JACKSONVILLE, Fla.--Much has been published of late, in medical journals as well as in the general media, concerning the national rise in both the Cesarean section and premature birth rates. While not directly connected, the two medical concerns have many interrelated variables. Nationally, the Cesarean section rate has risen to 32 percent of all births, while the rate of premature birth has climbed to just over 12 percent. The World Health Organization, the American Academy of Pediatrics and the American Congress of Obstetrics and Gynecology all define a term pregnancy as one that has reached 37 weeks of a usual 40-week pregnancy. The most significant rise in premature births nationwide has been in the segment of births referred to as late preterm birth, or a birth that takes place between 34 weeks and 36 weeks and six days. The large majority of late preterm births are spontaneous and not preventable, or they result from high-risk obstetrical situations in which delivery before term is in the best interest of the mother or the baby.
Florida obstetricians are keenly aware that the rates of both Cesarean section (38 percent) and premature birth (14 percent) are higher in Florida than the national averages. As a reaction to these concerns, Florida obstetricians, through the Florida Section of The American Congress of Obstetrics and Gynecology (ACOG) and the Florida Obstetrics and Gynecology Society (FOGS), began in 2009 to collaborate with the Florida Department of Health and the March of Dimes in an effort to form the Florida Perinatal Quality Collaborative. As conceived, this group will consist of obstetricians, maternal fetal medicine specialists, specialists in premature children, representatives from Florida medical schools, and other experts in maternal and child health from both the public and private sectors. The mission of the initial Collaborative work group was to establish a formal Collaborative organization, evaluate the problem, define potential preventable causes, recommend effectual action and, finally, develop an effective method to measure progress. The March of Dimes is sponsoring a five-hospital grant program to study the effectiveness of these initiatives. Florida ACOG members provided a significant portion of the grant money needed to study the problem of late preterm birth specific to Florida. Through their two state organizations, Florida obstetricians are working directly with the Collaborative and the March of Dimes to begin a major educational effort focused on obstetricians, midwives, healthcare institutions, patients and the general public. This project will contain multiple components, including awareness information and a tool kit designed to assist obstetricians and their health care institutions in developing programs aimed at lowering the number of preventable preterm births and safely reducing the Cesarean section rate.
One example of an effort to reduce preventable preterm birth is the drive toward adopting the “39 week rule,” a policy that precludes elective deliveries (those not associated with high-risk indications) from being performed until the 39th week of pregnancy. ACOG has recommended this rule for years. Dr. Hal Lawrence, Vice President of Practice Activities at ACOG, testified recently before Congress that a majority of ACOG members follow this rule. These facts contradict misleading statements found in several recent articles being circulated in the general media, the most glaring and inaccurate of which is an article entitled “Scalpel-Crazy OB’s Trigger Crisis,” first published in the May 14, 2010, issue of Health News Florida. In both this article and one printed in the June 15 edition of the same publication, the reporter seems unaware that a significant majority of obstetricians apply this rule to their practices and that the obstetrical departments in many Florida hospitals have had such policies in place for quite some time. Designed to reduce late preterm birth, the push to establish the “39 week rule” is often initiated by the obstetrical departments and supported by the healthcare institutions. Tallahassee Memorial Hospital, St. Joseph Women’s Hospital in Tampa, Sarasota Memorial Hospital, and Winnie Palmer Hospital in Orlando are just four examples of hospitals from all over the state where obstetricians have played a vital role in instituting effective policies of this nature.
The increasing rate of Cesarean section is an extremely complex issue. There are many medical causes for this increase, including the nationwide epidemic of obesity and the related conditions of excessively large babies, hypertension and diabetes; the increasing percentage of women who delay their decision to have a baby until over age 35; the increasing incidence of multiple births, particularly twins; lower parity; safer anesthesia and surgery; and an awareness of the catastrophic complications of uterine rupture resulting from attempts at vaginal birth after a previous Cesarean section (VBAC).
When evaluating the rising Cesarean section rate, there are also many non-medical variables to consider. As documented by the March 2010 consensus statement from the National Institutes of Health Conference on Vaginal Birth after Cesarean, the current status of our tort system as it relates to professional liability and the real threat of a lawsuit in adverse outcomes have a major impact on the willingness of healthcare institutions and physicians to assume even acceptable complication rates in the laboring patient, particularly after a prior Cesarean birth or the birth of large babies. Obstetricians are rarely sued for performing a Cesarean birth, but they are often sued for “failure to perform a timely Cesarean section,” a phrase that is all-too-common in malpractice lawsuit documents. There are multiple other non-medical explanations for the rise in the Cesarean section rate, including more stringent guidelines by professional associations such as ACOG requiring major changes in provider availability, surgical and anesthesia capability in order to allow for a relatively safe trial of labor after a Cesarean birth. These guidelines may not be practical or possible for many solo practitioners and smaller obstetrical services. As a result of these guidelines, the awareness of occasional catastrophic complications and their medical and legal consequences has led to a significant decline in VBAC.
Another major non-medical factor in the increasing Cesarean rate and the declining VBAC rate is high patient expectations in conjunction with increasing legal obligations that require physicians to document informed decision-making by their patients. Because it identifies the risks associated with a vaginal versus a Cesarean delivery, this practice of informed consent often discourages the patient from attempting a vaginal delivery.
Florida obstetricians seek the assistance of all stakeholders, citizens, legislators and responsible members of the media in our ongoing efforts not only to lower premature and Cesarean birth rates, but also to reach the more lofty goals of reducing maternal and perinatal mortality and morbidity in our state.
Washington C. Hill, MD, FACOG
Member, Florida Perinatal Quality Collaborative Work Group
Medical Director, Labor and Delivery
Director, Maternal-Fetal Medicine
Sarasota Memorial Hospital
Robert W. Yelverton, MD, FACOG
Member, Florida Perinatal Quality Collaborative Work Group
Chief Medical Officer
Women's Care Florida
Date Published: June 25, 2010
Media Contact: Kim Savage
Phone: (941) 917-6271