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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Authors' Response on Native American Community Cesarean Rate
Low Cesarean rate in another Native American community
Safe birth possible outside the big city?
Hopefully not a bygone era
Missing the forest for the trees
There is hope...
Did low usage of epidural play a role?
Cesarean sections in Indian country
Its Labor Management!!
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Lawrence M Leeman, Assistant Professor of Family and Community Medicine and Ob/Gyn University of New Mexico, Leeman Rebecca
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We appreciate the thoughtful responses to our article . Several respondents (Klein, Goer, Goetter, and Blenning) mention potential implications of our findings in relation to the steadily increasing cesarean delivery rate in the U.S. We would like to share the most recent cesarean delivery statistics. On June 25th the National Center for Health Statistics released preliminary birth data for 2002 . The cesarean delivery rate has now increased to 26.1%. This is a 7% increase in a single year and the highest level ever in the U.S. The increase resulted from a precipitous decrease in VBAC from 16.4 to 12.7% in one year and a continued increase in the primary cesarean rate. The primary cesarean rate increased 7% to 18.0% and has increased 23% from the 14.6% rate in 1996. The VBAC rate is falling due to concerns about the risks of uterine rupture. Many women no longer have access to VBAC in their local communities. The rise in the primary cesarean delivery rate is harder to explain. The increase in the primary cesarean rate comes at a time of increasing use of labor induction, often for social or elective indications. A recent study by Johnson et al demonstrated that inducing labor in nulliparous patients with an unfavorable cervix resulted in a 31.5% cesarean delivery incidence compared to 11.5% in nulliparous women in spontaneous labor and 18.1% in nulliparous women induced with ripe cervix. Pregnant women, physicians and midwives should avoid unneeded labor inductions, especially in nulliparous women with an unripe cervix. Dr. Carol Blenning suggested that the limited use of epidural analgesia might have been a factor on the low cesarean rate. Although this issue remains controversial, two recent systematic reviews were unable to demonstrate an effect of epidural use on cesarean delivery rates. Epidural analgesia does increase the rate of operative vaginal delivery and the infrequent use of epidural use may have played a role in the low utilization of operative vaginal delivery in the Zuni-Ramah population. An alternative to epidural analgesia that has been shown to decrease the likelihood of cesarean delivery is continuous emotional labor support by a doula. This is analogous to the role played by the female relatives that accompanied many of the laboring women from Zuni-Ramah. Such continuous labor support has been shown to decrease the relative risk of a cesarean delivery by close to 25% . Henci Goer attributes the low cesarean delivery rate to the primary caregivers being midwives and family physicians. Although there are studies in the medical literature suggesting these groups have lower rates, the studies are methodologically limited by the bias from patients choosing perinatal providers whose practice matches their own philosophy. A woman choosing a family physician or midwife may be less likely to request elective labor induction or to ask for a cesarean delivery after a short period of labor dystocia. Another example is a woman who is highly motivated to have a vaginal birth after cesarean may choose a family physician or midwife, while a woman considering a repeat cesarean may choose an Ob/Gyn. We believe that the individual’s practice style is likely more important than the specialty of the perinatal provider. The low cesarean delivery rate in Zuni-Ramah was facilitated by a group of Ob/Gyns at Gallup Indian Medical Center who supported the practices of the family physicians and CNMs doing most of the deliveries. A recent article does demonstrate that differing practice patterns of physicians were a significant factor in predicting the likelihood of cesarean delivery . We appreciate Drs Waxman, North and Murphy sharing their research and experience of childbirth in Native American communities. We share Dr Murphy’s concern for the loss of rural VBAC access. An encouraging development for maintaining such access is the Vermont/New Hampshire VBAC project (http:// www.nneob.org/vbac.html). The project involved collaboration between local hospitals and University perinatalogists to develop regional definitions of “immediate availability” based on the risk status of laboring women and may be a model for other rural areas. Lawrence M Leeman MD, MPH Rebecca Leeman CNM, MSN 1 Leeman L, Leeman R. A Native American community with a 7% cesarean delivery rate: Does case mix, ethnicity, or labor management explain the low rate? Ann Fam Med 2003; 1: 36-43 2 Hamilton BE, Martin JA, Sutton PD. Births: Preliminary data for 2002, National vital statistics reports, vol 51 no 11. Hyattsville, Maryland: National Center for Health Statistics. 2003 3 Johnson DP, Davis NR, Brown AJ. Risk of cesarean delivery after induction at term in nulliparous women with an unfavorable cervix. Am J Obstet Gynecol 2003; 188:1565-72. 4 Hodnett E. Continuous emotional support during labor (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. 5 Luthy DA, Malmgren JA, Zingheim RW, Leininger CJ. Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol 2003; 188:1579-87. Competing interests: None declared |
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Charles Q. North, family physician Indian Health Service, Chief Clinical Consultant for Family Practice
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The Leeman's account of birth experience in Zuni is very interesting to Indian Health clinicians in the southwest. He asks what aspect of the population accounts for the low cesarean rate. Timothy Vollmer, MD and I conducted a chart review of 615 Native Americans who presented in labor to an isolated Southwestern reservation hospital without surgical capability from 1977-1979. Cesarean sections accounted for 7.3% of all deliveries. Tribe A had significantly (p<.o5) more cesareans than tribe B (9.6% vs. 6.4%) although the primary cesarean rate was higher for tribe B (9.5% vs. 2.3%). Among tribe A 37.5% had repeat cesareans and in tribe B only 17.9% had repeat cesareans. The perinatal mortality rate was 11.4, comparable to the 1975 rate published for Sweden and better than the all US rate in 1976 (16.7) and far better than the isolated rural counties US rate in 1973 (22.3%). The tribes were similar in many respects to the population described by the Leemans but the hospital was even more remote from surgical capability (90 miles). Medical complications, especially diabetes rates, were low in our cohort in the 1970's. Unlike the Leemans' population, our population had a significant rate of repeat cesareans. It is curious that both populations had exactly the same total cesarean rates of 7.3%. Some of our findings were presented at the 15th Annual Professional Association meeting of the United States Public Health Service meeting in Houston, Texas, May 26-29, 1980. The similarity of our findings 15-19 years apart makes me think that cultural attitudes toward childbirth, design of the perinatal system and genetic factors may all contribute to this remarkably lower cesarean rate.
Competing interests: None declared |
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Margaret Ramsey, Registered Midwife Vancouver Island Health Authourity Department of Midwifery
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As a practioner in a rural area with similar resources as the authours, it is heartening to have acess to research that supports the safety of obstetric practise outside of a tertiary care centre. Bravo, keep it coming! One small line did tweak my radar however: "Several female family members usually accompany a Zuni woman in labor. These labor companions may function in a role similar to doulas." Shouldn't that be "doulas function in a role similar to Zuni female family members" ? Competing interests: None declared |
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Neil J Murphy, OB/GYN Chief Clinical Consultant, IHS Alaska Native Medical Center, Women's Health Service
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I want to thank the Leemans and women of Zuni-Ramah for this important and timely contribution to the literature. When reviewed with their previous article on the Zuni-Rahmah experience (1), one can see the benefit of a rational regionalization of health delivery as practiced in the Indian Health, tribal, and urban facilities that care for American Indian and Alaska Native (AI/AN) women. While the Zuni-Ramah experience is exemplary, it is not unique to Zuni-Ramah. I believe the Leeman’s data may be generalized to other systems. The national AI/AN cesarean delivery experience is outlined in the Indian Health Focus: Women, 1998-99.(2) The Indian Health Service (IHS) data shows that there are two entire IHS Areas with lower rates of primary cesarean delivery than whole Albuquerque area, of which Zuni is part, e.g., Albuquerque Area (11.0) versus Navajo (8.0%) and Alaska (7.3%). Smith and Murphy’s description of Alaska’s experience is of interest here, because of Alaska’s widespread lack of access to rapid cesarean delivery capacity for both non-Native and Native women alike. (3) As Dr. Waxman points out in his comments, the Zuni experience cannot be entirely supported by a biologic component, because there were IHS Areas with primary cesarean rates that exceeded the national rate at the time, e.g., Oklahoma (15.0%) and Nashville (15.2%). Lastly, I am glad the Leemans have documented this data now. I think it may be part of a bygone era, as less facilities offer vaginal birth after cesarean (VBAC) at all. I am troubled by an increasing trend of VBAC no longer being offered in whole communities. Unfortunately, some medical communities have interpreted an American College of Obstetricians and Gynecologists (ACOG) Level C recommendation for 'immediately' available delivery to mean no VBACs. (4) Let us recall that what ACOG actually said was “After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician.” 1.) Leeman L, Leeman R. Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. J Fam Pract 2002;51:129–134 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11978210&dopt=Abstract 2.) Indian Health Focus: Women, 1998-99. Indian Health Service. Rockville, MD http://www.ihs.gov/MedicalPrograms/MCH/M/MCHprograms.asp#Women 3.) Smith DW, Murphy NJ. Alaska's obstetrical delivery systems: a descriptive epidemiologic study. Alaska Med. 2000 Jul-Sep;42(3):78-84. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11042940&dopt=Abstract 4.) ACOG Practice Bulletin Vaginal Birth After Previous Cesarean Delivery July 1999 No 5. American College of Obstetricians and Gynecologists. Washington, D.C. Competing interests: None declared |
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Henci L Goer, medical writer none
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The main reason this population had a markedly lower cesarean rate with equally good infant outcomes despite a significant proportion of potentially problematic labors was because the primary caregivers were midwives and family practitioners. Studies have repeatedly shown that whether a woman has a cesarean has little to do with her condition and everything to do with the philosophy and practices of her care provider. Sincerely, Henci Goer Author of *The Thinking Woman's Guide to a Better Birth* and *Obstetric Myths Versus Research Realities* Competing interests: None declared |
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Mary Kay Goetter, Nurse Educator RNC, United Medical Center
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Thank you for making this article available on Medscape. It is so encouraging to know there are still women and providers who seek a birth experience that isn't driven by medical interventions and unrealistic maternal demands. I no longer work as a Labor and Delivery nurse or teach prepared childbirth classes because the culture of induction, epidural, and surgery on demand for "birth by convenience" is too disheartening. The positive outcomes experienced by this population are a testimony to the belief that "expectant management", patience, and labor support are the safest plan. Competing interests: None declared |
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Carol E Blenning, family physician Oregon Health and Science University
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Once (and still?) controversial is the concept of epidural anesthesia leading to higher rates of cesarean delivery. Perhaps the fact that epidural was rarely used at one facility and not available at the other contributed to the lower rates of cesarean section. Competing interests: None declared |
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Alan G. Waxman, Associate Professor, Ob/Gyn University of New Mexico School of Medicine
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Lawrence and Rebecca Leeman's study in this issue of the Annals of Family Medicine validates a model of maternity care that has been in use in many rural Native American Communities for over 25 years. This model is comprised of low-risk maternity centers participating in a regional network with larger hospitals that have obstetrical specialty and surgical capability. This allows Native American women to receive prenatal care and to safely deliver in smaller medical facilities near their homes and in their own tribal communities. The hallmarks of this system are careful evaluation and risk assessment ongoing throughout pregnancy, close consultation and collaboration with obstetricians at regional medical centers with periodic discussion of all high-risk patients, transfer of patients who require oxytocin for labor induction or augmentation, and timely triage of those who might ultimately need operative deliveries. The medical culture and practice patterns at Indian Health Service hospitals receiving patients transferred from facilities such as Zuni- Ramah add to the factors detailed by the Leemans' to keep the cesarean section rates low. For example, at the Gallup Indian Medical Center in the mid 1990s, all cesarean sections were subject to critical peer review. Fetal distress and failure to progress were rigorously defined. VBAC was encouraged in eligible women and external cephalic version was offered for breech presentation. The cesarean section rate was generally kept below 10%.[1] As the Leemans point out, the desire for vaginal delivery on the part of the women, themselves, is a major determinant in keeping cesarean section rates low. In those areas of Indian country where repeat cesareans are preferred, Indian Health hospitals sometimes have had to compete with hospitals offering repeat cesarean section as the norm. The c -section rates in those areas are much closer to the national average than experienced at Zuni-Ramah.[1] Among the Ramah Navajo and Zuni Pueblo women, however, vaginal delivery in a setting close to home fits well with community and cultural expectations. Alan G. Waxman, MD, MPH Former IHS Chief Clinical Consultant for Obstetrics and Gynecology 1. Waxman AG. Cesarean deliveries within the Indian health system. The IHS Provider 1999;24(2):21-23. Competing interests: None declared |
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Michael C. Klein, Family Physician Head Division of Maternity and Newborn Care University of British Columbia Family Practice
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The authors make a convincing case for management as the answer to their title question in this carefully constructed report. While genetic and motivational factors in the population cannot be ruled out as having some import, the other "native" comparison group with a considerably higher cesarean rate makes the racial/ethnic explanation unlikely. The apparent safety of a setting at considerable distance from cesarean backup is an important point not emphasised enough by the authors. The support of the referral center is key--such that the low cesarean rate appears not to put the population at risk for adverse maternal or newborn outcomes. In my view the limitation of induction encouraged the Zuni-Ramah physicians to consider a more biologically reasonable approach to the duration of pregnancy. Allowing more spontaneous labors dramatically reduced the known "cascade" that follows from anxiety driven inductions. But they were not ignoring their patients. Reasonable antepartum fetal surveillance was practiced--especially impressive in a population prone to hypertensive diseases of pregnancy and gestational diabetes--and the low cesarean rates were found in the range of subgroups according to risk. The management of dystocia, the appreciation of the importance of labor support and most impressively the extraordinarily high (93%) success rate for women laboring with a uterine scar tell a story of how labor can be facilitated and celebrated. Native and non-native populations and caregivers have much to learn from this natural experiment that stands in stark contrast to the increasing trend to cesarean section on demand as a response to fashion and fear of pregnancy and labor. Competing interests: None declared |
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