(1110) The Effect of Second Provider Consultation and Checklist Utilization on the Cesarean Delivery Rate

Effect of mandatory second provider consultation using  California Maternal Quality Care Collaborative (CMQCC) checklist on the Nulliparous, Term, Singleton, Vertex (NSTV) cesarean rate.

Study Design: Prospective cohort study conducted 3/1/2021-2/28/2022. Unscheduled cesareans required consutation with second attending and use of CMQCC checklist. The primary provider ultimately decided whether to proceed with cesarean. Nulliparous patients with vertex, term, singleton pregnancies were included. Multiple gestations, preterm pregnancy, scheduled cesarean, malpresenting fetus were excluded. The primary outcome was NTSV cesarean rate. The study period was compared to a pre-COVID (3/1/2019-2/29/2020) and COVID cohort (3/1/2020-2/28/2021).

Results:

1365 patients were included, 10.8% Asian/Pacific Islander, 11.0% Black, 55.5% White and 20.1% Other. 50.5% were non-Hispanic. English was the primary language for 96.6%. 23.4% had public insurance. During the study period, NTSV cesarean rate was 25.6% (vs 29.4% COVID, p=0.01; vs 31.1% pre-COVID, p=0.0002). Black patients had a higher NTSV cesarean rate in all cohorts. Within the study period, the rate was 32.7% for Black, 22.7% for White, 31.8% for Asian/Pacific Islander and 27.0% for Other (p=0.01). Second opinion/checklist did not modify the relationship between race and NTSV cesarean rate (p= 0.69). Over all cohorts, the privately insured had a higher NTSV cesarean rate compared to the publicly insured (p< 0.0001). During the study period, the privately insured had a rate of 28.2% (vs 18.2% publicly insured). Second opinion/checklist did not modify the relationship between insurance and NTSV cesarean rate (p= 0.14). There was no association between ethnicity or primary language and NTSV cesarean rate. The neonatal composite outcome was 6.8% (vs 39.6% pre COVID, p< 0.0001; vs 36.1% COVID, p< 0.0001).

Conclusion:

Pre-cesarean checklist with second provider consultation reduced the NTSV cesarean rate without increasing neonatal morbidity, but disparities based on race and insurance persist.