Variation in Hospital Intrapartum Practices and Association With Cesarean Rate

Abstract

Objective: To examine hospital variation in intrapartum care and its relationship with cesarean rates.

Design: Cross-sectional survey.

Setting: Connecticut and Massachusetts hospitals providing obstetric services.

Participants: Nurse managers or other clinical staff knowledgeable about intrapartum care.

Methods: We assessed labor and delivery unit capacity and staffing, fetal monitoring, labor management, intrapartum interventions, newborn care, quality assurance, and performance review practices. Association of hospital characteristics and intrapartum practices with cesarean rate was evaluated using Wilcoxon exact rank sum test and Kendall's tau-b correlation coefficient.

Results: Among 60 eligible hospitals, respondents from 39 hospitals (65%) completed the survey. Cesarean rates varied from 21% to 42% (median = 30%). Regular review of cesarean rates and indications (85%), regular provision of feedback on cesarean rates and indications to physicians (80%), and regular review of vaginal birth after cesarean rates (94%) were commonly performed at responding hospitals. These practices, however, were not associated with hospital cesarean rate. Hospitals that offered cesarean at the request of the woman (p < .01) and had more liberal indications for labor induction (p < .01) and cesarean birth (p < .01) had significantly greater cesarean rates than institutions without these practices. Routinely placing an intravenous line (p < .01) and drawing blood for complete blood count/type and antibody screen (p < .01) in low-risk women were associated with greater cesarean rates; having a certified nurse-midwife in house at all times (p = .01) and permitting women to eat during labor (p = .02) were associated with lower cesarean rates.

Conclusion: Intrapartum practices of hospitals varied markedly. These different patterns of care may suggest differing levels of intrapartum intervention.

Keywords: cesarean; hospital variation; intrapartum care; obstetric; survey.