Dissertation
Understanding the individual, provider and facility level determinants of cesarean overuse
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Summer 2024
DOI: 10.25820/etd.007614
Abstract
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.
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.
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.
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.
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.
Details
- Title: Subtitle
- Understanding the individual, provider and facility level determinants of cesarean overuse
- Creators
- Abhismitha Ramesh
- Contributors
- Jonathan Platt (Advisor)Stephanie Radke (Committee Member)Ryan Carnahan (Committee Member)Hyunkeun Cho (Committee Member)Nichole Nidey (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Epidemiology
- Date degree season
- Summer 2024
- DOI
- 10.25820/etd.007614
- Publisher
- University of Iowa
- Number of pages
- xiii, 93 pages
- Copyright
- Copyright 2024 Abhismitha Ramesh
- Language
- English
- Date submitted
- 07/17/2024
- Description illustrations
- illustrations, tables
- Description bibliographic
- Includes bibliographical references (pages 77-93).
- Public Abstract (ETD)
- Despite increasing c-section rates there is no evidence of a decrease in poor maternal health outcomes suggesting potential c-section overuse. Research studying c-section overuse is important, as it is associated with poor clinical outcomes and financial consequences. In aim 1 of this dissertation, we found that less than half of the women in the study had adequate c-section risk perception accuracy, and that Black women had decreased odds of having high accuracy when compared to White women. The observed differences in c-section risk perception accuracy are valuable in identifying potential individual-level factors related to c- section use. Aim 2 explored the relationship between shared decision-making (SDM) barriers and c- section use. We found that almost half of respondents experienced at least one SDM barrier. The study results indicate that there is a not a significant relationship between the explored SDM barriers and c-section use. These results encourage future research to explore other SDM constructs that may influence birth mode decision making and potential SDM differences between c-section indications. Aim 3 examined the relationship between provider type and labor unit culture by facility improvement status within the Iowa AIM Cesarean Collaborative. (aim 3). We found that physicians had less agreement with most labor culture practices supportive of vaginal birth when compared to nurses. 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 participation in the collaborative. Improved facilities had smaller differences in labor culture between nurses and physicians for best practices to reduces cesarean delivery, physician oversight, and patient safety promoting vaginal birth sub-scales when ix compared to facilities with more potential. Given the consistency in provider type labor unit culture differences, it is possible that there may be other factors that could be more influential on c-section use than cohesiveness of labor culture between providers. The evaluation of labor unit culture change over time may also be a useful tool in predicting quality improvement efforts towards reducing c-section rates.
- Academic Unit
- Epidemiology; Addiction Medicine; Craniofacial Anomalies Research Center
- Record Identifier
- 9984698250202771
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