Association of Catastrophic Neonatal Outcomes With Increased Rate of Subsequent Cesarean Deliveries

Dan, Ohad; Hochner‐Celnikier, Drorith; Solnica, Amy; Loewenstein, Yonatan

doi:10.1097/aog.0000000000001925

Cited by 7 publications

(5 citation statements)

References 18 publications

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“…Unlike previous measures of health care organizational culture, which have focused specifically on safety culture, 22,24,25 the LCS chose to focus on constructs unique to birth: the value of vaginal birth, reducing unnecessary intervention, and empowering women. [26][27][28] This concept is supported by our findings that each of the theoretical constructs had the majority of its individual items showing significant associations with NTSV cesarean delivery rates in the hypothesized direction. [26][27][28] This concept is supported by our findings that each of the theoretical constructs had the majority of its individual items showing significant associations with NTSV cesarean delivery rates in the hypothesized direction.…”

Section: Discussionsupporting

confidence: 61%

“…Although reducing cesarean overuse certainly improves patient safety, the root of many of the clinical practices associated with increased cesarean rates seems to stem from defensive and fear-based, rather than evidencebased, medicine. [26][27][28] This concept is supported by our findings that each of the theoretical constructs had the majority of its individual items showing significant associations with NTSV cesarean delivery rates in the hypothesized direction.…”

Section: Discussionsupporting

confidence: 61%

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Measuring labor and delivery unit culture and clinicians’ attitudes toward birth: Revision and validation of the Labor Culture Survey

VanGompel

Perez

Wang

et al. 2018

Birth

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Background Cesarean delivery rates in the United States vary widely between hospitals, which cannot be fully explained by hospital or patient factors. Cultural factors are hypothesized to play a role in cesarean overuse, yet tools to measure labor culture are lacking. The aim of this study was to revise and validate a survey tool to measure hospital culture specific to cesarean overuse. Methods A panel of clinicians and researchers compiled an item bank from validated surveys, added newly created items, and performed four rounds of iterative revision and consolidation. Obstetricians, family physicians, midwives, anesthesiologists, and labor nurses were recruited from 79 hospitals in California. Exploratory factor analysis was used to reduce the number of survey items and identify latent constructs to form the basis of subscales. Confirmatory factor analysis examined reliability in 31 additional hospitals. Poisson regression assessed associations between hospitals’ mean score on each individual item and cesarean rates. Results A total of 1718 individuals from 70 hospitals were included in the exploratory factor analysis. The final Labor Culture Survey (LCS) consisted of 29 items and six subscales: “Best Practices to Reduce Cesarean Overuse,” “Fear of Vaginal Birth,” “Unit Microculture,” “Physician Oversight,” “Maternal Agency,” and “Cesarean Safety.” Conclusions The revised LCS is a valid and reliable tool to measure constructs shown to be associated with cesarean rates. These findings support prior research that has shown that hospital culture is measurable, and that clinician attitudes are predictive of clinician behaviors. Unique to our survey is the construct of labor and delivery unit microculture.

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Section: Discussionsupporting

confidence: 61%

Section: Discussionsupporting

confidence: 61%

Measuring labor and delivery unit culture and clinicians’ attitudes toward birth: Revision and validation of the Labor Culture Survey

VanGompel

Perez

Wang

et al. 2018

Birth

View full text Add to dashboard Cite

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“…Finally, ongoing training and support after experiencing a traumatic delivery event may mitigate some of the fear attitudes associated with increased cesarean rate, which appear to impact entire hospital units and not just the providers involved. This was described recently in a study of unplanned hospital cesarean rates, which increased and stayed elevated for 4 weeks after any catastrophic neonatal outcome within that hospital [ 28 ].…”

Section: Discussionmentioning

confidence: 93%

Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study

VanGompel

Main

Tancredi

et al. 2018

BMC Pregnancy Childbirth

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BackgroundWhen used judiciously, cesarean sections can save lives; but in the United States, prior research indicates that cesarean birth rates have risen beyond the threshold to help women and infants and become a contributor to increased maternal mortality and rising healthcare costs. Healthy People 2020 has set the goal for nulliparous, term, singleton, vertex (NTSV) cesarean birth rate at no more than 23.9% of births. Currently, cesarean rates vary from 6% to 69% in US hospitals, unexplained by clinical or demographic factors. This wide variation in cesarean use is also seen among individual providers of intrapartum care. Previous research of birth attitudes found providers of intrapartum care hold widely differing views, which may be a key underlying factor influencing practice variation; however, further study is needed to determine if differences in attitudes are associated with differences in clinical outcomes. The purpose of this study was to estimate the association between individual provider attitudes towards birth and their low-risk primary cesarean rate.MethodsFour hundred providers were drawn from a stratified random sample of all California providers of intrapartum care in 2013 and surveyed for their attitudes towards various aspects of labor and birth. Providers’ NTSV cesarean birth rates were obtained for 2013 and 2014. Covariates included gender, years of experience, practice location, and primary hospital’s NTSV cesarean rate. We used adjusted multivariate Poisson regression to compare cesarean rates and linear regression to compare attitude scores of providers meeting versus not meeting the Healthy People 2020 (HP2020) goal.ResultsTwo hundred nine total participants (obstetricians, family physicians, and midwives) completed surveys, of which 109 perform cesareans. Providers’ NTSV cesarean rate was significantly associated with their composite attitudes score [IRR for each one-point increase 1.21 (95% CI 1.002–1.45)]. Physicians meeting the HP2020 goal held attitudes which were significantly more favorable towards vaginal birth: mean 2.70 (95% CI 2.58–2.83) versus 2.91 (95% CI 2.82–3.00), p < 0.01.ConclusionsProvider attitudinal differences are associated with NTSV cesarean rates. Those meeting the HP2020 goal hold attitudes more favorable towards vaginal birth. These findings may present a modifiable target for quality improvement initiatives to decrease low risk primary cesareans.

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“…So there may be many more timescales than what we characterized, ranging from one trial to thousands of trials, and these time constants themselves may also be adaptive. We should also note that our primary interest in this study was the role of very slow learning, over very long time constants 53 . Hence we did not analyze the effect of what is often referred to as change-point detection, where subjects detect and rapidly speed up their learning rates in response to sudden changes in reward schedules (e.g.…”

Section: Discussionmentioning

confidence: 99%

Deviation from the matching law reflects an optimal strategy involving learning over multiple timescales

et al. 2019

Self Cite

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Behavior deviating from our normative expectations often appears irrational. For example, even though behavior following the so-called matching law can maximize reward in a stationary foraging task, actual behavior commonly deviates from matching. Such behavioral deviations are interpreted as a failure of the subject; however, here we instead suggest that they reflect an adaptive strategy, suitable for uncertain, non-stationary environments. To prove it, we analyzed the behavior of primates that perform a dynamic foraging task. In such nonstationary environment, learning on both fast and slow timescales is beneficial: fast learning allows the animal to react to sudden changes, at the price of large fluctuations (variance) in the estimates of task relevant variables. Slow learning reduces the fluctuations but costs a bias that causes systematic behavioral deviations. Our behavioral analysis shows that the animals solved this bias-variance tradeoff by combining learning on both fast and slow timescales, suggesting that learning on multiple timescales can be a biologically plausible mechanism for optimizing decisions under uncertainty.

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Association of Catastrophic Neonatal Outcomes With Increased Rate of Subsequent Cesarean Deliveries

Abstract: The increase in the rate of unscheduled cesarean deliveries after a catastrophic neonatal outcome may result in short-term changes in obstetricians' risk evaluation.

Cited by 7 publications

References 18 publications

Measuring labor and delivery unit culture and clinicians’ attitudes toward birth: Revision and validation of the Labor Culture Survey

Measuring labor and delivery unit culture and clinicians’ attitudes toward birth: Revision and validation of the Labor Culture Survey

Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study

Deviation from the matching law reflects an optimal strategy involving learning over multiple timescales

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