Lessons at Indian Hospital About Births

Lessons at Indian Hospital About Births
By DENISE GRADY
Copyright by The New York Times
Published: March 6, 2010
http://www.nytimes.com/2010/03/07/health/07birth.html?th&emc=th


TUBA CITY, Ariz. — After less than two hours in the maternity ward, with her boyfriend, his mother and a nurse-midwife by her side, Jacquelynn Torivio gave birth to a five-pound, five-ounce son with his grandmother’s dimples and a full head of shiny black hair.

As she held him, Ms. Torivio’s spirits clearly matched her Hopi name, Nuquahynum — “a feather flying high.”

It was the kind of birth that many women in the United States could only wish for. Ms. Torivio had a vaginal birth, even though her previous child had been delivered by Caesarean section. Because of that prior surgery, many hospitals would not have let her even try to give birth vaginally, but would have required another Caesarean.

The Tuba City Regional Health Care Corporation is different. Its hospital, run by the Navajo Nation and financed partly by the Indian Health Service, 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.

This week, the National Institutes of Health will hold a conference in Bethesda, Md., about the country’s dismal rates of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), which have plummeted since 1996. “I think it’s the purpose of this conference to see if we can turn the clock back,” said Dr. Kimberly D. Gregory, vice chairwoman of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in Los Angeles.

Tuba City will not be on the agenda, but 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.

Changes in malpractice insurance would also help, so that obstetricians would feel less pressure to perform Caesareans. (The hospital and doctors in Tuba City 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.) Patients, too, would have to adjust their attitudes about birth and medical care during pregnancy and labor.

The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.

Even the American College of Obstetricians and Gynecologists has acknowledged that the operation is overused. 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.

“VBAC” has become a battle cry, with fierce advocates on both sides—women who insist that they should not be forced into surgery versus doctors and hospitals who insist on repeat Caesareans, citing the risks of labor and concerns about liability and insurance.

Originally, the mantra was “once a Caesarean, always a Caesarean” because of fears that the scar on the uterus would rupture during labor, which can be life-threatening for both the woman and the child. But after an expert panel in 1980 declared it safe for many women, vaginal birth after Caesarean had a heyday: in 1996, the rate reached 28.3 percent in women with previous Caesareans.

Then, there were some ruptures, deaths and lawsuits. The obstetricians’ group issued stricter guidelines, and the rate sank. It is now below 10 percent, and some experts think the pendulum has swung too far the other way.

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. Four other hospitals in New Mexico and Arizona, run by the Indian Health Service, also offer vaginal birth after Caesarean to some women (it is not safe for all) and have relatively low Caesarean rates without harming mothers or children, whose health in the first month after birth matches nationwide statistics. Doctors say there is no scientific evidence that Native American women are more able than others to have vaginal births.

“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.

Nurse-midwives at these hospitals deliver most of the babies born vaginally, with obstetricians available in case problems occur. 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.

In the rest of the country, 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.

Dr. Kathleen Harner, an obstetrician in Tuba City, said: “Midwives are better at being there for labor than doctors are. Midwives are trained for it. It’s what they want to do.”

Dr. Amanda Leib, the director of obstetrics and gynecology at Tuba City, said: “I think the midwives tend to be patient. They know the patients well, and they don’t have to leave at 5 to get home for a golf game or a tennis game. As crass as that sounds, I do think it has some influence.”

Donna Rackley, a nurse-midwife in Tuba City, said that at a previous job in North Carolina, doctors who did not want to work late would sometimes set an arbitrary deadline and declare that if a woman did not deliver by then, she would have to have a Caesarean.

“I found myself apologizing to patients,” Ms. Rackley said.

In Tuba City, she said, if labor is slow but there is no sign of fetal distress and the patient wants more time, the doctors will wait.

Something that has led many other hospitals to ban vaginal birth after Caesarean poses less of a problem at Tuba City. The American College of Obstetricians and Gynecologists recommends that an obstetrician and an anesthesiologist be “immediately available” during labor for patients who have had a previous Caesarean in case something goes wrong.

Many hospitals, especially small ones, say they cannot afford to pay these specialists to wait around. But in Tuba City, doctors live on the hospital grounds or just minutes away, and they are immediately available even if they are at home.

Doctors and midwives here earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery. (Doctors earn $190,000 to $285,000 a year, and midwives $80,000 to $120,000.)

“My colleagues here truly want to practice medicine and help people,” said Dr. Jennifer Whitehair, an obstetrician. “That’s not true everywhere. Here they’re not thinking, how much can I make off this procedure?”

The hospital and doctors are federally insured against malpractice, in contrast to other hospitals, where private insurers have threatened to raise premiums or withdraw coverage if vaginal birth after Caesarean is allowed.

As a result, Dr. Leib said, doctors in Tuba City are free to “think about what’s best for the patient and not what covers our butts.”

Some of Tuba City’s success probably arises from Navajo culture and customs. Couples often want more than two children, but repeated Caesareans 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.

Can the rest of the country learn from Tuba City? Doctors say they are intrigued by the model but not sure how transferable it is.

Dr. Gregory said it would not be easy to lower the Caesarean rate because of entrenched practices that raise it, like labor induction, repeat Caesareans and in vitro fertilization procedures that produce multiple births. Obesity also drives up Caesarean rates.

“I believe that a 15 percent rate is possible and not unreasonable — as a researcher,” Dr. Gregory said. “As a clinician, if you factor in patient autonomy and the number of interventions we do, it’s not likely to be possible if we keep doing what we’re doing.”