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The purpose of this study was to identify the key differences between successful and nonresponder hospital labor and delivery units after participation in the Supporting Vaginal Birth initiative for 18 months. Successful hospitals were defined as those that were able to lower their cesarean delivery rate below 24% or by at least 5 percentage points. Nonresponder hospitals, or unsuccessful hospitals, maintained or even increased their cesarean delivery rate above 24%. The Supporting Vaginal Birth initiative was created by the California Maternal Quality Care Collaborative (CMQCC) to reduce the number of cesarean deliveries performed in hospitals. The hospitals included in the initiative had a starting cesarean rate of higher than 24%. The group discussed the importance of such an initiative due to the high cost of performing cesarean deliveries and the associated recovery, possibility for complications, and overall medical risk of the procedure.
The study focused on two domains identified by the consolidated framework for implementation research: inner setting and characteristics of individuals. These domains were evaluated used Labor Culture Surveys (LCS) and key informant interviews with labor and delivery unit leaders. The group discussed the advantage of this approach as it allowed for both quantitative and qualitative data to be obtained and compared. The LCS was completed by 37 participating hospitals with a multitude of labor and delivery roles represented. The key informant interviews were completed by 12 individuals representing 8 hospitals and included physicians and registered nurses in leadership roles.
The LCS identified that physicians in successful and nonresponder hospitals differed on the mean subscale scores of best practices, fear, cesarean safety, physician oversight, and microculture. Meanwhile, only the microculture score differed significantly for nurses. This contrast was spoken about extensively by the group identifying that physicians play a key role in the outcomes of the hospital they work at. Nurses’ opinions may often be dismissed by physicians or, alternatively, the culture of the workplace may not foster and environment in which nurses feel comfortable speaking up about concerns.
The authors identified 5 themes that were echoed across the key informant interviews: ease of access to shared resources, fear and resistance to change, collaboration, leadership, and the role of subcultures. An interesting subtheme that seemed to be a significant barrier to change was the number of years a physician had been in practice. Physicians that had been practicing for less years were more open to “confrontation” by nurses and altering the way they practice. The group discussed the connotation of the word “confrontation” and how a more collaborative approach between physicians and nurses would likely lead to more successful outcomes, especially in terms of labor and delivery. Additionally, the study identified that a diverse team, in terms of both demographic characteristics and labor and delivery roles, was a key feature in successful hospitals. Members of the group noted that diversity in both aspects may be difficult to obtain in rural hospitals as the number of members on the team is limited. Conversely, since a rural labor and delivery team would likely be smaller, members of the team may be more comfortable with one another to voice opinions.
The quantitative and qualitative data parallel one another fostering confidence in the results. The implications of this study are that the culture of a labor and delivery unit greatly influence the success in supporting vaginal birth as opposed to performing cesarean delivery. The ideal qualities of a successful team are effective communication, leadership, and diversity. The group discussed that both labor and delivery team leaders as well as patients should be aware of the findings of this study. It is important for patients to understand the factors that may influence their delivery and the options that they have.
The applicability of these findings was discussed by the group. First, hospital systems would need to identify if this is an issue that is occurring at their location. If so, it would be critical to understand the beliefs of their practice and readiness for change. Prior to implementing changes, the hospital must assess the current culture and resources available to their specific setting and identify if additional unit roles are available. The ultimate key to success would be to find a champion in the organization that can advocate for change. A barrier to implementing changes would be the buy-in from those in a position of power in the hospital, thus a champion for change would be critical. A limitation of the study identified by the group was the applicability of the findings since changes are context specific. For example, in settings where resources are limited, such as at a rural hospital, changes may not be as straightforward to implement and additional factors, like the type and number of available physicians in the area, may play a role in the rate of cesarean delivery.
Further research on this subject could explore the current decision tree that physicians on labor and delivery units use to decide between performing cesarean delivery and vaginal birth. It is not clear what accounts for the difference in attitudes on vaginal birth between physicians in practice for many years and those more recently out of residency. Such a study could identify the factors perpetuating this difference, finding another point for possible intervention.