Variation in Cesarean Birth Rates by Labor and Delivery Nurses

Abstract

Objective: To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses.

Design: Retrospective cohort study.

Setting: One high-volume labor and delivery unit at an academic medical center in a major metropolitan area.

Participants: Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation.

Methods: Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses.

Results: Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile.

Conclusion: The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.

Keywords: cesarean; measurement; nursing; quality indicators; variation.