By John C. Hobbins, MD
Professor, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora
Dr. Hobbins reports no financial relationships relevant to this field of study.
SYNOPSIS: A recent study has shown a decrease in rates of induction, cesarean section, and preterm birth in hospitals after instituting a laborist model, compared with matched-control hospitals using the traditional model.
SOURCE: Srinivas SK, Small DS, Macheras M, et al. Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes. Am J Obstet Gynecol 2016;215:770 e1-9.
There is a growing movement in this country to compartmentalize the management of inpatient from outpatient care. Patients admitted to the hospital are handed off to physician hospitalists, who are then in charge of their care until discharge. This happens often without input from the patients’ primary care physicians, or, in pregnancy, their obstetricians. In the latter case, the hospitalist becomes a “laborist.” The movement was initiated to improve efficiency and safety (by avoiding fatigue). Yet, until now, data have been scarce to demonstrate that these goals have been met.
Srinivas et al collected information from the National Center/Quality Analytic Services Database on patient outcomes before and after three years of experience with a laborist model. Each of eight hospitals who started this system between 2000 and 2010 were chosen and compared to two carefully matched control hospitals that did not have this type of system in place during the same time span. Rates of the following were analyzed: cesarean sections, chorioamnionitis, inductions of labor, preterm birth (PTB), lengthy hospital stays, five-minute Apgar scores < 7, birth asphyxias, birth injuries, and neonatal deaths.
Data were analyzed from 550,000 patients in the 24 hospitals chosen for the study. In concert with the rising trend in the United States during the study periods, the cesarean section rate rose in both the laborist and control hospitals. However, the rise was 33% less in the former group than in the control group (1.07% vs. 3.22%; P = 0.011). Also, the labor induction rate rose during the same study window but was 17% less in the laborist hospitals vs. controls (0.68% vs. 3.9%; P = 0.09). The only difference in the above neonatal outcome measures was an actual drop in PTB in the laborist group by 0.68%, while in the control group the rate increased by an average of 0.99% (P = 0.04) over the study period. Breaking this down further, the investigators found the major difference to be in spontaneous PTBs, rather than in medically indicated early deliveries. There were no statistically significant differences between groups in any of the other outcomes studied.
This study suggests that there may be a slight but significant reduction in inductions, cesarean sections, and PTBs when a laborist model is introduced, with seemingly no downside — at least, regarding the maternal events and neonatal outcomes that were evaluated. The authors postulated fewer inductions led to lower cesarean section rates. Fewer inductions also beget fewer PTBs, because in the control group some of these inductions could have been in patients in the “iffy” gestational age range that could overlap into the 36-36/6 week “late PTB” category. The authors then speculated, and I think appropriately, that these inductions in the control hospitals might have been booked for times that were more convenient for the patient or the provider.
The study design had limitations. Based on the only data that were available, the authors could not document their late PTB hypothesis and, although they felt they had weeded out many of the confounding variables, they could not address the possibility that laborist models vary between hospitals and that certified nurse midwives, often working in conjunction with laborists, might have had a greater effect than the laborist alone.
One possible downside often glossed over is the emotional effect that this type of compartmentalized care has on patients who may be still expecting the continuity once provided by their primary caregiver. However, it seems that today’s patients may be even more adaptable to this model than their older providers (who for years have willingly provided continuity of care for their laboring patients), as long as they have been apprised of the handoff model when obstetrical care is first undertaken. Time will tell how well this plays out.