Objective
We sought to investigate the relationship between obstetricians’ cognitive traits and delivery outcomes among women with a prior cesarean delivery.
Study Design
A total of 94 obstetricians completed 5 standardized psychometric scales: Reflective Coping, Proactive Coping, Multiple Stimulus Types Ambiguity Tolerance (MSTAT), Need for Cognition, and State-Trait Anxiety Inventory. Scores were analyzed by quartile. Delivery data were collected for primiparas with 1 prior low transverse cesarean delivery and a term, cephalic singleton. We used χ 2 tests and random effects logistic regression to examine the relationship between obstetricians’ cognitive traits and their patients’ frequency of trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC).
Results
Of 1502 eligible patients, 22.6% underwent TOLAC. Women were more likely to undergo TOLAC when cared for by physicians with scores in the highest quartile of the proactive coping (33.6% vs 19.6%; P < .001), MSTAT (29.2% vs 21.0%; P = .002), and Need for Cognition (27.9% vs 21.5%; P = .02) assessments, or in the lowest quartile for anxiety assessment (28.0% vs 20.6%; P = .001). Similarly, those with high proactive coping (18.0% vs 11.3%; P = .001), high MSTAT (16.6% vs 11.8%; P = .03), and low anxiety (19.2% vs 10.4%; P < .001) had greater VBAC rates. Random effects regression analyses revealed physicians with high proactive coping remained significantly more likely to have patients undergo TOLAC (adjusted odds ratio, 1.86; 95% confidence interval, 1.10–3.14) and those with low anxiety remained significantly more likely to have patients experience VBAC (adjusted odds ratio, 2.08; 95% confidence interval, 1.28–3.37).
Conclusion
There is an increased likelihood of TOLAC and VBAC for women delivered by physicians with more proactive coping and less anxiety.
In the United States, nearly one third of births occur via cesarean delivery (CD) and approximately 90% of low-risk women with a prior cesarean undergo a repeat CD. The rising cesarean rate is of significant public health concern due to the associated maternal morbidity. As a result, reducing primary and repeat CD, the latter of which account for half of the increase in cesarean rate, is a goal of numerous professional organizations and the US Department of Health and Human Services. While many patient- and system-based factors contribute to the cesarean rate, little work has focused on provider contributions to delivery approach and mode.
The dramatic decrease in the vaginal birth after cesarean (VBAC) rate has been attributed largely to a decrease in the likelihood of choosing a trial of labor after cesarean (TOLAC), yet evidence suggests a majority of women with 1 prior low transverse cesarean are TOLAC candidates. While the American Congress of Obstetricians and Gynecologists notes that after appropriate counseling, “the ultimate decision to undergo TOLAC or a repeat CD should be made by the patient in consultation with her health care provider,” some evidence suggests provider factors can influence patient decisions in this regard.
Patient safety and quality improvement initiatives increasingly reflect the concept that provider traits are associated with patient outcomes. Beyond demographic or training characteristics, provider cognitive traits are one type of characteristic thought to affect clinical decisions. Cognitive traits include cognitive biases and clinical reasoning skills, coping ability, analytical skills, cognitive efficiency, and learner motivation. Provider emotional influences and affective traits, or predisposition toward types of emotional responses, have additionally been proposed to affect clinical decisions. In a small study of 12 obstetricians, Dunphy et al found that physicians with better coping skills and lower trait anxiety were more likely to care for women who achieved spontaneous vaginal deliveries. In previous work, our group studied the relationship between obstetrician cognitive traits and delivery outcomes for nulliparas, finding decreased risk of operative vaginal delivery for patients delivered by providers who evidenced more adaptive decision making. Such findings suggest physician cognitive traits may influence outcomes in situations, such as intrapartum care, that are unpredictable. Yet, the role of provider factors, and physicians’ cognitive traits specifically, in the availability and management of TOLAC is not well understood, and remains a critical evidence gap.
Thus, we designed this study to investigate the association between physician cognitive and affective traits and patient delivery outcomes among women with 1 prior CD who were eligible to undergo TOLAC. We hypothesized that providers scoring in the highest quartile of cognitive and affective assessments, representing the most adaptive cognitive and affective traits, would have higher frequency of TOLAC and VBAC among their patients.
Materials and Methods
This was an observational study examining the relationship between obstetricians’ cognitive and affective traits and their patients’ delivery outcomes among women with 1 prior CD. Methods for assessment of cognitive and affective traits have been described previously. In brief, providers of obstetric care at a single academic institution were surveyed using 5 standardized psychometric measures. Their patient outcomes were then retrospectively reviewed to identify differences in delivery outcomes associated with provider cognitive characteristics. Institutional review board approval from Northwestern University was obtained prior to initiation of the study.
Eligible participants included all attending obstetricians practicing at a single institution and their eligible patients. General obstetricians and maternal-fetal medicine specialists were included. Trainees and midlevel providers were not surveyed in this study, as all delivery decisions are ultimately the responsibility of the attending physician. Attending physicians directly participate in all births, including those of patients who received prenatal care in the hospital-based clinic staffed by residents with faculty supervision. From 2012 through 2013, obstetricians completed a written survey that included demographic characteristics and 5 established, validated scales: Reflective Coping (RC), Proactive Coping (PC), Multiple Stimulus Types Ambiguity Tolerance (MSTAT)-II, Need for Cognition (NFC), and the trait component of the State-Trait Anxiety Inventory (STAI). The RC, PC, MSTAT, and NFC largely measure cognitive traits, whereas the STAI is a measure of an affective trait. These scales were chosen on the basis of use in prior work, their high construct validity, and the theoretical basis of these traits’ relationships to medical decision making. Details of each instrument can be found in Table 1 .
| Instrument | Construct | No. of items |
|---|---|---|
| Reflective Coping scale of Proactive Coping Inventory |
| 11 |
| Proactive Coping scale of Proactive Coping Inventory |
| 14 |
| Multiple Stimulus Types Ambiguity Tolerance-II |
| 13 |
| Need for Cognition |
| 18 |
| State-Trait Anxiety Inventory-trait component |
| 20 |
Patients eligible for study inclusion were primiparas age ≥18 years with 1 prior low transverse CD and a term, cephalic singleton who were delivered by a physician who completed the survey. All deliveries meeting criteria from January 2008 through June 2013 were reviewed to provide a final population for analysis that would allow for adequate power (see below). The population was limited to women with 1 prior CD (and no prior vaginal deliveries) to limit the possibility that provider decisions would have been influenced by prior vaginal birth(s) or the number of prior CD. Women with fetuses with major anomalies, who had a fetal demise, or who were otherwise ineligible for vaginal birth (placenta previa, prior classical CD, prior cavity-entering myomectomy) were excluded.
Sample size was determined based on the number of patients needed to demonstrate a difference in TOLAC rate between patients delivered by providers scoring in the highest quartile compared to providers scoring in the lower 3 quartiles. Prior work has suggested that women delivered by providers with coping scores in the highest quartile had a 30% lower risk of operative vaginal delivery. If approximately 30% of women undergo TOLAC when cared for by physicians with cognitive trait scores in the highest quartile of cognitive scores, to have 80% power at an alpha = 0.05 to detect a 30% difference in the proportion of women undergoing TOLAC among providers with scores in the lower 3 quartiles, an estimated 1400 participants were required. Data were abstracted from the electronic medical record.
The primary outcomes were frequency of TOLAC and VBAC. Secondary outcomes included clinically significant uterine rupture (uterine rupture with clinical consequence for the mother or fetus, not including an incidentally noted uterine “window” or scar dehiscence), maternal chorioamnionitis (defined as a temperature >100.3°F without an identified etiology other than intrauterine infection), postpartum hemorrhage (defined as estimated blood loss >500 mL for a vaginal delivery or >1000 mL for a CD), major genital tract lacerations (defined as a third- or fourth-degree laceration), episiotomy, and maternal ICU admission. Neonatal outcomes included 5-minute Apgar score <4, umbilical cord artery pH <7.0, neonatal sepsis, neonatal seizures, neonatal hypoxic ischemic encephalopathy, and admission to the neonatal intensive care unit.
We described patient characteristics stratified by mode of delivery using χ 2 and analysis of variance tests. The psychometric scales were scored using established scoring techniques, and scores were categorized by quartile; top quartiles of scores were compared to the bottom 3 quartiles. Scores were evaluated by quartile to assess the most extreme behavioral phenotype, which was thought to be the most clinically relevant exposure. For the RC, PC, MSTAT-II, and NFC, the fourth quartile (highest scores) represented the most advantageous traits and was used as the referent. For the STAI, lower scores indicated the least trait anxiety, and thus the lowest quartile scores were used as the referent group and here are referred to as the fourth quartile. Frequency of TOLAC and VBAC was investigated by cognitive and affective quartile using χ 2 analysis.
Hierarchical random effects multivariable logistic regression model was utilized to examine relationships between physician cognitive and affective traits and likelihood of undergoing TOLAC and VBAC. The regression analysis adjusted for potential confounders, including patient characteristics identified to be significantly associated with mode of delivery and delivering physicians as random effect terms that accounted for the effect of nonindependence due to clustering by physician. This method accounts for clustering of patients by physician. Finally, additional regression analyses were performed to investigate the secondary outcomes by quartile of physician cognitive and affective traits. Statistical analyses were undertaken using software (STATA, version 13; StataCorp, College Station, TX). All analyses were 2-tailed and P < .05 was used to define statistical significance.
Results
Of the eligible 115 obstetricians, 94 (82%) signed written, informed consent and completed the survey. During the period of study, 1502 of their patients met inclusion criteria. The patients’ mean age was 33.9 years (SD ±0.12), mean body mass index was 30.6 kg/m 2 (SD ±0.15), and mean gestational age at delivery was 39.1 weeks (SD ±0.02). The population was largely (69.5%) Caucasian and most (91.5%) were privately insured. In all, 340 women (22.6%) underwent TOLAC, of whom 56.5% achieved VBAC (ie, a 12.8% VBAC rate). The majority (78.7%) of VBACs occurred spontaneously, with the remainder being operative vaginal deliveries. Patient characteristics differed significantly based on delivery mode ( Table 2 ).
| Characteristic | Vaginal birth after cesarean (n = 192) | Repeat cesarean delivery (n = 1310) | P value |
|---|---|---|---|
| Age, y, mean (SD) | 32.4 (4.7) | 34.1 (4.5) | < .001 |
| Body mass index, mean (SD) | 29.5 (4.9) | 30.8 (5.9) | .005 |
| Ethnicity | .066 | ||
| Caucasian | 118 (61.5%) | 926 (70.7%) | |
| African American | 26 (13.5%) | 124 (9.5%) | |
| Hispanic | 29 (15.1%) | 165 (12.6%) | |
| Asian | 13 (6.8%) | 94 (7.2%) | |
| Insurance | < .001 | ||
| Private | 161 (83.9%) | 1228 (93.7%) | |
| Medicaid | 31 (16.1%) | 82 (6.3%) | |
| Gestational age, wk (SD) | 39.3 (1.0) | 39.1 (0.7) | < .001 |
Multiple obstetrician cognitive and affective traits were significantly associated with likelihood of undergoing TOLAC ( Table 3 ). Women were more likely to undergo TOLAC when cared for by physicians with PC (33.6% vs 19.6%; P < .001), ambiguity tolerance (29.2% vs 21.0%; P = .002), and NFC (27.9% vs 21.5%; P = .02) in the highest quartile. Women also were more likely to experience TOLAC (28.0% vs 20.6%; P = .001) when delivered by physicians with the least trait anxiety. There were no differences in TOLAC rates based on physicians’ RC. Similarly, obstetrician traits were found to be associated with likelihood of experiencing VBAC ( Table 4 ). Women delivered by physicians with high PC (18.0% vs 11.3%; P = .001), high tolerance of ambiguity (16.6% vs 11.8%; P = .03), and low anxiety (19.2% vs 10.4%; P < .001) had a higher chance of VBAC. There were no differences in VBAC rate based on physician RC or NFC. Among the population of women undergoing TOLAC, low anxiety among their physicians remained significantly associated with VBAC (68.4% vs 50.4%; P = .002).
| Variable | No trial of labor (n = 1162) | Trial of labor (n = 340) | P value |
|---|---|---|---|
| Reflective Coping a | .79 | ||
| Q4 b | 292 (77.9%) | 83 (22.1%) | |
| Q1–3 | 870 (77.2%) | 257 (22.8%) | |
| Proactive Coping c | < .001 | ||
| Q4 b | 217 (66.4%) | 110 (33.6%) | |
| Q1–3 | 945 (80.4%) | 230 (19.6%) | |
| Tolerance of ambiguity d | .002 | ||
| Q4 b | 213 (70.8%) | 88 (29.2%) | |
| Q1–3 | 949 (79.0%) | 252 (21%) | |
| Need for Cognition e | .021 | ||
| Q4 b | 199 (72.1%) | 77 (27.9%) | |
| Q1–3 | 963 (78.6%) | 263 (21.5%) | |
| Trait anxiety f | .001 | ||
| Q4 b | 293 (72.0%) | 114 (28.0%) | |
| Q1–3 | 869 (79.4%) | 226 (20.6%) |
a Scale measures self-efficacy and coping in setting of stress
b Indicating highest scores with most adaptive traits–for all scales, represents most adaptive traits on scale being measured
c Scale measures proactive goal attainment, self-confidence, and self-regulatory behavior
d Multiple Stimulus Types Ambiguity Tolerance scale measures tolerance of ambiguity, degree of comfort with uncertainty, and receptiveness to change
e Scale measures learner motivation, engagement with cognitive efforts, and adaptive decision making
f Component of State-Trait Anxiety Inventory measures stable tendencies toward anxiety and is measure of affect.
| Variable | Vaginal birth after cesarean (n = 192) | Repeat cesarean delivery (n = 1310) | P value |
|---|---|---|---|
| Reflective Coping a | .99 | ||
| Q4 b | 48 (12.8%) | 327 (87.2%) | |
| Q1–3 | 144 (12.8%) | 983 (87.2%) | |
| Proactive Coping c | .001 | ||
| Q4 b | 59 (18.0%) | 268 (82.0%) | |
| Q1–3 | 133 (11.3%) | 1042 (88.7%) | |
| Tolerance of ambiguity d | .026 | ||
| Q4 b | 50 (16.6%) | 251 (83.4%) | |
| Q1–3 | 142 (11.8%) | 1059 (88.2%) | |
| Need for Cognition e | .18 | ||
| Q4 b | 42 (15.2%) | 234 (84.8%) | |
| Q1–3 | 150 (12.2%) | 1076 (87.8%) | |
| Trait anxiety f | < .001 | ||
| Q4 b | 78 (19.2%) | 329 (80.8%) | |
| Q1–3 | 114 (10.4%) | 981 (89.6%) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
