Reflections on Must Read Article From The NY Times: Lessons at Indian Hospital About Births

Note: All quotes are directly from Lessons at Indian Hospital About Births written by Denise Grady for the New York Times.

Don’t miss the excellent multimedia presentation that accompanies the article.

Saturday’s New York Times featured an article by Denise Grady, Lessons at Indian Hospital About Births. The article focuses on The Tuba City Regional Health Care Corporation in Arizona and its Navajo Nation-run hospital. This hospital is not what many would consider state of the art. It is not shiny and new. It is not as well resourced as the hospitals that routinely win the “Best Hospital in the US” awards, but its maternity care and outcomes are significantly better.

In a country with a national caesarean rate of 31.8 percent, this hospital’s rate is just 13.5 percent. Many physicians would reflexively hypothesize “well, they must not handle the same high-risk population.” Oh yes they do. They have a higher than average percentage of patients with diabetes and high blood pressure, two of the conditions most often resulting in the classification of high-risk pregnancy. Grady’s article shows that the rate of caesarean section in this country is not just about the patient population, it’s about patient care, and also about culture. The culture of a community. The culture of birth. The culture of medical practice in the US. The culture of litigation. All of these things influence the care mothers and babies receive. I am sharing some excerpts from the article here, but you need to read it in its entirety. It begins with the story of a typical birth in Tuba City:

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….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 article shines a light on the issue of VBAC (vaginal birth after caesarean) which is a hot topic as “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.” How can maternity care practices and outcomes across the US get closer to those in Tuba City? By heeding the lessons learned there. Below are four that I found particularly compelling. Once you read the whole article, please come back and tell me which lessons resonated most with you.

Lesson 1: Honor birth

In mainstream US culture, birth is simultaneously sequestered from “real life” and overhyped in countless media images of women losing their minds, screaming for epidurals, yelling at their husbands, and barely making it through. Contrast this with the birth culture in Tuba City where “Birth is a joyous affair here, and the entire family—from children to great-grandparents—often go to the delivery room.” Grady explains that in this environment, “many young women have already seen children born by the time they become pregnant, and birth seems natural to them, not frightening.”

In New York City where I live and practice, most hospitals place limits on the number of people who can support a laboring mother, a policy wholly out of sync with a culture like the one described in the article. At the same time, I have seen situations where additional family members were allowed in a hospital room, but because of their own unfamiliarity with and fear of birth they were not able to exude the calm confidence that a laboring woman needs. Both of these situations are out of whack, and a result of a culture that needs to rebuild a healthy relationship with birth.

The cultural dynamics that intersect with birth go well beyond attitudes about the birth event itself. In Tuba City, the larger context of Navajo culture and customs is also taken into account. “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.” This kind of culturally competent healthcare should be the standard of care.

Lesson 2: Midwives are the professionals best equipped to manage labor and normal birth

In Tuba City,

“Nurse-midwives…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.

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.”

This description of how midwives practice is true in New York City as well, and in contrast to the care received by patients of ob/gyns. I try to prepare my doula clients who choose an ob/gyn as their provider that they will likely not spend much time in the labor room until they are actually pushing the baby out. Hospitals are not really for labor, they are for birth, which is reflected by the practice of active management that is typical on most maternity wards in this country. Although ob/gyns are expert at high-risk and surgical birth, for which they are the provider of choice hands down, their training does not focus on evidence-based management of normal labor and delivery. As I reflect on my time as a labor and delivery RN, and now as a doula, I realize I have never once seen an ob/gyn talk a woman through a contraction, or recommend a position, or comfort technique to help her manage the pain. I have seen midwives do all of the above, often. This attention to the whole process allows the laboring mother to be more than just her fetal heart rate and contraction strip, and the whole picture can be taken into consideration as her labor and birth unfold. The rates of interventions and caesareans for midwives vs. ob/gyns prove that this makes a difference in outcomes.

Lesson 3: Take away the profit motive for increased interventions and procedures in healthcare

Tuba City’s doctors and midwives, “earn salaries and are not paid by the procedure, so they have no financial incentive to perform surgery.” Author Denise Grady quotes Dr. Jennifer Whitehair, an obstetrician who says, “My colleagues here truly want to practice medicine and help people. That’s not true everywhere. Here they’re not thinking, how much can I make off this procedure?”

This just makes good sense. I think we all want to know that as patients, we are receiving care based on what is the absolute best for our health and wellbeing. Period.

Lesson 4: If we are going to create true healthcare we have to learn from those who have better outcomes, and then make necessary changes

In the US, the maternal death rate is the highest it has been in decades, and our maternal mortality ranking world-wide was #41 in 2005 (based on the research of The World Health Organization, UNFPA,the United Nations Population Fund, UNICEF (the United Nations Children’s Fund), the UN Population Division and The World Bank). As in Tuba City, the nations of Denmark and Sweden utilize the midwifery model as the primary model of maternity care, and they rank in the top 8 world-wide in maternal mortality.

We need to learn from these success stories. Grady offers a lot to think about on the matter:

“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.

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.”

I am incredibly appreciative of Denise Grady for writing Lessons at Indian Hospital About Births with a journalist’s attention to detail, and a storyteller’s voice. Her compelling report helps bring into awareness the important issues of mothers and babies that affect our communities and country as a whole. I’m also thrilled that her editor at the NY Times supported this work, and lastly, I am thankful to the people of Tuba City and the Navajo Nation for showing us a better way. Here’s hoping we are willing to go there.