Scalpel-crazy OB's trigger 'crisis'
Efforts to curb risky and unnecessary cesarean sections have had the added benefit of lowering preterm births nationally for two successive years. But not here in Florida, where C-sections and preterm births continue climbing above the rest of the country.
"We have a public-health crisis," said Rep. Kathy Castor (D-Tampa). "Our rates are much higher than the national average."
Castor spearheaded a hearing in the House Subcommittee on Health Wednesday about the risks of preterm births and why they're closely tied to the rate of C-sections. Since the early 1980s, preterm births have risen by a third to more than 12 percent of all births, according to the National Center for Health Statistics. They dipped just slightly between 2006 and 2008.
Here in Florida, the situation is worse. Florida is among only 15 states that did not have a decline in preterm births since 2006. The rate of preterm deliveries here is nearly 14 percent. Florida also has a C-section rate of 38 percent, considerably higher than the 32 percent national average.
"If babies are not full term, a few will die," said Dr. Charles Mahan, dean emeritus of the University of South Florida College of Public Health and founder of the college's Lawton and Rhea Chiles Center for Healthy Mothers and Babies. "Many will have respiratory problems, often educational issues, attention-deficit disorder, things like that."
Mahan spoke at the House hearing about the link between elective C-sections and preterm births, and suggested drastic steps to bring both down.
Non-emergency C-sections promote preterm births because doctors try to schedule them before the patient goes into labor, which normally happens between 37 and 42 weeks gestation. The American College of Obstetrics and Gynecology (ACOG) advises members to avoid preterm deliveries by scheduling elective C-sections no sooner than 39 weeks.
ACOG Vice President Dr. Hal Lawrence III testified at the hearing that 96 percent of members follow the guidelines. But a miscalculation in the due date sometimes leads to births at 34 to 37 weeks, or late preterm.
"Seventy-one percent of all preterm births are late preterm," Castor said, "and C-sections account for nearly all the rise in late preterms."
Lori Reeves, Florida's program director for the March of Dimes, believes doctors' interest in avoiding nighttime and weekend deliveries when the patient is in labor leads them to schedule C-sections too early.
"More and more births are scheduled before that 39-week mark," she said. "It's more convenient for doctors to know when the delivery is going to occur."
Physicians once thought a couple days in neonatal intensive care would clear up the often minor breathing and other physical problems associated with late preterm births. But research in the past couple years suggests that many late-preterm youngsters suffer from subtle learning deficits that might not be apparent until they start school.
"Evidence shows that babies born even a couple weeks early do have a high risk of complications," Reeves said. "Some physicians might not have been aware of those risks."
Estimating the due date can be tricky, Mahan explained. Ultrasounds taken around 18 weeks of pregnancy give a good approximation of gestational age, while ultrasounds delayed until later can lead to miscalculations of up to three weeks.
Mahan believes no woman should get a C-section that's not medically necessary, even if she's definitely past 39 weeks. He recommended to the House subcommittee that Medicaid stop paying for all C-sections that are not medically necessary. He called for more vaginal births after cesareans (VBACs).
Although VBACs were common in the 1990s, many doctors and hospitals now consider them too risky to perform. As an incentive, Mahan told the committee insurers should pay physicians $2,000 for VBAC deliveries, $1,500 for vaginal births and only $1,000 for C-sections. Doctors now are paid the most for C-section births.
"The World Health Organization says the (C-section) rate should be 15 percent," Mahan said. "I would say with the obesity epidemic, 20 percent would be reasonable."
To approach that goal, the Florida March of Dimes, Department of Health and University of Florida are sponsoring the Florida Perinatal Quality Collaborative. Their first mission will be to slash the number of elective C-sections before 39 weeks gestation.
"We need to educate moms about their rights during pregnancy and we need to educate doctors to give informed consent," Reeves said.
She expects the program to begin this summer at five hospitals to be chosen. The collaborative will give the hospitals grants and information on how to train physicians to reduce preterm deliveries, and how to collect and assess data.
Physicians who perform elective C-sections will have to provide justification to the hospital. California and a few other states have reduced their C-section rates through similar efforts.
"It's a quality improvement and safety issue," said Mahan, who also is involved with the Collaborative.
Although ACOG and other medical organizations for many years have been calling for fewer C-sections, he believes doctors are ready to listen.
"Now that we're showing doctors this is causing problems, they're backing off," he said. "There's a lot of interest in turning (the preterm rate) around."
--Cynthia Washam is an independent journalist in Jensen Beach. Questions and comments can be sent to Editor Carol Gentry.