Family Medicine Presence on Labor and Delivery: Effect on Safety Culture and Cesarean Delivery

Abstract

PURPOSE Currently, 40% of counties in the United States do not have an obstetrician or midwife, and in rural areas the likelihood of childbirth being attended to by a family medi­cine (FM) physician is increasing. We sought to characterize the effect of the FM presence on unit culture and a key perinatal quality metric in Iowa hospital intrapartum units. METHODS Using a cross-sectional design, we surveyed Iowa physicians, nurses, and mid­wives delivering intrapartum care at hospitals participating in a quality improvement initia­tive to decrease the incidence of cesarean delivery. We linked respondents with their hospi­tal characteristics and outcomes data. The primary outcome was the association between FM physician, obstetrician (OB), 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 A total of 849 clinicians from 39 hospitals completed the survey; 13 FM-only, 11 OB-only, and 15 hospitals with both. FM-only hospitals were all rural, with <1,000 annual births. Among hospitals with <1,000 annual births, births at FM-only hospitals had an adjusted 34.3% lower risk of cesarean delivery (adjusted incident rate ratio = 0.66; 95% CI, 0.52-.0.98) compared with hospitals with both. Nurses endorsed unit norms more sup­portive of vaginal birth and stronger safety culture at FM-only hospitals (P