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Cutting Less: VBAC Navajo Style

The National Institutes of Health VBAC conference is stirring up coverage all over the internet (including our own blog carnival) and in the press.  On Sunday, the New York Times published an astounding story about cesareans and VBACs at a Navajo hospital in Arizona.

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.

Tuba City Regional Health Care Corporation boasts the following statistics:

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 article cites three factors that contribute to Tuba City’s success: 1) midwives, 2) salaried care providers, and 3) federal malpractice insurance.

With regard to midwives…

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.

…and salaried care providers…

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?”

…and, finally, federal malpractice insurance…

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.”

But can other hospitals do what Tuba City does? One NIH panelist acknowledges the challenges are steep:

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.”