Small Reservation Hospital Contributes to Growing Proof We Can Do Better in Birthing

Jodi Jacobson

A small Arizona hospital run by the Navajo nation outperforms much larger and more highly-resourced facilities in reducing the rate of unnecessary c-sections.

As experts prepare to convene this week at a conference to be held at the National Institutes of Health to examine data on the too-high rate of cesarean sections in the United States, a small hospital in Tuba City, Arizona is contributing to growing evidence that VBACs or vaginal birth-after-cesarean are safe and effective.

A New York Times article this weekend profiles the Tuba City Regional Health Care Corporation hospital, run by the Navajo Nation and financed partly by the Indian Health Service.  The hospital, according to the Times, “prides itself on having a higher than average rate of vaginal births among women with a prior Caesarean, and a lower Caesarean rate over all.”

As Washington debates health care, this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.

Because of a prior c-section, notes the Times, many hospitals would not have let a woman in labor even try to give birth vaginally, but would have required another Caesarean.  The Times notes the dismal rates of vaginal birth after Caesarean in the U.S., which have plummeted since 1996.

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Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused, says the Times. “Though there is no consensus on what the rate should be, government health agencies and the World Health Organization have suggested 15 percent as a goal in low-risk women.”

While Tuba City will not be on the agenda at the NIH conference, notes Denise Grady, the author of the Times article, “its hospital, with about 500 births a year, could probably teach the rest of the country a few things about obstetrical care. But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.”

In Tuba City last year, 32 percent of women with prior Caesareans had vaginal births. Its overall Caesarean rate has been low — 13.5 percent, less than half the national rate of 31.8 percent in 2007 (the latest year with figures available). This is despite the fact that more women here have diabetes and high blood pressure, which usually result in higher Caesarean rates.

The hospital serves mostly Native Americans — Navajos, Hopis and San Juan Southern Paiutes. The hospital employees nurse-midwives who deliver most of the babies born vaginally, backed up by obstetricians should anything go wrong. 

Midwives staff the labor ward around the clock, a model of care thought to minimize Caesareans because midwives specialize in coaching women through labor and will often wait longer than obstetricians before recommending a Caesarean. They are also less likely to try to induce labor before a woman’s due date, something that increases the odds of a Caesarean.

“There is a significant lesson here about the ability of most women to deliver vaginally,” said Dr. Jean E. Howe, the chief clinical consultant for obstetrics and gynecology at Northern Navajo Medical Center in Shiprock, N.M.

“In the rest of the country,” writes Grady, “nurse-midwives attend about only 10 percent of vaginal births, though their professional society, the American College of Nurse Midwives, hopes that will grow to 20 percent by 2020.”

Reducing the over-reliance on c-sections, say experts, will require a number of changes in our current approach to labor and delivery, including changes in doctor-patient attitudes about birthing practices, and changes in malpractice insurance to reduce the perceived pressure on obstetricians to perform Caesareans. In Tuba City, the hospital and doctors are insured by the federal government, and therefore insurance companies cannot threaten to increase their premiums or withdraw coverage if they allow vaginal births after Caesarean, which dramatically reduces such pressure.

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