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Cesarean overuse and the culture of care
Author(s) -
White VanGompel Emily,
Perez Susan,
Datta Avisek,
Wang Chi,
Cape Valerie,
Main Elliott
Publication year - 2019
Publication title -
health services research
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.706
H-Index - 121
eISSN - 1475-6773
pISSN - 0017-9124
DOI - 10.1111/1475-6773.13123
Subject(s) - medicine , cesarean delivery , poisson regression , family medicine , multivariate analysis , unit (ring theory) , obstetrics , nursing , pregnancy , psychology , population , genetics , mathematics education , environmental health , biology
Objective To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery. Data Sources/Study Setting Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse. Study Design Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates. Methods Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates. Principal Findings 1718 respondents from 70 hospitals responded to the Labor Culture Survey. The “Unit Microculture” subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8‐items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = −47 to −35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates. Conclusions Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.