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The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates

Rosenstein, Melissa G. MD, MAS; Nijagal, Malini MD; Nakagawa, Sanae MS; Gregorich, Steven E. PhD; Kuppermann, Miriam PhD, MPH

doi: 10.1097/AOG.0000000000001032
Contents: Original Research
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OBJECTIVE: To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates.

METHODS: This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean delivery were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean delivery and VBAC; an interrupted time-series analysis estimated the annual rates before and after the expansion.

RESULTS: There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean delivery during the study period; 45% were among privately insured women whose care model changed. The primary cesarean delivery rate among these privately insured women decreased after the change, from 31.7% to 25.0% (P=.005, adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.39–0.81). The interrupted time-series analysis estimated a 7% drop in the primary cesarean delivery rate in the year after the expansion and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward (adjusted OR 2.03, 95% CI 1.08–3.80).

CONCLUSION: The change from a private practice to a collaborative midwifery–laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.


Supplemental Digital Content is Available in the Text.Changing from a private practice to a collaborative midwifery–laborist model is associated with decreased rates of primary cesarean delivery and increased rates of vaginal birth after cesarean delivery.

Departments of Obstetrics, Gynecology, and Reproductive Sciences, Medicine, and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, Prima Medical Foundation, Novato, and Marin General Hospital, Greenbrae, California; and the Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.

Corresponding author: Melissa G. Rosenstein, MD, MAS, 550 16th Street, 7th Floor, Box 0132, San Francisco, CA 94143; e-mail:

Dr. Rosenstein is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Grant # HD01262, as a Women's Reproductive Health Research Scholar. The work was also funded in part by the National Center for Advancing Translational Sciences, Grant # UCSF-CTSI UL1 TR000004, and the nonprofit Prima Medical Foundation.

Presented at the 35th Annual Meeting of the Society for Maternal-Fetal Medicine, San Diego, California, February 5–7, 2015.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.