Introduction

A just-published study in BMC Pregnancy and Childbirth, "Do provider attitudes influence cesarean delivery rate: a cross-sectional study" shows that not only is it important what hospital a person chooses to give birth in, it is also very important to choose a provider whose attitudes favor vaginal births for their patients and clients. Hospitals in the United States demonstrate a ten-fold increase in cesarean rates, ranging from 7.1 percent to 69.9 percent. Even more concerning, low-risk people (those birthing for the first time at term, carrying one baby in the head down position, referred to as NTSV) experienced a fifteen-fold variation in cesarean rates amongst hospitals, from 2.4 percent to 36.5 percent. Many people do not have a choice of which hospital to birth in due to insurance restrictions. Even more critical, particularly in rural America, hospitals are shutting the doors on their labor & delivery units, leaving pregnant families no choice but to travel much further to receive any maternity care at all. There are still states in the United States where home birth is only legal with Certified Nurse Midwives, (CNMs) who may be hard to find. 23 states do not permit home birth with Certified Professional Midwives (CPMs) who do the majority of the home births in the nation.

Taking all the above items into consideration, it is clear that the provider a pregnant person chooses to birth with (or who is on call in the case of a group practice) can make a considerable difference in whether or not that person will be delivered by cesarean. The purpose of the study I am reviewing here was to estimate the association between individual provider attitudes towards vaginal birth and their low-risk primary cesarean rate.

How was the study conducted

Over 400 providers from the state of California were included in the study and 209 completed the survey. To be included, the provider needed to have done a minimum of 10 deliveries a year and be licensed in the state of California with one of the following licenses:

• maternal-fetal medicine
• OB,
• family medicine
• CNM
• LM

The providers were questioned about their attitudes in the six categories listed below:

• attitudes regarding use of electronic fetal monitoring
• factors that increase cesarean rates
• fears of birth mode by respondents or their partners/spouses
• factors that decrease cesarean rates
• maternal choice and mothers' roles in birth
• safety by mode or place of birth

Lower scores on the composite scale indicate attitudes more favorable toward vaginal birth, while higher scores indicate attitudes that favor cesarean birth. Researchers obtained both the total number of NTSV births that providers attended in 2013 - 2014 and the total number of those births that were delivered via cesarean during the same time period. Demographics including age, gender, years in practice and other attributes were collected.

Discussion and Results

The OBs were most likely to favor cesarean sections and the midwives were the least likely to favor cesareans. Family practice doctors were in the middle but closer to the midwives' responses. The MFM pool was most consistent with the OBs, but many of their expressed attitudes fell between average risk OBs and FP physicians. The widest variation among one provider type was in the OB group.

There was a correlation between the providers' attitudes and beliefs about birth and their NTSV cesarean rate. One surprising result was that OBs attitudes were most likely to favor cesareans, even more so than their MFM colleagues. The OBs were more pro-cesarean than any other group. The more pro-cesarean a provider was, the higher their cesarean rate was among their low-risk patients (NTSV). Despite hospital culture that we know can influence a facility's cesarean rate, (see above), an individual provider's beliefs played a large role in behavior during the intrapartum period and affected birth outcomes.

Researchers also discussed the following in regards to what can influence a specific providers' attitudes around cesarean and vaginal birth:

"Training may offer a promising target for influencing attitudes that favor vaginal birth. One study found that providers who trained in hospitals with lower obstetric complication rates continued to have lower complication rates once in practice. Most recently, one hospital program significantly decreased their primary cesarean rate by providing senior obstetric supervision of residents on labor and delivery, highlighting the impact of preceptor experience level on trainees. The impact of integrating midwives into traditional obstetric training has been posited but not yet rigorously tested against clinical outcomes. Finally, ongoing training and support after experiencing a traumatic delivery event may mitigate some of the fear attitudes associated with increased cesarean rate, which appear to impact entire hospital units and not just the providers involved. This was described recently in a study of unplanned hospital cesarean rates, which increased and stayed elevated for 4 weeks after any catastrophic neonatal outcome within that hospital."

Takeaways for educators

Families who make an intentional effort to choose providers that are fully in support of vaginal birth will increase the chances that they do deliver vaginally. Unfortunately, there are not a lot of resources available to help pregnant people to make a provider decision. Information about hospital cesarean rates are hard to come by, and cesarean rates on the provider level or almost impossible to find. In fact, many providers themselves are not provided with their cesarean rates from the facilities that they work in. Consumer Reports is a great source of information on the hospital level. By the time families are in your childbirth classes, they are already receiving care from a specific practice or provider. Create space in your classes for discussions about the importance of having a supportive doctor or midwife can help. Let families know that changing providers can be an option for them if they are not feeling supported. Hold an early pregnancy class where these type of provider and facility choice discussions can happen more authentically is a great idea. Share the results of this study with your students along with providing them some questions to ask their providers (page 10 of this document) and themselves (see quiz on page 2) about what kind of birth they would want and with what type of provider is also critical, no matter where they are in their pregnancy. Continue to be a resource for them if they are making decisions to change their intended birthplace or provider is very helpful.

Will you share this study with the families you work with? How will you discuss this research? Let us know in the comments section below.

Graph image source: BMC Pregnancy & Childbirth

References

Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302:1277-83.

Bardos J, Loudon H, Rekawek P, Friedman F, Brodman M, Fox NS. Association between senior obstetrician supervision of resident deliveries and mode of delivery. Obstet Gynecol. 2017;129:486-90.

Dan O, Hochner-Celnikier D, Solnica A, Loewenstein Y. Association of Catastrophic Neonatal Outcomes with Increased Rate of subsequent cesarean deliveries. Obstet Gynecol. 2017;129:671-5.

Hung, P., Kozhimannil, K. B., Casey, M. M., & Moscovice, I. S. (2016). Why Are Obstetric Units in Rural Hospitals Closing Their Doors? Health Services Research, 51(4), 1546-1560. http://doi.org/10.1111/1475-6773.12441

King TL, Laros RK, Parer JT. Interprofessional collaborative practice in obstetrics and midwifery. Obstet Gynecol Clin N Am. 2012;39:411-22.

Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs, 32(3), 527-535.

VanGompel, E. W., Main, E. K., Tancredi, D., & Melnikow, J. (2018). Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study. BMC pregnancy and childbirth, 18(1), 184.

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