Epidural analgesia use as a marker for physician approach to birth: implications for maternal and newborn outcomes.
BACKGROUND
Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes.


METHODS
Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low-risk women attended by 96 family physicians within an 18-month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay.


RESULTS
Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0-30 percent (15 physicians, 263 births); medium, 31-50 percent (55 physicians, 1323 births); and high, 51-100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse) (23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%).


CONCLUSIONS
In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity.
Klein
M C
MC
Department of Family Practice, Room F412, Children's & Women's Health Centre of British Columbia, 4500 Oak Street, Vancouver, British Columbia, Canada V6H 3N1.
Grzybowski
S
S
Harris
S
S
Liston
R
R
Spence
A
A
Le
G
G
Brummendorf
D
D
Kim
S
S
Kaczorowski
J
J
D000328:Adult; D015360:Analgesia, Epidural; D001955:British Columbia / Q000453:epidemiology; D015331:Cohort Studies; D036861:Delivery, Obstetric; D005260:Female; D006771:Hospitals, Maternity; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies