Daniele S. Feldman

Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals.

OBJECTIVE The objective of the study was to describe the resources and activities associated with childbirth services. STUDY DESIGN We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals). RESULTS Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001). CONCLUSION Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

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

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.

The Laborist: Is This New Trend Associated With Higher Rates of Primary Cesarean Delivery?

INTRODUCTION: Many hospitals across the nation use laborists, yet little evidence exists to suggest how this affects patient outcomes. We aim to determine if the presence of a laborist is associated with primary cesarean delivery rates. METHODS: We designed and validated a survey to collect information on policies and practices on labor and delivery units across all hospitals in southern California. Hospital-level primary cesarean delivery rates were obtained from the California Office of Health Planning and Development. Recursive partitioning algorithms were used to evaluate the primary cesarean delivery rates. We evaluated structural variables associated with primary cesarean delivery including obstetrics–gynecology resident teaching, presence of laborists and volume (low volume=200–2,000 deliveries per year; midvolume=2,001–3,500 deliveries per year; high volume=3,500 deliveries or more per year). Analysis was weighted by delivery volume. Logistic regression was performed to confirm these results. RESULTS: Seventy percent of hospitals responded (84/121). Recursive partitioning algorithms showed an initial branch point by hospital volume with comparable primary cesarean delivery rates among these (low volume: 19.9%, midvolume: 18%, high volume: 19.7%). The second branch point differed by hospital volume. Teaching status was most discriminant for low-volume hospitals, whereas the presence of a laborist was most discriminant for midvolume and high-volume hospitals. The highest and lowest primary cesarean delivery rates were in nonlaborist hospitals with midvolume (17.6%) and high volume (22.5%), respectively. Controlling for structural risk factors, logistic regression showed no statistically significant difference between primary cesarean delivery rates across groups. CONCLUSION: Among southern California hospitals that participated in the survey, primary cesarean delivery rates are comparable to the state average of 17% and did not vary significantly among hospitals with laborists.