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

Abstract

BACKGROUND Reducing cesarean deliveries is a major public health goal. The low rate of vaginal birth after cesarean (VBAC) has been attributed largely to a decrease in likelihood of choosing a trial of labor after cesarean (TOLAC), despite evidence suggesting a majority of women with one prior low transverse cesarean are TOLAC candidates. While a number of reasons for this decrease have been explored, it remains unclear how systems issues such as physician call schedules influence delivery approach and mode in this context. OBJECTIVE To investigate the relationship between obstetricians’ call schedule and obstetric outcomes among women eligible for a TOLAC. STUDY DESIGN This is a retrospective cohort study of likelihood of attempting TOLAC and achieving VBAC among women with one prior low transverse cesarean delivery and a term, cephalic singleton gestation based on delivering provider's call schedule. Attending obstetrician call schedules were classified as traditional or “night float” call. Night float call was defined as a schedule in which the provider only had clinical responsibilities for a day or night shift, without other clinical responsibilities before or after the period of responsibility for laboring patients. Call schedules are determined by individual provider groups. Bivariable analyses and random effects logistic regression were used to examine the relationship between obstetricians’ call schedule and the frequency of TOLAC. Secondary outcomes including frequency of VBAC and maternal and neonatal outcomes also were assessed. RESULTS Of 1502 eligible patients, 556 (37%) were delivered by physicians in a night float call system. 22.6% underwent TOLAC and 12.8% achieved VBAC; the VBAC rate for women attempting TOLAC was 56.5%. Women were more likely to undergo TOLAC (33.1% vs. 16.5%, p<0.001) and achieve VBAC (18.7% vs. 9.3%, p<0.001) when cared for by physicians with a night float call schedule. Regression analysis demonstrated physicians with a night float call schedule remained significantly more likely to have patients undergo TOLAC (aOR 2.64, 95% CI 1.65-4.25) and experience VBAC (aOR 2.17, 95% CI 1.36-3.45) after adjusting for potential confounders. However, the likelihood of achieving VBAC if TOLAC was attempted was not different based on provider call type (aOR 0.96, 95% CI 0.57-1.62). Although women delivered by providers with a night float schedule were more likely to experience uterine rupture (1.8% vs. 0.6%, p=0.03), chorioamnionitis (4.3% vs. 1.7%, p=0.002), postpartum hemorrhage (7.6% vs. 4.8%, p=0.03), and neonates admitted to the NICU (6.8% vs 3.9%, p=0.01), these associations did not persist when the population was limited to women attempting TOLAC. CONCLUSIONS While physicians working on a night float call system were significantly more likely to have patients with a prior cesarean undergo TOLAC and achieve VBAC, their patients also were more likely to experience maternal and neonatal morbidity. However, these differences did not persist when limiting analyses to women att...

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi‐country population‐based study

“…Guidelines recommend that the final decision to undergo TOLAC should be made through shared decision‐making by the woman in consultation with her obstetrician . It stands to reason, supported by growing evidence, that obstetricians can easily influence women's decisions . Obstetricians, in turn, will be influenced by factors related to the healthcare system, institutional and organisational factors, and litigation .…”

“…Healthcare providers can contribute to lower TOLAC rates by providing higher reimbursement for CSs compared with vaginal deliveries. Yee et al identified a more than two‐fold increase in the likelihood of attempting TOLAC, with a similar increase in VBAC, in a night float call system (schedule in which the provider has clinical responsibilities for labouring women only for a day or night shift) compared with a traditional call system . Obstetricians working in institutions with obstetric, paediatric, anaesthetic and operating room staff immediately available might be more likely to offer TOLAC.…”

“…11,12 It stands to reason, supported by growing evidence, that obstetricians can easily influence women's decisions. 16,39 Obstetricians, in turn, will be influenced by factors related to the healthcare system, institutional and organisational factors, and litigation. 16 Healthcare providers can contribute to lower TOLAC rates by providing higher reimbursement for CSs compared with vaginal deliveries.…”

Geospatial variation in caesarean delivery

“…(Munro et al, 2017) Associations between quality of care and lack of resources have previously been described, such as lack of a local NICU resulting in low birth weight infants born at hospitals without a NICU and physician call schedules associated with use of TOLAC. (Kozhimannil, Hung, Casey, & Lorch, 2016;Yee et al, 2017).…”

“…(Edmonds, O'Hara, Clarke, & Shah, 2017;Jolles, 2017;Plough et al, 2017;Prasad, Hung, Henning-Smith, Casey, & Kozhimannil, 2018;Sebastiao et al, 2016) Additional characteristics that vary by hospital, such as physician workload and access to hospital surgical resources, are associated with access to Trial of Labor after Cesarean (TOLAC). (Munro et al, 2017;Yee, Liu, & Grobman, 2017) It is not yet known how geographic characteristics of the county of maternal residence contribute to these hospital variations.…”