TCRHCC is run by the Navajo Nation on the Navajo reservation. It serves mostly Navajos, Hopis and San Juan Southern Paiutes. The hospital takes pride in its high rates of vaginal births, even among women with prior Caesareans.
TCRHCC may be old and underfunded, but it still outperforms richer, more famous hospitals by keeping Caesarean rates down to 13.5% -- less than half the national rate. Not only does this save money, but it's healthier and safer for most mothers and infants.
The national Caesarean rate of 31.8%, has been rising for the 11 years. Critics say that doctors are performing too many Caesareans, which expose women and infants to surgical risks. It also adds up to billions of dollars of extra bills, precisely what the health care overhaul is supposed to address.
Some medical organizations admit that that Caesareans are overused, but no one knows what the rate should be. The World Health Organization suggest 15% as a goal in low-risk women.
With its 500 births a year, Tuba City has much to teach the rest of the country about obstetrical care. But the medical industry would need to make huge changes to match Tuba City's success. This includes
midwives to handle more
Removing the profits earned through surgeries.
Making changes in malpractice insurance
Requiring patients to adjust their attitudes about birth and medical care during pregnancy and labor.
Nurse-midwives deliver most of the babies born vaginally, with obstetricians available in case problems occur. Midwives staff the labor ward around the clock. They coach women through labor and often wait longer than obstetricians before recommending a Caesarean. They are also less likely to try to induce early labor, something that increases the odds of a Caesarean.
In the rest of the country, nurse-midwives attend about only 10%of vaginal births.
“Midwives are better at being there for labor than doctors are," said Dr. Kathleen Harner, an obstetrician in Tuba City. "Midwives are trained for it. It’s what they want to do.”
Donna Rackley, a nurse-midwife in Tuba City, said that at a previous job, doctors would sometimes set an arbitrary deadline. If the woman did not deliver by then, she would have to have a Caesarean. “I found myself apologizing to patients,” Rackley said.
Dr. Amanda Leib 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.” In Tuba City, she said, if labor is slow but the baby and mother are safe, the doctors will wait.
Doctors and midwives in Tuba City earn salaries and are not paid by the procedure. The federal government insures them against malpractice. this allows doctors in Tuba City to “think about what’s best for the patient and not what covers our butts,” said Dr. Leib.
“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?”
Some of Tuba City’s success may arise from Navajo culture and customs. Couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy. Also, Navajos regard incisions as a threat to the spirit.
At Tuba City, birth is a joyous affair. Entire families -- from children to great-grandparents -- often go to the delivery room. As a result, many young women have already seen children born by the time they become pregnant. Birth seems natural to them, not frightening.
“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.”