Monday, July 27, 2009

Cesarean Central: Miami Florida

I recently found this blog entry from Our Bodies Our Blog on the mind-bogglingly excessive cesarean rates in many hospitals in the Miami area in Florida.

Now, I knew the cesarean rates in Florida were bad, but wow, just wow.

The blog entry links to this article from the Miami Herald, which discloses that the cesarean rate in the Miami area now hovers around 50%, or HALF of all women who give birth in Miami.

That means that more women are giving birth surgically than are giving birth vaginally.....and that it's considered business as usual, no big deal.

But that's just the average; some hospitals are lower, while many are higher. In one hospital, the Kendall Regional Medical Center, the cesarean rate is an astounding and shameful 70.3%.

This absolutely boggles the mind. SEVENTY PERCENT??? Almost 3/4 of women there are subjected to the risks of surgery in order to have a baby?

Here's a quote from the article:

Last year, for the first time, more babies in Miami-Dade County were born by cesarean section than were born vaginally, according to state records, and Broward's not far behind, with a rate of 43.7 percent -- both far above the national average.

At Kendall Regional Medical Center in Southwest Miami-Dade, seven out of 10 babies were delivered by C-section, a rate that University of Miami obstetrician Gene Burkett called "just astounding.''
Want to know some of the reasons the doctors in Miami blame for the high cesarean rates there? Wait for it.....wait for it......yes, one of the top reasons cited in the Miami article is obesity. Sigh.

I keep saying it, again and again. If obesity were truly an intractable CAUSE of not being able to birth vaginally, there would have been a consistently high rate of cesareans in "obese" women over time. Yet the cesarean rate for "obese" women used to be MUCH lower than it is now.

Yes, "obesity" is a risk factor for some complications, and that can lead to more cesareans. But obesity was a risk factor for those complications then as well as now......yet somehow they kept the cesarean rate far lower then than now.

What's really changed is the perception of the risks of obesity and the highly interventive protocols around management of obese women. That has greatly increased the cesarean rate in women of size, not obesity itself.

But enough about that, back to the cesarean rate debate.

A Blast From The Past

Contrast the 50%+ cesarean rates from Miami....and the lack of concern about them from many of the local Miami OBs.....with the cesarean rates cited in this 1989 L.A. Times article about how the cesarean rates need to be reduced, and how perhaps half of all cesareans done are "unnecessary."

About half the Cesarean section surgeries in the United States in 1987 should not have been performed, according to a new report designed to focus attention on what it terms "an onslaught of unnecessary and dangerous surgery."

The report by the consumer advocate group includes Cesarean rates for about 2,400 hospitals in 30 states, including 1986 statistics for California hospitals, and statewide figures for an additional 11 states....

Cesarean section rates show "extraordinary variations between states and between hospitals within states," according to Dr. Sidney M. Wolfe, director of the Health Research Group and one of the authors of study. "The national rate is twice as high as it should be."

The Cesarean rate nationally--the percentage of all deliveries performed by Cesarean section--has increased steadily over the last two decades--from 5.5% in 1970 to 24.4% in 1987. Cesareans are now the most common major operation in the United States.

The study said the 475,000 "unnecessary" Cesareans performed in 1987 resulted in 25,000 serious infections, 1.1 million extra hospital days and a cost of more than $1 billion. These conclusions were based on an analysis of data obtained from 41 states, a review of studies published in medical journals and other publicly available data.
A Change in Attitudes

Didja see my keen and subtle sense of irony in contrasting these two articles?

The "too high" national cesarean rate cited in the 1989 article was 24.4%, and everyone was up in arms over its rapid rise and excessiveness.

Yet the national cesarean rate now is almost 32%, and of course now there are hospitals in the country with 50%, 60%, even 70% cesarean rates.

Where is the outrage now? The Miami story was largely ignored by the national press.

If you've read my earlier blog entry, A History of Cesareans and VBACs in the USA, you will know that the cesarean rate rose rapidly from 5% to ~25% in the 70s and 80s. Such a rapid increase set off alarms in many public health groups, and a strong campaign to reduce cesarean rates was instituted. Here's a quote from my article, slightly rearranged:

Remember when public health officials got all up in arms in the late 80s because the cesarean rate had spiked to around 25%? Well, they did reduce it for a while (it dropped down to 20.8% by 1995), but now it has spiked again, even higher than it was then. Now the cesarean rate has soared up to over 30% nationally...and is still going up.

Only this time, almost no one cares.
Having areas of the country---like Miami----where more babies are born by surgery than vaginally is a disgrace, and it's leading to poorer outcomes in babies, an increase in maternal mortality, and higher healthcare costs. (If you want to read more about the risks of cesareans, read this recent Medscape article about it. It's not just some benign minor surgical procedure.)

The epidemic of cesareans has become, in essence, a giant medical experiment.....with most of the subjects not given any choice about whether or not to participate. If you circumvent nature's highly evolved way of doing things, there are inevitably unexpected outcomes, and often more harms than are initially anticipated.

As Dr. Sarah Buckley, a family doctor and author from Australia writes (emphasis mine):

Caesarean delivery is not safer, and our high rates (especially among first-time mothers) may be setting a reproductive time bomb. A US study published in September 2006 found that low-risk babies born by caesarean to healthy mothers were almost three times more likely to die in the first year of life, compared to babies born vaginally. A French study, published at the same time, confirmed the risks to healthy caesarean mothers, who were three times more likely to die after a caesarean, compared with women giving birth vaginally.

As Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta who has studied respiratory problems in C-section babies says, "We have created a monster here without knowing what the long-term impact is."
Where is the outrage?

Yet despite increasing evidence of the harm of an overly high cesarean rate, it's very difficult to get anyone to care about this now, unlike in 1989. Where is the outrage? Where are the voices from within for reform?

Where is the outrage from healthcare proponents who bemoan excessive healthcare costs? Cesarean births cost more up-front than vaginal births, and when you factor in the costs of rehospitalization afterwards for wound complications and the costs of placental complications in future births, vaginal birth is more cost-effective by far.Yet why is over-intervention in maternity care being left out of the healthcare reform discussion?

Where is the outrage from feminists about women essentially being forced into unnecessary surgery, often against their will? These days if you have a breech baby, twins, or a previous cesarean, it's almost always an automatic cesarean, with the mother basically having no say in the matter, whether she wants the surgery or not. And that doesn't even count the women who are pushed into cesareans via excessive intervention during labor over which they have little say. Why are women supposed to be arbiters of their own bodies and choices in everything else except giving birth?

And most importantly, where has the outrage from doctors gone? In the late 80s, many doctors were alarmed by the quintupling of the cesarean rate from 1970 to 1988 because they recognized the harm that this was causing. They got behind a national campaign to lower the cesarean rate, and they succeeded in at least lowering the cesarean rate to 20% before they suddenly just abandoned the campaign in 1995 and started cutting women left and right.

From a "low" of 20.8% in 1995, the cesarean rate has now rebounded to almost 32% nationally, with pockets of the country (see table 14, page 19) like Florida, New Jersey, parts of the deep South, and Southern California having widespread cesarean rates of 35-40%. And Puerto Rico has a cesarean rate of nearly 50% already.

Even worse, there are individual hospitals in New Jersey and Florida (and probably elsewhere) where the cesarean rates are 50%, 60%, and as we see above, even 70%.

Where is the pressure from fellow doctors to reform such outrageous rates, to insert the voice of reason, to speak up and advocate for the women who are being cut unnecessarily every day? Consumer advocates can only do so much; until doctors get on board and push for reform, consumer-initiated change will only go so far.

To their credit, there are a few doctors and other healthcare workers who are speaking out against the high cesarean rate and trying to reform a runaway system. Bravo to them. It takes a strong person to speak out against injustice, and especially to face down pressure to be silent from your peers and colleagues. May more doctors and healthcare workers gain the strength and bravery to join the ranks of those speaking out.

But right now, most doctors are hiding behind excuses. They blame the high cesarean rate on mothers, saying that it is women who are driving the cesarean rates by being older, fatter, or being too selfish to go through labor. They bring out that tired old excuse, fear of liability, as a fig leaf to cover up and excuse every excess.

Well, bullshit. Doctors are not innocent bystanders in the rising cesarean rate, forced against their wills into higher rates simply by changing demographics, supposedly riskier mother profiles, liability concerns, and maternal demands.

The truth is that the cesarean rate is being driven primarily by doctor-initiated protocols that promote excessive intervention, excessive attention to physician convenience factors, and excessive hospital financial gain.

Providers need to acknowledge that the way they manage births has been a very significant factor in the tremendous rise in the cesarean rate. They need to take responsibility for their own contributions to the cesarean rate, and they need to get off their asses and start advocating for the benefit of the patient again.

And a 70% cesarean rate is definitely not for the benefit of the mothers or babies.


Meems said...

In an area like Miami, in which there is an especially high focus on thinness and physical perfection, I have to wonder if part of the reason the c-section rate is so high is because women can get a tummy tuck at the same time...

jaed said...

One comment - have you heard about the case where a mother was deprived of custody of her newborn child, apparently in large part because she refused a caesarean? (The child was born without surgery and was fine.) This was discussed at the Volokh Conspiracy a few days ago

maggie said...

i have never had a child, and despite still not knowing whether or not i want to have children of my own, i want to be a doula to help women birth their babies the way we evolved. that said, i just need to say i find it ironic that fat women (myself included) are too often told to lose weight before a surgery, yet are just as quickly put under the knife for a c-section or wls. funny that.