The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates

Abstract

Objective To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates. Methods This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean and VBAC; an interrupted time series analysis estimated the annual rates before and after the expansion. Results There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean during the study period; 45% were among privately insured women whose care model changed The primary cesarean rate among these privately insured women decreased after the change, from 31.7% to 25.0% (p=0.005, adjusted odds ratio (aOR) 0.56 (95% CI 0.39 – 0.81). The interrupted time series analysis estimated a 7% drop in the primary cesarean rate in the year after the expansion, and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward; aOR 2.03 (95%CI 1.08 – 3.80). Conclusion The change from a private practice to a collaborative midwifery–laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.

Midwifery presence in United States medical centers and labor care and birth outcomes among low‐risk nulliparous women: A Consortium on Safe Labor study

“…Increasing access to interprofessional models of care for low-risk women could further lower the rate of cesarean births, including repeat cesarean delivery, in the United States. Previous studies of midwifery care models found that women cared for by midwives have lower cesarean rates, 7,24,35 and our study further validates these findings.…”

Obstetrician call schedule and obstetric outcomes among women eligible for a trial of labor after cesarean

“…11,12 More recently, work at a California community hospital demonstrated lower primary and repeat cesarean deliveries when women were cared for within a midwife-obstetrician laborist (shift-based) practice model compared to a traditional private practice model. 13,14 Along with our data, the results of these studies suggest obstetrical care provision may differ based on issues such as work schedule.…”

Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model

“…12 More recent publications have focused on differences in outcomes with laborist compared to traditional private practice models. Several of these publications have demonstrated benefits of laborist models 2-4 , while others fail to demonstrate a difference in outcomes, and specifically cesarean delivery rates, with and without laborists. 6 Based on our findings, some of this heterogeneity of results may depend on the individual laborists hired.…”

“…2-4 An ACOG Committee Opinion defines a laborist as an obstetrician-gynecologist who is employed by the hospital to manage laboring patients and attend to obstetric emergencies. 5 Given this definition, this reduction in cesarean delivery is plausible with the increased availability of the laborist, focused expertise in labor management, and potentially a greater objectivity in assessing the clinical scenario when not managing a private patient.…”