Cesarean overuse and the culture of care

Abstract

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.

Maternal and system characteristics, oxytocin administration practices, and cesarean birth rate

“…It is possible that a large number of women admitted on the night shift actually delivered on the day shift, which could explain why directional differences are seen between nurse cesarean rates and patient cesarean rates by shift between these two studies. There may also be differences in labor and delivery unit culture related to interprofessional team members’ attitudes, values, and beliefs surrounding labor and birth . Higher incidence of disagreement about labor management among team members across disciplines was found to be related to higher cesarean birth rates …”

“…There may also be differences in labor and delivery unit culture related to interprofessional team members’ attitudes, values, and beliefs surrounding labor and birth . Higher incidence of disagreement about labor management among team members across disciplines was found to be related to higher cesarean birth rates …”

Promoting active labor admission: Early labor lounge implementation barriers and facilitators from the clinician perspective

“…The pregnant women who experienced triage and use of the ELL were not included. This aspect of the study was designed in this way because there is marked variation in care provided to pregnant women and that unit culture is and hospital staff perspectives require research . Women in the hospital were surveyed, and if they used the lounge they had a very positive experience…”

The association between longer durations of the latent phase of labor and subsequent perinatal processes and outcomes among midwifery patients

“…Maternity care team culture has been linked to variation in intervention rates 18 and may importantly influence when a diagnosis of labor dystocia leads to cesarean. 19 During the study period of 2012-17, the overall OHSU unscheduled primary cesarean delivery rate was 11.8%. In addition, several other characteristics signal a culture favoring vaginal birth; for example, nurses frequently remain with women during labor, and doulas are routinely part of many women's labor support teams.…”