Abstract
BackgroundUnexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals.MethodsWe undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes.ResultsForty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician’s perception of medical risk in the pregnancy (influenced by the obstetrician’s personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a ‘gatekeeper’ in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates.ConclusionImproved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.
Highlights
Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences
Variation in interventions occurs due to differences in population co-morbidities and patient preference, it is unexplained variation that is of concern
Qualitative analysis of transcript and field note data found recurring themes reflecting variation in IOL decision-making of participants
Summary
Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals. One of the commonest interventions in pregnancy is induction of labour (IOL), which is associated with almost one-quarter of all births, [3, 4] with wide unexplained variation in rates of IOL between countries, [5] provinces [6] and hospitals, despite adjusting for differences in patient comorbidities [7, 8]. Women’s experiences and preferences for IOL have been explored, [10,11,12] but there are no studies investigating the role of physician practice styles, preferences and decision-making to explain variation in hospital IOL rates. We Nippita et al BMC Pregnancy and Childbirth (2017) 17:317 aimed to explore factors that influence clinical decisionmaking for IOL in New South Wales (NSW), Australia using qualitative research methods
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