Cesarean overuse and the culture of care

To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.

Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.

Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.

Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.

1718 respondents from 70 hospitals responded to the Labor Culture Survey. The "Unit Microculture" subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8-items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = -47 to -35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.

Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.