Rise in C-sections stirs health worry

By PHIL GALEWITZ
http://www.palmbeachpost.com

After 11 hours of sweat and pain, Kristen Hibdon’s labor was no longer progressing.

Hibdon opted – with her doctor’s urging – to have the baby via a Caesarean section, a form of abdominal surgery.

“Initially, I was disappointed,” she said of her C-section at Good Samaritan Medical Center in West Palm Beach. “But you have to think of the safety of your child.”

Hibdon is one of a growing number of local women giving birth by C-section: Palm Beach County’s rate now tops 40 percent, nearly double the rate of 10 years ago and significantly higher than the national average of 31 percent.

The rising rates worry public health officials who fear too many women are having the surgery unnecessarily, which puts them and their babies at risk and contributes to rising health costs.

Why the double-digit hike?

Several local doctors blame the county’s higher C-section rate on doctors’ fears of being sued. Most obstetricians in Palm Beach County have dropped liability coverage because of the high cost, and some believe doctors are less likely to be sued if they perform a C-section.

“Every doctor knows you can’t get sued for doing a C-section, but you can get sued for not doing one,” said Dr. Allan Dinnerstein, an obstetrician at Bethesda Memorial Hospital in Boynton Beach.

Dr. Peter Dayton, a Stuart obstetrician, said flatly: “C-sections are only related to one factor: malpractice risk.”

True, there are other explanations. “I have a large amount of high-risk and complicated pregnancies,” said Dr. Brian Bernick, a Boca Raton obstetrician. Bernick cites other factors:

  • Fewer doctors and hospitals offer the vaginal birth option to women who have had C-sections. As a result, once women have a C-section, their next birth is almost guaranteed to be by C-section.
  • The rise in infertility treatments, which often lead to twins, who are typically born via C-section.
  • Increasing numbers of older women giving birth.Jupiter obstetrician Dr. David Feld cites the rise in teen pregnancy and obesity for causing more C-sections. And Bernick points to yet another reason that troubles public health officials: More women are asking for C-sections so they can plan their due date and avoid labor.

    “It has become more popular nationally and locally for patients to request an elective C-section as their route of delivery for a variety of reasons,” Bernick said.

    “I get asked about it about once or twice a month,” said Feld, who delivers about 100 babies a year. Feld said he lays out the risks and benefits. If the patient still wants a C-section, he agrees.

    Dinnerstein seldom hears about pregnant women requesting that their babies be delivered by abdominal surgery for nonmedical reasons. One notable exception: his daughter, Jane. “I thought she was crazy,” Dinnerstein said.

    Legal pressures

    Not every doctor agrees that legal issues are a factor.

    “Liability risk never enters into it,” Feld said.

    However, Dr. Samuel Lederman, the West Palm Beach obstetrician who delivered Hibdon’s baby, said the liability issue hangs over every physician’s head.

    “You don’t want to regret delaying a C-section,” he said.

    In June, a Broward County jury hammered home that message, awarding $35 million in a case against Broward General Medical Center. The jury found that the hospital delayed too long in doing a C-section. The baby was born with brain damage.

    If a patient asks for a C-section, the doctor declines and something goes wrong with the vaginal birth, physicians believe they may be especially vulnerable to a malpractice suit. Since many Palm Beach County obstetricians have dropped malpractice insurance, losing a case could be financially ruinous. In Martin County, where most obstetricians still have malpractice coverage, the C-section rate is 15 percentage points lower than in Palm Beach County.

    “I think the professional liability pressure for obstetricians in Florida is higher than any state in the nation,” said Dr. Robert Yelverton, an official with the Florida Obstetric and Gynecologic Society.

    Although that’s a familiar refrain, court data show that the number of Palm Beach County malpractice suits filed against obstetricians has dropped during the past four years as the number of C-sections has grown.

    Yet despite the big rise in C-sections, which were designed to reduce risk to mother and baby, there’s mixed news on whether birth outcomes have improved. True, Palm Beach County’s infant mortality rate fell from 8.6 infant deaths per 1,000 live births in 2002 to 5.5 in 2006. But the rate of babies with low birth weights climbed from 8.4 to 9 over that same time. Babies born under 5 pounds, 8 ounces are at increased risk for medical problems.

    “It’s frustrating to know as a speciality that we’ve increased C-sections without any meaningful improvement in outcomes,” Lederman said.

    Small babies, big problems

    Twenty years ago, a C-section meant a five-day hospital stay and at least a month or two recovering at home. Today, the average hospital stay is three days. Anesthesia has improved. Incisions are smaller. Women usually are back to their daily routine within a few weeks.

    Hibdon, who previously delivered vaginally, said her recovery from the C-section was better than expected.

    “I feel like the C-section has been easier,” said Hibdon, a flight attendant. “I felt back to myself within a week.”

    At 39 weeks, Julie Mondello’s baby girl had not dropped into the right position. Feld, her obstetrician, was willing to induce labor but cautioned that it might be long, Mondello said.

    “He point blank said it was whatever I wanted,” she said. Mondello, of Delray Beach, chose a C-section. Surgery was scheduled for 7:30 a.m. Josefina was born 27 minutes later. Two weeks later, Mondello was not just up – she was running.

    While C-sections are designed to protect the safety of mother and baby, the procedure still carries the risk of any surgery, such as anesthesia and infection problems. William Sappenfield, a Florida Department of Health epidemiologist, said there is concern that the increased C-section rate is contributing to an increase in babies born before 37 weeks.

    It’s a slight increase in the number of these early births – 2 percent in three years – and the delivery may be only a week or two before the actual due date. Babies born between 34 and 36 weeks are usually considered healthy.

    But a baby’s lungs and brain mature late in pregnancy. Compared with a full-term baby, an infant born between 34 and 36 weeks is more likely to have problems with breathing, feeding and neurological development.

    Although the risk remains small, when problems do appear, “these babies cost a lot of money to treat and there is a greater mortality risk and of having long-term handicaps,” Sappenfield said.

    Sappenfield theorizes that women and doctors are at risk of scheduling C-sections a few weeks too early because it can be tricky to pinpoint the date of conception.

    Another risk of C-sections is they usually lead to repeat Caesareans, which carry greater risks for the mother and baby.

    Such potential complications are one reason Dr. Charles Mahan, an obstetrician and former dean of the University of South Florida College of Public Health, said the rising number of C-sections “is a big public health problem.”

    Benefit to hospitals

    Obstetricians get roughly the same amount regardless of how the baby enters the world. Lederman said most insurers pay about $2,000 per birth – a figure that includes a dozen or so prenatal visits, delivery and postpartum care for six weeks. Medicaid pays about $1,600.

    Hospitals, though, do benefit from the increased number of C-sections, because C-sections cost twice as much as nonsurgical deliveries – an average of $16,020 vs. $8,500.

    Hospitals in poorer cities also are likely to have higher C-section rates, because women there are less likely to get prenatal care and may have other health conditions complicating birth. This helps explain why Glades General Hospital in Belle Glade has the region’s highest C-section rate at nearly 48 percent.

    But locally, C-section rates vary among hospitals close to each other. In 2007, Palms West Hospital in Loxahatchee had a 42.5 percent C-section rate while Wellington Regional Medical Center recorded a 37 percent rate. In St. Lucie County, Lawnwood Regional Medical Center and Heart Institute had a 41.8 percent C-section rate while St. Lucie Medical Center’s rate was 29 percent.

    Hospitals specializing in high-risk deliveries or sick babies would be expected to have higher C-section rates. But the C-section rate at West Boca Medical Center, which has a Level 3 neonatal intensive care unit treating the sickest newborns, has a 39.9 percent rate. By contrast, Boca Raton Community Hospital’s rate is 43.2 percent.

    Rising numbers of C-sections aren’t likely to go down soon. That’s because one C-section virtually guarantees a woman will have her next baby by C-section. The American College of Obstetrics and Gynecology in 2003 recommended that obstetricians be “immediately available” when a woman is attempting a vaginal delivery after having delivered another child via C-section.

    That policy requires that obstetricians remain in the hospital for the duration of the labor – something impossible for most doctors, or hospitals that don’t keep obstetricians in the hospital around the clock.

    A recent state study found C-sections are commonly done on Fridays – rarely on weekends or after midnight. That leaves some to believe C-sections are done for the physician’s convenience.

    St. Mary’s Chief Nursing Officer Joey Bulfin said that’s not the case. Women prefer to deliver on Friday mornings so they can be in the hospital over the weekend, she said.

    Regardless, Dinnerstein said C-sections remain the second-best way to deliver a baby.

    “Research still shows C-sections are more dangerous than having a vaginal birth,” he said. “Everyone seems to overlook that.”

    Staff researchers Melanie Mena and Michelle Quigley contributed to this story.

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