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Marin General Hospital’s Innovative OB Program Attracts National Attention As It Decreases Cesarean Deliveries

Society for Maternal-Fetal Medicine features study on successful program

An innovative expanded midwifery program at Marin General Hospital in Greenbrae, California is significantly reducing cesarean delivery rates, according to a study to be presented the morning of Feb. 5 in an oral plenary session at the Society for Maternal-Fetal Medicine’s annual meeting in San Diego. The study is one of only eight chosen from among over 1800 papers submitted to be given as 10 minute oral presentations at the opening session of The Pregnancy Meeting™, attended by obstetricians, academic and non-academic Perinatologists from all over the world. The meeting is often the first place where major advances in OB are presented.

Rising primary and repeat cesarean delivery rates are considered a major problem in the U.S. where nearly one-third of women deliver by cesarean compared to 21 percent in 1995. Cesarean delivery is associated with a higher risk of maternal complications, longer length of stay and longer postpartum recovery but it has been difficult to lower the rates.

The study, titled The Effect of Expanded Midwifery and Hospitalist Services on Primary Cesarean Delivery Rates, examined data from a diverse patient population at Marin General Hospital, a community hospital that changed its maternity program in April 2011 making midwives available to all laboring women, and changing staffing practices to allow doctors to focus solely on their laboring patients instead of having to juggle their surgical and office responsibilities. Before the change was instituted, women cared for under the traditional, private practice obstetrician model had high cesarean delivery rates that had been increasing every year, which was the same trend taking place nationally. After the changes were made, cesarean delivery rates not only dropped but they continued to decrease more each year.

The study collected data for all singleton term deliveries at the hospital between January 2005 and April 2014. Demographic, clinical and outcome data were collected at the time of delivery.

“Both primary and repeat cesarean delivery rates have been at an all time high in recent years and it has been difficult to identify what can be done to reverse the trend,” stated Melissa Rosenstein, MD, one of the researchers on the study who is with the University of California, San Francisco, Division of Maternal-Fetal Medicine. “This research demonstrates that changing from the traditional model of obstetric care to one that expands access to midwives and to OB/GYN doctors whose schedule is structured to allow them dedicated time spent delivering babies, without having to come in from the office or from home, is an intervention that can successfully lower cesarean delivery rates and make childbirth safer.”

A copy of the abstract is available at http://www.smfmnewsroom.org and below. For interviews please contact Jamie Maites (240-506-8556).

The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine. The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed. For more information visit www.smfm.org.
 

Abstract 8: The effect of expanded midwifery and hospitalist services on primary cesarean delivery rates

Objective: To examine the impact of changing the labor and delivery care system for privately insured women from a private practice care model to a 24-hour obstetrician-midwife hospitalist model at a community hospital. Prior to adopting this change, only the hospital’s publicly insured women utilized this hospitalist model while the privately insured were managed by their individual obstetricians.

Study Design: This was a prospective cohort study of all singleton term deliveries at a single community hospital between Jan 2005 and Apr 2014. The change occurred in April 2011. Demographic, clinical, and outcome data were collected at the time of delivery. Primary cesarean delivery (CD) rates among nulliparous, term, singleton, vertex (NTSV) women and vaginal birth after cesarean (VBAC) rates among women with prior CD were compared before and after the change. Multivariable logistic regression models controlling for confounders estimated the effects of the change on the odds of NTSV CD and VBAC.

Results: There were 3684 NTSV deliveries and 1375 with prior CD during the study period; 49% were to privately insured women whose care model changed. The NTSV CD rate among these women decreased after the change, from 32.2% to 25.0% (p=0.002), while the rate did not change among publicly insured women. (Table) A 5% drop in the NTSV CD rate was estimated at the time of the change, after which the rate decreased by 2% per year. (Figure) Among the privately insured, the adjusted odds ratio (aOR) of the effect of the change for NTSV CD was 0.61 (p=0.007); for VBAC the aOR was 1.94 (p=0.035). There were no statistically significant changes in the odds of NTSV CD or VBAC among the publicly insured.

Conclusion: The change from a private practice to a hospitalist model was associated with a dramatic decrease in NTSV CD rates and increase in VBAC rates, while the rates among the women who continued under the hospitalist model did not change. Adopting this model at other US hospitals could have a significant impact on CD and VBAC rates.

About Marin General Hospital

For more information or a physician referral, please visit www.maringeneral.org or call the Marin General Health Line at 1-888-99-MY-MGH (1-888-996-9644).

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Jamie Maites                                       
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