Sunday, May 10, 2009

Births on cue: C-sections soar in S. Florida

More babies in Miami-Dade are now born by cesarean section than by natural childbirth, state records reveal. Experts won't predict how much higher the rate will go.


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.''

Locally and nationally, the cesarean rate has been creeping up annually for years. In 2007, the U.S. rate reached 31.8 percent, according to the National Center for Health Statistics -- an increase of more than 50 percent over the past decade.

Many of the reasons have been oft-repeated: doctors afraid of being sued if something goes wrong with natural childbirth and expectant mothers, particularly professional women, wanting to schedule a birth into tight work schedules.

In South Florida, virtually no obstetrician has malpractice insurance, and most believe that they're less likely to be sued if they choose to be active in a crisis, such as operating to remove a baby from the womb, rather than allowing nature to take its course.

But Amitabh Chandra, a Harvard professor of public health policy, said Miami also has a long-standing reputation for high healthcare costs in many programs, including Medicare.

''There is an extraordinary culture of medicine you have there in Miami,'' he said. ''Miami has always been very aggressive in its practice of medicine,'' with specialists dominating treatment patterns and being highly active in care options. ``And cesareans would just be another example.''

Such decisions drive up costs. Data from the Florida Agency for Health Care Administration shows cesareans in South Florida hospitals range from $11,000 and $30,000 -- about twice the $5,000 to $16,000 range for natural births.


Traditionally, many doctors have warned against cesareans because of the risks anytime a patient is cut open. ''Definitely surgery always has a chance of a serious complication,'' said Douglas Richards, a professor of obstetrics-gynecology at the University of Florida.

Still, in recent years, such warnings have been muted. ''The risks and benefits are much more balanced than they used to be,'' Richards said. ``Cesareans have become so safe and relatively easy for women.''

He means in particular planned C-sections -- ''no rushing around, the baby doesn't have to come out right away.'' Improved anesthetics allow patients to rebound quickly. ``They're happy and pain-free and walking around the first day. Many go home after 48 hours.''

There's also been an opinion shift about the risks of ''V-backs,'' giving birth vaginally after having had a C-section. Some studies have shown that in some situations, such as when the baby is in a breech position, a V-back should be avoided. ''Certain hospitals will not do vaginal deliveries after cesareans,'' said UM's Burkett, who delivers babies at Jackson Memorial, where he says the staff remains committed to V-backs if clinically possible.

Burkett and some other obstetricians also say that some women have abandoned the view that natural childbirth is a badge of honor for womanhood. ''I don't think it's so much a rite of passage anymore.'' But Zulma Berrios, chief of obstetrics at South Miami Hospital, said she has seen no evidence to back that up.

Another key issue is patient choice. The American College of Obstetricians and Gynecologists ''now says the consumer has a right to choose'' a cesarean if they so desire after being informed of the risks and benefits, Burkett said. That's a departure from the past, when many doctors actively discouraged patients from seeking C-sections.

No one in South Florida has statistics on how many women are choosing C-sections, but Berrios at South Miami said, ''Some patients want to be on a planned schedule. They have to juggle work and the baby.'' She says many professional women, including physicians, choose cesareans because they're squeezed for time.

In fact, a recent study from the University of California-Berkeley, found that mothers who took a leave in their last month of pregnancy were less likely to have cesarean deliveries than mothers who worked right up to the end.


Obesity also has become an issue. Richards says 25 percent of the expectant mothers seen in Gainesville are clinically obese at the start of their pregnancy, meaning they are more likely to have complications at birth.

More debated is the mother's ''pelvic floor.'' G. Willy Davila, a urogynecologist at the Cleveland Clinic in Weston, said natural childbirth can lead to tendencies later in life for problems like ``leaky bladders.''

Davila said for women planning to have one or two children, C-sections ''could be beneficial . . . an acceptable delivery option'' to avoid urinary problems later.

Three other ob-gyns, however, said that idea is still being debated. ''The jury is still out,'' Berrios said.

Davila and others emphasized that repeat C-sections for women planning to have many babies could pose considerable dangers. ``The risk goes way up for the third, fourth or fifth cesarean for things like the placenta being in the wrong place and other issues.''

AHCA's most recent data measured births from July 2007 through June 2008. Miami-Dade's C-section rate was 51.2 percent.

In addition to Kendall Regional, the hospitals with rates higher than 50 percent were South Miami (59.9), Mercy (58), Hialeah (52), Baptist (50.3) and Jackson Memorial (50.4). In Broward, the lone hospital higher than 50 percent was Holy Cross, at 51.6.

Many of the hospitals didn't want to discuss cesareans. Kendall Regional spokesman Peter Jude acknowledged the AHCA numbers were correct and said the hospital is ``first and foremost committed to the well being and health of our mothers and infants. There are a number of factors patients and physicians consider when determining the delivery method.''

Berrios at South Miami said her hospital has been designated a center for high-risk cases and was close to an infertility clinic, where many of the patients had various risk factors, including multiple fetuses.

Jackson Memorial's rate is high because the hospital gets most of the high-risk births for the entire county, said Burkett, noting that he had just been notified a woman carrying a fetus with heart problems was on her way from the Virgin Islands.

While supporting many reasons for C-sections, Richards in Gainesville emphasized he didn't want to appear to be endorsing rates of 50 percent to 70 percent. ''That's pretty astounding.'' He noted one reason ``not to have a more liberal cesarean policy is that babies born without labor tend to have more respiratory problems.''

Still, when Richards and three other ob-gyns were asked whether there was an upper limit on how high the C-section rate could go, in South Florida or the nation, none wanted to venture a guess. ''We just don't know,'' Berrios said.

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