Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability.

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 <.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.