Lowering Cesarean Rates, One Laborist at a Time

There is no doubt about it: birth by cesarean section has seen what seems like unstoppable growth over the last decade. At about one third of all deliveries, having a "c" has become commonplace. Increasing numbers of researchers have explored whether a new model of care for Labor and Delivery departments will decrease the c-section rate. The "laborist model" is becoming ever more popular in the United States. Now about 40% of US hospitals are using a laborist model. In this type of structuring of Labor & Delivery units, the obstetrician working on Labor & Delivery does not have a clinic to compete with her attention. Although the exact execution of the laborist model differs from hospital to hospital, it generally means that the doctor who delivers your baby is not running over from clinic but rather she spends most or all of her undivided time working on Labor and Delivery. 

Current research suggests that having a "laborist" working on Labor & Delivery leads to fewer c-sections and more readiness to try a "Trial of Labor after Cesarean" (TOLAC) in order to achieve a successful vaginal birth or "Vaginal Birth After Cesarean" (VBAC). A group of researchers from the University of California San Francisco, the Prima Medical Foundation, and Boston Medical Center teamed up with the folks at Marin General Hospital. Dr. Rosenstein and colleagues report in the October 2015 issue of the Green Journal on the changes in c-section rate and the rate of VBAC after converting from a private practice model to a laborist model. The authors collected data on the rate of c-sections and VBAC from 2005 to 2011 when Marin General Hospital's Labor and Delivery department operated under the traditional private practice model for privately insured patients. The hospital switched over to a laborist model for all patients in 2011, so the authors then collected data on the rates of c-section and VBAC from 2011 to 2014. 

In doing their statistical analysis, the authors not only looked at before and after rates, but they also analyzed the trends over time before and after to control for changes that were the result of trends unrelated to the change in delivery of care model. Their findings were consistent with many previous studies. There were 4,884 deliveries in the study period included in analysis. For privately insured women, the primary c-section rate dropped from 31.7% to 25% after the change to a laborist system. Using the fancy time-trends analysis, this is approximately a 7% drop in the primary c-section rate in the first year of implementation and then a 1.7% drop in the following years. For privately insured women, the VBAC rate increased from 13.3% to 22.4%. The same team had previously published reports on the results for publicly insured women. To summarize, publicly insured women were under a laborist model for all the years of the study, and their c-section rate and VBAC rate did not change significantly.

Perhaps laborists have a higher threshold for equivocal fetal heart rate tracings or more patience because their focus is solely on Labor and Delivery and not the clinic. Regardless of the reasons, this study adds to the existing literature suggesting that converting to a laborist model for our Labor and Delivery units is one way to decrease the cesarean section rate in the United States.