Do laborists improve delivery outcomes for laboring women in California community hospitals?

doi:10.1016/j.ajog.2015.05.051

American Journal of Obstetrics and Gynecology

Volume 213, Issue 4, October 2015, Pages 587.e1-587.e13

Presented in oral format at the 35th annual meeting of the Society for Maternal-Fetal Medicine, San Diego, CA, Feb. 2-7, 2015.

https://doi.org/10.1016/j.ajog.2015.05.051 Get rights and content

Objective

We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals.

Study Design

This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012.

Results

Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P < .0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate.

Conclusion

We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction.

Section snippets

Materials and Methods

This is a cross-sectional study of community hospitals in California that provided obstetrical services and reported to the California Office of Statewide Health Planning and Development (OSHPD) in calendar year 2012. This is a planned analysis of data from a comprehensive study designed to evaluate the impact of hospital clinical resources on maternal childbirth outcomes. Labor and delivery nurse managers participated in a 1-hour structured interview, providing answers to 185 hospital-specific

Results

In 2012, there were 248 hospitals reporting to OSHPD, and 239 completed the survey (96.4% response rate). After exclusions, 182 community hospitals remained in the study (Figure 1). Based on survey results, 23.6% of community hospitals (43/182) reported that they had a laborist working on their labor and delivery unit (Figure 1). Most hospitals employing laborists (39/43) reported that they provided continuous 24/7 coverage; however 4 hospitals reported only part-time in-house coverage (eg,

Comment

In community hospitals the laborist staffing model appears to be expanding, and there is a need to demonstrate its impact on childbirth outcomes. The outcomes were selected because we theorized they would be amenable to modification by the presence of an onsite dedicated clinician. After adjusting for patient and hospital factors, this study found that the presence of a laborist did not impact the cesarean rate or the rate of maternal complications. There are several potential explanations for

Acknowledgments

The authors would like to thank all the participants in this study for their time and attention. We would also like to thank Kevin Van Oterloo at the Community Perinatal Network.

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Cited by (15)

Variation in primary cesarean delivery rates by individual physician within a single-hospital laborist model
2016, American Journal of Obstetrics and Gynecology
Citation Excerpt :
More recent publications have focused on differences in outcomes with laborist compared with traditional private practice models. Several of these publications have demonstrated benefits of laborist models,2-4 whereas others fail to demonstrate a difference in outcomes, and specifically cesarean delivery rates, with and without laborists.6 On the basis of our findings, some of this heterogeneity of results may depend on the individual laborists hired.
Laborist practice models are associated with lower rates of cesarean delivery than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed decrease in rates of cesarean delivery in some hospitals that implement a laborist model.
Our objective was to evaluate the degree of variation in rates of primary cesarean delivery by individual laborists within a single institution that uses a laborist model. In addition, we sought to evaluate whether differences in rates of cesarean delivery resulted in different maternal or short-term neonatal outcomes.
At this teaching institution, one laborist (either a generalist or maternal−fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007 to 2014. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% confidence intervals. Laborists were grouped by tertile as having low, medium, or high rates of cesarean delivery. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared with the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics.
Twenty laborists delivered 2224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% confidence interval 21.4−26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (P < .001), and a 2.9-fold (1.5−5.4, P = .001) variation between the cesarean delivery rates of the greatest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (P = .0265) with the difference between physicians expanding to 3.58 (1.72−7.47, P <. 001). Between groups of laborists with low, medium, and high rates of cesarean delivery, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes, including Apgar scores, arterial cord blood pH, or the incidence of neonatal encephalopathy.
The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physician decision-making on cesarean delivery rates even within a laborist care model. Further exploration of the role of individual physician decision-making on cesarean rates may help to better elucidate the effect of the laborist model.
Clues for understanding hospital variation among obstetric services
2015, American Journal of Obstetrics and Gynecology
Examining provider practice-level disparities in delivery outcomes among patients with a history of Cesarean Delivery
2024, BMC Pregnancy and Childbirth
Examining Provider Practice-Level Disparities in Delivery Outcomes Among Patients with a History of Cesarean Delivery
2024, Research Square
Use of Obstetric and Gynecologic Hospitalists Is Associated with Decreased Severe Maternal Morbidity in the United States
2023, Journal of Patient Safety
Factors Associated with Meeting Obstetric Care Consensus Guidelines for Nulliparous, Term, Singleton, Vertex Cesarean Births
2021, AJP Reports

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: This project was funded by Agency for Healthcare Research and Quality grant number 5 R01 HS020915. D.S.F. was supported by the Duchesnay USA Research Fellowship Award, American College of Obstetricians and Gynecologists, for her contribution to this project.

: The authors report no conflict of interest.

: Cite this article as: Feldman DS, Bollman DL, Fridman M, et al. Do laborists improve delivery outcomes for laboring women in California community hospitals? Am J Obstet Gynecol 2015;213:587.e1-13.

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Meeting paperSMFM paperDo laborists improve delivery outcomes for laboring women in California community hospitals?

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Acknowledgments

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Semin Perinatol

Am J Obstet Gynecol

Am J Obstet Gynecol

The emerging role of “hospitalists” in the American health care system

N Engl J Med

Laborist model of care: who is using it?

J Matern Fetal Neonatal Med

Reducing obstetric litigation through alterations in practice patterns

Obstet Gynecol

Meeting paper
SMFM paper
Do laborists improve delivery outcomes for laboring women in California community hospitals?