture of the community. Ten of the 12 Florida hospitals with the highest rates of cesarean section delivery are in Miami-Dade County, where 62 percent of residents claim Hispanic ancestry.

“It’s sort of a cultural phenomenon,” said Dr. Rafael Perez, an obstetrician on the South Miami Hospital executive committee, where 61 percent of births are c-section.

Florida's highest C-section rate is at Kendall Regional Medical Center, where almost two-thirds of babies are delivered via that way. All  Miami-area hospitals except two that are part of the public system deliver about half of babies by c-section.

The findings echo a 2006 state report that found women of Hispanic ethnicity had a higher c-section rate than women of other backgrounds.

While culture may explain why Florida's rate is far above the national average, it doesn't explain the inexorable increase, from 26.2 percent in 2000 to to 41.2 percent in 2009.

The Florida Department of Health, working with physicians and other groups in the Florida Perinatal Collaborative, has been working for more than two years on a report on the reasons for preterm delivery, in which c-section is often implicated. That report may be ready by the end of the year, said DOH epidemiologist William Sappenfield, MD. 

In the meantime, physicians, parents and healthcare advocates point at a variety of causes, and sometimes at each other.

“It’s becoming an epidemic, and it’s being swept under the rug,” said Laura Gilkey, a Sarasota mother and advocate for natural childbirth.

Se habla espanol?

Florida experts have noted the link between Hispanic ethnicity and c-section rates before. A 2006 study by the Agency for Health Care Administration found that Hispanic women were the most likely to deliver by section.

That tendency surfaces in examinations of other countries. A Centers for Disease Control study found c-section rates of 45 percent in Puerto Rico in 2002, nearly double the mainland United States’ rate at the time. And some Central and South American countries have even higher c-section rates -- like Brazil’s 70 percent.

South Miami’s Dr. Perez said about two-thirds of his patients are Hispanic, and they have a different approach to childbirth. They are eager to attempt natural birth, said, but also quick to abandon it if they sense problems. “They have a fear of complications,” he said.

But mothers in general have changed, he said. He is seeing more older mothers, often using fertility treatments. “The people coming to see us now are not the same as the ones in the ‘50s and ‘60s,” Perez said. “They are delivering one baby, later in life, and they want it to be perfect,” he said.

About a quarter of his patients have c-sections, he said. Of them, about half attempt labor first. But his other patients’ choices illustrate some of the controversy surrounding cesarean sections.

No more VBACs

About half of Perez’s c-sections were likely from the outset, because of complications or because the mother had a prior c-section. Obstetricians have become reluctant to allow mothers to deliver vaginally after c-sections, a procedure known as VBAC. Studies show that in slightly less than 1 percent of cases, it can cause the mother’s uterus to rupture.

The American College of Obstetrics and Gynecology in July said the sharp decline in VBACs was a major cause of rising c-section rates. It issued new guidelines on when the procedure is safe, to persuade more doctors to perform it.

Doctors may still have doubts. VBACs are successful only about 70 percent of the time, so many end up with a c-section anyway, Perez said. In the rare uterine rupture, a medical team must anesthetize the mother and deliver the baby in a 10-minute window before lack of oxygen causes brain damage.

That illustrates another incentive for c-sections: Physicians’ fears of malpractice lawsuits.

“The first thing the lawyer is going to tell you, when you have a baby with a neurological impairment, is ‘Why did you do a VBAC?’” Perez said. “These kinds of lawsuits go into the millions of dollars, and that weighs heavily,” he said.

A handful of his patients will choose a cesarean delivery from the start, he said. Physicians, researchers and childbirth advocates have targeted those elective c-sections as the most dangerous.

ACOG guidelines tell members to avoid performing elective c-sections before 39 weeks of gestation, but difficulties in estimating fetal growth can result in babies born weeks before they reach full-term. This is the focus of the ongoing Perinatal Collaborative study.

“You absolutely cannot predict with certainty the gestational age of the fetus,” said Jennifer Highland, a registered nurse and director of the Sarasota County Healthy Start Coalition.

Incorrect age estimates result in elective c-sections performed too early, leading to health problems for infants. “It is the number one reason why our prematurity rates are going up,” Highland said.

Babies born in planned c-sections ended up in neo-natal intensive care units almost twice as often as those delivered vaginally, and had twice the risk of pulmonary problems, according to a 2006 study published in the American Journal of Obstetrics and Gynecology.

“We’re electing to put those risks on the baby, for no good reason,” Highland said.

Convenience a factor?

Doctors say some parents press for early deliveries for convenience or to avoid pain. Healthy childbirth advocates say some doctors also do so out of convenience. Perez said he educates his mothers about the risks.

“Babies should be born at 39 weeks,” he said. “Delivering at 38, 37 weeks -- that is not a good medical decision.”

Reducing those early c-sections -- the goal of initiatives by March of Dimes, hospital accrediting group the Joint Commission, and others -- may improve outcomes, but will not significantly change c-section rates, he said.

Despite those concerns, Perez sees cesarean deliveries as an advance in obstetrics and a safe choice for most women

“You have to ask a philosophical question: Are c-sections that bad?” he said. “Nowadays, a c-section is one of the safest procedures, because we do so many of them.”

That’s where physicians and advocates differ. C-sections carry significantly higher risks of infection and surgical injuries, and slightly higher risks of death or blood clots leading to stroke. “You don’t want to have surgery unless you have to have surgery,” Highland said.

Gilkey, the Sarasota mother, has two children. Both were 10 pounds at birth, both delivered at a birthing center with a midwife. In one birth, the midwife resolved a case of shoulder dystocia, allowing the natural delivery to proceed. “That never would have happened in a hospital,” she said.

While she believes hospital deliveries are best in some cases, the experience turned her into an advocate for natural childbirth. “Where birth is concerned, we live in a culture of fear,” she said.

--Dave Gulliver is an independent journalist in Sarasota and founder of Sarasota Health News. Carol Gentry, Editor, can be reached at 727-410-3266 or by e-mail