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

This mixed methods study makes an important contribution by helping us understand factors that contribute to success in a hospital quality improvement initiatives, specifically here, an initiative to support vaginal birth. I am delighted to see rigorous measurement of institutional culture, which many clinicians know in their gut contributes critically to the care they provide, but which is difficult to measure and I feel is under-studied. The paper is also important because quality improvement initiatives abound, but the assessment of when and how they work deserves more attention. Finally, I am grateful that the authors highlight a few important take-home points: 1) The voice of patients in clinical decision making needs to be central (perhaps no more so than in giving birth, which is such a personal and impactful moment in life), but often patients lack information to be full participants. 2) When we level our traditional hierarchies in medicine, so that members of a care team feel comfortable communicating across roles, hospitals are more likely to improve the care that patients receive. 3) Doulas, nurses, midwives, and family physicians continue to play important roles in the care of birthing patients, and hospitals that welcome and empower these providers may see better patient outcomes.