Research
Obstetrics
Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals

https://doi.org/10.1016/j.ajog.2015.08.013Get rights and content

Objective

The objective of the study was to describe the resources and activities associated with childbirth services.

Study Design

We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals).

Results

Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001).

Conclusion

Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

Section snippets

Materials and Methods

The study was approved by the Cedars-Sinai Institutional Review Board (protocol PRO00032669 certified exempt) and complied with all stipulated criteria for participant protection.

Results

The domains and subdomains of childbirth services as represented in the conceptual framework are listed in Table 1.

The survey response rate was 96% (239 of 248), with 25 IDS, 27 teaching, and 187 community hospitals reporting. Nine hospitals, 4 IDS, and 5 community hospitals did not respond. The 4 IDS hospitals were large urban hospitals with delivery volumes ranging from 2000 to 5000 annual births. Of the 5 nonresponding community hospitals, 2 had rural status with approximately 400 annual

Comment

This study describes a thorough inventory of hospital childbirth services in California. It illustrates the technical complexity and broad diversity of the resources involved in the provision of obstetrical care, suggesting that the variation in hospital-level services may provide some basis for variation in the outcomes achieved by childbirth hospitals.

We analyzed the data by hospital type (ie, community, teaching, and IDS) because of inherent substantial differences in hospital infrastructure

Acknowledgment

We are grateful to the many individuals and organizations that have contributed to this effort, including the staff of all of the participating hospitals. We specifically acknowledge the Regional Perinatal Programs of California for their assistance in providing introductions and contact information for participants, and Kevin Van Otterloo (Community Perinatal Network in Yorba Linda, CA) for his assistance with recruitment and scheduling participant interviews (funded in part by the March of

References (30)

  • M.D. D’Alton et al.

    Putting the “M” back in maternal-fetal medicine

    Am J Obstet Gynecol

    (2013)
  • L.M. Korst et al.

    Monitoring childbirth morbidity using hospital discharge data: further development and application of a composite measure

    Am J Obstet Gynecol

    (2014)
  • Levels of maternal care. ACOG Obstetric Care consensus no. 2

    Obstet Gynecol

    (2015)
  • C.S. Phibbs et al.

    Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants

    N Engl J Med

    (2007)
  • S.M. Lasswell et al.

    Perinatal regionalization for very low-birth-weight and very preterm infants

    JAMA

    (2010)
  • J.H. Chung et al.

    The effect of neonatal intensive care level and hospital volume on mortality of very low birth weight infants

    Med Care

    (2010)
  • J.A. Martin et al.

    Births: final data for 2012

    Natl Vital Stat Rep

    (2013)
  • A. Donabedian

    The definition of quality and approaches to its assessment. Explorations in quality assessment and monitoring, Vol 1

    (1980)
  • Y. Eggli et al.

    A conceptual framework for hospital quality management

    Int J Health Care Qual Assur

    (2003)
  • California Code of Regulations. Title 22. Social Security. Available at:...
  • I.R. Shihady et al.

    Vaginal birth after cesarean: do California hospital policies follow national guidelines?

    J Reprod Med

    (2007)
  • Regional Perinatal Programs of California. Available at: http://www.cdph.ca.gov/programs/rppc/Pages/default.aspx....
  • American Medical Association. FREIDA Online. Available at:...
  • American Hospital Association (AHA). AHA Annual Survey Database Fiscal Year 2012. Available at:...
  • Cited by (15)

    • Using Potentially Preventable Severe Maternal Morbidity to Monitor Hospital Performance

      2023, Joint Commission Journal on Quality and Patient Safety
      Citation Excerpt :

      In brief, California hospitals with an average annual delivery volume ≥ 200 and deliveries in all three years of study 2016–2018 were included (N = 225). Given that childbirth hospitals are known to differ substantially with respect to their resources, policies, practices, discharge coding intensity, and case mix,10 and that hospital performance comparisons are likely to be more interpretable when compared to peer institutions, California hospitals were classified into one of four types: (1) Community, (2) Teaching, (3) Integrated Delivery System (IDS), and (4) IDS Teaching. These hospital types are mutually exclusive and were analyzed separately.

    • Severe Maternal Morbidity in California Hospitals: Performance Based on a Validated Multivariable Prediction Model

      2021, Joint Commission Journal on Quality and Patient Safety
      Citation Excerpt :

      These exclusions reduced the overall three-year sample from 1,371,767 live births in 271 hospitals to 1,357,250 births in 225 hospitals. Given that hospitals are known to differ substantially with respect to their resources, policies, practices, and case-mix,20–22 hospital performance comparisons are likely to be more interpretable when compared to peer institutions.18 Furthermore, public health practice for the design, implementation, and tracking of quality improvement (QI) strategies will likely vary based on these differences.

    • Variation in Hospital Intrapartum Practices and Association With Cesarean Rate

      2017, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
      Citation Excerpt :

      We found notable differences in staffing arrangements, labor management policies, and performance review processes across hospitals. A recent descriptive analysis of childbirth hospitals in California also found considerable variation in a range of maternity services, practices, and resources across hospitals (Korst et al., 2015). Such variation may carry important implications for patient outcomes and resource use and warrant further research.

    • Clues for understanding hospital variation among obstetric services

      2015, American Journal of Obstetrics and Gynecology
    View all citing articles on Scopus

    The funding sources had no involvement in the conduct of the research or preparation of the manuscript.

    Financial support was provided by the Agency for Healthcare Research and Quality (grant 5 R01 HS020915) (all investigators except D.S.F.). Additional support was provided by the March of Dimes (to L.M.K., M.F., and D.L.B.) and by the American College of Obstetricians and Gynecologists/Duchesnay USA Research Award in Quality Improvement in Maternity Care (to D.S.F.).

    The authors report no conflict of interest.

    Cite this article as: Korst LM, Feldman DS, Bollman DL, et al. Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals. Am J Obstet Gynecol 2015;213:523.e1-8.

    Deceased.

    View full text