Provider and hospital factors associated with vaginal birth after cesarean: A survey of obstetric providers at two inner city teaching hospitals

Abstract

CESAREAN: A SURVEY OF OBSTETRIC PROVIDERS AT TWO INNER CITY TEACHING HOSPITALS ETOI GARRISON (F), LENORA SMITH, LAURI GIVENS, HOWARD STRASSNER, LAURA STUDEE, HIBBARD JUDITH, SARAH KILPATRICK, University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, Illinois, Rush University Medical Center, Obstetrics and Gynecology, Chicago, Illinois OBJECTIVE: To determine if there is an association between provider opinions regarding Vaginal Birth after Cesarean Section (VBAC) and the VBAC rate at two teaching hospitals. STUDY DESIGN: 123/128 providers were surveyed at both hospitals regarding VBAC experience, management, counseling, and malpractice. VBAC statistics for 2004 were obtained from a medical record database. Categorical data were assessed by Relative Risk (RR), Pearson’s Chi square, or Fisher’s exact test, p!0.05 was considered significant. Linear regression analysis was used to determine variable association. IRB approval was obtained. RESULTS: In 2004, the VBAC rate was 39% at Hospital A and 1.4% Hospital B. At Hospital A, certified nurse midwives (CNM) and family practice (FP) attendings co-manage VBAC patients with OB attendings. There were no significant differences between OB attendings (n = 20), CNMs (n = 25), and residents (n = 32) within Hospital A or between attendings (n = 14) and residents (n = 24) within Hospital B. Attendings were 6 times more likely at Hospital A to ‘‘encourage’’ VBAC to women with a prior low transverse cesarean delivery (LTCD) [RR 6.30, 95% CI 1.7-22.9]. With an unknown scar, 50% of OB attendings at hospital B would ‘‘discourage’’ VBAC while 60% of OB attendings at Hospital A would ‘‘encourage’’ this option (p!0.05). Attendings were more likely to feel ‘‘comfortable’’ with VBAC induction at Hospital A than at Hospital B [RR 1.90, 95%CI 1.11-3.24]. More attendings at Hospital B believed that ‘‘lack of support from other physicians’’ and ‘‘fetalmaternal concerns’’ limited VBAC success [RR 3.3, 95%CI 1.1-10.7]. More patients with private insurance were delivered at Hospital B (B34.2% vs A1.6%), p!0.05. All of the attendings at Hospital B have private malpractice insurance compared to none of the attendings at Hospital A. There was a significant association between hospital VBAC rate and the encouragement of VBAC (R 0.57, p!0.005). CONCLUSION: Providers at teaching hospitals with a high VBAC rate are more likely to have favorable opinions regarding VBAC counseling and management. S124 SMFM Abstracts