Original Research

Do All Hospitals Need Cesarean Delivery Capability?

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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.

  • Rural hospitals without cesarean delivery capability can safely offer obstetric care to selected patients as part of an integrated perinatal network.
  • Measures of maternal and neonatal morbidity and mortality were at or below national averages despite a higher-risk population.
  • Antepartum (25.6%) or intrapartum (9.5%) transfer to hospitals with surgical or tertiary-care facilities was required for 35% of pregnant women.
  • The use of oxytocin induction or augmentation, if determined safe, may significantly lower the transfer rate from rural hospitals that lack cesarean delivery capability.

The availability of perinatal care in rural communities produces better pregnancy outcomes than do perinatal systems that require rural women to seek maternity care in distant urban areas.1-3 Unfortunately, rural maternity care has been affected by the loss of physicians who offer these services and by the closing of many rural hospitals’ maternity care units. Maintaining 24-hour operative obstetric capabilities is difficult in rural areas because they have an insufficient population base to support a physician trained in operative obstetrics. Another barrier is the lack of anesthesia services and operating room personnel.

The Guidelines for Perinatal Care developed by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) state, “All hospitals offering labor and delivery services should be equipped to perform emergency cesarean delivery.” 4 Nevertheless, not all rural obstetric units can offer cesarean delivery and must transfer patients to a referral hospital for operative needs. Advisory panels in the United States and Canada have recommended similar models of rural perinatal care.5-8 A Canadian panel estimated that 125 Canadian hospitals offer obstetric care without surgical facilities.

Studies of rural hospitals in Canada, Australia, and the United Kingdom that lack continuous on-site cesarean capability are limited by the small number of deliveries.9-12 Most such studies are hospital based rather than population based and lack data on women who are transferred to outlying hospitals. The only population-based study that we identified found no evidence of adverse events caused by the lack of cesarean facilities; the sample size, however, was limited to 286 births.9

We studied all pregnancies occurring in a predominantly Native American region of New Mexico over a 5-year period to ascertain the safety of rural perinatal care based in a hospital without cesarean capability. Population-based and hospital-based outcomes are presented. This is the first study from a US community using this model of care.


We conducted an outcomes study using a historical cohort study design of all pregnancies beyond 20 weeks of gestation in the Zuni Pueblo and Ramah Navajo communities of northwestern New Mexico from 1992 to 1996. The perinatal services based at the Zuni-Ramah Indian Health Service (IHS) Hospital are the focus of this study. This 37-bed community hospital, staffed by family physicians and a part-time nurse-midwife, is part of an integrated perinatal system. The birthing unit has access to obstetrician-gynecologist (OBG) consultants at the Gallup Indian Medical Center (GIMC), 33 miles to the north, and perinatology and neonatology care in Albuquerque, 147 miles to the east. GIMC, the primary referral hospital and closest surgical facility, has an obstetric unit staffed by OBGs, family physicians, and nurse-mid-wives. Transportation time is 40 minutes by ground ambulance to GIMC or by fixed wing aircraft to Albuquerque.


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