Low‐Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors

Abstract

Introduction: Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals. Methods: Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low-versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis. Results: We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P Ͻ .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group. Discussion: Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.

A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse‐Midwives and Nurses

“…Web-based simulation training could be used effectively in this setting, as could audit and feedback and team training and coaching. Hospitals with higher use of IA, along with other lowintervention labor care approaches, have lower cesarean rates compared with hospitals that rely on EFM, 15 and improvement programs that increase appropriate use of IA have been successful in reducing hospital rates of nulliparous, term, singleton, vertex cesarean birth. 16,17 There is growing concern that high cesarean rates in low-risk nulliparous individuals contribute to excess maternal and fetal and neonatal health risks in current and subsequent pregnancies.…”

The Effectiveness of Midwifery Care in the World Health Organization Year of the Nurse and the Midwife: Reducing the Cesarean Birth Rate

“…The hospitals were categorized as low‐ versus high‐interventional labor management practices. Hospitals with midwife‐led or physician‐midwife collaborative management were more than 7 times as likely to use low‐interventional practices than hospitals with physician‐led decision making (aOR, 7.52; 95% CI, 2.53‐22.38; P < .001) . Declercq et al conducted a survey of 2539 women who had given birth in a California hospital within the past year .…”

“…18,19 Lundsberg et al divided 185 hospitals in California into 2 groups based on their use of interventions such as intermittent auscultation, admission in latent-phase labor, and use of nonpharmacologic methods of pain relief. 18 The researchers assessed these practices via responses to questions that were part of a comprehensive, statewide, voluntary survey of hospitals providing labor and birth services. The hospitals were categorized as low-versus high-interventional labor management practices.…”

“…Hospitals with midwife-led or physician-midwife collaborative management were more than 7 times as likely to use low-interventional practices than hospitals with physician-led decision making (aOR, 7.52; 95% CI, 2.53-22.38; P Ͻ .001). 18 Declercq et al conducted a survey of 2539 women who had given birth in a California hospital within the past year. 19 Compared with women whose birth was attended by an obstetrician, women whose birth was attended by a midwife had a lower risk of interventions including attempted labor induction, labor augmentation, and use of pharmacologic pain medications, intravenous fluids, and epidural analgesia (aOR, 0.50; 95% CI, 0-36.0.69).…”

“…Two other studies in this issue evaluated outcomes from large data sets collected in California and provide additional insights . Lundsberg et al divided 185 hospitals in California into 2 groups based on their use of interventions such as intermittent auscultation, admission in latent‐phase labor, and use of nonpharmacologic methods of pain relief . The researchers assessed these practices via responses to questions that were part of a comprehensive, statewide, voluntary survey of hospitals providing labor and birth services.…”