Cesarean delivery rates dropped from 31.7% to 25.0% (P = .005) after Marin General Hospital in California switched from a private practice model to one with 24-hour laborist and midwife coverage. Rates of vaginal birth after cesarean (VBAC) also increased.
"Our study adds to the growing literature on the association between laborists and midwives and decreasing primary cesarean delivery rates and increasing VBAC rates," the investigators write in their article, published online September 8 in Obstetrics & Gynecology.
The laborists at this hospital were obstetricians who provided in-house labor and delivery coverage without competing clinical duties. Previous studies have suggested that laborists achieve lower cesarean rates by being more tolerant of changes in fetal heart rate and by having less competition between managing labor and other duties.
At Marin General Hospital, women insured by the state's Medicaid program served as the control group; most received care from midwives with 24-hour laborist backup. The study covered a period before and after 2011, when most privately insured women were switched to the same type of coverage. Previously, these women's care came from a private physician who managed labor remotely. After the change, women could request that their obstetrician be present to deliver the baby, but their labor would still be managed by the in-house laborist.
Between 2005 and 2014, there were 13,194 births at the hospital. The study included 3560 births from nulliparous women with singleton vertex term babies, and 1324 births from women with a history of cesarean delivery; approximately half of each were in the private insurance group.
The new model of care led to a "clinically and statistically significant" decrease in primary cesareans (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI], 0.39 - 0.81). Before the change, the group's cesarean delivery rate had been increasing 0.6% per year, which is comparable to national trends. The rate among publicly insured women did not change significantly during the study.
In addition, vaginal births after cesarean (VBAC) increased for the privately insured women, going from 13.3% under the previous care model to 22.4% with midwife/laborist care (P = .002). In the years after the change, the rate increased by 8% annually. Publicly insured women did not have a significant change in their VBAC rate.
There were no significant differences in adverse outcomes for babies, including Apgar scores below 7, umbilical artery pH less than 7.0, or umbilical artery base excess greater than 12 (composite score, 1.3% before the change vs 2.3% after; P = .07).
Limitations of the study, according to the authors, include the single-center design and a lack of power to detect small changes in outcomes for babies. They write: "We therefore cannot rule out a true small increase in adverse neonatal outcomes, and future studies should focus efforts on complete data collection of adverse neonatal outcomes including neonatal intensive care unit admission, birth trauma, and routine cord gas assessment."
The authors have disclosed no relevant financial relationships.
Obstet Gynecol. Published online September 3, 2015. Abstract
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