Search

PURPOSE Currently, 40% of counties in the United States do not have an obstetrician or midwife, and in rural areas the likelihood of childbirth being attended to by a family medicine (FM) physician is increasing. We sought to characterize the effect of the FM presence on unit culture and a key perinatal quality metric in Iowa hospital intrapartum units. METHODS Using a cross-sectional design, we surveyed Iowa physicians, nurses, and midwives delivering intrapartum care at hospitals participating in a quality improvement initiative to decrease the incidence of cesarean delivery. We linked respondents with their hospital characteristics and outcomes data. The primary outcome was the association between FM physician, obstetrician (OB), or both disciplines' presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or Both). RESULTS A total of 849 clinicians from 39 hospitals completed the survey; 13 FM- only, 11 OB-only, and 15 hospitals with both. FM-only hospitals were all rural, with CONCLUSIONS Birthing hospitals staffed exclusively by FM physicians were more likely to have lower cesarean rates and stronger nursing-rated safety culture. Both access and quality of care provide strong arguments for reinforcing the pipeline of FM physicians training in intrapartum care. Key words: family medicine; cesarean birth; organizational culture, https://doi.org/10.1370/afm.3157 INTRODUCTION The United States is facing multiple maternal health crises including increasing severe maternal morbidity (SMM) and mortality, racial inequities in SMM, and a shrinking footprint of pregnancy care [...]

PURPOSE Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals' success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not. METHODS A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals' net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators. RESULTS Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians' individual attitudes differed by hospital success on 5 scales: best practices (P = .003), fear (P = .001), cesarean safety (P = .014), physician oversight (P CONCLUSIONS Successful hospitals' culture and context was measurably different from nonresponders. Leveraging these contextual factors may facilitate success. Key words: cesarean section; health care quality; maternity hospital; organizational culture; patient care team, INTRODUCTION Since the Alliance for Maternal Safety released the Safe Reduction of Primary Cesarean/Support for Intended Vaginal Birth safety bundle in 2018, (1) statewide perinatal quality collaboratives have initiated large-scale [...]

Context: The consequences of continued loss of family physicians(FMs) practicing obstetrics in the United States has been characterized in terms of loss of access to care, particularly for rural patients; however, the impact on quality of care needs further study. Reducing the low-risk, primary cesarean rate is a national quality goal. Iowa is a state with a strong FM obstetrics presence where many rural hospitals are staffed exclusively by FMs with general surgery on call for cesarean deliveries. Objective: To characterize the FM impact on cesarean delivery in Iowa birthing hospitals. Study Design: Survey linked with administrative hospital data. Dataset: Hospital characteristics were obtained from the Iowa Department of Public Health or self-reported. Population Studied: Iowa clinicians delivering intrapartum care at hospitals participating in an initiative to reduce cesarean. Instrument: The Labor Culture Survey is a valid measure of individual attitudes, beliefs, and unit culture on intrapartum units. Outcome Measures: Primary outcome was the association between FM, obstetrician, or both disciplines' presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or both). Results: 849 clinicians from 39 hospitals completed the survey; 12 FM-only, 12 OB-only, and 15 hospitals with both. FM-only hospitals were all rural with less than 1,000 annual births. FMs practicing at FM-only hospitals had been practicing maternity care for longer than FMs at hospitals with both (13 vs 4 years, p=.02). Among hospitals with less than 1,000 annual births, compared to hospitals with both, births at FM-only hospitals had an adjusted 39% lower risk of cesarean (95% CI -0.16 to -0.62%; p, Presenters Emily White VanGompel, MD, MPH, Stephanie Radke, Lavisha Singh, MPH, Francesca Carlock, [...]

Purpose: Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals' success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not., Methods: A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals' net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators., Results: Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians' individual attitudes differed by hospital success on 5 scales: best practices ( P = .003), fear ( P = .001), cesarean safety ( P = .014), physician oversight ( P <.001), and microculture ( P = .044) scales. Patient ability to make informed decisions showed poor agreement across all hospitals, but was higher at successful hospitals (38% vs 29%, P = .01). Important qualitative themes included: ease of access to shared resources on best practices, fear of bad outcomes, personal resistance to change, collaborative practice and effective communication, leadership engagement, and cultural flexibility., Conclusions: Successful hospitals' culture and context was measurably different from nonresponders. Leveraging these contextual factors may facilitate success., (© 2021 Annals of Family Medicine, Inc.)