SAN DIEGO – A shift from a conventional private practice model to a 24-hour obstetrician and midwifery model was associated with a dramatic decrease in the nulliparous term single vertex cesarean delivery rate, and an increase in the vaginal birth after cesarean delivery (VBAC) rate among privately insured women who delivered at a single community hospital.
The nulliparous term single vertex cesarean delivery (NTSV CD) rate among privately insured women prior to the model change was 32.2%, compared with 25% after the change, with a 5% decrease at the time of the change, and a nearly 2% decrease per year thereafter. Prior to the change, the rate had been increasing by 0.6% annually, which was similar to national trends. The odds ratio for NTSV CD was 0.56 after adjustment for maternal age, race/ethnicity, induction , epidural use, birth weight, gestational age, maternal medical problems, and birth year, Dr. Melissa Rosenstein reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
Further, the VBAC rate, which was decreasing slightly each year before the change, increased from 13% to 22% after the change (adjusted odds ratio, 1.94), and increased by about 8% per year thereafter, said Dr. Rosenstein of the University of California, San Francisco.
Prior to the change, privately insured women were managed by their individual obstetricians; only publicly insured women utilized the hospitalist model. The rates of NTSV CD and VBAC in the publicly insured women did not change significantly during the study period – the NTSV CD rates were 15.7% and 15.8% before and after the change, and VBAC rates were 33.9% and 27.9% before and after the change (aOR, 0.84 and 0.76, respectively), she said.
Interrupted time series analyses showed that the change in VBAC rates among the publicly insured women represented a persistent trend rather than any change from the intervention and also showed no significant adverse effect of the intervention on short-term neonatal outcomes, she noted.
The prospective cohort study included all singleton term deliveries at the community hospital between January 2005 and April 2014. The model shift occurred in April 2011. Overall, 3,684 NTSV deliveries and 1,375 deliveries in women with a prior cesarean delivery were included in the analysis.
The pre- and post-model change cohorts were similar with respect to delivery volume, gestational age, maternal age, and ethnic makeup.
The findings are notable, because the practice of obstetrics in the United States faces multiple challenges, Dr. Rosenstein said, noting that nearly a third of all births are by cesarean section, while VBAC rates continue to decline.
“These trends are accompanied by increasing maternal complications and rising costs,” she said.
Additionally, work force concerns are leading to decreased provider satisfaction and burnout among those who perform deliveries – due in part to the inherent conflict between labor and delivery responsibilities and office practice – and the difficulty of balancing these demands.
“At the same time, there have been increasing calls for expanding the availability of 24-hour in-house obstetric coverage to improve patient safety and decrease liability,” she said.
A potential solution to the problem of a shrinking workforce and rising cesarean delivery rates is increased use of midwives, whose involvement in deliveries is associated with excellent maternal and neonatal outcomes, Dr. Rosenstein noted.
Additionally, the employment of laborists, who provide in-house labor and delivery coverage without competing clinical duties, is increasing, and has been endorsed by the American College of Obstetricians and Gynecologists as a potential solution to improve provider satisfaction and patient safety. Data on outcomes associated with such a model are sparse, but encouraging, she said.
The shift from the private practice model to the laborist and midwifery model at a community hospital that provides services for an equal number of privately and publicly insured women posed an opportunity for University of California, San Francisco, researchers to prospectively study the effects of the model.
“We observed that the expansion of midwifery and laborist services in a collaborative practice model, was associated with decreased rate of primary cesarean delivery and an increased rate of VBAC, with cesarean rates continuing to decline during the 3 years after the practice change,” Dr Rosenstein said, noting that “the changes were seen to a statistically significant degree only in the group of women exposed to the practice change, suggesting causation rather than secular trends for other hospital-wide interventions.”
“We believe that this model could be instituted at other U.S. hospitals that are seeking to decrease their cesarean delivery rates,” she concluded.
This study was funded by the National Institutes of Health and the Prima Medical Foundation. Dr. Rosenstein reported having no disclosures.