The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates

Abstract

Objective: To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates.

Methods: This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean delivery were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean delivery and VBAC; an interrupted time-series analysis estimated the annual rates before and after the expansion.

Results: There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean delivery during the study period; 45% were among privately insured women whose care model changed. The primary cesarean delivery rate among these privately insured women decreased after the change, from 31.7% to 25.0% (P=.005, adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.39-0.81). The interrupted time-series analysis estimated a 7% drop in the primary cesarean delivery rate in the year after the expansion and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward (adjusted OR 2.03, 95% CI 1.08-3.80).

Conclusion: The change from a private practice to a collaborative midwifery-laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.

Level of evidence: II.

Figure 1

Nulliparous term singleton vertex primary cesarean delivery rate among privately and publicly insured women before and after expansion of midwifery and laborist services. This graph shows the rates of nulliparous term singleton vertex cesarean delivery plotted over time and the model-predicted rates before and after the practice change as predicted by the interrupted-time series analysis. *The slope is statistically different from zero.

Figure 2

Vaginal birth after cesarean delivery (VBAC) rate among privately and publicly insured women before and after expansion of midwifery and laborist services. This graph shows the rates of VBAC plotted over time and the model-predicted rates before and after the practice change as predicted by the interrupted-time series analysis. *The slope is statistically different from zero.

Figure 3

Composite adverse neonatal complication rate among privately and publicly insured women before and after expansion of midwifery and laborist services. This graph shows the rates of composite short term adverse neonatal outcomes (5 minute APGAR <7, umbilical artery pH<7.0, umbilical artery base excess <–12) plotted over time and the model-predicted rates before and after the practice change as predicted by the interrupted-time series analysis. None of the slopes were statistically different from zero.