Exploring non-clinical factors contributing to increased cesarean section rates: Does type of provider play a role?

Background: Rates of cesarean sections increased 50% between 1998 and 2008 with no evidence of improved health benefits for moms or babies in most cases. One community hospital had two separate systems of labor and delivery (L+D) care, with privately insured women delivering with an obstetrician in private practice (PrivOB), and publicly insured and uninsured women delivering within a Certified Nurse Midwife (CNM)-obstetrician hospitalist (HospOB) collaborative model. Rates for nulliparous, term, singleton, vertex births were 30.4% for private pay, 15.6% for publicly or uninsured women. Methods: PrivOBs, HospOBs, and CNMs completed a survey on attitudes about midwives, attitudes and practices regarding C-sections, and experiencing pressure to perform an elective C-section from different sources. The survey also described L+D scenarios with varied patient characteristics and asked about the degree to which participants would encourage a vaginal birth. T-tests were conducted to assess for differences in mean responses between different types of providers. Results: There were many significant differences between CNMs and PrivOBs, and HospOBs and PrivOBs, and fewer differences between CNMs and HospOBs. For women under 25, hospitalists were more likely than private OBs to recommend a VBAC (vaginal birth after cesarean) instead of C-section (M=3.78, SD= 0.44 vs. M=2.88, SD = 0.35), t(15) = -4.62, p = 0.0003. Overall, PrivOBs expressed the greatest willingness to perform C-sections in various scenarios. Conclusions: There were significant variations between provider groups regarding L+D practices which may partially explain the difference in C-section rates and suggest areas for future research and provider education.