Provider Staffing Models on Military Labor & Delivery Units: A Cross-Sectional Study

A variety of approaches to provider staffing (including physicians and certified nurse midwives) of Labor and Delivery (L&D) units exist nationwide, with variation based on volume, patient acuity, available resources, and the need to support training programs. Our objective was to describe provider staffing models at stateside U.S. military L&D units based on delivery volume.

The study protocol was submitted to the Naval Medical Center Portsmouth Clinical Investigations Department and exempted from review. We performed a cross-sectional study. An investigator contacted a representative from each stateside military treatment facility (MTF) that provides in-house L&D care (n=28). De-identified staffing schedules for January to March 2023 were obtained and reviewed and additional information was collected, including onsite residency training platforms, in-house versus home call, and use of a laborist/obstetric hospitalist model. Staffing ratios were compared to delivery volume obtained from the Defense Health Agency's Women's Health Clinical Management Team. Descriptive statistics were used to report on the aggregated data, and, where appropriate, the Kruskal-Wallis test was used to assess statistical significance between groups.

Over the 3-month period, delivery volume ranged from 7 to 461 (mean=166, SD=119) with an average staff pool of 17.1 per site equating to a median of 3.1 deliveries per credentialed provider per month (range 0.2-9.1). Six sites hosted a residency program in Gynecologic Surgery & Obstetrics, and 11 in Family Medicine. The average number of attendings per shift was 1. All sites utilized midwifery care, and 50% utilized Family Medicine physicians. Seven departments reported using only 24-hour call shifts.

Our study demonstrates considerable variability in provider staffing of L&D units at stateside MTFs. Although most units were staffed by a single attending provider per shift and all incorporated midwifery care, we found a variety of approaches to staffing in terms of provider type (including laborist/hospitalist care), shift duration, and on-call structure. We also observed a significant difference between the rate of births per provider per month in lower versus higher volume units.