Nicole S Carlson1, Elizabeth J Corwin1, Teri L Hernandez2,3, Elizabeth Holt4, Nancy K Lowe3, K Joseph Hurt5. 1. Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA, USA. 2. Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA. 3. University of Colorado College of Nursing, Aurora, CO, USA. 4. Department of Obstetrics and Gynecology, Reproductive Sciences, University of Colorado School of Medicine, Aurora, CO, USA. 5. Department of Obstetrics & Gynecology, Maternal Fetal Medicine & Reproductive Sciences, University of Colorado School of Medicine, Aurora, CO, USA.
Abstract
BACKGROUND: Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women. METHODS: Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type. RESULTS: A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births. DISCUSSION: In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.
BACKGROUND: Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women. METHODS: Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type. RESULTS: A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births. DISCUSSION: In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.
Authors: Robert M Silver; Mark B Landon; Dwight J Rouse; Kenneth J Leveno; Catherine Y Spong; Elizabeth A Thom; Atef H Moawad; Steve N Caritis; Margaret Harper; Ronald J Wapner; Yoram Sorokin; Menachem Miodovnik; Marshall Carpenter; Alan M Peaceman; Mary J O'Sullivan; Baha Sibai; Oded Langer; John M Thorp; Susan M Ramin; Brian M Mercer Journal: Obstet Gynecol Date: 2006-06 Impact factor: 7.661
Authors: Ana Pilar Betrán; Jianfeng Ye; Anne-Beth Moller; Jun Zhang; A Metin Gülmezoglu; Maria Regina Torloni Journal: PLoS One Date: 2016-02-05 Impact factor: 3.240
Authors: Denise Colter Smith; Julia C Phillippi; Nancy K Lowe; Rachel Blankstein Breman; Nicole S Carlson; Jeremy L Neal; Eric Gutierrez; Ellen L Tilden Journal: J Midwifery Womens Health Date: 2019-09-25 Impact factor: 2.388
Authors: Michelle P Debbink; Lynda G Ugwu; William A Grobman; Uma M Reddy; Alan T N Tita; Yasser Y El-Sayed; Ronald J Wapner; Dwight J Rouse; George R Saade; John M Thorp; Suneet P Chauhan; Maged M Costantine; Edward K Chien; Brian M Casey; Sindhu K Srinivas; Geeta K Swamy; Hyagriv N Simhan Journal: Obstet Gynecol Date: 2022-01-01 Impact factor: 7.661