Low-Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors.

Lundsberg LS1, Main EK2,3, Lee HC4,5, Lin H6, Illuzzi JL1,7,8, Xu X1.

Author information

1: Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
2: California Maternal Quality Care Collaborative, Stanford, California.
3: Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California.
4: California Perinatal Quality Care Collaborative, Stanford, California.
5: Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
6: Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut.
7: Laborists and Midwifery Section, Yale Medicine, New Haven, Connecticut.
8: Vidone Birthing Center, Yale New Haven Hospital, Saint Raphael Campus, New Haven, Connecticut.

Abstract

INTRODUCTION:

Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals.

METHODS:

Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis.

RESULTS:

We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group.

DISCUSSION:

Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.