Florida's new law allowing doctors to perform C-sections at outpatient birth centers has raised serious safety concerns among medical professionals. They say the procedure carries a small but real risk of life-threatening complications and should not be performed outside a hospital.
Critics have pointed out that the new facility, billed as a state-of-the-art birthing center, will not be able to quickly mobilize additional staff, equipment and expertise if complications suddenly arise.
“A pregnant patient considered low risk one moment may suddenly need life-saving treatment the next,” said Dr. Cole Greves, Florida District President of the American College of Obstetricians and Gynecologists. “There is,” he said.
“Even with increased regulations, state-of-the-art birth centers cannot guarantee the level of safety patients can receive within a hospital setting,” he said.
Florida's law, the first of its kind in the nation, comes as the United States grapples with maternal mortality rates that far exceed those in similar high-income countries.
Florida itself lags behind other states in maternal care and received a D+ grade in a recent March of Dimes report. Because maternal outcomes for black women are terrible. The state has a high rate of cesarean sections and rates of premature birth and infant death that are below the national average.
The law requires new luxury birth centers to have at least one operating room and the ability to transport patients to the hospital if necessary. The bill doesn't say how close hospitals must be.
But complications of cesarean section, such as bleeding and damage to surrounding tissues, “require immediate attention and support from other hospital teams, and resources such as intensive care units, ventilators and additional surgical support,” said Assistant Professor Nandini Raghuraman. Maternal Fetal Medicine at Washington University in St. Louis.
“These are all kinds of things that we need urgently when we need them,” she said. “Any delay could put lives at risk.”
The new law also allows advanced birth centers to care for women attempting vaginal birth after a previous cesarean section, despite the fact that such births can be extremely dangerous if the uterus ruptures and causes massive bleeding.
“You have about 15 to 20 minutes before the baby is deprived of oxygen and the baby dies or suffers brain damage,” said Dr. Aaron Elkin, a Florida obstetrician and gynecologist. He said he supports medical innovation, but believes patients should be informed of potential risks.
He said not only the fetus but also the woman in labor faces risks in these settings. “During pregnancy, 20% of the blood pumped by the heart is delivered to the uterus. You can lose your entire blood supply in a matter of minutes.”
KFF Health News reported that a group of doctors called Women's Care Enterprises, owned by London-based investment firm BC Partners, lobbied for the legislative change. Gov. Ron DeSantis signed the bill into law last March as part of a comprehensive health care package that included plans aimed at strengthening the state's health care workforce.
The law also increased reimbursement rates for Medicaid providers but did not expand the program to cover all low-income residents, leaving many Floridians uninsured.
A representative for the investment firm did not respond to questions about whether Women's Care Enterprises had lobbied for the new law. Women's Care Enterprises does not currently provide caesarean sections outside its hospitals, the organization said in a statement last week, and has no plans to do so in the future.
BC Partners' private equity director Mathieu Bigand and co-head of health Michael Chang did not respond to requests for comment. Gayle Harrell, an aide to state Sen. Gayle Harrell, who introduced the bill in the Florida Legislature, said she could not be reached for comment.
In recent years, advanced birth centers have been promoted as a way to expand access to obstetrics and gynecology care in a state where many hospitals have closed their labor and delivery departments. So-called maternal care deserts have grown in rural areas outside Florida's major cities.
This trend is nationwide. More than 200 hospitals across the country have closed their labor and delivery departments since 2011. This is because they are often less profitable than other hospital services and more difficult to secure staff.
Of Florida's 21 rural hospitals, only two were offering labor and delivery services as of April, according to a report from the Center for Healthcare Quality and Payment Reform, a national policy center.
Last February, North Shore Medical Center in northern Miami-Dade County, a medically underserved area, abruptly closed its labor and delivery department due to financial problems.
Experts said it's unclear whether the state-of-the-art birthing center will expand access to maternal care in the state. About half of all births in Florida are to women enrolled in Medicaid, government health insurance for low-income Americans. Medicaid's low reimbursement rates only cover a portion of the costs and place a strain on hospitals.
New laws require luxury birth centers to accept Medicaid patients, but private equity-owned clinics tend to focus on profitability and aim to maximize profits.
If centers accept privately insured patients and limit the number of Medicaid beneficiaries they primarily serve, facilities may pull well-insured patients away from hospitals, adding to their financial hardship and worsening inequities.
“I don’t think this will have any impact on addressing the provider shortages or maternal deserts that are common in rural areas,” said Julia Strasser, director of the Jacobs Institute for Women’s Health at George Washington University.
Mary Mayhew, president of the Florida Hospital Association, agreed, but said the association's main opposition to building a state-of-the-art birthing center is related to safety concerns.
“There is no such thing as a low-risk caesarean section and it should not be performed outside a hospital,” Mr Mayhew said.
The proposed center would be located outside a hospital, but would be different from a maternity center, which would be based on a midwifery model of care and only accept low-risk patients. Kate Bauer, executive director of the American Association of Birth Centers, said these facilities transfer all women who need a C-section to the hospital.
Bauer said the term “luxury birth center”, which is very similar to a birth center run primarily by midwives, would be confusing to patients.
Advanced birth centers are “180 degrees different from the birth center model,” she said. “A birth center is more than just wallpaper and curtains. It’s a whole model of care.”
Kara Newbury, chief advocacy officer for the Ambulatory Surgery Center Association, said even advanced birth centers cannot compare to ambulatory care surgical facilities that perform scheduled elective surgeries rather than emergency surgeries.
Most surgeries at an ambulatory surgery center “can be completed in less than an hour, and the majority of patients are discharged the same day,” she said. There is generally no risk of excessive blood loss with the procedure. It's also rare for ambulatory surgery centers to have agreements with blood banks, she said.
For smaller facilities, maintaining blood bank inventory on site can be difficult. Blood and platelets should be readily available, but have a short shelf life, according to American Red Cross spokesman Daniel Parra.
Conditions such as postpartum hemorrhage, which may require at least two units of red blood cells, can be fatal if not recognized and treated quickly, Ms. Farrar said. If bleeding continues or worsens, tens of additional units of blood may be needed, he added.
Obstetrician-gynecologist Dr. Grace Chen said doctors at advanced birth centers may be encouraged to perform planned cesarean deliveries more often because of higher reimbursement rates for providers compared to vaginal births and the convenience of pre-booking. She wrote about caesarean sections.
“I’m concerned that the cesarean section rate will increase,” Dr. Chen said. One in three births in the United States is a cesarean section, up from one in five in 1996. However, cesarean section surgery has more complications than vaginal birth and can increase the risk of future pregnancies.
Researchers have raised concerns about the quality of care in profit-driven medical facilities owned by investment companies.
A recent analysis of 4.1 million Medicare hospitalizations found that adverse events, such as falls and infections, were higher in hospitals owned by for-profit private equity firms compared to control hospitals, even though hospitals acquired by private equity firms were younger and had fewer low-cost hospitals. . We treated imported patients and transferred many patients with complex illnesses to other facilities.
Dr. Amos Grünebaum, a professor of obstetrics and gynecology at the Zucker School of Medicine at Hofstra University who has published research examining the safety of different birth environments, said this was the first time he had heard of C-sections being performed outside a hospital. oh my god.
“Pregnancy is like no other situation,” says Dr. Grünebaum. Because there are two patients, a baby and a mother, and sometimes they need to be cared for in different ways,” said Dr. Grünebaum.
He argued that there is no such thing as a low-risk patient or a low-risk cesarean section.
“All cesarean sections are high risk. period. “End of story,” he said.