Variation of intrapartum care and cesarean rates among practitioners attending births of low‐risk, nulliparous women

Iobst, Stacey E.; Storr, Carla L.; Bingham, Debra; Zhu, Shijun; Johantgen, Meg

doi:10.1111/birt.12483

Cited by 7 publications

(9 citation statements)

References 44 publications

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“…Our descriptive study could not provide a reason for this finding, but future studies might explore possible nonclinical influences on rural cesarean births, including differing practitioner attitudes, 40 hospital culture, 39,41,42 use of birth professionals such as doulas, 43 or the impact of using delivery practitioners associated with lower cesarean rates such as midwives or family physicians. [44][45][46] This study has several limitations. We explored deliveries from a single payment source (ie, Medicaid), which may have incompletely characterized maternity services statewide, although a recently published study of a single private health plan noted similar results.…”

Section: Discussionmentioning

confidence: 96%

Access to maternity and prenatal care services in rural Michigan

Wendling

Taglione

Rezmer

et al. 2021

Birth

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Background:The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. Methods: Descriptive, cross-sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High-risk geographic areas were defined as those where women needed to travel >30 miles for maternity-related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%-60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. Results: In Michigan's 57 rural counties, only 29 hospitals provide maternity care.Geographic high-risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. Conclusions: Maternity care services are limited for many rural Michigan women.Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities.

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Section: Discussionmentioning

confidence: 96%

Access to maternity and prenatal care services in rural Michigan

Wendling

Taglione

Rezmer

et al. 2021

Birth

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“…Therefore, the CS rate of NTSV pregnancies is de ned as an important quality indicator of obstetric care 7,8 . NTSV CS rates vary widely throughout the world and among medical institutions, and physicians and nursing care providers have indicated that clinical practice patterns in labor and delivery units affect the number of CSs performed 9,10 . Various intrapartum care methods for reducing the rate of NTSV CS births have been proposed, and they mainly focus on labor management and fetal heart rate interpretation for care providers 6,7,11,12 .…”

Section: Discussionmentioning

confidence: 99%

Reducing Primary Cesarean Delivery Rate Through Implementation of a Smart Intrapartum Surveillance System in a Labor and Delivery Unit

Cheng

Shaw

et al. 2022

Preprint

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The rapid changes in clinical maternity situations that occur in a labor and delivery unit can lead to unpredictable maternal and newborn morbidities. Cesarean section (CS) rate is a key indicator of the accessibility and quality of a labor and delivery unit. This retrospective cross-sectional study assesses the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates before and after the implementation of a smart intrapartum surveillance system. Research data were collected from the electronic medical records of a labor and delivery unit. The primary outcome was the CS rate of the NTSV population. The data of 3648 women admitted for delivery were analyzed. Of the studied deliveries, 1760 and 1888 occurred during the preimplementation and postimplementation periods, respectively. The CS rate for the NTSV population was 31.0% and 23.3% during the preimplementation and postimplementation periods, respectively, indicating a significant 24.7% (p = 0.014) reduction in CS rate after the implementation of the smart intrapartum surveillance system (relative risk, 0.75; 95% confidence interval, 0.71–0.80). In the NTSV population, the normal and CS birth groups, no significant difference in terms of newborn weight, neonatal Apgar scores, and the occurrence of the following: neonatal intensive care unit admission, neonatal meconium aspiration, chorioamnionitis, shoulder dystocia, perineal laceration, placental abruption, postpartum hemorrhage, maternal blood transfusion, and hysterectomy before and after the implementation of the smart intrapartum surveillance system. This study reveals that the use of the smart intrapartum surveillance system can effectively reduce the primary CS rate for low-risk NTSV pregnancies without significantly affecting perinatal outcomes.

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“…This is appropriate for hospital discharge data because ICD coding does not provide a way to accurately identify number of prior births. Although midwives do not perform cesarean surgery, care provided by midwives during pregnancy and labor is associated with lower rates of cesarean birth 15,16 …”

Section: Methodsmentioning

confidence: 99%

“…Although midwives do not perform cesarean surgery, care provided by midwives during pregnancy and labor is associated with lower rates of cesarean birth. 15,16 Preterm birth was measured as any birth less than 37 completed weeks' gestation based on the ICD-10-CM codes for gestational age (Z3A). Records missing a gestational age ICD-10-CM code were excluded from analysis of preterm birth.…”

Section: Variables and Measurementmentioning

confidence: 99%

Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

Vanderlaan

2023

J Midwife Womens Health

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IntroductionStudies comparing pregnancy outcomes before and after state transition to independent midwifery practice have found little change in primary cesarean birth and preterm birth rates. One reason may be the failure to control for midwife density. The objective was to test if the local midwife density moderates the association between state independent midwifery practice and pregnancy outcomes.MethodsBirth records were abstracted from the State Inpatient Databases for 6 states. The Area Health Resource File provided county variables. Midwife density was operationalized as no midwives, low midwife density (<4.5 per 1000 births), and high midwife density (≥4.5 midwives per 1000 births). Multivariate logistic regression models compared primary cesarean birth and preterm birth, controlling for maternal and county characteristics. Moderation was tested by including an interaction term (independent practice × density) to the regression models. The magnitude of association for the interaction was measured by stratifying the models.ResultsThe study included 875,156 women; most (79.7%) resided in a county with low midwife density. Restricted midwifery practice was associated with increased odds of both primary cesarean birth and preterm birth. The interaction term was significant for both preterm birth and primary cesarean, indicating moderation. The largest magnitude of difference was the increased odds of preterm birth in counties with a high midwife density and restricted practice (odds ratio, 3.50; 95% CI, 2.43‐5.06) compared with those with high midwife density and independent practice.DiscussionMidwife density moderates the association between independent midwifery practice and primary cesarean birth and preterm birth. Moderation may explain why prior studies found small or no changes in outcomes when states adopted independent practice. Moderation models can improve testing for associations with independent practice. Both midwife independent practice and increasing midwifery workforce size can be strategies to improve state pregnancy outcomes.

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Variation of intrapartum care and cesarean rates among practitioners attending births of low‐risk, nulliparous women

Cited by 7 publications

References 44 publications

Access to maternity and prenatal care services in rural Michigan

Access to maternity and prenatal care services in rural Michigan

Reducing Primary Cesarean Delivery Rate Through Implementation of a Smart Intrapartum Surveillance System in a Labor and Delivery Unit

Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

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