Belly Up

* bellies * birth * babies * breastfeeding *

Tuesday, February 15, 2011

Naming Names

Wouldn't it be nice if hospitals just posted this info at the entrance!
Below I have listed the primary c-section rates for a number of local (to me anyway) area hospitals for 2008, the latest year compiled and published.  These numbers are self reported to the state health department by each hospital and are risk adjusted, meaning the numbers do not include repeat c-sections, c-sections done on moms carrying multiples, breech positioning, previas, or other higher risk situations.  Basically, the percentage shown is just the rates for low risk moms.   A good estimate of the total  percentage of c-sections being performed at any given hospital can be gotten simply by doubling the number.  Not perfect, but that will get you a ball park.

Hospital                                                                         City                                   % 
Baylor Med Ctr-IrvingIrving22.74
Baylor Med Ctr at CarrolltonCarrollton20.3
Las Colinas Med CtrIrving28.22
Med Ctr-LewisvilleLewisville21.96
Med Ctr-ArlingtonArlington26.35
Baylor Med Ctr-FriscoFrisco20.63
Baylor Regional Med Ctr-GrapevineGrapevine24.23
Baylor University Med CtrDallas24
Centennial Med CtrFrisco22.08
Med City Dallas HospitalDallas25.98
Methodist Dallas Med CtrDallas13.12
Methodist Richardson Med CtrRichardson14.81
Parkland Memorial HospitalDallas12.35
Texas Health Presbyterian Hospital DallasDallas27.67
Texas Health Presbyterian Hospital-PlanoPlano31.53
Baylor All Saints Med Ctr-Fort WorthFort Worth21.1

Here is the link to full data for the state of Texas:

The two hospitals with the lowest c-section rates are Parkland and Methodist, both of which are county hospitals where mostly uninsured and those not eligible for Medicaid deliver.  Overall this is a higher risk population.  Many moms in this group, be it due to income or issues of legal residence, may not receive much or any prenatal care and may have other issues in their lives that could potentially adversely affect their pregnancy.  However, the c-section rates at these hospitals are low despite this higher risk population of clients.  Conversely, the hospitals with the highest rates of surgical birth are in the more wealthy suburban areas.  Without going too far on the basis of one statistic, there does seem to exist some correlation between c-sections rates and the ability of an OB to get paid for doing them.  This would be horrible if moms delivering at county hospitals were getting inferior care evidenced by higher maternal and fetal death rates, but I have seen no research showing that to be the case.  Instead it seems these hospitals get the job done safely for all parties but more often in the cheaper (and by that I mean vaginally) way.  Unfortunately this then also suggests that profit motive (perhaps on the part of the hospitals, the OBs, or even the OBs' liability insurance) may lead to a large percentage of the surgeries that are performed on insured women.  At minimum it helps demonstrate that a lot of women are having major surgery performed unnecessarily.

Oh course I am not running out to drop my health insurance coverage, but something to think about.

Tuesday, February 8, 2011

Questions for Choosing A Hospital

(Mom, ask some good questions!)
If you have been involved in a serious car accident, it is pretty likely you will be happy to have the ambulance chauffeur you to whatever hospital is closest as you will probably have neither the time nor inclination to be doing interviews.  However, childbirth is different in that you have at minimum 9 months to look around and you can even start looking before the test shows two lines.  Here are just a few suggestions of things you can ask to gauge if a hospital is a good fit for you. 

Are there any restrictions on who is allowed in the room? If you want the baby's siblings, relatives, doula or a photographer in the room, make sure you ask the hospital what its policies are. Some hospital limit visitors to 2, others allow a frat party to be held in the room while mom labors.  Also check to see who is allowed in the operating room in case of a surgical birth. Some hospitals allow (and encourage) doulas and birth photographers in while others do not. As a side note, hospitals can also be very helpful if you are trying to keep a certain someone out of the room as well.

Can I eat and drink during labor? Many US hospitals restrict women to sips of fluid or ice chips during childbirth, but studies find that drinking and eating during labor had no adverse effects on mothers or babies; in fact, it actually improves hydration and relates to more positive experiences. So unless your idea of a complete and nutritious meal is ice chips, this is an important question.

Can I walk and move around during labor?
The medical community agrees that moving around makes labor less painful and more efficient, so ask how the hospital supports mom to incorporate movement into her labor and if they encourage intermittent fetal monitoring. Intermittent monitoring, where the baby's heartbeat is checked at regular intervals and is based on what is happening in labor rather than protocol, promotes movement and position change.  Conversely routine continuous monitoring makes it difficult for laboring moms to change positions and cope with contractions as they are tethered to machines and movement causes the flat disks to slide off mom's round belly. Continuous monitoring also creates a fair number of false alarms. Studies have shown that continuous monitoring of low-risk labors does not improve fetal or maternal outcomes but does tend to increase cesarean rates. Boo.

What are the rooms like?
Ideally, you want a large private room with soft lighting, a comfortable chair, a CD player, access to the Internet, a mini refrigerator, and a deep tub, preferably with Jacuzzi jets. In reality, outside of your home or a birth center, this room does not exist for laboring moms. However a few local hospitals do allow moms to bring in a tub for both labor and birth and a few others have a tub that is available to moms under some circumstances. Find out if birthing balls are available, and if not, if you can bring your own. If tubs are not available, ask if you can bring your own tub.

Are there rules about what I can wear and what I can bring? Can you labor in a T-shirt, or even your leopard strip string bikini, or do you have to wear a hospital gown? Many women are more comfortable in regular clothes and there is no medical reason that a mom cannot do so. If you want to record the birth, ask about any rules regarding still and video cameras. Lawsuits have prompted some hospitals to ban recording devices during some parts of labor and delivery while others allow full access. One of my favorite quotes from an OB was when he was asked about filming mom’s impending surgical birth. He simply answered, “ It’s your body and your baby so film anything you want.” Cool.

Do I have to deliver lying flat on my back? Squatting during delivery increases the pelvic opening by approximately 28 percent, reduces the need for forceps and speeds up the birthing process, however it is still common for hospitals and doctors to have mom on her back with her legs up in stirrups for the birth. Does the hospital have squat bars or other tools to help a mother who wants to squat during delivery? Will they be supportive if this is your choice?  Will they be able to find the squat bar when and if you want it?

Can I nurse my baby immediately? Studies show that infants who nurse soon after birth have a longer duration of breastfeeding than infants who are first put to breast 3 to 6 hours after birth. Yet many hospitals still take the baby after birth to be washed, weighed, and then rewarmed under a warmer in the nursery rather than in mom's arms. Ask whether you can nurse your baby immediately, perhaps even while he is still attached via your umbilical cord. Find out if the nurses are willing to do the baby's routine checks bedside or in the room with you and for what reasons your baby may be removed from your room at any point of your stay. Most hospitals (in my area anyway) are moving to the rooming in model of care but it is good to find this out beforehand as some hospitals have still not made the transition.  Those that have not transitioned generally take the baby away from the parents right at the 1 hour mark, even if you finally just got the little guy to latch on.

How does the hospital support breastfeeding? Do the nurses support rooming-in and breastfeeding-on-demand or scheduled feeding? The answer will be greatly effected by the answer to the previous question about often often the baby will be in the nursery vs in mom's room.  Also ask if there is a lactation consultant on staff and how often she is available. Some hospitals have great LCs but they only work Monday-Friday. Great if you deliver on Wednesday, not so great if you deliver on a Friday night.

Tuesday, February 1, 2011

Any Menie Moe? Choosing Your Hospital

Most of us wouldn't buy a car, or even a large appliance, without at least a passing glance at a Consumer Reports or the regulated sticker affixed to a product listing things like gas mileage, general features or energy efficiency. However many couples don't even do this much research when choosing where they will deliver their child.  I tend to believe that this is not because they don't care, but rather that this info is not as readily available since hospitals don't have a sticker stating their c-section rates or policies on the door at the entrance to L&D.  Nor do the hospital childbirth classes generally cover this material.

Where you choose to birth will make the most impact on what kind of birth you can expect.  The reality is that most couples, for a variety of reasons, will give birth in a hospital. Luckily there are good hospitals...but there are also plenty of less than great hospitals out there too who will be happy to bill your insurance and provide a place for your baby's arrival.  Luckily, while it is true that figuring out which hospital is a good fit for your choices is not as easy as reading a sticker, it's not rocket science either.

First of all it is easy to access the primary c-section rates of hospitals, at least here in Texas.  A quick google search will tell you that in the DFW area the rates for primary c-sections (meaning low risk, 1st time moms carrying head down singletons) run from 14% to 35%  depending on the hospital  If a hospital has a primary c-section rate of 40% you can safely assume its total c-section rate (which adds in repeat c-sections, twins, breeches and higher risk moms) is closer to 70%.  Unless you know some reason why only 30% of the women that birth at that particular hospital are capable of vaginal birth (recent epidemic of rickets maybe???), then that a huge red flag.  The vast majority of women that walk into that hospital to deliver, are rolled out with a scar on their uterus due to major abdominal surgery...though if you are having a c-section this is where to go!

After finding a hospital that is not likely to perform surgery simply for convenience, profit or perhaps just due to routine procedures that just happen to steer women toward surgical birth, you can further narrow your search.  I don't want to assume all my readers will want the same thing, however, a good rule of thumb is that if a hospital supports natural birth, VBACs and commonly works with doulas, then they are usually more open to working with moms whatever their choices.  Hospitals with rigid rules and routine procedures that everyone gets, needed or not, are more bureaucratic and less flexible....sort of like giving birth at the DMV! (my apologies to anyone working at a governmental agency, but really they are not usually very user friendly)

The next step is to talk.  Join a local pregnancy group, call a doula, call a friend, call a nurse who works at any given hospital.  You will get the goods this way much more reliably than most any other means.  This goes without saying, take the tour.  Better yet, take the tour and ask obscure questions.  Ask if they have a squat bar or a birthing tub, even if you have no desire to ever use either one.  The answers, and sometimes just the look on the guide's face, to the more off beat questions will sometimes tell you more than finding out if each room is equipped with an I-Pod dock (though that can also be a helpful bit of info!).

More in the next post....