Obstetric anesthesia workforce survey: twenty-year update.

A dvances and changes in any medical specialty are often defined and detected by surveys. This is particularly true in obstetric anesthesia, especially given the complications arising from medicolegal, financial, maternal, and fetal considerations. Economic pressures, payment variations, decreased numbers of anesthesia providers, patient expectations, and technical aspects have challenged obstetric anesthesia practice. This 2001 obstetric anesthesia workforce survey was performed in conjunction with the Society from Obstetric Anesthesia and Perinatology to estimate and assess current trends and identify potential areas for improvement. A stratified random sample frame of 1300 hospitals was selected. The institutions were stratified based on geographic region and number of births for that year (stratum I, >1500 births; II, 500–1499 births; and III, 100–500 births). Three key labor and delivery personnel were identified at each institution that responded to the initial query. These personnel included from each hospital the chief of anesthesiology, the chief of obstetrics, and the labor and delivery manager. The number of hospitals providing obstetric care decreased from 4163 in 1981 to 3545 in 1992, to 3160 in 2001. A substantial decrease in stratum III facilities occurred between 1992 and 2001 (1603 down to 1081). A total of 378 of the 1300 initially sampled hospitals responded to the request for contact information (29% overall response). In the anesthesiology survey, the response rate was 57% and that for the obstetrics survey was 45%. In the labor and delivery manager survey, the rate of response was 75%. An overall increase in the percent of maternity cases using regional analgesia for labor was noted across all strata. The use of epidural analgesia for labor increased compared with previous surveys; spinal analgesia was used in <10% of cases. Patient-controlled epidural analgesia was used in about 33% of stratum I and II hospitals but in only 18% of stratum III hospitals. For cesarean delivery, use of spinal anesthesia increased and use of epidural anesthesia decreased across all strata. Combined spinal-epidural anesthesia was used in <10% of cesarean deliveries in all strata. Availability of in-house regional analgesia during labor was reported by only 3% of the smallest hospitals. In-house coverage was available in 77% of stratum II hospitals, and only 3% of stratum III hospitals reported that regional analgesia for labor was unavailable. Across all strata in 2001, an anesthesiologist was slightly more often directly involved in the care of patients receiving regional analgesia for labor compared with 1981 and 1992 survey data. In stratum III hospitals, 34% of regional analgesics for labor were administered by independently practicing certified nurse anesthetists, with 14% administered by these personnel under the medical direction of nonanesthesiologist physicians. Pediatricians performed an average of 42% and 48% of neonatal resuscitations during cesarean deliveries in stratum I and II hospitals, respectively. Vaginal birth after cesarean delivery (VBAC) was allowed in 98% and 92% of stratum I and II hospitals, but only 68% of stratum III institutions. Only 25% to 30% of all patients attempted it across all strata. Based on the American College of Obstetricians and Gynecologists practice bulletin on VBAC, 40% of stratum III hospitals no longer perform VBAC, and stratum I and II hospitals reported a reduction in VBAC attempts. Across all strata, at least 60% of VBACs were successful. Most institutions in all strata required anesthesia providers to be in-house during epidural infusion. Between 63% and 94% of hospitals required providers to be in-house when women were attempting VBAC with regional analgesia. Although almost all hospitals allowed ambulation during labor, only about 50% allowed ambulation during epidural or combined spinal-epidural analgesia. Interestingly, only a very small percentage of patients actually ambulated. Across all strata, <10% of hospitals allowed labor floor nurses (LFNs) to reinstitute epidural infusions. LFNs could adjust infusion rates in 28% and 7% of stratum II and I hospitals, respectively. LFNs were allowed to administer epidural boluses in 13% and 3% of stratum II and I hospitals, respectively. Collection rates for professional fees for anesthesia for labor, vaginal and cesarean deliveries, and other surgical procedures steadily decreased from 1981 to 2001. Collection rates for cesarean delivery declined from 76% in 1981 to 70% in 1992 to 66% in 2001. Respective anesthesia collection rates for labor and vaginal delivery were 67%, 68%, and 60%, and for other surgical procedures, 85%, 74%, and 68%. Stratum I hospitals had the largest percentage of health maintenance organization payers, and stratum II and III institutions the largest percentage of Medicaid payers. Percentage payment of actual charges was similar among all groups of payers across all sizes of hospitals. The 2001 survey results indicate that, despite staffing and payment challenges in obstetric anesthesia care, availability of services and anesthesia personnel have improved.