Q. Do all hospitals need cesarean delivery capacity?

A. Here is an example in which careful triage leads to excellent
outcomes.

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 Feb;51(2):129-34.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract>

OBJECTIVES: We analyzed perinatal outcomes at a rural hospital without
cesarean delivery capability.

STUDY DESIGN: This was a historical cohort outcomes study.

POPULATION: The study population included all pregnant women at 20 weeks
or greater of gestational age (n = 1132) over a 5-year period in a
predominantly Native American region of northwestern New Mexico.

OUTCOMES MEASURED: The outcomes studied included perinatal mortality,
neonatal morbidity, obstetric emergencies, intrapartum and antepartum
transfers, and cesarean delivery rate. We did a detailed case review of
all obstetric emergencies and low-Apgar-score births at Zuni-Ramah
Hospital and all cesarean deliveries for fetal distress at referral
hospitals.

RESULTS: Of the 1132 women in the study population, 64.7% (n = 735) were
able to give birth at the hospital without operative facilities; 25.6%
(n = 290) were transferred before labor; and 9.5% (n = 107) were
transferred during labor. The perinatal mortality rate of 11.4 per 1000
(95% confidence interval, 5.1-17.8) was similar to the nationwide rate
of 12.8 per 1000 even though Zuni-Ramah has a high-risk obstetric
population. No instances of major neonatal or maternal morbidity caused
by lack of surgical facilities occurred. The cesarean delivery rate of
7.3% was significantly lower than the nationwide rate of 20.7% (P
&lt.001). The incidence of neonates with low Apgar scores (0.54%) was
significantly lower than the nationwide rate (1.4%). The incidence of
neonates requiring resuscitation (3.4%) was comparable to the nationwide
rate (2.9%).

CONCLUSIONS: The presence of a rural maternity care unit without
surgical facilities can safely allow a high proportion of women to give
birth closer to their communities. This study demonstrated a low level
of perinatal risk. Most transfers were made for induction or
augmentation of labor. Rural hospitals that do not have cesarean
delivery capability but are part of an integrated perinatal system can
safely offer obstetric services by using appropriate antepartum and
intrapartum screening criteria for obstetric risk

2.)

A Native American Community with a 7% Cesarean Delivery Rate: Does Case
Mix, Ethnicity, or Labor Management Explain the Low Rate?

Lawrence Leeman, MD, MPH; Rebecca Leeman, CNM, MSN

Annals of Family Medicine, Vol 1, 36-43.  May/June 2003

**PURPOSE** Cesarean delivery rates vary widely across populations.
Studying communities with low rates of cesarean delivery may identify
practices that can lower the cesarean rate.

**METHODS** A population-based historical cohort study included all
pregnant women (N = 1132) from 1992 through 1996 in a predominantly
Native American region of northwestern New Mexico known to have a high
prevalence of gestational diabetes and preeclampsia. The outcomes
studied included delivery type (eg, cesarean, operative vaginal,
spontaneous vaginal), indication for cesarean delivery, presence of
obstetrical risk factors, and use of labor induction or augmentation.

**RESULTS** The cesarean delivery rate of the study group (7.3%) was
only 35% of the 1996 US rate of 20.7%. Among study participants, the
relative risk of a primary cesarean delivery for dystocia was 0.22 (95%
CI, 0.14, 0.35). Trial of labor after cesarean delivery was attempted by
93% of study participants compared with 42% of women nationwide in 1994.
The cesarean delivery rates for women with diabetes in pregnancy (11.5%
versus 35.4%) and preeclampsia (14.8% versus 37.4%) were significantly
lower than nationwide rates. Case-mix analysis comparison with a
standardized population and comparison of standard (ie, term, singleton,
vertex) primiparous women demonstrate that the low rate of cesarean
delivery was not because of a lower prevalence of risk factors.

**CONCLUSIONS** The community's low rate of cesarean delivery is
primarily the result of a decreased use of cesarean delivery for labor
dystocia and an almost universal acceptance of trial of labor after
cesarean delivery. Cultural attitudes toward childbirth, design of the
perinatal system, and genetic factors also may explain the low rate of
cesarean delivery.

<http://lyris.aafp.org/t/15218/6112154/159/0/>

## OB/GYN CCC Editorial comment

This is the second in a series of articles by the Leemans that help
describe the excellent results that careful regionalization of care can
provide in Indian Country.

The new Annals of Family Medicine is an online Journal which invites
your comments. You can add them to the comments of **Alan Waxman, MD,
former IHS OB/GYN CCC** among others at:

<http://www.annfammed.org/cgi/eletters/1/1/36>

3.) Other resources

Please also see:

FAQ on Availability of emergency delivery: ACOG

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#C>

VBAC CME module (Free CME from the Perinatology Corner)

<http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>