Tuesday, April 20, 2010

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


  1. I love these articles and that this topic is getting attention... I love that just a few simple things can make such a difference. Why do so many hospitals act like its impossible to prevent c-sections?

  2. Very interesting! Some skeptical people may ask what the maternal and fetal mortality rates are though. Are they higher in those hospitals performing fewer cesareans?

  3. I am so happy to see that hospital births can be better, safer. I had a midwife for birth #7. She never left my side (except to go to the bathroom before I began pushing, it was just a short minute). I was monitored as was hosptial policy, but she held the thing on my tummy and encouraged me to be outside the bed. I am a person who labors upright and ends up only in the bed to push. I appreciated her care. I've had horrible experiences in the past with decels causing me to be forced into bed by the nurse, and not being allowed to go to the bathroom for hours. The midwife encouraged me to do what I felt was best, and almost every contraction early on was dealt with on the toilet...frequent drinks...walking walking walking...dancing by the bedside. A medical midwife can provide care that is safe and effective and leaves mom in charge.

  4. Similar to Katrina's comment, my thought was that with the simple steps as outlined by Dr. Maiman, we could decrease the national c-section rate by nearly 9%. And, it's not like those standards are extreme, and it doesn't seem like they'd be hard (nor expensive) to implement!!

    And, since maternal and fetal mortality rates DECLINE with decreased c-sections rates, it follows that Tuba City's mortality rates would be lower, too.

    I have driven through Tuba City many times, on my way from the Phoenix area to SW Colorado. It is not a prosperous place. Just goes to illustrate how appearances can be deceiving, and how, in spite of poverty and apparent high risk, much can be accomplished -- through simple change and cultural emphasis -- to the benefit of birthing mothers and their babies.

  5. Ah, you read my mind. I was mentally writing a piece very similar to what you just wrote.

    Apparently you're psychic!


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