title: Do laborists improve delivery outcomes for laboring women in California community hospitals?
abstract: OBJECTIVE
  We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals.
  
  
  METHODS
  This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012.
  
  
  RESULTS
  Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P < .0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate.
  
  
  CONCLUSIONS
  We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction.
authors.affiliation: Department of Obstetrics and Gynecology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: danielesfeldman@gmail.com.
authors.forename: Daniele S
authors.initials: DS
authors.lastname: Feldman
authors.affiliation: Community Perinatal Network, Yorba Linda, CA.
authors.forename: D Lisa
authors.initials: DL
authors.lastname: Bollman
authors.affiliation: AMF Consulting, Los Angeles, CA.
authors.forename: Moshe
authors.initials: M
authors.lastname: Fridman
authors.affiliation: Childbirth Research Associates, North Hollywood, CA.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Korst
authors.affiliation: Department of Obstetrics and Gynecology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Samia
authors.initials: S
authors.lastname: El Haj Ibrahim
authors.affiliation: Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Health Services Research, Fielding School of Public Health, University of California, Los Angeles, CA; Langley Research Institute, Pacific Palisades, CA.
authors.forename: Arlene
authors.initials: A
authors.lastname: Fink
authors.affiliation: Department of Obstetrics and Gynecology, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA.
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: Gregory
mesh_terms: D002140:California; D002585:Cesarean Section / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D020445:Hospitalists; D006764:Hospitals, Community; D006801:Humans; D007743:Labor, Obstetric; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D009774:Obstetrics / Q000706:statistics & numerical data*; D011247:Pregnancy; D016064:Vaginal Birth after Cesarean / Q000706:statistics & numerical data*
keywords: cesarean; hospital variation; hospitalist; laborist; maternal morbidity