(353) Changing Labor Unit Culture and Cesarean Delivery: A Prospective Study

To assess the association between maternity unit culture change and improvement in hospital nulliparous, term, singleton, vertex cesarean birth (NTSV CB) rates.

Study Design:

Clinicians at 69 Michigan birthing hospitals participating in the Obstetrics Initiative (OBI) funded by Blue Cross Blue Shield of Michigan were invited to complete the Labor Culture Survey (LCS) in 2020 and 2022 as a part of a statewide initiative to lower the NTSV CB rate.The LCS includes 28 Likert-style items covering 7 subscales measuring individual attitudes, beliefs and perceptions of unit norms. We examined the relationship between changing LCS scores and reduction of the NTSV CB rate. Excluding hospitals with a 2020 NTSV CB rate below the Healthy People 2030 (HP2030) goal (≤23.6%) we defined “successful” hospitals as those that either (a) achieved the HP2030 goal, or (b) reduced their NTSV CB rate by ≥5 percentage points by 2022. We compared differences in LCS scale means using Wilcoxon rank sum tests.

Results:

57 hospitals participated in the LCS both years, 44 (77%) of which had an NTSV CB rate above the HP2030 goal in 2020. Of these, 8 met criteria for “successful” hospital designation. There were no significant baseline differences in LCS scores between groups. In 2022, successful hospitals had significantly lower fear of vaginal birth (Fear) and significantly higher estimation of unit microculture supportive of vaginal birth (Table 1). Fear decreased over time at successful hospitals (-0.07, 95% CI -0.16 to 0.02, p< .05) and increased at unsuccessful hospitals (0.04, 95% CI -0.01 to 0.09, p< .05).

Conclusion:

Over the two year period, decreasing clinicians’ fear of vaginal birth was most predictive of successfully improving NTSV CB rates. Clinicians’ fear, as a barrier to change,  may impact the success of initiatives to safely reduce NTSV CB rates and should be considered in hiring decisions, training activities, and peer-support processes.