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Part 1: Birth on demand

Fellowship Story Showcase

Part 1: Birth on demand

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Abigail Martinez holds her firstborn, Natalia Zamora. Despite an uneventful pregnancy, Martinez had a C-section in December 2019
Abigail Martinez holds her firstborn, Natalia Zamora. Despite an uneventful pregnancy, Martinez had a C-section in December 2019 at Doctors Hospital of Laredo.
Courtesy Abigail Martinez
San Antonio Express-News
Thursday, December 3, 2020

LAREDO — Abigail Martinez was expecting her first child. It was a girl, and she’d already chosen a name: Natalia.

She was due the day after Christmas, but she said her obstetrician suggested inducing labor a week early because he might not be available around the holiday.

Martinez agreed. She arrived at Doctors Hospital of Laredo on Dec. 18, 2019, so medical staff could administer drugs to start her labor. But the next morning, labor wasn’t progressing as quickly as the doctor had expected. Martinez said he told her that if she wasn’t ready to give birth by around 5 p.m., he would perform a cesarean section.

“When I started asking him about it, he’s like, ‘I don’t have time for this, I have other babies to deliver,’” she recalled.

Her pregnancy had been uneventful. She hadn’t expected to undergo major abdominal surgery. Yet she did, and her experience is startlingly common for women giving birth at Doctors Hospital of Laredo.

The for-profit hospital on the U.S.-Mexico border had the highest rate of surgical intervention during childbirth of any hospital in Texas last year, a San Antonio Express-News investigation found.

Two-thirds of the women who gave birth there last year had either a C-section or an episiotomy, an incision through the birth canal that can speed delivery during vaginal births.

The Express-News collaborated with Christian McDonald, a data journalist who teaches at the University of Texas at Austin’s School of Journalism and Media. McDonald analyzed hospital billing data from the Texas Department of State Health Services to determine the rate of surgical interventions during childbirth at Texas hospitals.

A closely watched measure of hospital quality is the “primary cesarean” rate. It measures how often women without major complicating factors — those with no previous C-sections who are delivering a single baby, in the correct position, at term — undergo cesareans anyway.

C-sections can be lifesaving for mothers and babies, but they carry their own risks, some of them severe. A high rate is considered a strong indicator that a hospital may be overusing the surgery.

Of mothers who fit the criteria for low risk and who gave birth at Doctors Hospital in 2019, 31 percent had C-sections, McDonald’s analysis found.

That was the highest rate of primary C-sections among all nonmilitary hospitals with 30 or more births in Texas.

It was nearly double the statewide average, which was 18 percent.

Of 213 Texas hospitals included in the analysis, only two others had primary cesarean rates above 30 percent — Christus Southeast Texas-St. Elizabeth in Beaumont and Valley Regional Medical Center in Brownsville.

Doctors Hospital of Laredo also had the highest rate of episiotomies in Texas. The procedure was performed during nearly a third of vaginal deliveries at the hospital in 2019.

There is no national benchmark for episiotomies, but the Leapfrog Group, a national nonprofit that analyzes data on the quality and safety of hospital care, recommends a rate no higher than 5 percent. The statewide average last year was 6.5 percent.

Many factors contribute to the elevated rate of surgeries at the Laredo hospital. The few OB-GYNs are overloaded. Many women lack health insurance and receive little or no prenatal care. Obesity, diabetes, high blood pressure and other conditions that can complicate pregnancy are widespread.

But physicians who have studied the issue say those factors alone cannot explain why Doctors Hospital is such an outlier. They say C-sections offer overworked doctors a way to manage hectic schedules, clear crowded delivery wards and ensure time off for themselves.

The physicians at Doctors Hospital of Laredo are some of the busiest in Texas, each overseeing an average of six deliveries per week, the Express-News investigation found.

“What both an episiotomy and C-section have in common is they speed up the process,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. He has studied factors that cause high C-section rates.

“In childbirth, in labor and delivery, and in life, we often face these dichotomous choices between the right thing and the easy thing — and it’s easier to just pull the rip cord and do a C-section than it is to support somebody in labor,” Shah said.

Dr. Rafael deAyala, an obstetrician in Houston, said he witnessed that dynamic firsthand. He practiced in Laredo from 2005 to 2014 and said he was alarmed by the high rate of surgical interventions during childbirth.

“How do you maintain your income? You increase your volume. And when you increase your volume, how do you have a life? You shorten the amount of work that you do,” deAyala said. “And what’s the shortest way to shorten the work that you do? It’s to find an excuse to get the baby out in 30 minutes.”

C-sections put mothers at increased risk of infections, heavy bleeding after birth and a rare but life-threatening condition in later pregnancies in which the placenta grows too deeply into the uterus. Newborns delivered by a C-section are more likely to have breathing problems early in life and less likely to be successfully breast-fed.

Episiotomies, once believed to prevent vaginal tears, are now largely discouraged by OB-GYN experts because the incisions can lead to more painful recoveries, deeper tears in the pelvic muscles and, in rare cases, loss of bladder and bowel control.

“Hospitals that have sort of ‘with it’ quality improvement processes and concerned leadership are not going to have a huge episiotomy rate because that’s an easy one to fix with a little bit of attention and care,” said Dr. Steven Clark, a professor of obstetrics and gynecology at Baylor College of Medicine in Houston who has spearheaded efforts to reduce episiotomies.

“If the episiotomy rate is out of control, it would be reasonable to think that some other aspects of care are out of control as well.”

‘Failure to progress’

Childbirth can be dangerous to mothers and babies; and when things go wrong, C-sections save their lives.

If a mother’s uterus ruptures or the placenta grows over the cervix, blocking the birth canal, the surgeries are considered the safest way to deliver. C-sections can also be necessary when mothers have uncontrolled diabetes or high blood pressure, and when babies are in distress or in the wrong position for delivery.

But most commonly, doctors perform primary C-sections for less clear-cut reasons. The No. 1 indication is that labor is moving too slowly or has stalled, a broad category known as “failure to progress.”

“A lot of reasons for doing C-sections are basically subjective,” deAyala said. “If somebody is just tired, and it’s getting to be late, somebody might give them two or three more hours, or someone else might say, ‘Well, you just haven’t progressed, and we need to do a C-section.’”

The American College of Obstetricians and Gynecologists says the first stage of labor has been considered “prolonged” when it lasts more than 20 hours for first-time mothers — although that criterion is based largely on 1950s research and “should not be an indication for cesarean delivery.”

For women who have been induced through medication, as Abigail Martinez was, the first stage can last 24 hours or more.

Martinez said she’d been in labor for not quite 24 hours when a nurse checked her cervix and told her she wasn’t sufficiently dilated. Minutes later, medical staff began preparing her for a C-section.

Her doctor was Juan Montalvo, chief obstetrician at Doctors Hospital of Laredo.

Asked about Martinez’s account that he suggested inducing labor because he might not be available on her due date — the day after Christmas — Montalvo replied that he is a “workaholic” and had taken only one vacation during his 23-year career in Laredo. But he said it was possible he took a weekend off around Christmas last year.

He declined to comment further on Martinez’s case, saying he could not discuss individual patients. Speaking generally, he said a physician who is scheduled to be away on a patient’s due date could give the expectant mother the option of inducing labor as a “courtesy.”

Two-thirds of women who gave birth at Doctors Hospital of Laredo last year left with a C-section or episiotomy. CUATE SANTOS/STAFF PHOTOGRAPHER

He disputed the idea that a physician would perform a C-section solely for convenience: “That seems like a stretch.”

“It would seem like a convenient model, but if the experts would probably practice in a similar setting, I would think they would have similar results,” Montalvo said. “However, I do understand that we can do better.”

Montalvo said Doctors Hospital has made strides recently in reducing episiotomies, but that preventing C-sections is more difficult. In Laredo, many mothers do not receive prenatal care until late in their pregnancies, and underlying conditions such as obesity and diabetes are increasingly prevalent, he said.

Mirroring the national trend, “failure to progress” is the largest driver of C-sections at Doctors Hospital, Montalvo said. Other reasons he cited were “cephalopelvic disproportion,” when a baby’s head or body is too large to fit through a mother’s pelvis, and circumstances that arise when a mother is diabetic and the baby’s heart rate becomes abnormal.

Montalvo also said some Latina mothers want C-sections. “Believe it or not, patients often ask for elective cesarean sections, so we have to encourage the patients and say, ‘No, you need C-sections for the indicated reasons,’” he said.

Last year, five of Texas’ 10 highest primary C-section rates were at hospitals along the U.S.-Mexico border. But the trend doesn’t hold beyond those hospitals: Latinas elsewhere in the U.S. have historically had lower cesarean rates than both white and Black women.

“Hospitals and doctors like to blame patients for their C-section rates, which is pretty bogus,” said Dr. Elliott Main, a leading maternal health expert who is medical director of the California Maternal Quality Care Collaborative at Stanford University’s School of Medicine. “What about other hospitals that have the same patient population? Mexican American women, in general, have lower C-section rates.”

At some hospitals along the U.S.-Mexico border, including teaching hospitals that care for patients with the most complicated pregnancies, primary C-section rates are less than half the 31 percent rate at Doctors Hospital of Laredo.

The primary C-section rate at University Medical Center of El Paso was 9.9 percent last year. In the lower Rio Grande Valley, the rate at Women’s Hospital at Renaissance was 14.6 percent, and at South Texas Health System Edinburg, it was 10.1 percent.

“The biggest risk factor for the most common surgery is not a mom’s personal preferences or even her risks, but which hospital she goes to,” said Shah, the Harvard professor. “There’s been a narrative that has essentially blamed women for this trend, and it’s not the case.”

‘Very, very, very underserved’

Doctors Hospital of Laredo is one of only two hospitals that offer labor and delivery services in Webb County. The 183-bed institution is partly owned by the physicians on staff. The six OB-GYNs delivered about 1,800 babies last year.

A dozen work at the hospital’s 326-bed competitor, Laredo Medical Center, where about 3,200 babies were born in 2019. The Medical Center’s episiotomy rate was about 19 percent — more than double the state average — and the rate of primary C-sections was 24 percent, the Express-News investigation found.

“I’ve got my fair share of Laredo patients who drive all the way from Laredo because they are worried about the care they receive there,” said Dr. Kelly Morales, an obstetrician-gynecologist who practices in San Antonio, 160 miles away.

In all, Laredo has about 20 OB-GYNs, just three of whom are women, to serve almost 100,000 women in Webb County and more in neighboring rural counties. There are no high-risk pregnancy specialists in Laredo, so one flies 130 miles from Corpus Christi every weekday to treat patients with complicated pregnancies.

“We’re very, very, very underserved — we’re probably like 15 OB-GYNs short in this community,” said Dr. Dagoberto Gonzalez Jr., an obstetrician-gynecologist who delivers babies at Laredo Medical Center. “So people really work 100 miles per hour most of the time.”

“Hospitals and doctors like to blame patients for their C-section rates, which is pretty bogus.”

—Dr. Elliott Main

In such circumstances, performing C-sections, or planning elective inductions ahead of time, can make doctors’ schedules more predictable. That can be appealing to overworked physicians, who juggle office visits, the occasional on-call hospital shift, and births, which can happen at any hour of the day or night.

Some Laredo women with the financial means travel to hospitals and free-standing birth centers in San Antonio and Corpus Christi to avoid unnecessary medical interventions.

But not many can afford to go that route: In Webb County, about 42 percent of women between the ages of 15 and 44 have no health insurance, according to a 2019 report by the nonprofit Center for Public Policy Priorities in Austin.

Research has shown that access to midwives and doulas — professionals trained to support women during birth — can help women avoid cesareans that aren’t medically necessary. But there’s only one licensed midwife practicing in Laredo, and he caters to women traveling to the U.S. from Mexico to give birth.

Until a Laredo woman became certified as a doula this summer, the closest doula who could be found through extensive internet searches practiced 140 miles away in Castroville, a town west of San Antonio.

A growing number of hospitals have tried to improve care and ease the burden on OB-GYNs by hiring laborists: doctors or certified nurse midwives who provide around-the-clock care to women in labor and those with obstetric emergencies. They’re under no pressure to perform surgeries because of busy schedules.

Neither of the two hospitals in Laredo has laborists on staff.

“Realistically, it’s something you have to think of — the humanity of the physician,” said Dr. Shanna Combs, an obstetrician who oversees the OB-GYN rotation for medical students at the Texas Christian University and the University of North Texas Health Science Center School of Medicine in Fort Worth. “They’ve been on for three days, and they honestly need a break and to go home.”

Costs and complications

C-sections are the most common surgery in the U.S. and Texas. In 1970, 1 in 20 babies was born via cesarean. Today, it’s 1 in 3.

In Webb County, it’s nearly 1 in 2 births.

Webb County and Cameron County, on the southern tip of Texas, had overall C-section rates (including primary cesareans and all others) of 50 percent in 2019. That was the highest rate among U.S. counties with more than 100,000 residents, according to the U.S. Centers for Disease Control and Prevention.

The drive to reduce unnecessary C-sections springs from the desire to protect patients and control costs.

Texas hospitals charge an average of $24,000 each, compared with $15,000 for a vaginal birth, according to federal data from 2016, the most recent available. That places a burden on government insurance programs such as Medicaid, which finances about half of hospital births in Texas.

Rising C-section rates aren’t associated with improved outcomes for mothers and babies in the U.S. Infants born near their due dates in this country aren’t better off today than those born decades ago. And women overall are 50 percent more likely to die in childbirth than their mothers were.

Besides leading to longer and more painful recoveries, rising C-section rates are linked to a rise in a rare but life-threatening condition involving the placenta.

Placenta accreta spectrum occurs when the placenta attaches to a previous C-section scar. It behaves like a cancer, invading the uterus and sometimes other organs. During birth, if the placenta doesn’t detach properly, a woman can bleed to death in minutes.

“That’s the major driver — prior C-sections,” said Dr. Kayla Ireland, a maternal-fetal medicine specialist at UT Health San Antonio, which treats patients with some of the most complicated health conditions in South Texas.

The death rate of patients who develop placenta accreta spectrum has been estimated as high as 7 percent, Ireland said.

In the 1970s and ’80s, the condition was rare, occurring in as few as 1 in 4,017 pregnancies, according to the American College of Obstetricians and Gynecologists. By 2016, placenta accreta spectrum was diagnosed in 1 in 272 pregnancies.

At Doctors Hospital of Laredo, Montalvo, the chief obstetrician, said physicians see five to seven cases per year out of about 2,000 births. That’s 1 for every 300 to 400 births.

‘Never been so scared’

Leah Hood poses for a portrait with her 6-year-old son, Jude. When Hood was pregnant with Jude, she developed a life-threatening pregnancy complication called placenta accreta spectrum, which can cause a woman to bleed out during birth. GODOFREDO A. VÁSQUEZ/STAFF PHOTOGRAPHER

Leah Hood, who lives in College Station, had never heard of the disease before her doctors told her they thought she might have placenta accreta spectrum. One of her three previous births had involved a C-section — an emergency surgery to save her son’s life.

During her fourth pregnancy in 2014, she was 26 weeks along when her obstetrician sent Hood to Texas Children’s Hospital in Houston for specialized scans. When Hood began researching placenta accreta spectrum on the internet, she thought she was going to die.

It was a real possibility.

She spent the next six weeks at Texas Children’s. Her mother slept on a couch in her hospital room for the entire stay.

Hood’s doctors told her family to prepare for a 10-hour C-section (a typical cesarean takes 45 minutes). A team of specially trained doctors would deliver her son, then carefully remove the placenta that had invaded her bladder and cervix. The course of treatment almost always involves removing a woman’s uterus.

Patients can lose nearly all their blood in the process.

“Honestly, I’ve never been so scared, and not necessarily for me, because I have faith … but my kids,” she recalled. Six years later, the thought still makes her cry: “Leaving them — the thought of leaving them was hard.”

Hood was lucky. She didn’t need a blood transfusion. Her surgery took five hours, not 10. Her baby spent three weeks in the neonatal intensive care unit, but he is healthy today.

But the fear that her children and husband could be left without a wife or mother didn’t subside after she had healed. She began taking anti-anxiety medication. She spent years fearing that she would die unexpectedly.

“I am not anti-C-sections — clearly, my C-section with my third child was necessary and saved his life,” Hood said. “What I am anti is C-sections for convenience … I would say from my experience, there is no convenience worth the risk that comes with an accreta diagnosis.”

‘Good to go’

Nearly five hours after Abigail Martinez’s C-section, nurses brought her newborn daughter, Natalia, to her bedside.

Because of the surgical incision, it hurt to hold the 7-pound baby, even while lying in a hospital bed.

Martinez had always wanted a big family — at least three to four children. But after giving birth at Doctors Hospital, the idea of becoming pregnant again scared her. The hospital would now require that all her future deliveries be surgical.

The American College of Obstetricians and Gynecologists says vaginal births after cesareans, known as VBACs, can help women who want to continue having children avoid the risks associated with repeated cesareans.

Some of Texas’ most advanced hospitals permit such births: At University Medical Center in Lubbock, University Medical Center of El Paso and Harris Health System’s Ben Taub Hospital, at least 1 in 4 women with a previous C-section gave birth vaginally in 2019, the Express-News analysis found.

Doctors Hospital of Laredo used to permit VBACs, Montalvo said. But it changed its policy more than a decade ago after one or two women had serious complications with such births. At the state’s teaching hospitals, Montalvo said, “there’s more leeway of liability because you have a much larger conglomerate behind you.”

Martinez learned months after her birth that if she wanted to try to have a vaginal delivery in the future, she’d have to find one of the few doctors at Laredo Medical Center willing to handle them — or drive 160 miles to hospitals in San Antonio.

After her C-section, Martinez said a doctor she didn’t know checked her incision. “Oh, that’s a nice clean cut,” she recalled him saying. “Just wash it very carefully, and you’re good to go.”

She said she left the hospital without seeing Montalvo again.

[This story was originally published by San Antonio Express-News.]