Family Medicine Presence on Labor and Delivery: Impact on Quality and Safety

Context: The consequences of continued loss of family physicians(FMs) practicing obstetrics in the United States has been characterized in terms of loss of access to care, particularly for rural patients; however, the impact on quality of care needs further study. Reducing the low-risk, primary cesarean rate is a national quality goal. Iowa is a state with a strong FM obstetrics presence where many rural hospitals are staffed exclusively by FMs with general surgery on call for cesarean deliveries.

Objective: To characterize the FM impact on cesarean delivery in Iowa birthing hospitals.

Study Design: Survey linked with administrative hospital data.

Dataset: Hospital characteristics were obtained from the Iowa Department of Public Health or self-reported.

Population Studied: Iowa clinicians delivering intrapartum care at hospitals participating in an initiative to reduce cesarean.

Instrument: The Labor Culture Survey is a valid measure of individual attitudes, beliefs, and unit culture on intrapartum units.

Outcome Measures: Primary outcome was the association between FM, obstetrician, or both disciplines’ presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or both).

Results: 849 clinicians from 39 hospitals completed the survey; 12 FM-only, 12 OB-only, and 15 hospitals with both. FM-only hospitals were all rural with less than 1,000 annual births. FMs practicing at FM-only hospitals had been practicing maternity care for longer than FMs at hospitals with both (13 vs 4 years, p=.02). Among hospitals with less than 1,000 annual births, compared to hospitals with both, births at FM-only hospitals had an adjusted 39% lower risk of cesarean (95% CI -0.16 to -0.62%; p<.01) and births at OB-only hospitals had an adjusted 16% lower risk of cesarean (95% CI -0.01 to -0.32%; p=.04). Nurses endorsed unit norms more supportive of vaginal birth at FM-only hospitals compared with both (mean Likert score 3.04 vs 2.91; p=.03), and stronger safety culture compared to OB-only or both (2.92 vs 2.79 and 2.76, respectively; p=.01).

Conclusions: Birthing hospitals staffed exclusively by FMs were more likely to have lower cesarean rates and stronger nursing-rated safety culture. Both access and quality of care provide strong arguments for reinforcing the pipeline of FMs training in intrapartum care.