Patient Safety Culture or Embracing Low Intervention Evidence‐Based Care to Support Vaginal Birth: Where Should Hospitals Start?

Abstract

Research ObjectiveApplying safety culture concepts – effective teamwork, psychological safety, engaged leadership, vigilance, and error reporting ‐ to the prevention of medical errors has seen broad support to reduce catastrophic outcomes (i.e., maternal mortality, hemorrhage, eclampsia, etc); however, their role in efforts to minimize overuse is less clear. This study aimed to evaluate safety culture on maternity units in relation to cesarean overuse, and examine whether it is independent of vaginal birth culture, which emphasizes evidence‐based low intervention care.Study Design6 Likert‐style items measuring safety culture themes were developed based on previous qualitative interviews of nurse and physician maternity unit clinical leads and were appended to the validated Labor Culture Survey (LCS). Within the LCS, the vaginal birth unit microculture (VBM) scale consists of 8 Likert‐style items assessing unit norms around supporting vaginal birth. Birth certificate data and hospital characteristics were linked with hospitals and respondents' survey responses. Multivariate Poisson regression analyses were adjusted for hospital demographics and clinical risk profiles.Population StudiedNurses, midwives, and physicians providing intrapartum care at hospitals in Michigan participating in quality improvement efforts to reduce cesarean overuse.Principal Findings3011 clinicians from 54 out of 57 participating hospitals completed the survey with a minimum unit response rate of 30% per hospital. Safety culture individual item scores showed significant association (p < 0.05) with cesarean delivery rates after adjustment for hospital demographics and clinical risk. Specifically, as agreement increased on the following safety culture items, cesarean delivery rate decreased: a) frequent treatment team communication to discuss supporting vaginal; b) team members have equal input in management decisions; c) team members feel safe and encouraged to speak up if a patient's chance of having a vaginal birth may be negatively affected by management decisions; d) hospital leadership is engaged in making change to support vaginal birth; e) individual feels personally responsible to maximize the patient's chance of having vaginal birth; and f) nurses feel encouraged to play an active role in making patient management decisions. A safety culture composite score demonstrated a strong association with reduction in cesarean rate by hospital [−16% (95% CI ‐0.30 to −0.03)], parallel to but lower in magnitude to VBM [−30% (95% CI ‐0.48 to −0.13)]. No significant interaction effect between mean VBM and safety culture of a hospital was found (p = 0.79), suggesting that the effect of VBM versus safety culture on the hospital cesarean delivery rate are independent.ConclusionsVaginal birth microculture remains the strongest predictor of cesarean delivery overuse; however, safety culture characteristics including teamwork, psychological safety, and communication demonstrate a strong association with lower cesarean delivery rates, which appear to be similarly important, and independent of vaginal birth culture.Implications for Policy or PracticeHospitals addressing cesarean overuse should prioritize readiness for both the specific norms and behaviors of promoting vaginal birth and promoting a broader culture of safety. Measuring both aspects of hospitals' culture during quality improvement efforts may provide insight into organizations with high patient safety profiles that still struggle with high cesarean delivery rates.Primary Funding SourceSupport for the Obstetrics Initiative is provided by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program.