A tale of 3 hospitals

Last month, The New York Times featured an article about a rural Indian Health Service hospital that has achieved very low cesarean rates even with a higher-risk population. Tuba City Hospital's most current cesarean rate was 13.5%--the national average is over twice that number. Some of the policies at Tuba City Hospital influencing the low cesarean rate include:

• Encouragement of VBAC
• Midwives attend most vaginal births, with obstetricians available if the need arise
• Midwives are on-site around the clock and tend to do fewer inductions
• Midwives and doctors at Tuba City are more comfortable with slow labors and less likely to call a cesarean section for "failure to progress"
• Doctors and midwives are salaried, so there's no financial incentive to perform certain procedures
• Practitioners and Tuba City have federal malpractice insurance, so they are able to offer VBAC without fear of their malpractice carrier forbidding it

The Navajo culture also plays a role in keeping cesarean rates low:

Some of Tuba City’s success probably arises from Navajo culture and customs. Couples often want more than two children, but repeated Cesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery. Also, Navajos regard incisions as a threat to the spirit, something to be avoided unless necessary.

Birth is a joyous affair here, and the entire family — from children to great-grandparents — often go to the delivery room.

“I’ve had 12 family members in the room,” said Michelle Cullison, a nurse-midwife. “I’ve frankly never seen a place like this. Whoever that woman wants to be there is there. It’s something I would take out to the community.”

Linda Higgins, the head of midwifery at Tuba City, said: “All of a sudden Mom is surrounded by women, and they’re all helping her and touching her.”

As a result, many young women have already seen children born by the time they become pregnant, and birth seems natural to them, not frightening. 

And just yesterday, the NYT ran another article about two Staten Island hospitals with drastically different cesarean rates. Richmond University Medical Center has a 48.3% rate, while only a few miles away, Staten Island University Hospital has a 23% cesarean rate. What accounts for that huge difference? Chairman of OB/GYN Dr. Mitchell A. Maiman at SIUH has created--and enforces--policies that keep the cesarean rate at a more modest level. These include:

• No non-medical inductions before 41 weeks of pregnancy
• No maternal-request elective cesareans
• Active encouragement of VBAC
• Physician peer review and accountability; residents report if they see other physicians about to perform unnecessary cesareans