Functional Culture Creation and Trauma-informed Care: A Conceptual Model of Change for Labor and Delivery

Context: Reducing low-risk primary cesarean births is an important quality and equity goal. Existing evidence demonstrates the importance of culture change to achieve sustained improvement. However, a model to guide effective culture change on labor and delivery (L&D) units is lacking.

Objective: This study applied a Model of Creating Functional Cultures to the quality improvement process on L&D units that were particularly successful in achieving their quality and equity goals for low-risk primary vaginal birth, to explore the underlying theoretical concepts by which clinicians and staff on L&D achieved functional cultures.

Study Design and Analysis: Reflexive thematic analysis was used to analyze focus group and individual interview data.

Setting or Dataset: Labor and delivery units in hospitals, participating in a statewide quality improvement initiative, with a reduction in low-risk primary cesarean rate that was sustained for at least 1 year and/or a reduction or elimination of racial inequity in cesarean births were selected.

Population Studied: Nurses, family physicians, obstetricians, midwives, and hospital leaders involved in L&D at selected hospitals.

Results: Labor and delivery leaders reported reacting to external pressure (e.g. professional organizations, patients, participation in a perinatal quality collaborative) and shifting their L&D culture from a physician- or protocol-centric model to a patient- and team-centric model (e.g. high-touch labor support, trauma-informed care, “just” teamwork culture, vaginal birth articulated as a value). Both leaders and clinicians then created self-reinforcing cycles by (a) integrating the values into interview and training materials; (b) making the positive impact of desired behavior and practice highly visible on the unit (e.g., public announcements, posted materials, recognition and rewards); and (c) modeling desired behavior and practice by experienced clinicians, thereby allowing new or skeptical clinicians to witness the positive results and adopt the desired behavior and practice.

Conclusions: Reducing cesarean births and achieving equity may require shifting L&D unit culture to place the focus of birth on the laboring patient’s physical and emotional needs, including trauma-informed care practices (e.g. affording patients respect, empathy, and autonomy), active labor support, and creating a “just” teamwork culture that focuses on systems change, psychological safety, and strong team relationships.