By SUSAN DOMINUS
Published: April 19, 2010
This is a tale of two hospitals.
One has the highest rate of Caesarean sections in the city, the other the fourth lowest. They represent some of the city’s obstetric extremes, yet they sit just five miles apart on Staten Island, serving similar populations.
So what accounts for the difference?
Dr. Mitchell A. Maiman, at the computer screen, with a patient on Monday. He does not offer elective Cesarean sections.
In large part, determination, which Dr. Mitchell A. Maiman, the chairman of the obstetrics and gynecology department at one of the two, Staten Island University Hospital, has in ample supply. As New York City’s C-section rate has soared in recent years — by 36 percent, between 2000 and 2007, according to the New York State Department of Health — Dr. Maiman has kept his hospital’s rate around 23 percent of all births.
In 2008, according to numbers released by Choices in Childbirth, an advocacy group for pregnant women, working with state statistics, Staten Island University Hospital’s rate went down, while the rate at the other hospital, Richmond University Medical Center, went up again, to 48.3 percent. That made it, for the fifth consecutive year, the hospital with the highest C-section rate in the city. (The National Center for Health Statistics reported that the Caesarean rate reached 32 percent in 2007.)
Caesarean births are generally considered more prone to complications than natural births, so most hospitals at least pay lip service to their devotion to reducing them. But very few have pulled it off. What seems to have made the difference for Dr. Maiman’s department is building that goal into policy, even when it is unpopular with doctors — even, sometimes, when it may be unpopular with patients.
To start, Dr. Maiman and his colleagues do not allow unnecessary inductions for first-time pregnancies at any point before the 41st week, since they are a main cause of C-sections. They also do not allow C-sections for no reason other than the mother wants one.
C-sections are thought to be relatively lawsuit-proof, and they also let everyone go home on time. But such conveniences do not inform Dr. Maiman’s thinking. “You have to draw the line somewhere,” he said in an interview. “If you went to your doctor and said, ‘I want my gall bladder taken out electively,’ your doctor wouldn’t do that, probably.”
Mother-demanded C-sections are unusual enough that the policy is probably more useful to Dr. Maiman for the message it sends to doctors and patients, a clear sign that he values a noninterventionist policy as long as it is safe. It has become common for hospitals to prohibit what are known as VBACs (for Vaginal Birth After Caesarean, pronounced VEE-back) for reasons having to do with anesthesia availability and, more tacitly, a fear of lawsuits. Dr. Maiman actively encourages VBACs. Residents are trained not only to avoid unnecessary C-sections, but to let higher-ups know if they witness another doctor about to perform one.
Obstetricians with high Caesarean rates, Dr. Maiman said, invite scrutiny; doctors either come to see things his way or end up leaving the hospital.
“If a woman has a third or a fourth Caesarean, the maternal morbidity and mortality is astronomically higher,” Dr. Maiman said. “That’s when you see women dying in childbirth from obstetrical hemorrhage.”
Whether or not you like his policy — maybe you believe a mother’s choice should extend to controlling the hour of her delivery and how much it will hurt — you have to give Dr. Maiman credit for not just creating protocols to protect women’s health, but enforcing them. There is not a lot of incentive for hospitals to let conviction trump convenience, especially when convenience comes with the added bonus of lower legal risk.
Dr. Michael L. Moretti, the chairman of the obstetrics and gynecology department at Richmond University Medical Center, attributed the high rate of C-sections at his hospital to the reputation of its perinatal care center, which he said attracts women with high-risk pregnancies who are more likely to require surgically assisted births.
Dr. Moretti said he and his colleagues were trying to reduce C-sections with peer review of one another’s procedures. Women requesting C-sections are now required to meet with Dr. Moretti to discuss the risks. “What we find is that about half who come in requesting a C-section will change their mind,” he said, “so that’s helped a lot.”
Five miles away, Dr. Adi Davidov, one of Dr. Maiman’s colleagues, described similar conversations — but better results. “I find that most of the time, if you explain to a mother you’ll recover faster, it’s safer,” he said, “then most women will choose a vaginal delivery.”
I cannot say which doctor is the better obstetrician, but it seems like Dr. Davidov is the better talker. When it comes to patient care, that counts, too.
E-mail: susan.dominus
@nytimes.com
In large part, determination, which Dr. Mitchell A. Maiman, the chairman of the obstetrics and gynecology department at one of the two, Staten Island University Hospital, has in ample supply. As New York City’s C-section rate has soared in recent years — by 36 percent, between 2000 and 2007, according to the New York State Department of Health — Dr. Maiman has kept his hospital’s rate around 23 percent of all births.
In 2008, according to numbers released by Choices in Childbirth, an advocacy group for pregnant women, working with state statistics, Staten Island University Hospital’s rate went down, while the rate at the other hospital, Richmond University Medical Center, went up again, to 48.3 percent. That made it, for the fifth consecutive year, the hospital with the highest C-section rate in the city. (The National Center for Health Statistics reported that the Caesarean rate reached 32 percent in 2007.)
Caesarean births are generally considered more prone to complications than natural births, so most hospitals at least pay lip service to their devotion to reducing them. But very few have pulled it off. What seems to have made the difference for Dr. Maiman’s department is building that goal into policy, even when it is unpopular with doctors — even, sometimes, when it may be unpopular with patients.
To start, Dr. Maiman and his colleagues do not allow unnecessary inductions for first-time pregnancies at any point before the 41st week, since they are a main cause of C-sections. They also do not allow C-sections for no reason other than the mother wants one.
C-sections are thought to be relatively lawsuit-proof, and they also let everyone go home on time. But such conveniences do not inform Dr. Maiman’s thinking. “You have to draw the line somewhere,” he said in an interview. “If you went to your doctor and said, ‘I want my gall bladder taken out electively,’ your doctor wouldn’t do that, probably.”
Mother-demanded C-sections are unusual enough that the policy is probably more useful to Dr. Maiman for the message it sends to doctors and patients, a clear sign that he values a noninterventionist policy as long as it is safe. It has become common for hospitals to prohibit what are known as VBACs (for Vaginal Birth After Caesarean, pronounced VEE-back) for reasons having to do with anesthesia availability and, more tacitly, a fear of lawsuits. Dr. Maiman actively encourages VBACs. Residents are trained not only to avoid unnecessary C-sections, but to let higher-ups know if they witness another doctor about to perform one.
Obstetricians with high Caesarean rates, Dr. Maiman said, invite scrutiny; doctors either come to see things his way or end up leaving the hospital.
“If a woman has a third or a fourth Caesarean, the maternal morbidity and mortality is astronomically higher,” Dr. Maiman said. “That’s when you see women dying in childbirth from obstetrical hemorrhage.”
Whether or not you like his policy — maybe you believe a mother’s choice should extend to controlling the hour of her delivery and how much it will hurt — you have to give Dr. Maiman credit for not just creating protocols to protect women’s health, but enforcing them. There is not a lot of incentive for hospitals to let conviction trump convenience, especially when convenience comes with the added bonus of lower legal risk.
Dr. Michael L. Moretti, the chairman of the obstetrics and gynecology department at Richmond University Medical Center, attributed the high rate of C-sections at his hospital to the reputation of its perinatal care center, which he said attracts women with high-risk pregnancies who are more likely to require surgically assisted births.
Dr. Moretti said he and his colleagues were trying to reduce C-sections with peer review of one another’s procedures. Women requesting C-sections are now required to meet with Dr. Moretti to discuss the risks. “What we find is that about half who come in requesting a C-section will change their mind,” he said, “so that’s helped a lot.”
Five miles away, Dr. Adi Davidov, one of Dr. Maiman’s colleagues, described similar conversations — but better results. “I find that most of the time, if you explain to a mother you’ll recover faster, it’s safer,” he said, “then most women will choose a vaginal delivery.”
I cannot say which doctor is the better obstetrician, but it seems like Dr. Davidov is the better talker. When it comes to patient care, that counts, too.
E-mail: susan.dominus
@nytimes.com
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