Culture That Facilitates Change: A Mixed Methods Study of Hospitals Engaged in Reducing Cesarean Deliveries

Emily C. White VanGompel, MD, MPH; Susan L. Perez, PhD; Avisek Datta, MS; Francesca R. Carlock, MPH; Valerie Cape; Elliott K. Main, MD


Ann Fam Med. 2021;19(3):249-257. 

In This Article

Abstract and Introduction


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.


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 efforts to reduce cesarean overuse. The Alliance for Maternal Safety bundle details the need to "Build a provider and maternity unit culture that values, promotes, and supports…vaginal birth," yet translating this into practice is challenging. In the United States, hospital-level cesarean delivery rates range from 6% to 69%.[2] This variation cannot be adequately accounted for by differences in the health and risk profiles of childbearing women,[3–6] women's preferences,[7,8] or hospital demographics.[2,4,9]

Changing the mix of clinicians within labor and delivery units may be a way to change unit culture and improve birth outcomes.[10] Previous research has shown that clinicians who ascribe greater safety to cesarean birth and endorse greater fear of vaginal birth have increased individual clinician cesarean rates; with family physicians and midwives holding attitudes consistent with low cesarean utilizers.[11] At the unit level, differences in labor culture (eg, attitudes of individuals and unit norms) are associated with nulliparous, term, singleton, vertex (NTSV) cesarean rates;[12] however, the impact of labor and delivery unit culture on change efforts is not well characterized.

In 2015, the California Maternal Quality Care Collaborative (CMQCC) began the Supporting Vaginal Birth initiative to reduce cesarean delivery rates and range of variation in California.[13,14] CMQCC focused on intervention characteristics and processes, including an aggressive mentoring structure, local champions, resource dissemination, and cross-pollination.[13] Additionally, the state exerted substantial pressure on hospitals to reduce their cesarean rates to the Healthy People 2020 goal (<24%), or face loss of revenue through exclusion from the health insurance exchange plans.[15] Many hospitals saw significant reductions in cesarean rates after 18 months of participation; however, approximately 30% of hospitals remained unchanged and some saw an increase.[14] As similar initiatives move forward in other states, elucidating the mechanisms behind this differential success is essential.

In the course of creating the Supporting Vaginal Birth initiative, CMQCC focused heavily on intervention characteristics, such as those from the Institute for Healthcare Improvement collaborative model,[16] and specific processes (eg, mentoring, champions, and resource sharing). The outer setting in California included hospital public reporting and strong payer incentivization.[13–15] With these domains already getting significant attention, this study aimed to elicit key characteristics of individuals and features of the inner setting of hospital labor and delivery units that impacted hospital success.