Abstract: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… Show more
“…This study is consistent with prior work finding that attitudes and beliefs of individual providers are associated with variation in cesarean delivery rates, individual providers have different thresholds to perform cesarean delivery, and cesarean delivery rate variation is not attributable to patient differences . However, physicians and midwives do not practice in an isolated environment and are subject to the cultural norms, expectations, values, and beliefs existent in their hospital, which need to be accounted for to further explain the wide variation in hospital‐level cesarean delivery rates.…”
Section: Discussionsupporting
confidence: 88%
“…The sixth scale measures an individual's perceptions about their labor and delivery unit's norms and consists of eight questions created de novo from concepts identified in CMQCC's “Major Factors Influencing the Culture of Care and the Value of Vaginal Birth.” The survey underwent psychometric analysis, including exploratory factor analysis, iterative revisions using focus groups and individual interviews with labor and delivery personnel, and confirmatory factor analysis . The LCS was administered electronically via Survey Monkey (SurveyMonkey, Inc., San Mateo, CA, USA), and individual invitations to complete the survey were sent out by hospital administrators or labor and delivery unit leaders.…”
Objective
To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.
Data Sources/Study Setting
Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.
Study Design
Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.
Methods
Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.
Principal Findings
1718 respondents from 70 hospitals responded to the Labor Culture Survey. The “Unit Microculture” subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8‐items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = −47 to −35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.
Conclusions
Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.
“…This study is consistent with prior work finding that attitudes and beliefs of individual providers are associated with variation in cesarean delivery rates, individual providers have different thresholds to perform cesarean delivery, and cesarean delivery rate variation is not attributable to patient differences . However, physicians and midwives do not practice in an isolated environment and are subject to the cultural norms, expectations, values, and beliefs existent in their hospital, which need to be accounted for to further explain the wide variation in hospital‐level cesarean delivery rates.…”
Section: Discussionsupporting
confidence: 88%
“…The sixth scale measures an individual's perceptions about their labor and delivery unit's norms and consists of eight questions created de novo from concepts identified in CMQCC's “Major Factors Influencing the Culture of Care and the Value of Vaginal Birth.” The survey underwent psychometric analysis, including exploratory factor analysis, iterative revisions using focus groups and individual interviews with labor and delivery personnel, and confirmatory factor analysis . The LCS was administered electronically via Survey Monkey (SurveyMonkey, Inc., San Mateo, CA, USA), and individual invitations to complete the survey were sent out by hospital administrators or labor and delivery unit leaders.…”
Objective
To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.
Data Sources/Study Setting
Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.
Study Design
Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.
Methods
Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.
Principal Findings
1718 respondents from 70 hospitals responded to the Labor Culture Survey. The “Unit Microculture” subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8‐items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = −47 to −35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.
Conclusions
Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.
“…However, the observed differences in labor processes and outcomes noted are likely not fully attributable to the care provided by specific perinatal care providers (eg, midwives vs physicians) or care models, but may be influenced by multiple system factors. For example, the presence of midwives in a hospital may shift the institution's unit culture and approach to birth . Alternately, hospitals with a culture favoring vaginal birth may actively recruit and retain midwives.…”
Section: Discussionmentioning
confidence: 99%
“… This wide institutional variation cannot be explained by maternal risk factors alone. Health care systems factors may be a primary contributor . One less studied factor is how the presence of midwives as members of labor and birth teams affects variation in cesarean utilization across institutions.…”
Introduction: The Robson 10-group classification system stratifies cesarean birth rates using maternal characteristics. Our aim was to compare cesarean birth utilization in US centers with and without midwifery care using the Robson classification. Methods: We used National Institute of Child and Human Development Consortium on Safe Labor data from 2002 to 2008. Births to women in centers with interprofessional care that included midwives (n = 48,857) were compared with births in non-interprofessional centers (n = 47,935). To compare cesarean utilization, births were classified into the Robson categories. Cesarean birth rates within each category and the contribution to the overall rate were calculated. Maternal demographics, labor and birth outcomes, and neonatal outcomes were described. Logistic regression was used to adjust for maternal comorbidities. Results: Women were less likely to have a cesarean birth (26.1% vs 33.5%, P Ͻ .001) in centers with interprofessional care. Nulliparous women with singleton, cephalic, term fetuses (category 2) were less likely to have labor induced (11.1% vs 23.4%, P Ͻ .001), and women with a prior uterine scar (category 5) had lower cesarean birth rates (73.8% vs 85.1%, P Ͻ .001) in centers with midwives. In centers without midwives, nulliparous women with singleton, cephalic, term fetuses with induction of labor (category 2a) were less likely to have a cesarean birth compared with those in interprofessional care centers in unadjusted comparison (30.3% vs 35.8%, P Ͻ .001), but this was reversed after adjustment for maternal comorbidities (adjusted odds ratio, 1.21; 95% CI, 1.12-1.32; P Ͻ .001). Cesarean birth rates among women at risk for complications (eg, breech) were similar between groups. Discussion: Interprofessional care teams were associated with lower rates of labor induction and overall cesarean utilization as well as higher rates of vaginal birth after cesarean. There was consistency in cesarean rates among women with higher risk for complications.
“…12 This model has been used to connect labor and delivery nurses' attitudes with their intention to deliver supportive care to laboring women. 15 Though promising, these scales did not measure collective norms and values perceived by clinicians practicing on labor and delivery, which are another important facet to organizational culture. Klein et al's studies found differences in attitudes by membership within a discipline (obstetrician vs midwife vs nurse).…”
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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