Jill Arnold is updating the stats at CesareanRates.com, and according to her new tables, South Miami Hospital has the highest cesarean rate in Florida: 62%. This is nearly double the national average and 4 times the “threshold not be exceeded” identified by the World Health Organization. Let’s investigate.
Women have babies at the hospital’s Center for Women and Infants. Their patient brochure begins, “The philosophy toward childbirth at South Miami Hospital encourages your individuality and supports family involvement.” Such a statement indicates that the woman can call the shots in her own birth–an admirable goal as long as she is given evidence-based information to make choices. Except it turns out that she doesn’t actually have a lot of choices. Nor are routine hospital practices based on evidence.
For instance, here are some example from the “Frequently Asked Questions” page (all emphasis and commentary is mine):
3 Q: Will I be able to walk or use my birthing ball when I am in labor?
A: We encourage you to discuss this with your physician as you will want to be familiar with your doctor’s practices.
Um…what are the doctor’s birth ball practices? Should the woman expect to have to share?
6. Q: Will I be able to eat in labor? How soon will I be able to eat after the baby is born?
A: While in labor, it is recommended that you have only ice chips. The presence of food in the stomach may cause nausea and vomiting. In the event you should need anesthesia for your labor, vomiting could cause aspiration of food to the lungs, a condition that is dangerous to you. If you deliver vaginally, you will be able to eat once your recovery is complete. (…)
“It is recommended” by whom? There is no evidence base for denying women access to food and drink in labor. A Cochrane review on the subject notes that depriving women of food and drink leads to longer and more painful labors and concludes, “women should be free to eat and drink in labour, or not, as they wish.” And when would “recovery be complete”? Isn’t common wisdom that it takes about 6 weeks to recover from a vaginal birth? That’s a long time to survive on ice chips.
9. Q: What is a fetal monitor? Do you have wireless monitors in the labor rooms?
A: The fetal monitor is used to determine the baby’s well-being prior to birth. It provides a continuous printed record for the evaluation of uterine activity and the baby’s heart response. Your obstetrician may decide to use an external or internal monitor. Baptist Hospital does have wireless monitors. These monitors are used when appropriate and available.
Continuous monitoring has been shown to raise the risk of cesarean without producing superior maternal or infant outcomes and it is not recommended for low risk women–not even an initial test strip. In addition, if the wireless monitor is not available, the woman’s movement would be restricted, which would also go against evidence based practice. Internal monitoring can be painful and introduces risk of infection. According to Rebecca Dekker at Evidence Based Birth, “evidence clearly demonstrates that the best option for most women and babies is intermittent auscultation” (meaning using a handheld doppler at intervals throughout labor). Note that the best practice is not mentioned as an option. Whoops.
11. Q: Do you have a Jacuzzi?
A: Use of the Jacuzzi is based on room availability. In early labor, some patients enjoy relaxing in the Jacuzzi. Use of the Jacuzzi will depend on many circumstances revolving around your labor. Your physician will need to approve its use.
It’s interesting that the question is “do you have a Jacuzzi,” but the answer is about all the reasons a woman won’t be able to use one, even though there is a strong evidence base for laboring in water.
It’s also interesting that a physician would need to approve women’s evidence based requests, while the hospital will require women to follow non-evidence based routines. This does not seem particularly encouraging of individuality. Or of health.
Women are told they to be admitted at 3 centimeters’ dilation because that is when they are in active labor, even though the most current recommendations state that women should not be considered in active labor until 5-6 cm. Early hospital admission tends to lead to unnecessary cascades of intervention that increase birth costs and can lead to cesarean.
Even regarding non-medical issues, South Miami places limits on what women (or their families) can do. For instance, their video and photography guidelines have some practical information–tripods shouldn’t be used because they get in the way; doctors and nurses should give their permission before being photographed or video recorded. But the guidelines, which state that “the birth of a baby is an exciting time” also state that no one is actually allowed to photograph or videotape the birth:
1. For vaginal births, videotaping and photographing are permitted, but only after the birth, and when the baby is dried, cleaned and alert.
2. Videotaping is not allowed during a C-section delivery. Photographs may be taken only after the baby is dried, cleaned and alert.
Since a baby should go skin-to-skin with the mother directly after birth and remain with her there for about an hour, it may be a long time before anyone can get a picture of the baby. Unless South Miami is not following evidence based recommendations about skin-to-skin contact. Hmm…
We require labels on food packaging to give nutritional information. It seems we might benefit from hospital labeling to get health information. If a woman chooses to abide by non-evidence based practice, that is her right. But it is disingenuous for a hospital to proclaim that it supports a woman’s individuality in childbirth–as long as her individuality fits their mold.
You can read the second in this series, an analysis of the Mississippi hospital with the highest cesarean rate, here.