Florida becomes first state in the U.S. to allow C-sections outside of hospitals
TALLAHASSEE, Fla. - This spring, Florida lawmakers quietly passed a new health bill that allows doctors to perform cesarean sections (C-sections) in so-called 'advanced birth centers,' making the sunshine state the only place in the country where the surgical procedure is allowed outside of hospitals.
It’s a policy touted by lawmakers as a way to expand birth options for Florida moms but widely criticized by doctors across the state.
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"We worry about harm to patients," said Dr. Judette Louis, department chair of Obstetrics and Gynecology at the University of South Florida. "In the scenario where you have an unexpected hemorrhage, will you have the right resources on hand?
So, many of us have had instances where we've had to call in surgeons from other parts of the hospitals to help us with an unexpected hemorrhage. What will happen in a freestanding birth center when that happens? Will they have the resources around them to save that patient? We worry that they may not."
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Legislators behind the new law, which private equity firms lobbied hard to pass, say it increases access to maternal care in the Sunshine State.
"Free-market principles show us the private sector can innovate in ways government could never imagine," bill sponsor Senator Gayle Harrell said in a statement. "What government can do is facilitate the exploration and implementation of innovative technologies and delivery models that increase efficiency, reduce strain on the health care workforce, improve patient outcomes, expand public access to care, and reduce costs for patients and taxpayers without impacting the quality of patient care."
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‘Advanced Birth Center’ legislation has been tabled numerous times in various House and Senate committees since its introduction in 2018. Harrell, who once managed her husband’s Ob-Gyn practice in Stuart, has continued to re-introduce the concept over the years, finally succeeding this year by tying it to the broader ‘Live Healthy’ package.
Lawmakers say they’re hoping to bridge the care gap for pregnant women living in rural parts of the state. A recent federal review found 90 percent of Florida’s rural hospitals do not deliver babies, and women living in rural parts of the state must drive an average of 50 minutes to reach a hospital with obstetrics services.
According to March of Dimes, nearly 20 percent of Florida counties are maternity care deserts.
Under SB 7016, certified OB-GYNs working out of authorized advanced birth centers are allowed to perform planned C-sections for women deemed to be at low risk for birth complications.
The centers will be required to have two medical directors (an obstetrician and an anesthesiologist) and a written transfer agreement with a nearby hospital to accept its patients in the event of an emergency.
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But critics, including the nation’s leading obstetricians' association, say the new clinics won’t be able to offer the same level of timely emergency surgical care for patients.
"It is critical for patient safety to remain a top priority when seeking to improve maternal health care. A pregnant patient that is considered ‘low-risk’ in one moment can suddenly need lifesaving care in the next. Advanced birth centers, even with increased regulation, cannot guarantee the level of safety patients would receive within a hospital," said Dr. Cole Greves, MD, the Florida district chair for the American College of Obstetricians and Gynecologists.
While C-sections can prevent injury and death in women and their newborns during complicated deliveries, the procedure is also linked to an increased risk of severe bleeding, infections, blood clots, and complications in future pregnancies.
As Louis warns, cesarean sections are complicated surgeries that inherently involve serious risks for both moms and babies, even in pregnancies deemed ‘low-risk.’
"What we find is that when you know someone is high-risk, they actually end up doing better because you've put a lot of things in place to protect them from having a bad outcome. A lot of the unexpected, adverse outcomes we see are in people who are previously low-risk," said Louis.
"One of the biggest predictors of maternal morbidity and mortality is cesarean delivery, so by virtue, the procedure itself really amps up the risk to the mothers. The fact that we now would be doing it outside of a hospital setting, where you can have the backup that you need should things go awry, is very concerning to me."
Just over 36 percent of babies in Florida are delivered by C-section, one of the highest rates in the country, and well above the World Health Organization’s ideal target of 10 to 15 percent occurrence.
Numerous healthcare policy organizations, including the WHO, U.S. Department of Health and Human Services, and the Florida Department of Health have called on hospitals to help reduce the rates of low-risk C-sections in an effort to improve maternal and fetal health outcomes.
In fact, in 2022, Florida Lt. Governor Jeanette Nuñez visited Tampa General Hospital to present an award for the hospital’s "continued efforts to reduce unnecessary c-section deliveries and to promote safe vaginal deliveries."
Louis says she spent the weekend fielding emails and calls from obstetricians from across the country who are baffled by the legislature’s move to lighten regulations on C-sections, a move she worries could lead to an increase in unnecessary surgical procedures.
"I think we also can't ignore the fact that the people promoting it and who think it's a good idea are private equity-based companies," said Louis. "It’s Women’s Care Enterprises, and they are big money in the state of Florida, so you always have to be cautious about whether there is financial gain to be had by allowing a birth center to also do cesarean sections."
Women’s Care Enterprises, which is owned by investment firm BC Partners, claims to be the leading provider of women’s health services in Florida, California, and Kentucky.
Greves says he’s skeptical companies like Women’s Care will be inclined to set up advanced birth centers in rural areas where rising healthcare costs and fewer patients have prompted 19 of the state’s 21 rural hospitals to drop maternity and birth services.
"It remains to be seen how feasible these centers would be in areas that already face difficulty attracting obstetric care clinicians and keeping the few hospitals that do exist operational," said Greves. "Maternity care is complex and difficult to legislate even with the best of intentions. Ultimately, it is critical that any solution that aims to improve access to maternity care not sacrifice quality or safety in the process."
Louis says maternity teams across the state are short-staffed, even in Florida’s largest cities, where pregnant women can face months-long waits to see a specialist.
"Increasingly we are finding, especially in the state of Florida, but also in a lot of states where legislation is determining how we practice medicine, that OBGYNs are not coming at a rate to replace the ones that are fleeing," said Louis. "It’s making it harder to recruit healthcare professionals. I'm trying to recruit, and they cite they’re concerned that the legislative environment puts them at odds with the [Hippocratic] oath that they took."
No matter the birth plan, Louis says it’s more important than ever for expectant moms to learn all they can about their options and to go over emergency plans and training with their care team ahead of time.
"I think it starts with answering the question of what is it exactly that you're looking for and whether or not that can be met in a safer setting. There are a lot more options now than there used to be in terms of your birth setting. There are many hospitals that have midwifery services, things like early skin-to-chest, and early breastfeeding," said Louis. "And I think they should ask a lot of questions about what processes will be in place to help them should an emergency arise.
"We know that, when it comes to maternal morbidity and mortality, often there's a delay in recognizing that there's a problem. And then once they recognize there's a problem, there's a delay in getting the right treatment. I would ask the physician: who's performing your surgery at this center, what is the training in place to recognize a problem, and what is the plan to get you to a hospital in a timely manner."