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

Abstract

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.

Women’s experience of agency and respect in maternity care by type of insurance in California

“…There is also the possibility that, despite a wide array of confounders included in our models, remaining confounding variables are not accounted for. For example, we did not have institutional measures concerning levels of reimbursement, hospital maternity care culture, [39,40] quality of care or values of providers, and hospital patient mix, all of which may influence the treatment of women with Medicaid. [41] Nonetheless this paper represents one of the largest studies to date of insurance coverage and maternally-reported experiences in childbirth and, to our knowledge, the only one explicitly examining the association of maternal choice, autonomy and respect with insurance status.…”

Cesarean overuse and the culture of care

“…We measured labor and delivery unit culture using a survey comprised of 29 Likert‐style items measuring both individual attitudes and beliefs about birth and birth practices, as well as perceptions of the cultural norms on the individual's labor and delivery unit . All items use a 5‐point Likert scale, from strongly disagree to strongly agree.…”

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey

“…Providing higher quality care to women from these groups may offer important opportunities for safely reducing the cesarean rate. As hospital maternity units examine the impact of their highly variable unit culture [27] on cesarean rates and other birth outcomes, ensuring respectful, evidencebased care for all women can improve birth outcomes, reduce disparities and reduce costs.…”

“…They were divided into sociodemographic (race/ethnicity, maternal age, education, parity and type of insurance), health (BMI, pregnancy complications, labor and birth risks and gestational age), maternal attitudinal and experiential (feelings about medical interference with labor and sense of being pressured to have a cesarean) and pregnancy and labor management variables (prenatal provider, attempted induction, dilation at hospital admission, augmentation after labor began, amniotomy after labor began). Finally, as a surrogate for maternity unit culture, a hospital-level measure of the NTSV cesarean birth rate was included [27]. Because of the strong association between parity and reports of pressure to have a cesarean birth, we further stratified the full multivariable model by parity (nulliparous versus multiparous).…”

“…These include factors not previously reported in the literature, such as women's attitudes, behaviors, knowledge and preferences, as well as previously reported factors, such as members of the woman's care team and labor management practices. We also used the low-risk first birth cesarean rate at the woman's birth hospital as a proxy for local practice style [27]. To contribute to discussions about optimal ways to safely reduce the rate of cesarean birth, we carried out an adjusted analysis to examine possible associations between women's likelihood of cesarean birth and their attitudes, behaviors, knowledge and preferences, as well as their experiences with health professionals, the composition of their care team, and labor management and communication practices they experienced.…”