Obstetric Variation, Intervention, and Outcomes: Doing More but Accomplishing Less

Glantz, J. Christopher

doi:10.1111/birt.12002

Cited by 42 publications

(41 citation statements)

References 24 publications

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“…The midwifery philosophy of care emphasizes the inherent normalcy of birth, and midwives may bring this attitude with them to the labor and delivery unit in ways that change patterns of care provision . Hospital administration that is supportive of midwifery may shape the broader environment as well, or be indicative of a commitment to reducing unwarranted procedure use . Hospitals where midwives attend a larger proportion of the births may also structure their care for women differently; for example, one hospital combined a midwifery service with a laborist model of care and found that this resulted in lower rates of primary cesarean birth and higher rates of vaginal birth after cesarean (VBAC) .…”

Section: Discussionmentioning

confidence: 99%

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Attanasio¹,

Kozhimannil²

2017

J Midwife Womens Health

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Introduction:Research has shown good outcomes among individual low-risk women who receive perinatal care from midwives, yet little is known about how hospital-level variation in midwifery care relates to procedure use and maternal health. This study aimed to document the association between the hospital-level proportion of midwife-attended births and obstetric procedure utilization.Methods: This analysis used 2 data sources: Healthcare Cost and Utilization Project State Inpatient Database data for New York in 2014, and New York State Department of Health data on the percentage of midwife-attended births at hospitals in the state in 2014. Using logistic regression, we estimated the association between the hospital-level percentage of midwife-attended births and 4 outcomes among low-risk women: labor induction, cesarean birth, episiotomy, and severe maternal morbidity.Results: Hospital-level percentage of midwife-attended births was not associated with reduced odds of labor induction or severe maternal morbidity. Women who gave births at hospitals with more midwife-attended births had lower odds of giving birth by cesarean (eg, adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.59-0.82 at a hospital with 15% to 40% of births attended by midwives, compared to no midwifeattended births) and lower odds of episiotomy (eg, aOR, 0.41; 95% CI,74 at a hospital with more than 40% of births attended by midwives, compared to no midwife-attended births). Discussion:Our results indicate that hospitals with more midwife-attended births have lower utilization of some obstetric procedures among low-risk women; this raises the possibility of improving value in maternity care through greater access to midwifery care.

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Section: Discussionmentioning

confidence: 99%

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Attanasio¹,

Kozhimannil²

2017

J Midwife Womens Health

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“…43 It is problematic to specify the correct or target intervention rate such as a hospital IOL rate, particularly when the appropriate rate is likely to differ according to the ‘induction group’. Instead, the focus should be on achieving the best outcomes for mothers and babies with minimum intervention,1 reflecting not only improved clinical decision-making, but also efficient resource management. Hospitals that have lower rates of IOL, yet have the same outcomes for mothers and babies compared to hospitals with higher rates of IOL, provide opportunities to suggest changes in clinical practice for other institutions.…”

Section: Discussionmentioning

confidence: 99%

“…However, for many medical interventions including in obstetrics,1 much of the clinical practice variation is unexplained (ie, not due to patient profiles, preferences or medical science) 2. Unexplained clinical practice variation questions the appropriate usage of scarce resources,3 whether medical interventions are too few or too many, and whether healthcare provision is efficient or effective 4…”

Section: Introductionmentioning

confidence: 99%

Variation in hospital rates of induction of labour: a population-based record linkage study

et al. 2015

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ObjectivesTo examine interhospital variation in rates of induction of labour (IOL) to identify potential targets to reduce high rates of practice variation.DesignPopulation-based record linkage cohort study.SettingNew South Wales, Australia, 2010–2011.ParticipantsAll women with live births of ≥24 weeks gestation in 72 hospitals.Primary outcome measureVariation in hospital IOL rates adjusted for differences in case-mix, according to 10 mutually exclusive groups derived from the Robson caesarean section classification; groups were categorised by parity, plurality, fetal presentation, prior caesarean section and gestational age.ResultsThe overall IOL rate was 26.7% (46 922 of 175 444 maternities were induced), ranging from 9.7% to 41.2% (IQR 21.8–29.8%) between hospitals. Nulliparous and multiparous women at 39–40 weeks gestation with a singleton cephalic birth were the greatest contributors to the overall IOL rate (23.5% and 20.2% of all IOL respectively), and had persisting high unexplained variation after adjustment for case-mix (adjusted hospital IOL rates ranging from 11.8% to 44.9% and 7.1% to 40.5%, respectively). In contrast, there was little variation in interhospital IOL rates among multiparous women with a singleton cephalic birth at ≥41 weeks gestation, women with singleton non-cephalic pregnancies and women with multifetal pregnancies.Conclusions7 of the 10 groups showed high or moderate unexplained variation in interhospital IOL rates, most pronounced for women at 39–40 weeks gestation with a singleton cephalic birth. Outcomes associated with divergent practice require determination, which may guide strategies to reduce practice variation.

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“…Rates of older women giving birth, inductions of labour, and macrosomia have also increased, [40][41][42] and are all risk factors to be considered when a trial of vaginal delivery is discussed. In the clinical situation, with a woman attempting vaginal birth after a prior caesarean section, knowledge of risk factors that can be influenced during labour, such as method of induction, management of protracted labour, use of oxytocin, and epidural analgesia, is of importance, and should be taken into consideration when assessing the health and safety of woman and child.…”

Section: Discussionmentioning

confidence: 99%

The risk of uterine rupture is not increased with single‐ compared with double‐layer closure: a Swedish cohort study

Hesselman

Högberg

Selling

et al. 2014

BJOG

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Objective To compare single-with double-layer closure of the uterus for the risk of uterine rupture in women attempting vaginal birth after one prior caesarean delivery.Design Cohort study.Population From a total of 19 604 nulliparous women delivered by caesarean section in the years [2001][2002][2003][2004][2005][2006][2007] 7683 women attempting vaginal birth in their second delivery were analysed.Methods Data from population-based registers were linked to hospital-based registers that held data from maternity and delivery records. Logistic regression was used to estimate the risk of uterine rupture after single-or double-layer closure of the uterus. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).Main outcome measure Uterine rupture.Results Uterine rupture during labour occurred in 103 (1.3%) women. There was no increased risk of uterine rupture when single-was compared with double-layer closure of the uterus (OR 1.17; 95% CI 0.78-1.76). Maternal factors associated with uterine rupture were: age ≥35 years and height ≤160 cm. Factors from the first delivery associated with uterine rupture in a subsequent delivery were: infection and giving birth to an infant large for gestational age. Risk factors from the second delivery were induction of labour, use of epidural analgesia, and a birthweight of ≥4500 g.Conclusions There was no significant difference in the rate of uterine rupture when single-layer closure was compared with double -layer closure of the uterus.

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Obstetric Variation, Intervention, and Outcomes: Doing More but Accomplishing Less

Cited by 42 publications

References 24 publications

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Variation in hospital rates of induction of labour: a population-based record linkage study

The risk of uterine rupture is not increased with single‐ compared with double‐layer closure: a Swedish cohort study

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