Examining Provider Practice-Level Disparities in Delivery Outcomes Among Patients with a History of Cesarean Delivery 

Abstract

Background Choosing whether to pursue a trial of labor after cesarean (TOLAC) or elective repeat cesarean delivery (ERCD) requires prenatal assessment of risks and benefits. Providers play a central role in this process. However, the influence of provider-associated characteristics on delivery methods remains unclear. In this study we hoped to evaluate the impact of provider practice-level differences on delivery choice and outcome in a cohort of patients with prior cesarean delivery (CD). Methods This was a retrospective cohort study of deliveries between April 29, 2015 – April 29, 2020. Subjects were divided into three cohorts: ERCD, successful VBAC, and unsuccessful VBAC (patients who opted for TOLAC but delivered by CD). Disparities were reviewed between different obstetric provider practices, examining proportional differences through Chi-squared tests and logistic regression models. The delivering provider practice was determined from a breakdown of different providers delivering at the study site during the study period. Results 1,765 deliveries were included in the study. There were significant proportional disparities between patients in the different delivery groups. Specifically, patients with a provider in a midwifery practice were significantly more likely to undergo successful VBAC, while patients seeing a private obstetrician were more likely to deliver by ERCD (p < 0.001). In our multivariate analysis of successful VBAC versus unsuccessful VBAC, patients delivered by the Refuah (16.62; 95%CI: 2.54, 30.61) and midwife (14.12; 95% CI: 2.83, 25.71) practices had greater odds ratios of VBAC compared to the private obstetrician group. In our multivariate analysis of unsuccessful VBAC versus ERCD, patients delivered by the Refuah (29.92; 95% CI: 9.92, 70.34) and house staff (2.35; 95% CI: 1.40, 4.00) practices had greater odds ratios of unsuccessful VBAC compared to the private obstetrician group. Conclusion This study suggests that provider practice-level differences may be one factor influencing CD rates. These data also illuminate under-researched areas in which culture influences maternal and neonatal delivery outcomes. These findings help to guide future investigations to improve outcomes among patients with a history of CD. Trial Registration Icahn School of Medicine at Mount Sinai, Program for the Protection of Human Subjects, STUDY ID 20–00633, Approved 6/17/2020