Friday, May 8, 2015

A Midwife-Laborist Care Model Reduces Cesarean Rates

Here is brand-new research showing that a midwife-physician laborist care model resulted in lower cesarean rates than a private practice OB care model.

This could be one potent way to reduce stubbornly-high cesarean rates on a more widespread basis.

But first, let's start by discussing what a "laborist" is, since many readers may not be familiar with this model of care.

What is a "Laborist"?

More and more hospitals are beginning to implement "laborist" programs in their maternity wards. But what the heck is a "laborist"?

According to the American College of Obstetricians and Gynecologists:
The term laborist most commonly refers to an obstetrician–gynecologist who is employed by a hospital or physician group and whose primary role is to care for laboring patients and to manage obstetric emergencies.
Laborists are based on the "hospitalist" concept from other medical fields. A hospitalist is a physician that only works in the hospital and does not have care responsibilities elsewhere. Their focus is on hospitalized patients, not private patients.

A hospitalist might work up patients admitted to the hospital from the emergency room, get information from all the patient's doctors, order tests, look for potential cross-reactions between medications, and develop a plan of care for the patient's hospital stay, release, and after-care. The patient's main doctor collaborates with the hospitalist, but having a hospitalist assigned to a patient assures the patient of having a doctor immediately available if necessary, as well as someone who will coordinate care between various providers.

Basically, a laborist is a hospitalist in the OB-GYN field.

There are several different laborist models around so details can differ, but generally a laborist stays in the hospital and is in charge of consulting on patients in labor during his/her work shift. He/she would not be responsible for any other other duties or office hours, but instead manages whatever issues come up during that shift, including emergencies.

If a minor problem occurred, the woman's regular care provider and the laborist would consult on how to manage it. If there was an emergency that required immediate response, the laborist would handle it. If a c-section was needed, the laborist would do it (or would do it in conjunction with the woman's care provider). If a woman in labor came into the E.R. without an assigned physician from that hospital, the laborist would take the case. In addition, if the emergency room had an E.R. patient with a gynecological problem, the laborist would consult.

In the non-laborist model of care, a private OB group covers its own patients when they are in labor. This means that doctors must juggle covering office hours, meetings, and routine appointments with managing patients who are in labor. If there is an emergency, the doctor must drop everything to run over to the hospital and respond to the crisis. Regular patient appointments must often be rescheduled or covered by colleagues back at the office because of the unpredictable nature of labor.

Like hospitalists, the laborist care model is a rapidly expanding model of care. One survey showed that about 40% of the U.S. hospitals surveyed had moved to a laborist model, and this number is likely to increase over time.

That means it's time to have a more in-depth look at the pros and cons of laborist programs.

Advantages and Disadvantages of Laborists 

The biggest advantage of having a laborist is that an obstetric surgeon is always right at hand in the hospital, ready to intervene at a moment's notice if a true emergency occurred. 

This is HUGE in the field of obstetrics where sudden emergencies sometimes do occur. Most birthing women are surprised to learn that most hospitals don't have a doctor always on hand, ready to intervene. Thus there can be a critical delay while waiting for a physician to arrive from off-campus.

Private duty OBs juggle regular office hours with monitoring their patients in labor. They are usually on-call at a nearby office or home within a certain number of minutes, but that is not the same as being at the hospital 24/7. Having a laborist always on duty means that someone is always available right away on those rare occasions when immediate action is needed.

Another big advantage of laborist care is a more humane life-style for the care providers involved. In hospitals with laborist models, care providers have more off-duty time, more time with their families, and less need to juggle laboring patients with office hours. In a profession where stress contributes mightily to burn-out and substance abuse issues, a more sane schedule is a tremendous advantage for both care providers and the mothers they attend.

Laborists also offer business advantages. Hospitals with laborist programs have been able to reduce their malpractice premiums and do not have to hold as much money in reserve for possible liability claims. This means that even though laborists cost extra money in salaries, their overall effect often saves a hospital money.

One potential disadvantage of laborist care is less personal care. A woman might not be attended by her personal caregiver during labor. Many women feel strongly about having a personal relationship with a caregiver she knows and trusts, one who has a deep understanding of her medical history and birth preferences. A laborist model has the potential to decrease this. This is a real and substantial disadvantage.

However, the reality of hospital birth is that many caregivers already do not attend their own patients because they are part of large group practices. The mother gets whomever is on duty in the group on the day she goes into labor. Those caregivers who do promise to be there for a woman's labor often do so by inducing her when they are on duty, exposing the mother and baby to all the risks of induction and perhaps raising the risk for cesarean.

Additionally, most laborist models do allow the regular caregiver to attend a particular patient's birth if desired. It doesn't keep them from attending births, it just gives them more flexibility to balance other duties with births. And having a laborist working in conjunction with the regular caregiver might just ease some of the time constraints that caregivers feel and give the mother more opportunity to get the birth outcome she wants.

Possible Effect on Cesarean Rate

One VERY important potential advantage of having a laborist is hopefully lowering both the primary and repeat cesarean rate, while also increasing VBAC access. 

Because a private practice OB has dual duties with office hours and births, the constraints on their time may make them more quick to move to a cesarean. A laborist may have more patience to wait out a long labor because they don't have to rush off to other appointments, and they might be more willing to try alternatives (like mobility in labor, manual repositioning of the baby, etc.) when labor is "stuck." In this way, a laborist may help prevent primary cesareans, which in turn will help prevent many repeat cesareans in the future.

In addition, the current rules of many hospitals make it hard for many care providers to attend Vaginal Births After Cesarean (VBACs). Many hospitals demand that a doctor and anesthesiologist must be IN the hospital with a VBAC patient at all times, making it hard for caregivers to manage regular office hours and VBAC patients. This has resulted in many doctors refusing to attend VBAC mothers, forcing most of them into repeat cesareans.

Having a laborist on duty should boost the willingness of care providers to support VBAC patients.

This could be very important, since about one-third of U.S. hospitals have official VBAC bans, and many more have de facto VBAC bans. Many women are being forced into surgery they do not want or need by the "immediately available" VBAC criteria. Laborists can provide the 24/7 coverage needed to satisfy part of that criteria and may help bring VBAC back to many hospitals.

What Does the Research Say?

The theory has been that if laborists were added to hospitals, some lives would be saved, the quality of life of OBs would improve, and the cesarean rate would go down. But has the laborist model achieved this?

The research so far does seem to support this. In one study from Nevada, the cesarean rate dropped from 39% to 33% when a full-time laborist model was adopted ─ and this was during a period when the cesarean rate was rapidly increasing everywhere else.

[However, it's important to point out that even with the laborist model, the Nevada study still had a fairly high cesarean rate, over 30%, suggesting that there is still room for improvement.]

In 2013, three studies on laborist models were presented at a meeting of the Society of Maternal-Fetal Medicine. All three showed improvements with a laborist model of care, as summarized here:
Hospitals that employed laborists saw about a 15% decline in induction of labor and preterm deliveries after adjustment for other factors compared with centers that do not employ that OB equivalent of a hospitalist, Sindhu Srinivas, MD, of the University of Pennsylvania in Philadelphia, and colleagues reported.  
In a separate study, hospitals that provided 24-hour coverage through use of laborists or other means saw a similar reduction in cesarean delivery rates, with a more than twofold increase in attempted vaginal birth after a prior cesarean, said Yvonne Cheng, MD, PhD, of the University of California San Francisco and colleagues.
...In the third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues looked at a computer simulation comparing probabilistic scenarios for two events that require urgent delivery -- umbilical cord prolapse and major placental abruption -- at laborist and nonlaborist hospitals. In a theoretical cohort of 100,000 pregnant women, employment of laborists at hospitals with a volume of 1,000 deliveries a year would be expected to result in 83% fewer stillbirths, 17% fewer cases of major neurologic injury, and 13% fewer neonatal deaths.
So indeed, it does seem that a laborist model should save lives, lower the cesarean rate, and improve access to VBAC. Most OBs agree that it also brings a bit more sanity into their busy schedules and more time for family life.

All of this speaks strongly in favor of a laborist model of care. But what if that model of care could be improved on even further?

One hospital in California asked whether it could lower the cesarean rate even more by using both OBs and midwives in its laborist model.

Midwifery/Laborist Model of Care

Midwifery care has been shown numerous times to lower intervention rates and often c-section rates. Integrating midwives into a laborist care model might make for a particularly potent combination for reducing cesarean rates.

In this study from a community hospital in Marin, California, using both midwives and OBs as laborists helped lower the cesarean rate substantially compared to those handled in private OB practices.

In the study's private practice care model (also called an "out-of-hospital" model), a large practice of 18 OBs and 2 CNMs (Certified Nurse-Midwives) practiced together and handled 57% of the births during the 5-year study period.

In the collaborative midwife-laborist care model (also called an "in-hospital" model), a group of 20 CNMs and 25 OBs practiced together. They handled 42% of the births during the same study period. In this care model, both a midwife and an OB were on duty as laborists 24 hours a day. The care for most patients was midwife-led, with the OB laborist called in as the woman's risk factors and situation dictated.

In this study, women who were cared for in the private OB practice model had more cesareans than those under the care of midwife-laborist model, 31.6% vs. 17.3%

That's a HUGE difference. Even after adjusting for confounders, the women in private practice care had twice the risk for cesarean. They also had more inductions and more epidurals.

The midwife-laborist care model was effective for first-time mothers as well as multips. "NTSV" stands for Nulliparous, Term, Singleton, Vertex, and basically means first-time mothers, at full-term, with only one baby, and that baby is head-down. Many researchers feel these low-risk NTSV births are the best target for lowering overall cesarean rates because every primary cesarean prevented in NTSV mothers usually means that a repeat cesarean for a later birth is also prevented.

In this study, 29.8% of NTSV births in the private practice model ended in cesarean, whereas only 15.9% of NTSV births in the midwife-laborist care model ended in cesarean. That's a very important difference.

The difference was also clear in NTSV cesareans where medical judgment plays a critical part of when to move to a cesarean (such as interpreting abnormal fetal heart tracings or dealing with slower labors). In this situation, the private practice model had a 28.1% cesarean rate, versus a 15.6% cesarean rate in the midwife-laborist care model. The authors suggested that the difference may well have had to do with less competing demands for the care provider's time and as a result, more patience in labor.

The midwife-laborist care model was also helpful for mothers who had had a prior cesarean. 71.3% of women with prior cesareans had another cesarean in the private practice model, whereas 41.4% of women with prior cesareans seen in the collaborative care model had another cesarean.

This was probably both a reflection that midwives tend to be more supportive of offering VBACs, as well as the fact that 24-hour laborist care enabled more providers to meet the "immediately available" requirement without having to cancel regular office hours. So while the study did not have specific data on the "trial of labor" or success rates in each group, it's likely that midwife-laborist care model did significantly expand VBAC access at the hospital.

One item I'd particularly like studied in the future is whether a midwife-laborist care model could lower the cesarean rate in women of size. In the study, the authors did not have information on Body Mass Index and could not analyze for its effect. However, they pointed out that the midwife-laborist care model had far more Latina patients than the private OB care model. They noted that Latinas tend to have a higher prevalence of obesity than white women in the U.S. and that if that trend also held true in the study, the midwife-laborist care model "should" have had higher cesarean rates. <roll eyes> Yet the midwife-laborist care model actually had LOWER cesarean rates, despite a population that was probably heavier.

[Hmmmm. Maybe how an "obese" woman's labor is managed makes a big difference? Maybe differing expectations of normalcy make a difference? Maybe midwives should be handling more women of size? Sounds like this is a topic ripe to be studied in further detail, doesn't it?]

The authors concluded:
In this study, we observed a consistent pattern of a higher use of cesarean delivery among women cared for under a private model compared with women cared for under a midwife/laborist model...Based on our findings, the implementation of obstetrician-midwife laborist programs may also have a positive impact on reducing the rate of cesarean deliveries in the United States.
This is a study that deserves to be replicated to see if other hospitals can achieve similarly dramatic results. Heaven knows we need to reduce the amount of non-indicated cesareans we are doing in the U.S., and reducing that rate should help prevent some of the alarming downstream outcomes of a too-high cesarean rate, like placenta accreta, placenta previa, placental abruption, and cesarean scar pregnancies.

I'd also love to see researchers particularly focus on whether a midwife-laborist program can decrease the unacceptably high risk for cesarean among women of size, and thereby decrease their risks for downstream complications too.


These studies show that a full-time laborist care model can be part of a program to help reduce cesarean rates at the hospital level.

If having a laborist on duty at all times can help lower cesarean rates, make VBAC more accessible, save a few lives, and help make caregivers' lives more humane, then it's a win-win situation all around. Research shows that most women are satisfied with the care received under a laborist care model, despite some care providers' fears that they would not be.

Laborist care models seem like a winning innovation so far, but the California study shows that a midwife-laborist care model is worth looking at even more closely.

Note that the OB laborist program in Nevada reduced its cesarean rate from 39% to 33%, yet the midwife-laborist program in California reduced its cesarean rate from 31% to 17%.

This suggests that a midwife-laborist model of care is even more potent at reducing cesarean rates than an OB laborist model of care.

More research is needed to confirm these results, but this preliminary research is very promising. If hospitals are serious about lowering cesarean rates, then it's time they looked into a midwife-laborist model of care.


Am J Obstet Gynecol. 2015 Apr;212(4):491.e1-8. doi: 10.1016/j.ajog.2014.11.014. Epub 2014 Nov 13. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Nijagal MA1, Kuppermann M2, Nakagawa S3, Cheng Y4. PMID: 25446697
OBJECTIVE: The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESIGN: This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS: Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION: In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.
Am J Obstet Gynecol. 2013 Sep;209(3):251.e1-6. doi: 10.1016/j.ajog.2013.06.040. Epub 2013 Jul 29. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Iriye BK1, Huang WH, Condon J, Hancock L, Hancock JK, Ghamsary M, Garite TJ. PMID: 23904102
...In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. RESULTS: Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. CONCLUSION: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.
Other discussions of various "laborist" models:

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