It's well known that the rate of c-section in the United States is higher than it should be at 32 percent. It's also clear that the United States' high rate of death for moms and babies is not being helped by the amount of c-sections performed and that current maternal medical practices are not yielding better outcomes.
A study just published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing(JOGNN) called "Variation in Cesarean Birth Rates by Labor and Delivery Nurses" examines how individual nurses can influence the mode of birth (cesarean or vaginal) of patients in their care. The study also examines how individual nurses affect the care and outcomes of women and newborns during childbirth. This is the first time that researchers have examined the nurse's role for cesarean outcomes, but cesarean rate variations among physicians have been well-studied.
According to obstetrician Neel Shah, one of the researchers on this paper, both the hospital a person chooses to birth at and the provider that a person chooses to birth with may be the biggest predictors of the likelihood of giving birth by cesarean. What role does the labor and delivery nurse assigned to that laboring person play in that outcome?
Labor and delivery nurses attend almost all of the 4,000,000 births that occur in the hospital setting in the USA (Bingham and Ruhl, 2015). Previous research has shown that nurses affect a physician's clinical behaviors and decisions in labor. Labor and delivery nurses can have influence in their communication and ability to negotiate with physicians to provide additional time for labor. Nurses also are able to discuss and share their clinical opinions on baby's health and management of pitocin. Other factors regarding the role of the nurse in birth outcomes include how many nurses are caring for the patient through the course of the labor, a nurse's beliefs about birth, and how much time a nurse spends providing labor support versus other clinical duties. It is possible that an increased number of nurses managing a woman in labor, a nurse's belief that birth is a risky process, and less time spent providing direct nursing care and support at the bedside might increase the risk for cesarean.
How was the study done?
The researchers examined the cesarean rates in retrospect (after they happened) at a single, large, tertiary care (ie, "major") hospital. The facility sees approximately 3,500 births each year. Nurses are assigned to patients regardless of a person's risk for cesarean birth. All of the patients included in this study were nulliparous women (first-time pregnancy and birth), presenting with a term (at least 39 weeks), singleton fetus (only one baby) in the vertex position (head down) -- also known as "NTSV," which is considered the standard low-risk patient.
A total of 72 nurses fit the requirements for the study and were evaluated over a period of two and a half years, which totaled a review of 3,031 births. All schedule cesareans were excluded. After all the data was pulled, each nurse's cesarean rates were calculated from the total NTSV births they attended in the study period. The nurses were put into four groups based on their calculated cesarean rates. To determine if significant differences existed in the women included in the study, characteristics like maternal age, gestational age, birth weight, Apgar scores, and time of birth were compared.
What were the findings?
The findings showed a significant variation (nearly threefold) in the cesarean birth rates across labor and delivery nurses at the same institution. The nurses' NTSV cesarean rates ranged from 8.3% to 48.0%, with an average of 26.0%. For births that occurred during day shifts (1,535 births) the average nurse NTSV cesarean rate was 27.8% and for births that occurred during night shifts the average nurse NTSV cesarean rate was 23.8% (1,496 births). It may be helpful to know as a reference point that the cesarean rate among women with NTSV pregnancies at this hospital in 2015 was 24.3%.
The findings suggest that the nurse assigned to a birthing patient may influence the likelihood of cesarean birth for that patient. This finding is in line with previous research that found that which physician attended a labor and birth influenced a person's likelihood to have a cesarean birth. This is called the "physician factor." There appears to be a "nursing factor" at play as well. Although most nurses had rates similar to the hospital’s overall rate, a 40% difference was observed between the nurse with the highest rate and the nurse with the lowest rate.
Discussion and Conclusion
What could be the differences among various nurses? Differences in birth beliefs, skills, education levels, and experience levels could all contribute to the observed differences. Maybe those nurses who understand and consider physiologic birth (birth as it occurs naturally, without medical intervention) to be the norm have different behaviors that contribute to the difference. When nurses see labor and birth as an activity fraught with risk and danger, they may practice differently than those who see birth as normal (until it is not). As nurses were not identified in this study, each being assigned a number only, it is not possible to evaluate the above variables. Nurses assigned to the birth may not have been the nurse that provided the bulk of the patient care, which could also impact the results. The authors agree that more research is needed to take a deeper dive into examining how various factors of individual nurses impact cesarean rates of the patients they serve.
I was able to connect with Neel Shah, MD, MPP one of the study investigators and asked his thoughts around what families and professionals can learn from this study. He responded:
"We completely agree that this raises many questions and we are submitting an NIH grant next week to address some of them. The biggest question is how much influence does the nurse actually have on a person's chances of getting a c-section? Does one nurse at the hospital make their risk six times higher compared to another?
Last year we published this paper that makes the case for why your nurse matters. Nurses spend more time at the bedside than any other clinician and represent the largest clinical workforce. Everyone who works on a labor and delivery unit knows that some nurses are better than others. When it comes to c-sections, our goal is to try to understand what it is that makes the best nurses so good and how we can extract lessons for everyone else."
I have many questions and look forward to further studies that examine the impact that labor and delivery nurses have on cesarean rates. As a birthing family, you deserve transparency of care and improvement in practices to deliver better care.
A more in-depth version of this article can be found on our sister blog, Science & Sensibility.
Bingham, D., & Ruhl, C. (2015). Planning and evaluating evidence- based perinatal nurse staffing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(2), 290–308. http://dx.doi.org/10. 1111/1552-6909.12544
Edmonds, J. K., O'Hara, M., Clarke, S. P., & Shah, N. (2017). Variation in Cesarean Birth Rates by Labor and Delivery Nurses. Journal of Obstetric, Gynecologic & Neonatal Nursing.
Sharon Muza, BS, CD(DONA) BDT(DONA), LCCE, FACCE has been an active childbirth professional since 2004, teaching Lamaze classes and providing doula services to hundreds of couples through her private practice in Seattle, Washington. She also is a birth doula trainer and childbirth educator trainer. Sharon is a former co-leader of the International Cesarean Awareness Network’s (ICAN) Seattle Chapter, and a former board member of PALS Doulas and Past President of REACHE. Sharon has been the community manager and writer for Science & Sensibility, Lamaze International’s blog for birth professionals, since 2012. Learn more about Sharon at SharonMuza.com.