By John C. Hobbins, MD
Professor, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora
Dr. Hobbins reports no financial relationships relevant to this field of study.
: A study assessing the effects of instituting a model of certified nurse midwife with MD laborist backup on a private patient population showed a decrease in cesarean section rate and an increase in vaginal birth after cesarean delivery rate without any change in combined neonatal outcome.
: Rosenstein MG, et al. The association of expanded access to a collaborative midwifery and laborist model with Cesarean delivery rates. Obstet Gynecol 2015;126:716-723.
For many reasons, there has been a recent trend for labor management to be overseen in shift fashion by hospitalists (“laborists”), but little attention has been directed to the patient-related benefits and/or liabilities of these programs. To address these needs, Rosenstein et al launched a study to assess various clinical outcome measures before and after adopting a combined laborist/certified nurse midwife (CNM) program.
Marin County Hospital delivers care to a mixed pregnant population of public and private patients. Prior to 2011, the public patients insured under California’s Medi-Cal program, comprising about half of the patients, were cared for predominantly by CNMs, with backup by in-house “laborist” MDs employed by the hospital. The private patients were delivered by private practitioners, often taking calls from their offices or homes. In 2011, it became economically unfeasible to support the laborist/CNM type of coverage for the public patients only, so this type of coverage was expanded to include private patients wishing to use this practice model. Ten private physicians from community practices were hired part time to provide in-house shift coverage for the public and private patients in the new program. They functioned as backups to on-duty CNMs. Those not choosing this program were followed by the original private practice model. The apparent win/win aspect of the new program was more convenient for the physicians and, interestingly, became progressively more appealing to the private patient population as demonstrated by the CNM/laborist private deliveries increasing from 21% initially to 42% three years later.
The authors focused on three dependent variables: cesarean section rate (CSR), rate of vaginal birth after cesarean (VBAC), and combined neonatal outcomes, and comparisons were made between public and private patients before and after the program launched.
Between April 2005 and March 2014, there were 13,194 births, and of those meeting study criteria, 3413 were delivered before 2011 and 1474 were delivered after this time. Half of the patients had private insurance (49%). In publicly funded patients, 80-90% of deliveries were by CNMs before and after the program began.
In the private nulliparous group, the CSR decreased from 31.7% to 25% with the new program (odds ratio, 0.56; 95% confidence interval, 0.39-0.81). In contrast, the public patient CSR remained essentially the same at 15.5-16.1% throughout the study period. Interestingly, in the private group, the CSR rose steadily at a rate of 0.6% prior to the program’s start but had an immediate drop of 6.9% over the first year, while continuing to drop at 2% per year thereafter. VBAC rates in privates increased from 13.3% to 22.4% (P < 0.002). VBACs in the publicly insured patients stayed about the same, but the slope showed a gradual downward trend before and through the program’s initiation (following a nationwide pattern). There were no significant differences in combined neonatal morbidity between groups before or after the program began.
COMMENTARY
This study indicated that moving from a typical private practice labor model of having physicians from individual practices exclusively managing and delivering the patients in their practices to a combined CNM/laborist model resulted in lower CSRs and higher VBAC rates. The predominantly CNM-delivered public patients had consistently lower CSRs and higher VBAC rates than the private model, but there was little difference before and after the program began. The authors also noted that the new model was less expensive to maintain.
So the new system seemed to attain the goals set forth by the American College of Obstetricians and Gynecologists to reduce the CSR without adversely affecting neonatal outcomes, while costing less.
The “good old days” credo of following one’s patients in labor from start to finish, resorting to a handoff only when the doctor was too tired to function properly, is becoming a relic. Actually, this concept has been undergoing a fade out for many years, giving way to a model based on part-time employment, physician convenience, and, potentially, better patient safety. The CNMs provide the adjunctive components of competency and compassion.
The patients one might suspect to be the least satisfied are those possibly expecting to be managed throughout their pregnancies and delivered by the physician whom they had personally chosen to undertake their care. However, this has become an unrealistic expectation, since for years the obstetrician often has been juggling many balls in the air, only one of which involves labor management. And the warm and fuzzy aspects of labor management that are touted on websites and call-waiting advertisements are often provided at least as well by CNMs.
So, although some of us old timers might lament the probable demise of the old model, it seems that patients don’t expect this type of continuity of care anyway. Nevertheless, it is hoped that while we are adapting to the various new pressures of practicing medicine in an era of complicated electronic medical records, imposed documentation, relentless regulations, malpractice worries, and the current “punch in and punch out” mentality, the compassion and warmth with which we have always tried to deliver care can be retained.
