Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status

Validation of a new calculator for predicting success of vaginal birth after cesarean delivery

BACKGROUND

Race as a variable in a predictive model for a successful vaginal birth after cesarean delivery has been challenged as contributing to health inequity. In May 2022, the National Institute of Child Health and Development released a modified calculator that removed race as a variable.

OBJECTIVE

The aim of this study was to externally validate the revised calculator amongst a cohort at our institution.

STUDY DESIGN

We reviewed all patients who underwent a trial of labor after cesarean delivery in 2018 to 2020 at a tertiary academic medical center and calculated the predicted probability of successful vaginal birth after cesarean delivery for each patient using both original and revised classification calculators and compared these to observed birth outcomes. The area under the receiver operating characteristic curve was calculated for each model.

RESULTS

From the cohort of 225 patients that fit inclusion criteria, 37% (n=83) identified as African American or Hispanic, the vaginal birth after cesarean delivery success rate was 75% for the entire population, and 76% among African American and/or Hispanic patients. The area under the receiver operating characteristic curve of the original calculator was 0.71, compared to 0.74 for the new calculator. For African American and/or Hispanic patients, the average predicted success rates between the models rose from 60% to 69%.

CONCLUSIONS

Our review confirmed that African American and Hispanic patients were calculated to have a lower prediction score for a successful vaginal birth after cesarean delivery based on the original calculator as compared to the revised calculator. Our results also suggest that race/ethnicity did not significantly contribute to classification ability of the calculator in our patient population.

Racial bias in cesarean decision-making

BACKGROUND

Category II fetal heart tracing noted during continuous external fetal monitoring is a frequent indication for cesarean delivery in the United States despite its somewhat subjective interpretation. Black patients have higher rates of cesarean delivery and higher rates for this indication. Racial bias in clinical decision-making has been demonstrated throughout medicine, including in obstetrics.

OBJECTIVE

We sought to examine if racial bias affects providers' decisions about cesarean delivery for an indication of category II fetal heart tracings.

STUDY DESIGN

We constructed an online survey study consisting of 2 clinical scenarios of patients in labor with category II tracings. Patient race was randomized to Black and White; the vignettes were otherwise identical. Participants had the option to continue with labor or to proceed with a cesarean delivery at 3 decision points in each scenario. Participants reported their own demographics anonymously. This survey was distributed to obstetrical providers via email, listserv, and social media. Data were analyzed using chi-square tests at each decision point in the overall sample and in subgroup analyses by various participant demographics.

RESULTS

A total of 726 participants contributed to the study. We did not find significant racial bias in cesarean delivery decision-making overall. However, in a scenario of a patient with a previous cesarean delivery, Fisher's exact tests showed that providers <40 years old (n=322; P=.01) and those with <10 years of experience (n=239; P=.050) opted for a cesarean delivery for Black patients more frequently than for White patients at the first decision point. As labor progressed in this scenario, the rates of cesarean delivery equalized across patient race.

CONCLUSION

Younger providers and those with fewer years of clinical experience demonstrated racial bias in cesarean delivery decision-making at the first decision point early in labor. Providers did not show racial bias as labor progressed, nor in the scenario with a patient without a previous cesarean delivery. This bias may be the consequence of provider training with the Maternal-Fetal Medicine Unit Network Vaginal Birth After Cesarean Calculator, developed in 2007, and widely used to estimate the probability of successful vaginal birth after a cesarean delivery. This calculator used race as a predictive factor until it was removed in June 2021. Future studies should investigate if this bias persists following this change, while also focusing on interventions to address these findings.

Effect of birth plans integrated into childbirth preparation classes on maternal and neonatal outcomes of Iranian women: A randomized controlled trial

Background

Involvement of women in the decision-making process during childbirth plays an important role in their physical and psychosocial preparation. A birth plan allows the woman to express her expectations and facilitates her participation in her own care. The present study is the first to assess the implementation of birth plans integrated into childbirth preparation classes in Tehran, Iran.

Methods

This study is a randomized controlled clinical trial performed on 300 pregnant women at 32-33 weeks of gestation referring to four public health centers in Tehran, Iran. The participants were randomly allocated into intervention and control groups using block randomization method. A training session on the items of the birth plan checklist was held in the fifth session of childbirth preparation classes for the participants in the intervention group. Accordingly, a birth plan was prepared according to the requests of mothers. The birth plan was implemented after the women were admitted to the maternity ward. The primary outcomes were frequency of vaginal birth, mean duration of labor stages, and mean score of childbirth satisfaction. We used a checklist of maternal and neonatal outcomes, Mackey's childbirth satisfaction questionnaire, and a partogram form for data collection. Independent t-test, Mann-Whitney U-test, Chi-square test, Fisher's exact test, and logistic regression were used for data analysis.

Results

Vaginal birth rates were significantly higher in women who had birth plans compared with those without (81.9% vs. 48.7%, p < 0.001). Also, the lengths of the first and the second stages of labor were significantly shorter in women having a birth plan (p = 0.02). Women in the birth plan group were significantly more satisfied with the process of labor and childbearing (p < 0.001), and started breastfeeding after birth earlier than those in the control group (p < 0.001).

Conclusion

Having a birth plan and attending childbirth preparation classes can increase the rate of normal vaginal birth. Also, according to our results, women's participation in the decision- making process and fulfilling their preferences during birth can improve maternal and neonatal outcomes and childbirth satisfaction.Trial registration: IRCT20190415043283N2. 2020-12-07.

Factors associated with labor after cesarean in a prospective cohort

BACKGROUND

The goals of this study were (a) to determine how experiences in the first perinatal period shape birth mode preference among individuals with a first birth by cesarean; and (b) to examine the relationship between birth mode preference and other factors and subsequent labor after cesarean (LAC).

METHODS

Data are from the First Baby Study, a prospective cohort of 3006 primiparous individuals. The analytic sample includes individuals with a first cesarean birth and a second birth during the 5-year follow-up period (n = 394). We used multivariable logistic regression to examine the relationship between experiences in the first perinatal period and subsequent preference for vaginal birth, and between preference for vaginal birth and LAC in the second birth.

RESULTS

About a third of the sample preferred vaginal birth in a future birth, and 20% had LAC. Factors associated with higher odds of future vaginal birth preference were favorable prenatal attitude toward vaginal birth, lower perceived maternal-infant bonding at 1 month after the first birth, post-traumatic stress symptoms after the first birth, and desiring more than 1 additional child after the first birth. Odds of LAC were nearly 8 times higher among those who preferred vaginal birth (AOR = 7.69, P < .001). Fatigue after the first birth, post-traumatic stress symptoms after the first birth, and having higher predicted chances of vaginal birth after cesarean were also associated with higher odds of LAC.

CONCLUSIONS

Our findings suggest that the formation of preferences around vaginal birth may present a modifiable target for future counseling and shared decision-making interventions.

Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum

Objectives: Person-centered care has been increasingly recognized as an important aspect of health care quality, including in maternity care. Little is known about correlates and outcomes of person-centered care in maternity care in the United States. Materials and Methods: Data were from a prospective cohort of more than 3000 individuals who gave birth to a first baby in a Pennsylvania hospital. Person-centered maternity care was measured via a 13-item rating scale administered 1-month postpartum. Content validity was established through exploratory factor analysis. The resulting scale had scores ranging from 13 to 54, with Cronbach's alpha of 0.86. Using linear and logistic regression models to control for covariates, we examined associations between participants' characteristics and person-centered maternity care and between person-centered maternity care and postpartum outcomes. Results: Participants had a mean total score of 47.80 on the person-centered maternity care scale. Patient factors independently associated with more person-centered maternity care included older age, more positive attitude toward vaginal birth during pregnancy, and spontaneous vaginal birth. In adjusted models, higher person-centered maternity scale scores were strongly associated with many positive physical and mental health outcomes at 1 and 6 months postpartum. Conclusions: Our findings underscore the importance of person-centered maternity not just due to its intrinsic value but also because it may be associated with both mental and physical health outcomes through the postpartum period. Results suggest that policy efforts are necessary to ensure person-centered maternity care, especially for delivery hospitalization experience.

Women's perceptions of provider communication on birth options after cesarean: A qualitative study

In the United States, Hispanic and non-Hispanic Black women are more likely to have a repeat cesarean birth (RCB) than non-Hispanic White women. The underrepresentation of Hispanic women and women with previous cesarean births in prior studies has resulted in a limited understanding of the reasons for this disparity. This study used in-depth interviews to investigate the perceptions of 27 Hispanic and non-Hispanic Black and White women about the communication that took place with their providers about their birth options after a previous cesarean. The roles of cultural norms and trust in providers in communication about RCBs were also explored. Results suggest that patient-provider communication and trust of providers for Hispanic and non-Hispanic Black and White women may influence their perception of choice, uptake of information, and ability to make an informed choice regarding birth options. Findings have implications for providers and healthcare management systems who need to account for and attempt to address these differences as they directly affect women's birth outcomes.

The Impact of Culturally-Centered Care on Peripartum Experiences of Autonomy and Respect in Community Birth Centers: A Comparative Study

OBJECTIVE

National studies report that birth center care is associated with reduced racial and ethnic disparities and reduced experiences of mistreatment. In the US, there are very few BIPOC-owned birth centers. This study examines the impact of culturally-centered care delivered at Roots, a Black-owned birth center, on the experience of client autonomy and respect.

METHODS

To investigate if there was an association between experiences of autonomy and respect for Roots versus the national Giving Voice to Mothers (GVtM) participants, we applied Wilcoxon rank-sum tests for the overall sample and stratified by race.

RESULTS

Among BIPOC clients in the national GVtM sample and the Roots sample, MADM and MORi scores were statistically higher for clients receiving culturally-centered care at Roots (MADM p < 0.001, MORi p = 0.011). No statistical significance was found in scores between BIPOC and white clients at Roots Birth Center, however there was a tighter range among BIPOC individuals receiving care at Roots showing less variance in their experience of care.

CONCLUSIONS FOR PRACTICE

Our study confirms previous findings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturally-centered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners offering culturally-centered care.

Impact of socio-economic status and race on emergency hospital admission outcomes: Analysis from hospital admissions between 2001 and 2012

Socio-economic and racial/ethnic disparities in healthcare quality have been the point of huge discussion and debate. There is currently a public debate over healthcare legislation in the United States to eliminate the disparities in healthcare. We reviewed the literature and critically examined standard socio-economic and racial/ethnic measurement approaches. As a result of the literature review, we identified and discussed the limitations in existing quality assessment for identifying and addressing these disparities. The aim of this research was to investigate the difference between health outcomes based on patients' ability to pay and ethnic status during a single emergency admission. We conducted a multifactorial analysis using the 11-year admissions data from a single hospital to test the bias in short-term health outcomes for length of stay and death rate, based on 'payment type' and 'race', for emergency hospital admissions. Inconclusive findings for racial bias in outcomes may be influenced by different insurance and demographic profiles by race. As a result, we found that the Self-Pay (no insurance) category has the shortest statistically significant length of stay. While the differences between Medicare, Private and Government are not significant, Self-Pay was significantly shorter. That 'Whites' have more Medicare (older) patients than 'Blacks' might possibly lead to a longer length of stay and higher death rate for the group.

Launching the Reduction of Peripartum Racial/Ethnic Disparities Bundle: A Quality Improvement Project

INTRODUCTION

Health care organizations have a responsibility to reduce racial and ethnic perinatal health disparities. In the United States, Black women experience the worst perinatal outcomes. The process for successfully addressing this problem in clinical practice remains unclear.

PROCESS

A community hospital implemented components of the Alliance for Innovation on Maternal Health Reduction of Peripartum Racial/Ethnic Disparities Patient Safety Bundle. The purpose was to collect and share perinatal disparities data, increase staff awareness of perinatal racial and ethnic disparities, and engage staff to address these disparities at the project site. Perinatal care data were reviewed by race and ethnicity and results were shared with staff. Staff were engaged through a series of activities including a Health Equity Party, implicit bias workshop, Snack and Learn sessions, online modules, 2 grand rounds, and the establishment of a Health Equity Committee.

OUTCOMES

Racial and/or ethnic disparities were identified for perinatal outcomes and experience of care indicators including rates of cesarean birth, newborn mortality, and 30-day readmission. Of the staff 137 (65.9%) participated in project activities. The majority of participants were registered nurses (n = 82). Certified nurse-midwives (n = 10) were the profession with the highest rate of attendance (83.3%). Staff developed 26 new recommendations to address racial and ethnic disparities in care. After project implementation, mean scores of High Provider Attribution, an indicator of readiness to address health disparities, increased from preimplementation scores (P = .01). There was also a significant increase in the number of staff who reported engaging in activities to address the health care needs of racial and ethnic minority patients (P < .001).

DISCUSSION

This quality improvement project demonstrated that interventions at the health care organization level can be effective in influencing health care providers and staff to address racial and ethnic perinatal disparities.

Racial/Ethnic Differences in Socioeconomic Status and Medical Correlates of Trial of Labor After Cesarean and Vaginal Birth After Cesarean

Objectives: Black and Latinx women have higher rates of trial of labor after cesarean (TOLAC) compared with White women, but lower rates of vaginal birth after cesarean (VBAC). This study examined potential racial/ethnic differences in correlates of TOLAC and VBAC. Materials and Methods: The analytic sample includes term, singleton hospital births to women with one prior cesarean in birth certificate data for 2016. We estimated associations between medical factors (diabetes, hypertension, and prepregnancy obesity) and socioeconomic status (education level and insurance type) and TOLAC and VBAC using logistic regression, stratifying by race/ethnicity and testing whether coefficients differed across models. Results: Hypertension and obesity were more strongly related to reduced chances of TOLAC among White women than among women of color. For example, having a body mass index (BMI) between 30 and 39 (vs. normal BMI) was associated with a 6.3 percentage-point (pp) lower probability of TOLAC for White women, a 5.9 pp lower probability for Black women, and 2.9 pp lower probability for Latinx women. Paying out-of-pocket for birth was associated with a 5.5 pp increase in the probability of TOLAC among White women, versus a 3.2 pp decrease among Black women. Overweight and obesity were associated with lower probability of VBAC, but the magnitude of this association was smaller for Black and Latinx women than for White women. Conclusions: More research is needed to elucidate the underlying decision-making processes that lead to these associations. Future work should focus on ensuring equity in access to VBAC-supportive providers and hospitals and fostering informed decision-making after a prior cesarean.

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes

OBJECTIVE

This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction.

STUDY DESIGN

This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery.

RESULTS

Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours, p = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin.

CONCLUSION

In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.

Women's preference for vaginal birth after a first delivery by cesarean

BACKGROUND

Nearly 90% of United States pregnant women with a prior cesarean give birth by repeat cesarean. Public health goals encourage greater use of vaginal birth after cesarean (VBAC), but there is little prospective data on predictors of women's preference for VBAC. We characterized predictors of women's preferred mode of delivery after a first cesarean and thematically categorized reasons for their preference.

METHODS

Data were from a cohort of 3006 women whose first childbirth was in Pennsylvania in 2009-2011. The analytic sample included women who had their first birth by cesarean and reported mode of delivery preference for their next delivery at 12 months postpartum (n = 616). Associations with future birth mode preference were assessed using multivariate logistic regression, and reasons for preference were categorized using content analysis.

RESULTS

At 12 months postpartum, 45% of women who delivered by cesarean in their first birth wanted to have their next delivery vaginally. Independent predictors of VBAC preference were Black race/ethnicity, nonrecurrent indication for the first cesarean, planning three or more additional children, and difficulty recovering from the first cesarean. The most common reason for preferring a vaginal birth was wanting the experience of vaginal birth; the most common reason for preferring cesarean birth was that the first birth was by cesarean.

CONCLUSION

Nearly half of respondents preferred VBAC in future births, but national estimates indicate that only about 12% of women with prior cesareans have a VBAC. This suggests a need to ensure greater access to VBAC for women who want it.

Factors influencing women's perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth

OBJECTIVE

To examine correlates of shared decision making during labor and delivery.

METHODS

Data were from a cohort of women who gave birth to their first baby in Pennsylvania, 2009-2011 (N = 3006). We used logistic regression models to examine the association between labor induction and mode of delivery in relation to women's perceptions of shared decision making, and to investigate race/ethnicity and SES as potential moderators.

RESULTS

Women who were Black and who did not have a college degree or private insurance were less likely to report high shared decision making, as well as women who underwent labor induction, instrumental vaginal or cesarean delivery. Models with interaction terms showed that the reduction in odds of shared decision making associated with cesarean delivery was greater for Black women than for White women.

CONCLUSIONS

Women in marginalized social groups were less likely to report shared decision making during birth and Black women who delivered by cesarean had particularly low odds of shared decision making.

PRACTICE IMPLICATIONS

Strategies designed to improve the quality of patient-provider communication, information sharing, and shared decision making must be attentive to the needs of vulnerable groups to ensure that such interventions reduce rather than widen disparities.

Birth plans-Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study

OBJECTIVE

To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction.

METHODS

This was a prospective cohort study of singleton pregnancies greater than 34 weeks' gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi-squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables.

RESULTS

Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61-2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan.

CONCLUSION

Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth-related patient satisfaction.