REPRODUCTIVE RIGHTS III

This is awful.

Dr. Helen Sandland, an obstetrician in North Carolina, is leaving the hospital where she had been practicing.  The reason?  Hospital administrators were pressuring her to do more cesarean sections.

In the decade she has delivered babies and cared for their mothers in New Hanover County, she [Dr. Sandland] has always had a [C-section] rate below 10 percent.

“I’ve always maintained I’m a midwife with a MD behind my name,” she said from her two-story Pine Valley home last week while preparing to move. “It’s better for Mother Nature to decide when it’s time, not the doctor. My philosophy is you don’t interfere unless you really have to.”

Her philosophy, admittedly different from the mainstream, attracted many patients who wanted the best chance of having a vaginal delivery. Dr. Sandland became known as one of the few doctors in the area who would try to deliver breech babies naturally or pursue a vaginal birth with a woman who already had one child with a c-section. Her solo practice boomed.

If her lack of medical malpractice lawsuits and gratitude of patients are of any account, she was not only popular, but also successful.

Popular and successful.  Bringing business to the hospital and having good birth outcomes.  So what could be the problem?

But the Star-News viewed two letters addressed to her from committee members. Written on New Hanover Regional letterhead dated July 6 and July 7, 2004, the letters discuss the conversation committee members had with her.

The first letter, written by Dr. Cobern Peterson, chairman of the Professional Review Committee, stated “concerns” regarding her practice. They include higher than average infant birth weights, much lower than average c-section rates and later than average gestational age of neonates at delivery.

None of these concerns actually pose any danger to mothers or babies.  They didn't say that babies were being born with postmaturity syndrome or symptoms of hyperglycemia.  They said the babies weigh more than the other babies in the hospital and are older at birth (probably because she's not inducing labor before the baby is really ready to be born), and more mothers are successful at having normal vaginal births.

The letter states “the main concern reiterated several times was an overall practice attitude rather than any individual case.”

In other words, nobody has been harmed, they just don't like the way she does births.

The next letter, written by Dr. Janelle Rhyne, acting chairman of the Credentials Committee, states Dr. Sandland’s privileges at the hospital would be reappointed for a period of six months but monitoring would continue.

It reads, “Your c-section rate is to be within an acceptable range as determined by the NHRMC OB/GYN Department with a plus or minus deviation of two.”

(. . .)

The c-section rate at New Hanover Regional is 27.9 percent. At the time, Dr. Sandland said, it was about 26 percent. That meant the committee was requiring her to reach at least a 20 percent c-section rate. To do so, she’d have to more than double her current rate.

If her patient's are having good birth outcomes, that means that her current c-section rate of 10% has worked adequately to make c-sections available to the mothers who actually need them.  So to double her rate, for each woman who she sections because it's necessary, Dr. Sandland would have to do another section that's not necessary.

Why are they giving her this quota to reach?

“Barto said in a separate meeting that a c-section rate of 25 percent would reduce the likelihood of getting sued,” she recalled.

(. . .)

Other times, especially when the unit was overrun with laboring moms, she said, there was pressure from department heads to speed up labor or consider a c-section.

“Quite a lot of c-sections are being done for so-called failure to progress,” Dr. Sandland said. “If you haven’t progressed in a couple of hours, a c-section’s waiting. There’s certainly a pressure to keep patients moving on through.”

I definitely heard that sentiment when I was working as a Labor & Delivery nurse at King/Drew.  They didn't do a whole lot of cesarean sections, but they would take other steps to speed up a woman's labor because "we need to get the bed empty."

Consumer watch dog group Public Citizen has estimated that half of cesarean sections are unnecessary and result in 25,000 serious infections, 1.1 million extra hospital days and cost more than $1 billion each year.

(. . .)

“We are going to see an increase in morbidity and mortality for the mothers,” she said, explaining how the first and even second c-sections are fairly risk-free but then scar tissue builds up and increases the surgery’s risk.

“Every subsequent cesarean section, the risk of a woman ending up with a severe hemorrhage, losing her uterus or ending up dying goes up,” she said.

There is a trend these days for some women to choose elective c-sections rather than give birth normally.  But Dr. Sandland's patients were coming to her specifically because they wanted to have natural births.  This hospital wanted Dr. Sandland to disregard both her patient's desires and their best health interests and start slicing more of them open.  She refused to compromise and is leaving the hospital and moving to another state.

Too bad for the women of North Carolina.

Comments

[Michelle]

Grrr. Yes, it is a loss for those moms in North Carolina, but I sure do admire her for sticking to her guns. People like her seem to be in short supply these days.

[P]

I was a patient of Dr. Sandlands. In an effort to keep her c-section % down, she rushed my delivery by putting her hands (both) inside me to expedite dialation and using forceps. I had 3rd degree tears and still - four years later - have a fissure that opens when I have a strained bowel movement. She did a poor job stitching me. I never even went back to her for a follow up. My daughters' heart rate had dropped and she should have given me a c-section. But no....she has a point to prove...regardless of the outcome.

[LAmom]

P, I would encourage you any time you have a negative experience with a health care provider to talk with them and express your concerns and demand an explanation.

I don't claim to understand all the details of your delivery (trying to Monday-morning quarterback a birth is notoriously hard), but the amount that your baby had descended in your pelvis could be one deciding factor as far as whether an assisted (with forceps or vacuum) vaginal delivery or C-section would be preferred. And for most women the physical effects of a vaginal delivery are less traumatic than abdominal surgery. But again, I'm only speaking generally and don't claim to know your individual case. And none of the above excuses bad suturing.

It is always recommended to discuss problems like these with the provider who gave the care. Any time a patient has a bad outcome, it should be reviewed and analyzed. It is helpful to both the provider and the patient.

From what was written about the conflict between Dr. Sandland and the hospital, the issues the hospital was specifically raising didn't appear to cite actual harm that had been done to mothers or babies. The hospital seems to also be guilty of just looking at the numbers without regard to actual outcomes. I would still feel that their approach is not the correct way to evaluate a doctor's practice.

I hope that you are able to find a doctor you are comfortable with who can help you with the problem of your fissure. Best wishes to you and your little girl.

[Steve]

Having worked for 14 years in the healthcare finance field, I can tell you that the state of reimbursement systems are such that doctors and hospitals are getting paid less.

Today, hospitals are reimbursed under a "prospective payment system", which utilizes a coding nomenclature called "DRGs", which stand for Diagnostic Related Groups. Under this system, a patient is categorized based on the procedures they require. Each category in this system is associated with a lump sum dollar amount. That amount is what a hospital is paid.

It doesn't matter how long that patient stays in the hospital. The hospital always gets the same amount for the same "case".

So effectively, all women who present themselves to a hospital for the purpose of delivering a baby, each have the same "price tag" on their heads. A hospital cannot afford to keep a woman in-house too long, or else the hospital starts losing money.

In the old days, when hospitals were paid for each day's stay, a hospital was encouraged to keep patients in house much longer, perhaps even longer than medically necessary. But because reimbursement systems have shifted to the "prospective payment system", hospitals now have the burden of treating patients as quickly as possible.

But you're correct that C-sections are more expensive. Under the same DRG system, women who require C-sections have a higher "price tag" on their heads. So, presuming the hospital can get the mother out of the door in the same time frame, they'll do the C-section to get some extra money.

But don't blame the hospital for this. It was the federal government, under the Medicare system, that invented the Prospective Payment System, back in the late 1980's. Medicare had become SO expensive, that it had to cut its costs. Hence, they developed this system that shifted the ENTIRE state of healthcare in America, to where the healthcare providers are forced into pushing people out the door as fast they possibly can. The faster they push them out, the more money they keep for themselves.

The government created this wonderful system, to keep Medicare from going belly up. Instead, it created this "assembly line" style of healthcare. Like the old adage said, "You get what you pay for".

[Gar Lipow]

Umm as far as I know, not a whole of births are paid for by medicare. If such a system is in place for deliveries would that not be the private insurers?

[Nick Kiddle]

This is confusing me. It's unusual for women who've had one c-section to be offered the option of a vaginal delivery? In my baby books (UK-based) it says that "once a cesarian, always a cesarian" used to be true but hasn't been for a while now. Or is it coming back into fashion again?

[LAmom]

In the U.S. it's becoming more difficult for women who want to have a vaginal birth after a cesarean (VBAC). My belief is that as VBACs became more common, a lot of OBs started treating them just like any other birth, which often meant liberal use of Pitocin to induce and augment labor. There began to be an increase in the incidence of uterine rupture. The reaction of the medical community, instead of backing away from the Pitocin, was to back away from the VBACs.

[Inna]

I gave birth with Dr. Sandland's help. My baby was one week overdue. I am grateful that Dr. Sandland did not rush my delivery even after I was in labor for 12 hours. She did, however, break my waters, which is believed to speed things up a bit. There was never a suggestion for "scheduling" or induction from her. My friend had a baby in 2007, and they pretty much scheduled her on her due date, then induced her even though she was already dilating on her own, and finally c-sected her after the baby heart rate poorly reacted to induction medicine. She thinks c-section saved the baby and does not see it as a complication of the induction:-(
I know Sandland is not a perfect doc out there, for once her bedside manner leaft much to be desired, but I would select her again if I could because I share her principle "Let Mother Nature do the work" and due to my positive experience with natural birth.