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Florida has become the first state to allow doctors to perform C-sections outside of hospitals, with a private equity-owned physician group partnering with the move to lower costs and give pregnant women the homelier birth environment many desire.
But the hospital industry and the nation's leading obstetrician-gynecologist association say that although some Florida hospitals have closed their maternity wards in recent years, performing C-sections at doctor-run clinics increases the risk to women and babies of complications.
“One moment a low-risk pregnant patient can suddenly need life-saving care the next,” Orlando perinatologist Cole Graves, chairman of the Florida chapter of the American College of Obstetricians and Gynecologists, told KFF Health in an email. News. The new maternity clinics, “even with additional regulation, cannot guarantee the same level of safety patients would experience in a hospital.”
This spring, Law It allows “advanced birth centers” where doctors can deliver babies by vaginal or C-section to women at risk of complications. Women can spend the night at the clinics.
Women's Care Enterprises, Private equity-owned physician group Along with California and Kentucky, along with places mostly in Florida, they asked the state legislature to make the change. BC Partners, a London-based investment firm, acquired Women's Care in 2020.
“We have patients who don't want to give birth in the hospital, and that breaks our hearts,” said Stephen Snow, a recently retired Women's Care OB-GYN who testified before the Florida Legislature in 2018 for the change.
Brittany Miller, vice president of strategic initiatives at Women's Care, said the group would not comment on the matter.
Health professionals are brave.
“What this looks like is that paying for quality obstetrics is a poor substitute for effectively giving people more choices,” said Alice Abernathy, assistant professor of obstetrics and gynecology at the Perelman School of Medicine in Pennsylvania. “This feels like a bad Band-Aid on a chronic condition that makes the outcome worse rather than better,” Abernathy said.
About one-third of births in the U.S. occur by C-section, the surgical delivery of a baby inside the mother's abdomen and uterus. Generally, doctors use the procedure when they believe it is safer for the parents, the baby, or both than vaginal delivery. Such medical decisions can be made months before birth or in an emergency.
Florida state Sen. Gail Harrell, a Republican who sponsored the birth center bill, said having C-sections outside of a hospital may seem like a radical change, but so was the opening of outpatient surgery centers in the late 1980s.
Harrell, who manages her husband's OB-GYN practice, said birth centers must meet the same high standards for staffing, infection control and other issues as outpatient surgery centers.
“Where we are with the need and the birth deserts in the state, this is something that will help us and help mothers get better care,” she said.
According to the Florida Hospital Association, 17 hospitals in the state have closed their maternity units since 2019, with many citing low insurance payouts and high impairment costs.
Mary Mayhew, CEO of the Florida Hospital Association, said it's wrong to compare birth centers to ambulatory surgery centers because of the many risks associated with C-sections, such as bleeding.
Florida law requires advanced birth centers to have a referral agreement with a hospital, but does not specify where the facilities can be opened or how close they are to the hospital.
“We are deeply concerned about the impact this model will have on our collective efforts to improve maternal and infant health,” Mayhew said. “Our hospitals don't see this in terms of providing quality and safety during labor and delivery.”
Despite opposition to the new birth centers, the Florida Hospital Association did not fight the overall bill because it included a significant increase in the amount Medicaid pays hospitals for maternity care.
Mayhew said the birth centers are not expected to help address the shortage of care. Hospitals are already struggling with a shortage of OB-GYNs, she said, adding that it's unrealistic to expect more advanced birth centers to open in rural areas where more people are paid by Medicaid, which pays the lowest rates for labor and delivery care.
Although most insurers and Medicaid cover midwife-led birth centers, it is unclear whether insurers cover advanced birth centers. Advanced birth centers do not accept emergency admissions, and insurance only treats patients who contract with the facilities, keeping them in-network.
Snow, a retired OB-GYN with Women's Care, said the group plans to open an advanced birth center in the Tampa or Orlando area.
The advanced birth center concept is an improvement on midwifery care that allows for out-of-hospital births, as the centers allow women to stay overnight and provide anesthesia and C-sections if necessary.
Snow admits that, as a private equity firm investing in women's care, the birth center idea is also about making money. But he said hospitals have the same profit incentive and, like midwives, oppose the idea of centers offering C-sections because they can cut into hospital revenue.
“We are trying to reduce the cost of medicine, and this will be more cost-effective and more pleasant for patients,” he said.
Kate Bauer, executive director of the American Association of Birth Centers, said patients may confuse advanced birth centers with low-risk births that have been run by midwives for years. Currently, there are 31 licensed birth centers in Florida and 411 free birth centers in the United States, she said.
“This is a departure from the usual standard of care,” Bauer said. “This is a bad idea,” she said, because it could increase the risk to mother and baby.
No other state allows C-sections outside of hospitals. The only facility that offers similar care is a fertility clinic in Wichita, Kansas, which is a short walk from Wesley Medical Center.
The clinic offers “hotel-like” maternity suites where staff deliver about 100 babies a month, compared with 500 a month at the hospital.
Morgan Tracy, a maternity nurse at the centre, said the idea worked mainly because the hospital and delivery units could share staff and pharmacy services, and if complications arose, patients could be transferred to the main hospital more quickly.
“The beauty is there are team members on both sides of the aisle,” Tracy said.
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