A first-time mother with a low-risk pregnancy is more likely to deliver her baby by cesarean section in Miami than if she were to give birth almost anywhere else in the nation, according to a study released today by Consumer Reports.
The Consumer Reports analysis of more than 1,200 hospitals across the country — all of which self-reported C-sections for mothers considered least likely to need the surgery — found that Florida had one of the nation’s highest rates in 2014 and that Miami-Dade is home to the top outlier, Hialeah Hospital.
On average, Florida hospitals performed C-sections for about 32 percent of low-risk pregnancies, which was defined as a woman delivering a single baby for the first time, not breached and carried to a term of 37 weeks or longer. Only Washington, D.C., reported a higher ratio of 35 percent.
“Certainly, Florida is one of the outliers,” said Doris Peter, director of the Consumer Reports Health Ratings Center, which produced the study.
Cesarean section is the most common surgery performed at U.S. hospitals. Roughly one of every three babies born in the United States, or about 1.3 million children each year, are delivered through a surgical incision.
But Miami area hospitals were even more likely to perform C-sections for low-risk pregnancies than the statewide average of 32 percent. About 40 of every 100 deliveries at Miami area hospitals were performed through cesarean operations in 2014, according to the study.
Hialeah Hospital, a for-profit medical center owned by Tenet Healthcare, topped all medical centers in the country reviewed by Consumer Reports. Its C-section rate: 68 percent.
Nationwide the rate of C-sections for low-risk pregnancies was about 26 percent during the same year, a finding that matches reports from the federal Centers for Disease Control and Prevention.
Yet even the national average of C-sections for low-risk pregnancies is considered high by Consumer Reports’ standards, which gives hospitals with a 26 percent ratio a “middle” rating.
Obstetricians, health economists and other experts say there are many reasons for the high rate of C-sections in Florida and the nation — including unrealistic expectations that every birth should take place without complications, doctors practicing defensive medicine or chasing higher payment rates, patient preference and even cultural inclination.
Dr. Rafael Perez, an obstetrician for Baptist Health South Florida, said that Miami area physicians perform a lot of C-sections on first-time mothers with low-risk pregnancies because their patients demand it — and he said those patients tend to come from Latin American countries such as Argentina, Brazil and Chile.
“In those countries,” Perez said, “the C-section rate is very high, and the patients are used to delivering by C-section. There’s some cultural thought that if I deliver vaginally, my sexual function might not be the same as before.”
The patients are used to delivering by C-section.
Dr. Rafael Perez, Baptist Health South Florida
According to the CDC, Hispanic women in Florida are more likely to deliver a child by C-section than non-Hispanic whites or blacks. But across all states, the CDC reports that non-Hispanic blacks have the highest rates.
Perez said that even when he advises patients against C-sections, they frequently insist. But he believes patients should have a choice — and he doesn’t see C-sections as carrying an appreciably higher risk.
“They're not worse off if they choose one or the other,” he said. “That's why you can offer them the choice.”
Dr. Paul Gluck, a retired obstetrician and independent consultant on hospital safety, disagrees that C-sections are as safe as vaginal deliveries.
“It is much safer than it used to be,” Gluck said of C-sections. “But still there’s risk of blood transfusion, anesthetic complication, infection, blood clots in the leg.”
To be sure, Gluck said, there are medically necessary reasons for physicians to perform C-sections. But he believes the greatest driver of C-sections is the physician preference and not patient choice.
“The evidence has shown,” he said, “through many studies that it's not that the populations are different. It's that physician practices are different.”
40 Percent of C-section deliveries among low-risk pregnancies in Miami region as reported by hospitals in 2014.
Gluck and Perez, both of whom cited numerous reasons for Miami’s high C-section rates, strongly advised expectant mothers to consult with their doctors before choosing a method of child birth.
Sometimes, though, doctors may be motivated to choose the delivery method that pays more, said Alice Chen, a health economist at the University of Southern California.
“Any health economist will tell you financial incentives matter,” she said, “and we know physicians respond to financial incentives, whether it’s conscious or not.”
But Chen agreed that some expectant mothers want the convenience of scheduling their deliveries, and she added that some hospitals reporting high C-section rates may be caring for pregnant patients with higher risks of complications.
“You don't want to look at a hospital that has a high rate of C-sections and say, ‘I don’t want to be there,’ because that hospital has the specialists who can do this,” she said. “The reason they have high C-sections is not because they’re trying to game the system but because they’re trying to deal with a more difficult population.”
It’s unclear whether Hialeah Hospital cares for more complex pregnancies than other South Florida medical centers because Tenet Healthcare declined an interview request.
Cesarean delivery continued to increase with advancing maternal age in 2014, reported the Centers for Disease Control and Prevention. Women aged 40 and over were more than twice as likely to deliver by cesarean as were women under 20.
Shelly Weiss, a spokeswoman for Tenet Healthcare, issued a written statement on behalf of Hialeah Hospital that read, in part: “Our caregivers work to educate expecting families on all of their birthing options, in addition to encouraging patients and physicians to develop a birthing plan. … While they are many factors that impact a woman’s decision to have a cesarean section, we are focused on driving improvement in this area.”
Linda Quick, an independent healthcare consultant who has worked in South Florida for decades, said Hialeah Hospital has long had one of the nation’s highest C-section rates.
“One of the reasons,” she said, “was that most of their obstetricians were, I want to say, foreign-born obstetricians from Cuba and Central American countries, and they were petrified of malpractice litigation, and they were perfectly happy with this idea of having the whole family participate — the parents, the grandparents, the siblings — and to all be there to decide you want to be born on such and such a day, or your kids will be born on someone's birthday.”
But Quick acknowledged that there are new cultural pressures contributing to the high rate of C-sections across South Florida and the country.
“It's a different generation of childbearing age women, who in some respects are higher risk than earlier ones were because they're waiting longer to have their children,” she said, “and they think they can fit it into an otherwise wonderful and busy life schedule.”