Understanding the individual, provider and facility level determinants of cesarean overuse
Creators: name: Ramesh, Abhismitha
Publisher: name: University of Iowa
Year: 2024
Subjects: child
maternal
obstetrics
Public Health

description: Despite increasing cesarean (c-section) rates there is no evidence of a decrease in maternal mortality or morbidity suggesting potential c-section overuse. Prior research has shown that c-section overuse is associated with poor clinical outcomes and financial consequences. Potential determinants of c-section use include risk perception, shared decision-making barriers, and labor unit culture. Further research is necessary to examine the association between these multi-level risk factors and c-section use.
description: First, the relationship between sociodemographic characteristics and c-section risk perception accuracy among primary births was examined (aim 1). The 2013 installment of the Listening to Mothers Survey (LTM) data was leveraged for this analysis. Risk perception accuracy was determined by response to a survey question asking about agreement with c-section risk. Logistic regression modelling was employed to examine the relationship between sociodemographic characteristics and level of c-section risk perception accuracy. Overall, 23% of the sample was classified as having high accuracy of c-section risk. The study findings suggest that Black women had lower odds (OR: 0.12, 95%: 0.03-0.44) of having high c-section risk accuracy when compared to their White counterparts. The observed differences in c-section risk perception accuracy are valuable in identifying individual-level potential factors related to c-section use.
description: Second, this dissertation explored the association between shared decision-making barriers (SDM) and c-section use (aim 2). The third installment of the Listening to Mothers Survey (LTM) data was used for this analysis. SDM barrier exposure were determined by response to a survey question asking about experience with SDM barriers during prenatal visits. Logistic regression modelling was used to assess the relationship between three SDM barriers and c-section use. Overall, 25% of the sample had a c-section and 46% had experienced at least one SDM barrier during their pregnancy. The findings revealed no significant association between any of the following SDM barriers and c-section use: provider was rushed (OR:0.81, 95%: 0.51-1.27), wanted care that differed from the provider (OR:1.22, 95%: 0.74-2.02), or did not want to appear difficult with provider (OR:0.88, 95%: 0.54-1.44) SDM barriers. These study results suggest that effective SDM practices are not fully implemented during prenatal care, and that unexplored SDM elements may play a role in birth mode decision making.
description: Lastly, this dissertation examined the relationship between provider type and labor unit culture by facility improvement status within the Iowa AIM Cesarean Collaborative (aim 3). Data from the Iowa Maternal Quality Care Collaborative (IMQCC) and Iowa Labor Culture Survey (LCS) was used for this study. Provider agreement with labor unit culture practices was classified into six themes based on previously validated methodology. Mixed-effect linear regression was used to determine mean labor culture scores and score differences between nurses and physicians. Mixed-effect regression modelling was also used to identify whether there was increased cohesiveness of labor culture scores between nurses and physicians at facilities that improved in reducing c-section rates versus those that did not. Across facilities, physicians had significantly less agreement with the following labor culture practices when compared to nurses: best practice (0.38, 95%: 0.24-0.52), physician oversight (0.34, 95%: 0.17-0.51), and maternal agency (0.50, 95%: 0.30-0.71) labor culture scales. Study findings also indicated significant differences in labor culture between nurses and physicians across facilities that improved versus that did not or that were high achieving prior to the start of the collaborative. Facilities that demonstrated improvement had significantly smaller differences in labor culture between nurses and physicians for best practices to reduces cesarean delivery (0.20, 95%:0.03-0.37), physician oversight (0.25, 95%:0.05-0.47), and patient safety promoting vaginal birth (0.24, 95%:0.04-0.45) sub-scales when compared to more potential facilities. These study findings suggest that there are significant differences in agreement with labor culture practices between nurses and physicians, however there may be other factors that may be more influential than labor unit culture cohesiveness that could be driving c-section overuse.
description: In summary, each aim contributes valuable information to further the understanding of potential factors associated with c-section overuse. Future research can build upon these findings and existing literature with the use of mixed-method design to capture multi-dimensional concepts such as c-section risk-perception or SDM more accurately. These studies can help to guide future intervention efforts and translate research into practice with the goal of improving maternal and child health.