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J Midwifery Womens Health. 2020 Jan;65(1):33-44. doi: 10.1111/jmwh.13017. Epub 2019 Sep 10.

Low-Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors.

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Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
California Maternal Quality Care Collaborative, Stanford, California.
Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California.
California Perinatal Quality Care Collaborative, Stanford, California.
Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut.
Laborists and Midwifery Section, Yale Medicine, New Haven, Connecticut.
Vidone Birthing Center, Yale New Haven Hospital, Saint Raphael Campus, New Haven, Connecticut.



Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals.


Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis.


We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group.


Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.


hospital variation; intrapartum care; low intervention; quality


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