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

Read more ...

Elective(?) repeat cesareans

If a woman is forced to have an Elective Repeat Cesarean Section (abbreviated ERCS in the medical literature), but vigorously protests against it and does not agree to the surgery, can it really be called "elective"? One Arizonian woman says no. She is pregnant with her fourth baby. Her hospital, which allowed her to have a VBAC with her third child after her second was born via c-section due to placental abruption, has informed her that she will not be allowed to give birth vaginally. If she shows up in labor and refuses surgery, the hosital's CEO has told her they will seek a court order for a cesarean section. From the Lake Powell Chronicle:

A pregnant woman’s pleas not to have an unnecessary caesarean are being ignored by Page Hospital administrators.

Joy Szabo, 32, said she is upset with Page Hospital’s general ruling in June prohibiting vaginal births after cesareans (VBAC). The mother of three children, she has given birth to all of her children at Page Hospital, the only hospital in the immediate area. A placenta eruption caused her to have an emergency cesarean delivering her second child, but the hospital allowed her third child to be delivered naturally two years ago.

Now pregnant with her fourth child, she is being forced to have a caesarean due to lack of hospital staffing.

“Page Hospital is, as many small communities are, challenged with resources,” said Chief Executive Officer Sandy Haryasz. “Page simply does not have the physician resources to respond to an emergency."...

Joy thinks it is against her legal rights to force her to have unnecessary surgery that might place her and her baby at greater risk of harm than delivering naturally. Her only option to having natural birth is to travel to a women’s care clinic in Phoenix or have unassisted home delivery....

Joy said she voiced her concerns at a board of directors meeting and has met twice with Haryasz.

“I asked Sandy what would happen if I just showed up refusing a c-section and she said they would obtain a court order,” Joy said. “They don’t want to allow VBACs because she said they aren’t equipped for emergency c-sections, but if they can’t do emergency c-sections, they shouldn’t be having labor and delivery at all. That’s why women go to the hospital to have their babies – in case there is an emergency....
The Szabos think that lack of staffing is not sufficient cause for Joy to be forced to undergo unwanted, unnecessary surgery.

“My doctor doesn’t have a problem with me having natural delivery, but said that the hospital does,” Joy said. “The fact that I successfully had a VBAC two years ago lowers my risk for rupture, but that doesn’t matter since the hospital has decided that all VBACs have to have an ‘elective c-section.’ I think my definition of ‘elective’ differs from theirs because I don’t want this.”

Read the rest of the article here.

Read more ...

My last post was about the risks that repeat cesareans pose to the baby, specifically higher rates of NICU admissions and respiratory distress. I wanted to share one woman's personal experience facing those risks, in which she almost lost her baby due to a (not-entirely-elective) repeat cesarean.

Sarah H is a nurse who blogs at The Wonder of Birth. Her first cesarean was for twin boys, who were both lying transverse. She wanted a VBAC for her second but reluctantly "chose" a repeat cesarean for her daughter Audrey in part because she had so little support for her VBAC plans.

You can read about her first cesarean and the factors leading up to her "elective" repeat cesarean. Then read the birth story of Audrey.

Thanks to Birth Faith for the link.

Read more ...