Cesarean rates in rural Minnesota

A story on MPR appeared last week regarding the rate of cesareans in rural Minnesota. A report by the Minnesota Department of Health purported that the lack of physicians in rural Minnesota leads to increased rates of cesareans in rural counties as compared to more urban locations. Part of the explanation included:

“ Health providers can't count on being able to mobilize a team of doctors and nurses quickly enough for a more spontaneous natural birth, according to the work group.”

A very interesting statement I think, considering the recent report from the National Institutes of Health earlier this year showing that women today are actually taking longer to labor than in the past. As we know, most “spontaneous” natural births are in reality, not all that spontaneous. This statement definitely typifies the modern attitude that many have towards birth and labor as always being an “emergency” and a disaster waiting to happen. No doubt complications occur in labor and birth – many of us involved in ICAN have experienced them firsthand, whether naturally occurring, or created by unnecessary (or necessary) interventions. But personally, I feel like it is a little overkill to assume that all labors require the “mobilization” of a “team” of doctors and nurses at a moments notice.

Another statement that struck me in the article was:

“The problem is that with an aging rural Minnesota population, there aren't enough births in some parts of the state to support full time obstetricians.”

The lack of physicians in rural Minnesota is a problem, with that I agree. Physician shortages in rural areas of the state are cause for legitimate concern. But the above statement again typifies the assumption in our society, that pregnancy, even a healthy, normal pregnancy, mandates the care of an obstetrician. In reality, many women could, and would benefit from a less medicalized model of care. The article touches on a promising idea: “increasing the use of mid-level providers.” The article specifically mentions nurse-practitioners, which I think is a promising start, but the next logical step might be to support and encourage the acceptance and utilization of midwives in rural Minnesota. The use of midwives has seen growth in popularity in recent years, particularly in urban areas, even leading to an article proclaiming their “trendiness” recently in the New York Times. 

But when we look beyond the “trendiness” of the midwifery model of care, what we often find are professionally trained providers who endeavor to provide holistic, evidence-based health care to women. Midwives are the go-to in many European countries for women experiencing healthy, normal pregnancies.  Midwifery is expanding into the mainstream here in the United States – it holds a lot of potential for decreasing the cost of care for pregnancy and birth in the United States, and I think, would allow for obstetricians to focus on the cases that truly require their care and technical expertise.

This article was admittedly a bit disheartening. It highlighted some of the real problems that our maternity care system is experiencing in the United States, and obviously, even more so in rural areas. Some of the assumptions it is based on (that every birth and labor is an “emergency” and that obstetricians are the default care providers for all pregnant women) are flawed and problematic. But I wanted to share a glimmer of hope to round out my post. It was fitting that a couple of days after this article came out, that my close friend, a registered nurse in practicing in rural Minnesota happened to mention a lovely story about the doctors in her practice, who had recently attended the natural, vaginal birth of twins, one breech, in their tiny rural Minnesota hospital. She described it as complication-free, and “no big deal.” So there doom and gloom!