Wednesday, April 27, 2016

Your Hospital Choice Significantly Influences Your Cesarean Risk

Image from Consumer Reports 

Consumer Reports has a new report out for Cesarean Awareness Month, focusing on the variations in cesarean rates at hospitals across the United States. It highlights how different a woman's risk for a cesarean is, depending on which hospital she chooses.

One analysis points out the wide variations in cesarean rates for low-risk mothers in the Consumer Reports investigation. For example, Crouse Hospital in Syracuse, New York had an 11% cesarean rate in low-risk mothers, while Hialeah Hospital in Miami, Florida had a high of 68% for the same group. That kind of massive variation suggests there is more to the cesarean story than simple medical need.

Disclaimer: It's always important to remind people that no one begrudges a cesarean that is truly needed. No one is less of a woman or a mother if she has a cesarean, and it's perfectly okay to be happy with your cesarean. Don't make this about any one person's particular birth story, but rather focus on the big picture.

The big picture here is that over-utilization of cesareans brings significant risks on a public health level. Mothers and babies are being endangered by doing too many cesareans. 

It's time to shine a light on hospitals' cesarean rates so consumers can make fully-educated decisions about where they want to give birth.

Cesarean Rates in Low-Risk Mothers

The Consumer Reports article focuses on the cesarean rate in first-time, low-risk mothers. These rates act as a sort of canary-in-the-coal-mine warning of excessive cesarean rates. Their article explains further (my emphasis):
Consumer Reports’ analysis focuses on first-time mothers-to-be who should be at low risk of needing a cesarean: pregnant women expecting just one child (not twins, triplets, or other multiples) whose babies are delivering at full-term in the proper position, which means coming out head first. 
The target C-section rate for those births, set by the Department of Health and Human Services, is 23.9 percent or less. That’s 10 percent less than the rate for such births in 2007, which the government uses as a baseline from which to improve. 
But many experts say that the ideal C-section rate for those births is even lower. “Getting under 24 percent for low-risk births is something all hospitals should be able to do, but for those deliveries, hospitals should be aiming even lower,” Main says.

Yet nearly six in 10 of the hospitals we looked at had C-section rates above the national target for low-risk births. That means that 40 percent of hospitals already achieved this goal. “This sends a message that almost all hospitals should be able to achieve this rate,” Main says. 
The risk of having a C-section also varied depending on where in the country women lived. In general, rates were higher in the Northeast and South, and lower in the West and Midwest. 
Three states plus the District of Columbia had C-section rates of 30 percent or higher: Mississippi (31 percent), Kentucky (32 percent), Florida (32 percent), and D.C. (35 percent). 
And four states had rates below 18.5 percent: South Dakota (14 percent), Wyoming (17 percent), New Mexico (18 percent), and North Dakota (18 percent).
It's nonsensical to think that the uteri of women in South Dakota are vastly more efficient than the uteri of women in Mississippi. There is something else influencing cesarean rates here besides true medical need.

The Science and Sensibility analysis points out that hospital culture plays a very strong role in influencing cesarean rates, as demonstrated by wide variations of cesarean rates in hospitals serving the same basic community: 
For example, 30 percent of low-risk deliveries at the University of Chicago Medical Center were by C-section, while at Northwestern Memorial Hospital, another teaching hospital just 10 miles away, only 17 percent were. 
In southern California, 22 percent of low-risk deliveries at Kaiser Permanente Riverside Medical Center were cesareans, compared with 35 percent of low-risk deliveries at nearby Riverside Community Hospital.
According to this analysis, some hospitals have been able to substantially reduce their cesarean rates over time simply by internally publishing the rates for individual providers within the hospital. When care providers saw their rates compared to those of their colleagues, they often changed behaviors that led to a reduction of cesarean rates. 

So why not make the cesarean rates for EVERY hospital in the country publicly available? Perhaps peer pressure can work on a hospital level too.

If hospitals had to acknowledge that other hospitals with similar patient risk levels and demographics could safely have lower cesarean rates than they did, they might put more effort into policies which would help change their own rates.

Transparency in Cesarean Rates

Transparency in healthcare is vitally important. Consumers have the right to know how their local hospitals rate in measures of quality of care, and to make an educated decision on where to take their business as a result.

Many hospitals are already reporting on their infectious morbidity and other measures of quality ─ why shouldn't parents be able to research the cesarean risk at their local hospital? Parents deserve to be able to make an educated choice, yet right now these reports are completely voluntary and many hospitals don't report results at all.

For example, some of the most prominent hospitals in the U.S., like Mount Sinai in New York City or Yale-New Haven in Connecticut, do NOT practice transparency in cesarean rates. The Consumer Reports article notes (my emphasis):
Consumer Reports does not have C-section rates for more than half of the estimated 3,000 U.S. hospitals that deliver babies. That’s because hospitals are not required to publicly report that information, and many choose not to.
This urgently needs to change. Hospitals should be required to have transparency in quality measures such as infectious morbidity and low-risk cesarean rates.

I'd go even further and suggest that the cesarean rates for EVERY PROVIDER be made publicly available. Sure, you can ask your providers their rates, but not every provider tracks this, and some lie about their rates. Providers need to be held accountable for their rates, and we know that publishing rates is effective in reducing non-indicated cesareans.

Most importantly, though, prospective parents deserve to be able to learn about their likelihood of surgery with a particular provider. How can you be an informed partner in your own care when you can't get basic information like about the performance of your hospital and your provider? Consumers have every right to this information. 

Furthermore, transparency can have the added benefit of providing motivation for hospitals and providers to improve their results so consumers are more likely to bring their business. Experience shows that when substandard results are highlighted and a program is developed to address the issues, outcomes can be improved.

Transparency is powerful stuff in healthcare, and it has the potential to motivate major changes.

Kudos to Consumer Reports for shining a major spotlight on this issue. Now it's time for the hospitals who are not being transparent to change their policies and be accountable too. Otherwise, who knows what's really happening in those hospitals? Or how many women are being subjected to the immediate and future risks of major surgery on dubious grounds?

Tuesday, April 5, 2016

Forced Cesareans Because of Weight

Photography by Leticia Valverdes, Birth Marks Photography
Photo and story at A Beautiful Body Project
April is Cesarean Awareness Month. I had a different post for it planned for this week, but then I came across this outrageous, infuriating story of a women of size in Brazil who was basically forced into two cesareans simply because of her weight. I simply HAD to comment and bring this to people's attention.

Here is the photographer's summary of her situation (my emphasis):
Elaine was two times forced into caesarean sections for no medical reason other than her obesity, including second one where she arrived in hospital already 9 cm dilated but was forced into a c-section as the obstetric doctor said she would not look after her and the baby if she insisted on a natural labour. She locked herself in the toilette with her doula but got scared and allowed the C when already 10 cm dilated. She was told she was too fat to labour.
Too fat to labor? Yet she was already dilated! She'd done all of labor except pushing. But her doctor could not be bothered to attend her in labor for pushing; I'm sure he felt she was too "high-risk" to push out a baby. Yet other fat women can push out their babies ─ when they are given a real opportunity, which is far too rare these days.

Also frustrating to me is the fact that EVERYONE so far has missed the fact that she almost certainly has lipedema. Look at her legs and her behind. Classic shape and texture of advanced lipedema! They are blaming her for her fatness (and she blames herself, as you can see from her comments about herself in the article) when likely a great deal of it is beyond her control. But that certainly doesn't mean she can't push out a baby. Many of us with lipedema have. It's just bias, pure and simple, on the part of the doctor. And that highlights a troubling trend in cesareans these days.

As the Cesarean Awareness Month logo above notes, the overall cesarean rate in the United States is too high, with almost 1 in 3 women having a cesarean. Yes, some of those are absolutely necessary and life-saving, and no woman should ever be shamed or feel like less of a mother or a woman if she has had a cesarean. Please don't think I'm putting you down if you've had a cesarean.

But a too-high cesarean rate has major public health implications that we are ignoring, and women's health is being impacted by this.

Sadly, high BMI women are being disproportionately affected by this high cesarean rate, and this has major implications for our health. 

Sure, this story is from Brazil where the cesarean rate is sky-high, but don't be naive; there are "obese" women here who are being railroaded into cesareans only because of their weight.

I have written about the high cesarean rate in obese women many times. If you want to read a post with extensive research details on it, read this one ─ Astronomical Cesarean Rates in Women of Size. It has plenty of references and explanations, but here are a few highlights.

Too many care providers have taken the view that fat women "can't" birth normally or are "too risky" to birth normally. One recent study showed that about 1 of 3 "morbidly obese" women are being pressured into cesareans before labor. So the 1 in 3 national c-section figure above? The same rate happens in high BMI women ─ except that's only the pre-labor cesareans in obese group.

What about those who labor? Even when women of size are "allowed" to labor, the high-intervention and high-risk way that they are often managed mean that the resulting cesarean rate is even higher.

In many recent studies, the cesarean rate in obese women is around 50%, or ONE IN EVERY TWO WOMEN. 

Where's the graphic that reflects that?!? Where is the outrage in the birthing community? Where is the accountability for providers? Where are the hospital programs to try to reduce the enormous cesarean rate in high BMI women? NOWHERE.

Check out this study from 2013 which documented cesarean rates in high-BMI women in Tennessee. Note how this cesarean-oriented culture results in especially high rates in "morbidly obese" women:

"Underweight" women (BMI less than 18.5) -      26.0%
"Normal Weight" women (BMI 18.6 - 24.9) -      31.4%
"Overweight" women (BMI 25 - 29.9) -               39.1%
"Obese" women (BMI 30 - 34.9) -                       40.8%
"Morbidly Obese" women (BMI 40+) -               56.6%

This reminds me of a similar study from Kentucky, showing cesarean rates in morbidly obese women near 60% also.

You can find studies with even higher rates too, like this very large, multi-state study from more than a decade ago which found a c-section rate of 71% for women with a BMI of 52 or more.

Or a more recent study that found a nearly 70% c-section rate in women with a BMI of 35 or more.

Then there's this study from Michigan, which had a total cesarean rate of MORE THAN 80% for women with a BMI over 50.

And the cesarean rate in obese women continues to rise unabated and unchecked.

One German study we discussed recently showed that while cesarean rates have increased in all groups over time, they've increased the most in "morbidly obese" women. In just 22 years, the cesarean rate in Class III Obese women doubled, going from 26.9% to 55.2%.

Why? What changed? These stats compare women of the same size, so it wasn't the women who changed. Most likely it was the management of those women that changed, and the fear levels around their pregnancies. 

If the cesarean rate in fat women has increased from 27% to 55% in 22 years, how far will it go in the next 22?

How Can We Change This Trend?

The good news is that it doesn't have to be this way. 

As I've pointed out before, there was a large recent British study that found a 30% cesarean rate in "super-obese" women (BMI 50 or more) who were given a chance to labor.

Yes, 70% of these super-obese women were able to give birth vaginallywhen given the chance to do so.

Yet hospitals in Kentucky and Tennessee, as cited above, had c-section rates of around 60%, nearly TWICE the British rate. And the Michigan study had rates even higher than that. Why?

These differences suggest that there are key differences in how high BMI women are being managed that is resulting in such wide variations in cesarean rates in this group, both over time and by location.

It's time for care providers to start focusing on the cesarean practice rate variation in obese women and learning from it. Once we acknowledge that there is a wide range in the obese cesarean rate, we can more easily start studying the things that help lower the risk for cesarean in this group, and hospitals can work on meaningful changes that will improve outcomes. But I have yet to see one study that seriously addresses this issue.

What Can Be Done?

Even if we have no study that directly addresses this issue, there almost surely are things that can be done to lower the cesarean rate in higher weight women. You start with the things that have been shown to lower the cesarean rate in women of all sizes and make sure these things are applied to women of size as well (which they often aren't).

Based on the evidence (references and explanations in the last section of the original article), the most logical ideas would include:
  • A strong emphasis on preventing the first cesarean, especially scheduled cesareans that occur before labor. Far too many doctors are not giving fat women a chance to labor at all and then repeat cesareans become nearly automatic. Prevent the first cesarean and you quickly impact the overall cesarean rate in this group 
  • Less early induction of labor unless it is truly medically indicated since induction often increases the chance of cesarean; when induction is used, wait until the mother's cervix is ready for labor whenever medically possible 
  • Dating pregnancies more accurately in women of size with longer menstrual cycles so that more are truly ready for labor at term and not being induced too early
  • Reduction in the overuse of common interventions in obese women, like early breaking of water, early epidurals, and routine pitocin augmentation
  • Encouraging women of size to stay home longer in early labor, since research shows that coming into the hospital too early is strongly associated with higher cesarean rates
  • Giving women of size MUCH more time and patience in labor to account for a possibly slower dilation curve and a longer first stage of labor
  • More utilization of midwifery and/or a midwifery-laborist model of care for low-risk obese women since this has been shown to decrease the risk for cesareans
  • Strongly encouraging use of doulas and professional labor support for women of size since doulas have been shown to reduce cesarean rates significantly
  • A re-emphasis on the importance of properly-sized equipment like blood pressure cuffs so interventions are only undertaken when truly needed, based on accurate data
  • More attention to preventing and treating fetal malposition in women of size (who may be more at risk for fetal malpositions)
  • More freedom of movement in labor and utilization of alternative positions in pushing, instead of immobilizing the obese woman in bed and reducing her pelvic space
  • Fewer late ultrasounds for estimating fetal weight, since prediction of fetal weight increases the chance of cesarean beyond the baby's size alone
  • A revival of VBAC access for high BMI women, with fewer VBAC inductions and more patience during a "trial of labor" to give it the maximum chance to happen
Start with these ideas, then hospitals should organize some serious trials to see if they help. Make reducing cesarean rates in high-BMI women a strong priority in research and in practice. 


It's outrageous that this poor woman from Brazil was forced into a cesarean TWICE simply because of her weight, even after she arrived at the hospital nearly fully dilated. 

It reminds me of the story, told by an OB, of getting into trouble with her colleagues because she let a morbidly obese woman VBAC. The woman arrived at the hospital fully dilated (and with a history of a prior vaginal birth). Her colleagues raked her over the coals for not doing an automatic c-section, simply based on the mother's size. They would have forced this mother into another cesarean, even though her body had already proven it could give birth safely, and even though she was fully dilated, based on nothing more than her weight. And this was in the U.S., not very long ago!

I've heard from other fat women who were strongly encouraged or even coerced into signing papers for an elective cesarean early in pregnancy, based only on size. While it's by no means universal, it does still happen. Higher-weight women ARE being forced into cesareans based on their size alone, even here and now. 

Thank goodness, not all providers are like this. Even as we are outraged by stories like these, we must remember and acknowledge that there are wonderful midwives and doctors out there who are truly size-friendly, who give women of size every chance at vaginal birth, and who do support them in VBAC as well. Some maternity providers are wonderful with women of size and it's vitally important that higher-weight women seek out and find these size-friendly providers. 

On the other hand, there is a real callousness around care of high-BMI women among some providers, even an outright viciousness at times. The lack of caring among many providers about the extreme cesarean rates in high-BMI women says a lot. Most shrug off a cesarean as a natural consequence of obesity, pretending that their hands are tied. Baloney.

Historically, cesarean rates in high-BMI women were not as different from average-sized women as they are today. As we have seen, the cesarean rate has increased markedly in obese women in recent years, and there is a great deal of variation in the obese cesarean rate between institutions. 

This means that a high cesarean rate is not an inevitable outcome of obesity, and that many fat women can give birth vaginally with the right support. It also means that there are ways to lower the cesarean rate in higher-weight women ─ if we are willing to study it and make change a priority.

Far too many of the cesareans in women of size today are “iatrogenic”— influenced more by the attitudes and management protocols of the care providers than by the woman’s size. Far too many high BMI women are sectioned before labor even starts, induced before their bodies are ready, or have their labors cut short out of impatience or fear. But research has shown that most women of size can give birth vaginally if they are just given a real chance to do so.

It's time we work to make that happen. Let's not hear about any more cases like poor Elaine.