Student Projects
Quantitative Research Proposal

Factors influencing differences in primary cesarean section rates in midwife compared to physician practices

Kim Keen

Winter Term 2004


The cesarean section rate has soared to a record high of 26.1 % in the United States in 2002 and is the method of delivery for more than one out of every four women (Hamilton, Martin, & Sutton, 2003). Despite advances in surgical techniques, cesarean sections are not risk-free procedures, and yet, are being used more and more frequently for questionable indications. Various factors have contributed to the higher cesarean section rate. Among these factors, are the increasing incidence of labor inductions, the latest trend of "elective" cesarean sections, rapidly increasing professional liability insurance costs, the perception of protection against lawsuits for poor birth outcomes, recent research questioning vaginal birth after cesarean section (VBAC) outcomes, and the lack of universally accepted indications for primary cesarean sections. Increased risks of bleeding, infection, trauma to pelvic organs, post operative complications, and potential risks for future pregnancies are among the risks for the mother. Neonates are exposed to an increased risk of respiratory distress and the potential of delivery prior to full maturity. Midwives are an underused strategy in the nation's efforts to reduce the cesarean section rate to 15%, the goal of the US Department of Health and Human Services (Healthy People 2010). Midwives have demonstrated a lower cesarean section rate (8.8%) when compared to obstetricians (13.6%) and family practice physicians (15.1%) (Rosenblatt, Dobie, Hart, Schneeweiss, Bould, Rain, Benedetti, et al.,1997). Currently, midwives are presiding over approximately 10% of the nation's vaginal births (American College of Nurse-Midwives [ACNM], 2002). Hallmarks of midwifery care include recognition of pregnancy and birth as normal processes and advocacy of non-intervention in the absence of complications. This philosophically driven model of care, with respect for the natural processes of birth, and intervention only when necessary, may indeed account for midwives' lower cesarean section rate. Review of the literature revealed that midwives use less interventions and have lower cesarean section rates but the processes midwives use to achieve lower cesarean birth rates are not clearly understood. A quantitative comparative research study will examine factors influencing the differences in the primary cesarean section rates in selected care strategies of midwife compared to physician practices.


Chapter 1: Statement & Significance of the Problem

Introduction to the problem

A cesarean section is delivery of a fetus through a surgical incision in the abdominal wall, known as a laparotomy, and an incision through the uterine wall, known as a hysterotomy (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). This operation is intended to be used as a life-saving procedure for the mother and/or her baby. However, a number of factors, such as, the increasing labor induction rate, the option for women to choose an elective cesarean section, and the decreasing option of VBAC for women have led to its overuse in recent years. The cesarean section rate is rising despite national goals to decrease their occurrence to 15% (Healthy People 2010). The United States has recorded the highest cesarean section rate ever, accounting for 26.1% of all deliveries in 2002 (Hamilton, Martin, and Sutton, 2002). According to Hamilton et al. (2002), the rising cesarean section rate can be correlated to the dramatic decrease in vaginal births after previous cesarean deliveries. Vaginal births after cesarean section (VBACs) fell 23% from 2001 to 2002 to a low of 12.7% of all deliveries (Hamilton, et al). The primary cesarean section rate increased 7%, from 2001 to 2002, accounting for 18% of all cesarean section deliveries (Hamilton, et al.) In 2002, there were 4,019,280 births in the United States. With cesarean sections reaching a record high of 26.1%, over one million women and their infants were delivered by cesarean section (Hamilton, et al.,2002).

Phenomenon of interest

Despite national goals the reduce cesarean births, the rate continues to climb with each passing year. Many factors may be responsible for the steadily increasing rate. One area of debate is whether the increased rate of labor inductions directly affects the cesarean section rate. Another recent phenomenon is the option of elective primary cesarean section. Reasons offered for elective primary cesarean section range from convenience of choosing the date of delivery, to fear of labor, to maintaining pelvic floor integrity (Starr, 2003). Malpractice insurance for care providers must also be considered. According to Greve (2000), specialty areas, such as obstetrics, have seen triple-digit increases in their malpractice premiums which may force health care providers to alter the way they practice. Careproviders may opt to deliver care that involves the perception of the least amount of risk, which turns the focus to risk management, not patient safety (Greve). The current practice recommendations regarding indications for primary cesarean section delivery needs to be explored. Universally accepted criteria to indicate cesarean delivery, in general, are lacking. Reasons for cesarean section delivery vary according to author and research study (see table 1). An obvious answer to reduce the increasing rate of cesarean sections would be to decrease the amount of primary cesarean sections performed (ACNM, 2002). The phenomenon of interest for this study is the primary cesarean delivery rate. Of specific interest, is the impact that midwives may have on the overall cesarean section birth rate. Midwives are an untapped resource that may help to reduce the nation's cesarean section rate.

Table 1: Indications for cesarean section according to various authors.
Gregory, Korst, Gorbein &, Platt, 2002
Gabbe, 2002
DiGiuseppe, 2001
nonreassuring fetal heart rate
breech presentation
antepartum bleed
cephalopelvic disproportion
seizures during labor
failure to progress
severe hypertension
placental abruption
face or transverse presentation
uterine scar
placental previa
placenta previa
multiple gestation
conjoined twins
cord prolapse
abruptio placenta
unengaged fetal head
maternal soft tissue disorder
hypertension (other)
preterm gestation
fetal congenital anomaly
Significance of issue to midwifery/women's health

In the year 2000, midwives attended 297,902 deliveries in the United States. At almost 10%, this is a dramatic increase from 1975, when midwives attended 0.6% of all births (ACNM, 2002). While cesarean delivery is not within the scope of practice for midwifery, midwives are adept at screening for prenatal complications and labor abnormalities and arranging physician services as needed. Midwives consistently have a lower cesarean section rate when compared to their physician counterparts. Probably the most impressive study, includes a retrospective study of over 30,000 deliveries attended by midwives. The results of this study revealed an extremely low primary cesarean section rate of 1.8% along with a remarkably low neonatal intensive care admission rate of 1.5%. This study was done on low-income, Hispanic women and strongly suggests that midwives can deliver care that reduces cesarean section births without compromising maternal and fetal health (Greulich, Paine, McClain, Barger, Edwards & Paul, 1994). A nationwide study of free-standing birth centers, attended by midwives, revealed a low cesarean section rate of 4.4% along with a high patient satisfaction rate of 98.8% (Ernst, Rooks, Rosenfield, Stapleton & Weatherby, 1989). Another study found that CNMs had a cesarean section rate of 8.8%, compared to 13.6% for obstetricians and 15.1% for family physicians (Rosenblatt, Dobie, Hart, Schneeweiss, Bould, Rain, Benedetti, et al. 1997). In the same study, it was noted that CNMs used 12.2% fewer interventions while caring for their clients when compared to both the obstetricians and the family physicians, while achieving similar or better outcomes. True to the midwifery philosophy of non-intervention unless necessary, midwives not only use fewer interventions but use them when indicated to assist in achieving lower cesarean section rates when compared to their physician counterparts.

The time has come to implement a proactive plan towards decreasing the cesarean section rate. Midwives are an underutilized resource to combat the increasing cesarean section rate. According to the Public Citizen's Health Research Group in Washington, D.C., hospitals that employ the use of nurse-midwifery services have an average cesarean section rate of 13% lower than the average rate for all hospitals (Gabay & Wolfe, 1994). Public Citizen offers the following recommendations to help reduce the cesarean section rate: (1) hospitals should incorporate midwives and their philosophy of care into labor and delivery care programs; (2) insurance companies should encourage the use of midwives and free-standing birth centers by providing equal coverage for these providers and facilities; and (3) women and their partners should consider choosing a midwife for prenatal care and delivery.

Cesarean section delivery is not without risks or complications for women. Cesarean deliveries are potentially morbid procedures with overall infectious morbidity rates as high as 25% (Bashore, Phillips, & Brankman, 1990). In addition to the increased risk for infections with cesarean section, women are exposed to complications such as excessive blood loss and damage to pelvic organs (Starr, 2003). Future pregnancies may also be affected. There is an increased risk of uterine rupture, placenta accreta, and placenta previa associated with a previous cesarean section (Starr). Post operative complications include endomyometritis, wound infection, fascial dehiscence, urinary tract infections, bowel dysfunction, thromboembolic complications, and pelvic thrombophlebitis (Sedev, 2002). In many regions of the country, women are not allowed to VBAC and must resign to a repeat cesarean section with each successive pregnancy, exposing them to greater risks with each procedure and subsequent pregnancy. Seyb, Berka, Socol & Dooley (1999) conclude that aside from the increased delivery costs, future pregnancies are more likely to be complicated because of a primary cesarean section. A July, 2003 American College of Obstetricians and Gynecologist (ACOG) news release reported that cesarean birth significantly increased a woman's risk of a pregnancy related fatality (35.9 deaths per 100,000 deliveries with a live-birth outcome) compared to a woman who delivered vaginally (9.2 deaths per 100,000).

One of the main benefits heralded by the medical community, in support of cesarean section, is that women can maintain pelvic floor muscle integrity and decrease their risk for incontinence later in life by avoiding vaginal deliveries. Dietz & Bennet (2003) studied the effect of childbirth on pelvic organ mobility. They conclude that all forms of cesarean delivery are associated with less pelvic organ descent and therefore offers some protection over future pelvic floor disorders. Other studies yield different results. Lal (2003) studied the structural alterations in the continence mechanism following both vaginal and cesarean section deliveries and found that incontinence can occur post-cesarean section and without labor. He concluded that the current evidence does not support the routine use of elective cesarean section to prevent incontinence.

Cesarean delivery is not without risks or complications for neonates. Known risks include increased incidence of transient tachypnea, respiratory distress syndrome, hyaline membrane disease, and fetal lung immaturity related to surgical delivery prior to fetal maturity (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). Respiratory complications result from a larger residual volume of lung fluid in neonates immediately after delivery. With vaginal delivery, approximately one-third of the fetal lung fluid is removed by compression of the baby's chest during passage through the birth canal. This mechanism is missing with cesarean section delivery. With larger residual lung fluid, less surfactant is secreted leaving neonates delivered by cesarean section at risk for respiratory problems (Roth-Kleiner, M., Wagner, B. P., Bachmann, D., Pfenniger, F., 2003).

Study purpose

The purpose of this study is to investigate the degree to which midwifery care can influence the primary cesarean section rate. This study will explore factors influencing the differences in the primary cesarean section rates in midwife compared to physician practices.

Type of study

A quantitative comparative research method will be used to explore the type of care given by midwives and by physicians and the impact it has on the primary cesarean section rate. A prospective comparative research design will compare clients receiving midwifery care to clients receiving physician (Ob/Gyn) care. Differences in care practices between groups in the natural setting are of primary interest. In this comparative study, four groups of nulliparous, pregnant clients will be followed for their delivery outcomes, vaginal or cesarean section, while also recording selected independent variables. Two control groups, one group of midwife clients and one group of physician clients, will be created by allowing clients to self-select a midwife or physician provider. Two more groups will be randomly assigned to either midwife or physician care. Using the design of studying self-selecting clients and randomly assigned clients will eliminate a common critique of midwife versus physician comparative studies, which suggests that midwife clients are different to begin with, leading to better outcomes.

Study question

1. What factors influence the difference in cesarean section rates between midwives and physicians?

Theoretical and operational definition of terms

Independent variables:

Induction of labor: Use of interventions to induce the onset of labor prior to the normal physiologic processes that cause the onset of labor. Interventions to induce labor would include: artificial rupture of membranes, use of Pitocin, or use of cervical ripening agents (cytotec, prostaglandin gel, prepidil, cervidil). Induction of labor is the stimulation of contractions before the spontaneous onset of labor (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). Elective inductions of labor are associated with an increased risk of cesarean section delivery (Seyb, Berka, Socol & Dooley, 1999).

Augmentation of labor: Augmentation of labor is the stimulation of spontaneous contractions that are considered inadequate because of failure of progressing dilatation and/or descent (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). For the purposes of this study, augmentation of labor will be limited to the use of Pitocin, cytotec or artificial rupture of membranes. The use of interventions, to include induction/augmentation of labor, is associated with a higher cesarean delivery rate (Rosenblatt, Dobie, Hart, L.G., Schneeweiss, Gould, Raine, et al., 1997).

Time subject spends out of bed: Actual time, in hours and minutes, that study subjects spend out of bed during labor, once admitted to the hospital. Midwives are more in favor of giving the women the option to remain upright instead of recumbent during the first and second stages of labor (Fullerton, Hollenbach, & Wingard (1996).

Time careproviders spend with subjects during labor: Actual time, in hours and minutes, that careproviders spend in the subjects room during labor. Midwifery care that includes one-on-one labor support is associated with a lower cesarean section rate (Butler, Abrams, Parker, Roberts, & Laros (1993).

Dependent variable:

Cesarean section rate: The number of subjects, in each study group, which deliver by cesarean section. In the United States, careproviders are encouraged to reduce their cesarean delivery rates in an effort to reach a national goal of 15% (Healthy People 2010).

Assumptions and philosophical approach

Midwifery care focuses on the normal processes of pregnancy and childbirth and is known for its non-interventionist approach. Interventions, like induction/augmentation of labor, during the intrapartum period may lead to maternal exhaustion, inability of the woman to effectively deal with stronger, more frequent contractions, and fetal distress, which could lead to a cesarean delivery. One-on-one labor support by a careprovider can facilitate the normal processes of labor and delivery by providing encouragement, support, and suggestions for coping with labor. Supportive careproviders can recommend position changes, be a role model for the patients' labor support person(s), evaluate the patients' coping mechanisms, and provide hands-on assessments of maternal and fetal status. Time spent out of bed can facilitate the labor process by using gravity to aid in dilatation and fetal descent. Position changes can offer distraction and comfort to the laboring woman and give her a sense of control over her labor and delivery. The philosophical approach for this study stems from the midwifery model of care which strives to protect the normalcy of labor and delivery and intervene only if indicated.

Limitations of the study

This proposed study will compare four groups of nulliparous, pregnant women that are cared for by a midwife or a physician (half randomly assigned and half self-selecting). Cesarean delivery rates will be compared as well as independent variables of care provided. Labor and delivery nurses will be collecting the intrapartum data. Individual variations in data collection may occur despite attempts to achieve high interrater reliability. With the prospective design of this study, careproviders may be influenced by the fact that they know they are being studied and may alter their care.

Chapter 2: Review of the Literature & Conceptual Framework.

Review of the Literature

With more than one out of every four women delivering their babies by cesarean section, this method of delivery has reached a record high. With VBAC deliveries falling out of favor with the medical community, the primary cesarean delivery rate needs to be addressed. Having a primary cesarean section puts a woman, her baby, and future pregnancies at risk. A review of the literature was done to explore indications for primary cesarean sections; relationships between inductions of labor and cesarean delivery; mode of delivery and its impact on pelvic floor dysfunction; midwifery care and cesarean section rates; practice styles and philosophy of care issues; and interspecialty differences.

The literature review was performed via an internet search. Several search engines were used including, Medscape, Yahoo, and AOL. The following websites were also used:;; and These resources provided a multitude of information in the form of abstracts, full text articles, and associated websites. Key search words used were: "cesarean section", "midwife", "malpractice", newborns and cesarean section", risks and cesarean section", "elective cesarean section", "pelvic muscles" and "vaginal and cesarean." Articles that contained information on primary cesarean sections were preferred as were articles that compared outcomes of midwifery care.

Indications for primary cesarean section

One important area to explore is medical indications for primary cesarean sections. Gregory et al.(2002), used a quantitative study to investigate the reasons for primary elective cesarean sections. Elective primary cesarean section (EPC) is defined, by the researcher, as undergoing a primary cesarean section delivery without a trial of labor, regardless of whether it is for a medical or a non-medical indication. The purpose of their study was to develop a standardized methodology using readily available hospital data to identify indications for elective primary cesarean sections (EPCs). This data would be used to describe parameters in which primary elective cesarean sections may be indicated. This tool could be available to physicians to help in the decision making process when considering EPCs for their clients. The researchers hypothesized that women who underwent EPCs would represent a "high risk" group with clinical conditions that would contraindicate proceeding with a vaginal delivery.

In 1995, Gregory et al.(2002) examined all discharge deliveries, as reported by the California Office of Statewide Health Planning and Development (OSHPD). The study population consisted of a total of 463,196 discharge deliveries: 443,532 (95.75%) who labored, and 19,664 (4.25%) who underwent EPC delivery without labor. The investigators used ICD-9-CM codes as the source of their data. Up to 25 codes were recognized in this study. Excluded were patients with a history of previous cesarean delivery (code 654.2) and patients that delivered at hospitals with fewer than two hundred deliveries per year. Since no ICD-9-CM code exists for labor, and because EPC deliveries occur in the absence of labor, an algorithm based on the presence of specific ICD-9-CM codes was developed to stratify the study patients into labor and nonlabor groups. Patients who had a vaginal delivery or discharge codes representing fetal distress, labor abnormalities, cord prolapse, and breech converted to vertex were categorized as having labored. Data was entered into a recursive partitioning algorithm to develop a hierarchy of clinical conditions by which patients with multiple conditions could be sorted with respect the binary outcome of labor versus EPC without labor. A random sample representing half of the patients was used to develop the hierarchy and was subsequently validated on the remaining half of the patients. The exhaustive CHAID (Chi-Square Automatic Interaction Detector) was used and allowed up to four levels of integration among the indicators. Patient conditions in the hierarchy were listed in the order by which the greatest statistical difference was found between those who labored and those who underwent EPC without labor. Those who did not fit into any of the categories were identified as having an "unspecified" indication for delivery. The clinical investigators examined the empirically derived hierarchy for clinical consistency by comparing it to conventionally recognized obstetrical conditions for EPC, literature review, and clinical experience. The hierarchy was accepted as representative of "reasonable" indications for EPC delivery. The descriptive data was analyzed and calculated for the proportions of patients undergoing EPC delivery for each indication. Categorical variables were analyzed using chi-square analysis with Yates correction. Means were expressed [+ or - ] the standard deviation and statistical significance was defined at the p< 0.05 level. Relative risks (RR) and 95% Confidence Intervals (CI) were reported. All analyses were performed using SAS statistical software. The recursive partitions algorithm specifying the clinical hierarchy, was constructed using the Answer Tree module of SPSS.

According to Gregory et al.(2002), the study found that EPC deliveries account for approximately 4% of all births to women without a previous cesarean. Ninety three percent of EPC deliveries were able to be explained with 12 specific clinical indications ( see table 2). Noteworthy was that many of the subjects were classified with indications strongly associated with cesarean (strong RR) but delivered vaginally. The "unspecified" group accounted for 7.1% of all EPCs and may represent women who chose EPC without having a medical indication. This study suggests that there are very few absolute medical indications for EPC delivery.

One of this study's (Gregory et al., 2002) strengths is its large population size covering many different hospitals. The population size gives this study credibility as a likely representation of the general population. This study demonstrates transferability by comparing the hierarchy of clinical conditions found in their data analysis to current practice, clinical experience and literature review. Limitations may be found in the data collection phase. It was not specified who collected the data and what their credentials were. Coding errors may have been made by the original care providers or office staff that may have thrown off the results of this study. By looking simply at ICD-9-CM codes, the investigators are limited in the amount of information they have for the true reason for the EPC delivery. These codes are used for billing purposes and some diagnoses may not have codes, forcing the provider to choose a code that resembles but does not accurately reflect the clinical circumstances. Obstetric care providers could benefit from a tool to guide them in their clinical decision when faced with suggesting EPC for their clients. The fact that a high percentage of women coded as having clinical indications for EPC were not delivered by cesarean section deserves attention. This fact alone contradicts the rising cesarean section rate in this country and should have women, care providers and insurance companies demanding to know the real reasons behind the current cesarean section rate of 26.1% (Hamilton, et al., 2003).

Table 2: Indications for primary cesarean section.

Gregory, Korst, Gorbein &, Platt, 2002
antepartum bleed
severe hypertension
uterine scar
multiple gestation
unengaged fetal head
maternal soft tissue disorder
hypertension (other)
preterm gestation
fetal congenital anomaly

Correlation between elective labor inductions and cesarean section delivery

Along with the rising cesarean section rate, the rate of elective inductions have increased. Seyb et al.(1999) investigated the phenomenon of elective induction of labor in term, nulliparous women. The purpose of their study was to quantify the risk of cesarean delivery associated with elective induction of labor. Candidates for this cohort study were limited to nulliparous women admitted to a major urban hospital within an 8-month period. Women were classified according to the following categories: spontaneous labor, elective induction of labor, or medical induction of labor (see table 3). Spontaneous labor was defined as regular, painful uterine contractions together with either complete cervical effacement or rupture of membranes. For labor inductions, if cervical ripening was indicated, laminaria or extraamniotic saline infusion was used. Oxytocin, with or without amniotomy, was used for labor induction. All subjects were at least 37 weeks gestation, with a singleton fetus in the vertex presentation. The final study group consisted of 1561 women. Subjects were categorized at the time of admission to the hospital and later verified with the hospital database. Additional data collected on each subject included: maternal age, race, managing service, gestational age, maternal height, and body mass index. Other factors quantified during this study include cervical dilatation on admission, time in labor and delivery, timing of epidural placement, length of postpartum stay, postpartum complications, and cost analysis. Delivery data included route of delivery, indication for cesarean delivery, birth weight, Apgar scores, umbilical artery cord gases, presence of meconium, and neonatal intensive care unit (NICU) admission. Data was obtained from subjects during admission; by reviewing the prenatal records, hospital charts and hospital perinatal data base; and by reviewing information on cost analysis from the hospital finance department.

Table 3 : Indications for Medical and Elective Inductions of Labor according to Seyb et al. (1999)
Indications for Medical Induction of LaborIndications for Elective Induction of Labor
(cited by the admitting physician)
Gestational age >/= 41 weeksElective (term, favorable cervix or "impending" postdates)
Premature rupture of membranes (PROM)"Suspect" preeclampsia ( BP < 140/90 and/or < 1+ proteinuria)
Fetal growth restriction (Ultrasound estimated < 10%tile)"Suspect" fetal growth restriction (no ultrasound documentation)
Preeclampsia (BP >140/90 and proteinuria > 1+)"Suspect" macrosomia (no ultrasound verification)
Chronic hypertensionDecreased amniotic fluid (but amniotic fluid index > 5)
Nonreassuring fetal surveillanceOther (hx of multiple pregnancy losses, idiopathic polyhydramnios, remote hx of genital herpes, paraplegia, gastroenteritis, family hx preeclampsia, successful external cephalic version,
hx cholelithiasis, infertility with donor oocyte)
Macrosomia (Ultrasound estimated > 4000 gms)
Diabetes mellitus
Other (Cholestasis of pregnancy, maternal thrombocytopenia, recurrent nephrolithiasis)
Statistical analyses used for this study (Seyb et al. 1999), were performed using SAS 6.10 (SAS Institute, Cary, NC). Analyses included analysis of variance with Scheffe test for differences between groups, X2, and X2 for trend. A stepwise multiple logistic regression analysis was used to create a final model of risk factors for cesarean section delivery, with P < .05 for entry of a variable into the model. The cesarean section rate for women presenting in spontaneous labor was 7.8% compared to 17.7% for medical inductions and 17.5% for elective inductions. The researchers concluded that factors associated with an increased risk of cesarean section delivery include: elective or medical induction, maternal BMI above 26 kg/m2, gestational age of 40 weeks or greater, neonate birth weight above 4000 grams, PROM, epidural use, magnesium sulfate use during labor, and chorioamnionitis. When compared with women admitted in spontaneous labor, women undergoing elective induction were older, white and had private obstetricians. Women who were electively induced, used epidurals more frequently and had higher mean birth weight. In the medical induction group, the mean gestational age was higher, most likely because pregnancies induced for postdates were included in this group. Also, in the medical induction group, the mean BMI was higher than that of the other two groups. Induction of labor was related to increased time spent on labor and delivery and associated with longer postpartum stays. Labor dystocia was the most common indication for cesarean delivery and was cited as the reason for this mode of delivery more frequently in the induction groups.

The study performed by Seyb et al. (1999) shows a strong correlation between labor inductions and the potential for cesarean section delivery. This study relied on convenience sampling and had a fairly large sample size, consisting of 1561 women, recruited over an eight-month period. This study was able to show results that were statistically significant and controlled for factors such as type of cervical ripening and recruiting subjects greater than 37 weeks gestation. A weakness of this study is the definition of spontaneous labor. The researchers define spontaneous labor as regular, painful uterine contractions together with complete cervical effacement or rupture of membranes. Women can be in spontaneous labor without rupture of membranes or complete cervical effacement. No mention of cervical dilation is listed as criteria for spontaneous labor. In the goal to reduce the cesarean section rate, care providers and women need to be aware that induction of labor greatly increases the risk of cesarean delivery. When indicated, induction of labor for medical reasons is an acceptable practice. However, elective induction, in absence of medical necessity is quickly becoming common practice. An important factor of this study is that it was conducted on nulliparous women. The results of this study can be directly applied to a returning trend of "once a cesarean section, always a cesarean section." Steps need to be taken to reduce a woman's risk of primary cesarean section. According to this study, labor inductions increase cesarean section rates. The practice of elective labor induction without medical reason needs serious reconsideration. Review of the literature by Seyb et al. revealed only one other study that had been done solely on nulliparous women and elective inductions of labor. Results of that study were similar. Other studies have been done without differentiating between nulliparous and multiparous but included much smaller sample sizes. In light of the increasing cesarean section rate and the decreasing VBAC rate, more research is indicated in the area of elective inductions of labor on nulliparous women.

Mode of delivery and pelvic floor integrity

One of the main benefits heralded by the medical community, in support of cesarean section, is that women can maintain pelvic floor muscle integrity and decrease their risk for incontinence later in life by avoiding vaginal deliveries. MacLennan, Taylor, Wilson & Wilson (2000) set out to study the phenomenon of pelvic floor disorders. The purpose of their study was to define the prevalence of pelvic floor disorders and to determine the relationship to gender, age, parity and mode of delivery. The South Australian Health Omnibus Survey was used to select a large random sample of adults 15 years of age and older. Interviews were conducted in the subjects' homes by trained female interviewers. A total of 3010 men (48.7%) and women (51.3%), 15-97 years of age, were included in this cross sectional survey. Respondents were questioned in layman's and medical terms about whether they had experienced the following within the last year: flatus incontinence, fecal incontinence, urge incontinence, and/or stress incontinence. Female subjects were questioned about how many pregnancies they had that progressed past 20 weeks. Women that had been pregnant were asked if their delivery was by cesarean section, instrumental delivery, or spontaneous vaginal delivery. Women with a history of cesarean section were asked whether they had labored at all prior to delivery and women with vaginal deliveries were asked if they required sutures after delivery. All women were asked if they had undergone a vaginal hysterectomy, a vaginal bladder repair, a vaginal rectal repair, or any other type of bladder repair for incontinence. If it had been more than three months since their last delivery, women were asked about symptoms of uterine prolapse, excessive vaginal laxity during intercourse or dyspareunia. Demographic data included gender, age, area of residence, country of birth, education, work status (full/part-time), marital status, and gross annual household income. Medical information collected included co-morbidity variables, specifically diabetes, osteoporosis and arthritis. Presence or absence of respiratory problems were recorded if subjects had medically confirmed asthma, bronchitis, or emphysema. If confirmed respiratory problems were present, respondents were asked if they coughed every day, most days, occasionally or never over the last 3 months. BMI was also recorded for this study. The SF-36 Health Survey was included in interviewing the respondents.

Analyses of the data was performed using SPSS Version 8.0 and Epi-Info 6.04 a; X2 analyses was used to determine the dependent and independent relationship variables. A conventional Pvalue of 0.05 was used for all tests of significance. Two multivariate analyses were run, one with urinary incontinence as the dependent variable, and one on women only, with the four major forms of pelvic floor disorders as the dependent variable. Independent variables with a statistically significant level of 0.25 were entered into a logistic regression analysis to determine the best joint predictors of women with pelvic floor dysfunction and of people with urinary incontinence. Tests for interaction were performed on likely combinations of variables. Data was analyzed to determine the presence of confounders and to determine if muliti-collinearlity existed (MacLennan, et al. 2000).

Results of the study (MacLennan, et al. 2000) revealed that women experience urinary and anal incontinence more commonly than men. When compared to men, nulliparous women experienced stress incontinence four times more frequently, the prevalence rose to 37.4 % after the first pregnancy. Overall, urinary incontinence was reported in women 35.3% and in men 4.4%. Female urinary incontinence was reported most frequently in the 70-75 year age group (59%) and pelvic floor surgery rose markedly after the age of 45. Out of all women respondents, 46.2% had experienced pelvic floor dysfunction in the categories of stress or urge incontinence, flatus or fecal incontinence, vaginal prolapse or previous pelvic floor repair. Pelvic floor dysfunction increased greatly after the first pregnancy and further with additional pregnancies. The mode of delivery increased all types of pelvic floor dysfunction with results noted as: nulliparity (12.4%); cesarean section (43.0%); spontaneous vaginal delivery (58.0%); instrumental vaginal delivery (64.0%). When compared, cesarean section (43.0%) and vaginal-spontaneous and instrumental-(59.6%) both resulted in high percentages of pelvic floor dysfunction. Significant difference was not noted (P=0.52, P value=0.25) between elective cesarean deliveries (38.8%) and cesarean deliveries after labor (45.3%) in regards to pelvic floor dysfunction. Univariate analysis revealed that increasing age, parity, marital status, work status, education level, low income, increasing weight, mode of delivery, poor quality of life, respiratory problems, coughing, high use of health services, visit to psychiatrist, diabetes, osteoporosis and arthritis were all associated with pelvic floor dysfunction. The authors concluded that disorders of the pelvic floor are very common and are highly associated with female gender, aging, pregnancy, parity and instrumental vaginal delivery. They state that cesarean delivery does not significantly reduce long term pelvic floor morbidity when compared with vaginal delivery.

The study by MacLennan et al.(2000) helps to quantify what factors increase the risk for pelvic floor disorders. In the past few years, elective cesarean sections have been "advertised" as an option for women with increasing frequency. One of the benefits of elective cesarean delivery that has been suggested is decreased risk for pelvic floor disorders, such as incontinence. This study does not support that theory but points to pregnancy as being one of the main contributors to long term pelvic floor dysfunction. Women are being given the wrong information by both care providers and the media. One way to decrease the cesarean section rate is to give women the correct information so they are not undergoing surgery for unsubstantiated claims. Another area to note is that this study points to increased pelvic floor dysfunction with instrumental vaginal delivery. Care providers need to be aware of this and not use instrumentation for delivery unless clearly indicated. A strength of this study is its large sample size and the cross sectional inclusion of men and women ages 15-97 years of age. A large number of variables were studied which helps to fully examine all associated factors that may contribute to pelvic floor disorders. This study does rely on the subjects to self-report a variety of details from their past medical history, via an interview, which may allow for some inaccuracies.

Midwifery care and cesarean section rates

Cesarean section rates for midwives, historically, have been lower when compared to physicians. Many argue that the reason for the lower cesarean delivery rate for midwives is that they care for low-risk clients. Midwives argue that the care they give is more client-centered and involves fewer interventions which is the reason for the lower incidence of cesarean delivery. Two research studies will be reviewed, the first study compares delivery outcomes in low-risk patients managed by midwives and obstetricians; the second study investigates whether supportive midwifery care is associated with lower cesarean section rates.

Davis, Riedmann, Sapiro, Minogue, & Kazer (1994) designed a study to assess the impact of selected medical interventions used in labor upon cesarean section rates. They compared the maternal and neonatal outcomes of low-risk clients managed by obstetricians and midwives. The purpose of their study was to retrospectively compare the cesarean delivery rates of obstetric clients cared for midwives and obstetricians and to evaluate the relationship of specific interventions to cesarean delivery rates. It was hypothesized that different management styles between these two providers may result in different delivery outcomes. The study population consisted of 529 patients cared for by 4 midwives and 12,077 patients cared for by 35 obstetricians at a women's hospital during a four year period. Clients with known risk factors for cesarean delivery were excluded, however those with a previous cesarean section who wanted to try a VBAC were not excluded because both practitioners routinely cared for these clients. Data was collected from the perinatal computer data base and included maternal age, race, parity, infant birth weight, gestational age, mode of delivery, stated indication for cesarean delivery, and the obstetrician or midwife that provided care. Specific interventions were analyzed to investigate the differences in labor management styles and included: use of oxytocin for induction or augmentation, and use of narcotic analgesia or epidural anesthesia. Neonatal outcomes were evaluated by incidence of 5-minute Apgar score < 7 and umbilical artery cord blood pH <7.00.

Davis et al. (1994) used the SCC:Statistical software (Statsoft; Tulsa, Oklahoma to perform statistical analyses. The study groups were compared for differences with regard for rate, maternal age, parity, and birth weight by chi-square analysis, ANOVA, and Student t-test where necessary. Pregnancies greater that 41 weeks were compared separately as a possible confounding variable, using chi-square analysis. Chi-square was also used to compare cesarean delivery rates, use of oxytocin, analgesia, anesthesia, and infant outcomes. Stepwise logistic regression analysis was performed using the method of delivery as the outcome variable for the following components: maternal age, race, and parity, gestational age, oxytocin augmentation or induction, analgesia or epidural anesthesia, and provider type.

The results of the study (Davis et al. 1994) revealed that the difference in cesarean section rates between midwife and obstetrician managed clients was statistically significant (P< .004). Primiparas with midwifery care had a cesarean section rate of 12.7% compared to 18.1% for obstetrician care (P<.02). Multiparas with midwifery care had a cesarean section rate of 1.9% compared to 6.6% for obstetrician care (P<.007). Midwife patients underwent fewer operative (physician performed) vaginal deliveries by forceps (P<.0001) but there was no difference in vacuum-assisted deliveries between the two groups. Oxytocin for induction of labor was used less frequently in the midwife group when compared to the physician group, 8.5% versus 15% (P<.0001). The use of oxytocin to augment labor was also used less frequently in the midwife group as opposed to the obstetrician group, 23% versus 31% (P<.0001). Epidural anesthesia was used in 53% of the obstetricians' clients and 11% of the midwives' clients (P< .0001), and narcotic analgesia was used for 21% of midwife patients and 25% of physician patients (P< .05). No significant difference was noted in neonatal outcome between the two groups. According to the results of a stepwise logistical regression, the major determinant of cesarean delivery was the use of epidural anesthesia, followed by oxytocin use for induction or augmentation.

This study (Davis et al. 1994) is rather unique in that is accommodates for the differences in midwife versus physician practices by studying only low-risk women. The results of the study show that obstetricians use oxytocin and epidural anesthesia more frequently and that midwives have lower operative vaginal deliveries and cesarean section rates. It was noted that epidural use was associated with higher cesarean section rates. Midwives often provide labor support for their patients. This practice may contribute to the decreased use of epidurals and, consequently, cesarean delivery. A limitation to this study may lie in the fact the patients who seek midwifery care often make their choice based on their desire for non-intervention and a more natural approach to childbirth. This may contribute to the lower use of epidurals in the midwife group. In an effort to decrease the cesarean section rate, according to this study, practitioners should avoid active management of labor and epidural use unnecessarily. Midwifery care focuses on the woman and the normality of labor and delivery. Midwives believe in intervention only if necessary and this belief, put into practice, may be an important tool to meet the goal of lowering the cesarean delivery rate. A strength of this study is its large population size, retrospectively studied over the course of four years. Subjects, variables and outcomes were able to be examined without bias or manipulation. There were also a large number of careproviders studied, allowing for variety providers and practices be examined.

Butler, Abrams, Parker, Roberts, & Laros (1993) examined the phenomenon of the rising cesarean delivery rate and explored what impact midwifery care had on this rate. The purpose of the study was to examine whether care delivered by a midwife, including one-on-one labor support, was associated with a reduced risk of cesarean delivery. A retrospective cohort study was used to compare patients of mixed socioeconomic and ethnic backgrounds at a university hospital. Subjects were women that were deemed low-risk, meaning they didn't have any of the 52 antenatal problems associated with cesarean delivery, attended at least 5 prenatal visits, delivered term, singleton, live-born infants without congenital anomalies, in the occiput presentation. Subjects self-selected midwife or physician providers for their obstetric care. The final study group consisted of 4607 women, 3551 were designated as physician patients and 1056 as midwife patients. Nurses working on the labor and delivery unit had the same responsibilities for midwife and physician clients. Midwives, when on call, had no other scheduled responsibilities and were readily available for one-on-one care for their clients. Physician clients were cared for by first- or second-year obstetric residents. The resident physicians were responsible for multiple patients and also were on call for complications on the antenatal and postpartum unit. One-on-one care was often not possible for their clients. A faculty obstetrician was designated, for both groups, to make all final decisions on deliveries requiring operative delivery. Data was collected using a perinatal database that contained a computerized record of approximately 300 clinical variables for each woman that delivered at the hospital. Data on labor, delivery, and pregnancy outcome were entered at the time of delivery and were obtained by a professional chart abstractor after the patients discharge. Univariate statistical techniques (x2and t tests) were used to contrast the differences in incidence of cesarean delivery and sociodemographic and labor characteristics between the midwife and physician clients. The relationship between each characteristic and the type of care provider was deemed statistically significant if the two-tailed pvalue was <0.05. Potential confounders such as year of delivery, sociodemographic characteristics, and infant size were entered into a multiple logistic regression to calculated adjusted odds ratios.

The overall cesarean section rate of deliveries at the hospital during the study period was 19.8%, when the same restrictions were applied as for the study participants, the final low-risk rate was 11.7% (Butler et al. 1993). The researchers found that midwives had a cesarean delivery rate of 9.75% and physicians had a rate of 12.3% (p=0.02). Since all other factors associated with cesarean delivery had been eliminated to create a low-risk subject group, all cesarean deliveries in the subject groups were associated with fetal distress or labor abnormalities. Even after adjusting for confounding factors, midwife patients were 50% less likely to be diagnosed with fetal distress and 25% less likely to experience labor abnormalities. Midwife patients had an epidural use rate of 22.8% compared to physician patients at 42.2% (p<0.0001). The researchers wanted to evaluate the effect of midwifery care without a major confounding variable, epidural use. The incidence of cesarean delivery was investigated in women, in both groups, who did not receive epidural anesthesia. The rate of cesarean delivery in women without epidurals was 2.4% for midwife clients and 4.1% for physician clients (p=0.02). Outcomes such as blood transfusion, febrile morbidity, birth trauma, and admissions to neonatal intensive care unit were observed to determine if midwife clients and their infants experienced more problems as a result of the lower cesarean delivery rate. This was not found to be true, in fact, in most of the outcomes studied, midwives had lower incidences of complications when compared to physicians.

One of the strengths of this study (Butler et al. 1993) is the large number of study subjects that all delivered in the same facility. Another important factor is that the researchers had cases suggestive of cesarean delivery, reviewed by a faculty physician who made all final surgical decisions, therefore minimizing potential bias related to different physicians using different standards for cesarean section criteria. A potential weakness may be in the design to have residents provide the care to the physician group of clients when they may be compared to experienced midwives. This study shows evidence that midwife care, which includes personal one-on-one support during labor, improves labor outcomes and reduces cesarean delivery. This study does not address what the midwives did, specifically, during the labor process. Midwives are known to be advocates of ambulation during labor, intermittent monitoring, whirlpool use, position changes, and comfort measures such as massage and reflexology. From this study it is not known what specific labor support measures were taken indicating that more research is needed in this area.

Practice styles and philosophy of care

Fullerton, Hollenbach, & Wingard (1996) explored the intrapartum practice styles of midwives and obstetricians. The purpose of their study was to investigate similarities and differences between obstetricians and midwives in specific processes while managing perinatal care. The researchers hoped the results of this study would be used to empower women and educate them on the different options of childbirth providers and birth place settings available to them. The Iain Chalmers' list of beneficial perinatal care procedures was used as the foundation for a study instrument. From the Iain Chalmers' list, 24 items were specifically selected for their suspected variance between how physicians and midwives practiced. The 24 items were developed into a study instrument which included specific interventions used in labor along with their documented benefits. Four areas of care were studied: 1) social and psychological support; 2) pain management; 3) preventive care; and 4) delivery techniques. Each of the 24 items was followed with three questions: 1) how important it is that the intervention be available for the stated purpose (not important, available for a few, some, most, or all patients); 2)what is the policy of the facility in which the provider practices regarding the availability of the intervention in the clinical setting (never available, used at providers' discretion, or used for all patients); and 3) how frequently does the provider use the process (never used, used when need is indicated, or used for all patients). The questionnaire was mailed out to all the active obstetrician/gynecologists (ob/gyns) and certified nurse-midwives (CNMs) in SanDiego. All questionnaires included return envelopes, and self-addressed, stamped envelopes. After two-weeks, a follow-up letter was sent to those who had not responded. Usable responses were obtained from 20 (28.5%) of the midwives and 57 (15.9%) of the ob/gyns, these two groups became the study population.

The Statistical Package for Social Sciences (SPSS) and Epilnfo statistical software was used for data analyses (Fullerton et al. 1996). Descriptive statistics and chi-square analyses were used to measure differences between the two groups. Data was analyzed separately for CNMs and ob/gyns, and also for males and females to identify gender bias. Under the three categories of social support during labor and unrestricted mother/infant contact after delivery, all the midwives responded that this should be available to all or most women. When asked the same question, only 55-75% of the ob/gyns felt it was important to have this option available. CNMs were more in favor of giving the women the option to remain upright instead of recumbent during the first (CNMs 95%; ob/gyns 52%) and second stages (CNMs 95%; ob/gyns 43%) of labor. Most CNMs and ob/gyns agreed that systemic narcotics should be available during labor; however, 25% of CNMs and 16% of physicians responded that systemic narcotics need not be available or only available to a few women. Physicians were more likely to use epidural placement rather than systemic narcotic use (P<.001). Both types of providers held similar views of amniocentesis use, responding that it should be used when need is indicated. Ultrasound use had notable differences when comparing CNMs (6% never use, 94% use for some women, 0% use for all women) and ob/gyns (70% use when indicated, 28% use for all women). CNMs were in favor of external cephalic version being an option to women in an effort the reduce a possible cesarean section at a rate of 80% compared to ob/gyns at 36%. CNMs were more likely to allow exhalatory versus sustained bearing down during the second stage of labor (74% versus 36%) and favored late versus early pushing (84% versus 43%). Active management of third stage was less likely to be used by CNMs, 29% would never do it compared to 6% of ob/gyns that would be less likely to support its availability. Ob/gyns were more likely to use electronic fetal monitoring and scalp sampling during labor versus intermittent auscultation, 63% of the physicians thought these interventions should be available to most or all women, compared to 30% of CNMs.

The results of this study (Fullerton et al. 1996) give some broad insights on the different practice styles of ob/gyns and CNMs. One of the weaknesses of this study is that it is based solely on responses of how careproviders say they practice but it does not show how they truly practice. The sample size was fairly small and a large percentage of the responding CMNs worked only in freestanding birth centers which may not truly reflect how CNMs who deliver their clients in hospitals practice. Mailed questionnaires are notorious for low response rates and can lead to bias because those responding are not the same random subset that the researcher intended to study. The researchers admit that the small sample size and limited data collected led to an inability to adjust for confounding variables. Some of the practice styles of CNMs found in this study can be correlated to a lower risk for cesarean section and should be further explored. Because of the low response rate, study population cannot be assumed to be representative of the population. This study should be replicated with attempts made to include more care providers in the sample population, perhaps a phone-interview type of data collection could be considered.

Yankou, Petersen, Oakley & Mayes (1993) designed a study that would explore the philosophy of care for CNMs and physicians. The purpose of this study was to describe and compare the beliefs and care philosophies of CNMs and ob/gyns in the area of antepartum and intrapartum care of low-risk women. The subjects consisted of seven CNMs and ten obstetricians. The work environment for both groups were comparable as both groups delivered their clients at the same hospital, shared clinical facilities and held offices along the same corridor. The practice relationship between the two groups is collaborative in nature; referrals and consultations occur in both directions. Official statements from the American College of Nurse-Midwives (ACNM) and the America College of Obstetricians and Gynecologists (ACOG) were examined for similarities and differences in standards. Study questions were compiled from areas of similarity from both organizational standards. A four and one-half page survey was created and consisted of demographic information, questions about scheduled time for client appointments, and practice philosophies. To help ensure content validity, the self-report questionnaire was developed by clinical experts well versed in the national organizational statements for both ACOG and ACNM. The chief of each practice was a co-principle investigator. This study was part of a larger study to compare the processes of care and outcomes for women cared for by CNMs and obstetricians.

Analyses of this study (Yankou et al. 1993) was done using the median test. The median test was used because the data was ordinal and there were significant differences in the variances in the two subject groups. Problems with outliers and the small sample size also made the median test a more conservative test. The Bonferroni procedure was used to select an appropriate alpha level to assess significance to be able to achieve an overall level of significance of .05 for the family of tests. For this study, a value of .0008 is considered statistically significant. Results of the study showed that CNMs schedule an average of 49.3 minutes for the first prenatal visit and 29.3 minute for return obstetric (OB) visits compared to physicians; 29.8 minutes for a first prenatal visit and 14.6 minutes for return OB visits (P=.0004 for both comparisons). The subjects were asked to rate the importance of types of care in four distinct areas. In the first area, providers were asked to rate the importance of inquiring about 6 areas in the client's life that would be important to safe, effective prenatal care and rate the importance of five elements of prenatal care management. Although CNMs rated five of the information areas higher, for example: whether the pregnancy was planned, the differences were not statistically significant. In the philosophy of managing prenatal care nutrition, screening was rated higher in the CNM group and ultrasound use and alpha-fetoprotein screening was rated higher in the physician group. Again, these differences were not statistically significant. In the second area, providers were asked to rate the importance of providing prenatal information on 15 topics. CNMs rated these topics as more important than physicians but the differences were not significant. In the third area, providers were asked to rate the importance of client teaching of medical, non-medical, and psychosocial aspects of care. CNMs rated higher, all areas as important ranging from 76.4% of respondents to 96.4 %, while physicians rated the importance of teaching in different areas 25% of respondents to 65%. The fourth area asked providers to rate the importance of intrapartum care philosophies. CMNs responded that ambulation in labor and choice of birth positions were of great importance while physicians rated the use of Pitocin and intravenous fluids as having importance. Once again, the differences were not statistically significant.

The study by Yankou et al. (1993) failed to show statistical significant differences between CNM and physician care practices, influenced by their professional philosophies. However, this is probably due to the very small sample size. Expected differences in the philosophy of care to low risk women were noted in all areas and may become statistically significant with a larger sample size. As part of the research method, the researchers used official statements on philosophy of care from the ACNM and ACOG but failed to ask the individual respondents what model of care they used for practice. A strong part of the design of this study was similar practice areas regarding hospital of delivery, shared clinical site and the close proximity of the practices. A study done on a larger sample size may validate some of the basic philosophy of care practices midwives use that may have an impact on the cesarean section rate.

Interspecialty differences

Rosenblatt et al. (1997) examined interspecialty differences in the obstetric care of low-risk women. The purpose of the study was to test the hypothesis that core differences exist in resource management styles for care provided to similar groups of women by certified nurse-midwives, family physicians, and obstetricians. The researchers hypothesized that obstetricians would display the most interventive practice styles and CNMs the least interventive, with family physicians falling somewhere in the middle. A random, stratified sample of low-risk obstetrician, family physician, and certified nurse-midwife patients were abstracted during a one year period in an urban area. A total of 156 providers contacted, 54 obstetricians, 59 family physicians, and 43 certified nurse-midwives, agreed to participate. From each provider, 11 eligible charts were randomly selected for the total of 1322 patients after some charts were omitted for incomplete records. The unit of analysis in this study was provider behavior. Chi-square and F-test statistics were used and ttest was used to adjust for multiple comparisons. Statistical significance was set at P< .01.

Results of the study (Rosenblatt et al. 1997) showed that during the prenatal period, obstetricians saw their clients slightly less than the other two providers and did less screening tests. Most notable was that obstetricians performed more amniocentesis (6.8% compared to 1.4% for family physicians and 2.2% for CNMs) for reasons charted as genetic diagnosis and fetal lung maturity. CNMs ordered more nonstress tests than the other two care providers but also had more postdate pregnancies. The majority of differences were noted in the intrapartum period. CNMs showed statistical differences in that they were less likely to induce or augment their clients, use continuous fetal monitoring, use epidural anesthesia, or perform episiotomies. The practices styles between family physicians and obstetricians were fairly similar except in the area of epidural use, a statistical difference was noted in the less frequent use of epidurals in the family physician group. The cesarean section rates for the respective groups were CNMs 8.8%, obstetricians 13.6%, and family physicians15.1%. Important to note is that when they compared cesarean delivery rates in the nulliparous clients, it was higher for all specialties: CNMs 11.7%, obstetricians 23.0%, and family physicians 26.4%. When comparing costs, obstetricians used 12.2 % more resources for their clients than CNMs, with family physicians falling in the middle. This can be interpreted as CNMs use less interventions for their clients.

Although patients were randomly selected for this study (Rosenblatt et al. 1997), the patients did select their careproviders on their own which may enter some bias into this study as to the type of interventions the clients' desired. A strength of this study was the large number of providers, representing the three groups that were studied. However, only 11 patient charts were used for each provider which may not provide enough information for a particular provider. The findings of this study may point to a core difference between the three different specialties. One may deduce that the type of training and philosophy of training may dictate how a particular care provider will practice. An important finding of this study is that CNMs use fewer interventions for their clients and ultimately end up with a lower cesarean section rate. These two factors seem to go together and cannot be ignored. The use of midwifery care may be one of the solutions to the problem of the rising rate of cesarean sections.

Hueston & Rudy (1993) explored the management styles of nurse-midwives and family physicians. The purpose of this study was to determine if differences in management styles existed between midwives and family physicians and how they affect patient outcomes. The study population were patients from a co-practice of family physicians and midwives. The purpose of this co-practice originated to offer perinatal services to an indigent population in northeast Kentucky. In the practice, patients see both midwives and family physicians. When patients present to the hospital in labor, they are cared for by a midwife or a physician depending on who is on call. Patients were randomly selected via a retrospective chart audit of patients that received care during a period of one year. To ensure randomization, charts were selected based on computer-generated random numbers that corresponded to the order in which patients gave birth in a particular month. A total of 800 patients were used for the study; 400 in the midwife group and 450 in the physician group, which represented 84% of all patients that delivered within the study period. The type of careprovider that presided over intrapartum care determined which group the patient was to be assigned. Data collected from the charts included demographics, medical and obstetrical history, labor and delivery results, and identity of careprovider during labor and delivery.

Data analysis in this study (Hueston & Rudy, 1993) was performed using two-tailed Student's ttest for normally distributed data and the Kruska-Wallis Htest for data not normally distributed. A two tailed chi-square was used for categorical variables, with Fisher's exact test for expected cells less than 5. A bivariate analysis was performed separately for primiparous and multiparous clients to allow for the strong effect of parity of labor, delivery, and outcomes. Stepwise logistic regression was performed with Epistat software to adjust for computer identified variables. Independent variables identified were provider specialty, parity, and the total number of preexisting risks. The dependent variable was route of delivery, vaginal or cesarean section. Results of the study found some differences between the two specialties. During management of labor, multiparous patients under physician care were twice as likely to be augmented with oxytocin (P=.02). Primiparous clients managed by midwives were more likely to undergo amniotomy (p=.01). Other areas like labor induction rates, prostaglandin use and all types of labor anesthesia were similar between the two providers. There were some notable differences in the area of management of delivery. Episiotomies were used less frequently by midwives (P=.02) and the rate of third and fourth degree lacerations was less for midwife clients (P=.007). Most notably was that family physician clients had a higher cesarean delivery rate when compared to the midwife clients (P=.05). Reasons for cesarean delivery were recorded as dystocia or failure to progress. Patients in the physician group that underwent cesarean delivery did so at a lower cervical dilation than the midwife clients.

This study (Hueston & Rudy, 1993) introduced a unique practice of family physicians and midwives to compare. Patient preference for a certain type of provider was eliminated by using the provider on call for management of the intrapartum period. The researches of this study had the foresight to realize that some patients would start the intrapartum period with one provider but be delivered by a different provider if the labor overlapped the time frame that the providers were on call. Patients that were managed by two different types of careproviders were excluded from this study to avoid the potential for invalid data collection. Although the patient sample size was adequate, the number of providers was small which may limit the transferability of the results of this study to the larger population. By studying a practice composed of midwives and family practice physicians, the management styles of the different careproviders during the prenatal period should have been analyzed. While the differences in management styles during the prenatal period may be more difficult to pinpoint in an integrated midwife/physician practice, they should be explored. The results showed a decreased rate of cesarean deliveries in midwife clients but do not offer the reasons for the lower rate. It was noted that family physician clients underwent cesarean delivery at a lower cervical dilatation and reasons for that mode of delivery were frequently cited as dystocia and failure to progress. This may suggest that midwives were simply more patient and allowed their clients to labor longer. More study is needed to explore the true reasons for the decreased rate of cesarean deliveries in midwife clients.

Jackson, Lang, Swartz, Ganiats, Fullerton, Ecker, et al (2003) desired to use a large prospective cohort study to explore outcomes of birth center deliveries. They wished to avoid problems of previous studies on this subject which were related to the perception that women who choose a birth center delivery are healthier and seek low-intervention care. The purpose of this study was to compare outcomes, safety, and resource utilization in a collaborative management birth center model of perinatal care versus traditional physician-based care. Meticulous attention was paid to the perinatal risk of all the women in the study to ensure that both groups were low-risk. The study population were low-income, low-risk women who presented for prenatal care and delivery at several study sites. Two study programs were compared: collaborative management/birth center care and traditional care. The subjects included 2957 women: 1808 received collaborative care and 1149 received traditional care. In the collaborative care model, obstetricians and CNMs comprised the same practice. During the antepartum period, 30% of the subjects saw only CNMs, 65% were collaboratively managed, 5% were exclusively managed by a physician. Low-risk women in this group were given the option of delivering at the freestanding birth center managed or co-managed by CNMs. The birth center provided a home-like atmosphere and promoted non-intervention. Intermittent auscultation was used along with encouraging ambulation, emotional support, warm baths, and narcotic analgesics as needed. Epidural analgesia was not available. Traditional care was performed at two hospital-based prenatal care clinics and 7 private physician practices. Subjects in this group were managed by obstetricians or obstetric residents. The hospital where these women would deliver had 24-hour anesthesia services, used continuous fetal monitoring and intravenous fluids routinely, and had neonatal intensive care units. Collaborative care subjects were assessed at the first prenatal visit to determine birth center eligibility. Traditional care subjects were also assessed to determine if they would meet the criteria of a birth center delivery for comparison. Data was collected on maternal, perinatal, and neonatal mortality and morbidity; antepartum, intrapartum, and postpartum risk factors and complications; sociodemographics; use of resources and procedures; and neonatal outcomes such as birthweight, gestational age, and Apgar scores.

For this study (Jackson et al. 2003), three categories of outcomes were studied: maternal, neonatal, and behavioral. The researches recognized that there would be a low occurrence of major perinatal complications in the low-risk group and assigned aggregate variables for serious morbidity. All potential risks or complications were evaluated for potential to contribute to serious morbidity or mortality and comparability of information across study groups. The researchers used the general linear modeling with SAS GENMOD (SAS Institute, Inc. Cary, NC) with binomial distribution and identity link function, to produce adjusted risk differences and Wald estimates of 95% confidence intervals.

The researchers (Jackson et al. 2003) found that the use of resources and interventions varied between the two groups. Subjects in the traditional care model received more interventions like oxytocin induction and augmentation, episiotomies, and epidural use. Women in the collaborative care model had access to less technical interventions like ambulation, tub or shower use, and oral fluids. The cesarean section rate was 10.7% in the collaborative care model and 19.1% in the traditional model. Women in the traditional group were more likely to receive an episiotomy (37.8%) compared to women in the collaborative group (13.1%). Fetal heart rate abnormalities were reported in 10.5% of the collaborative subjects and 19.4% of the traditional subjects. Neonatal outcomes were similar in both groups but the newborns in the traditional model received sepsis workups (with and without treatment) more frequently. The researchers concluded that low-risk women in both models received safe care for mothers and babies. The collaborative model was able to deliver safe outcomes with less interventions and resources.

Once again, care delivered by midwives, with less intervention, results in a lower cesarean section rate. Not only were they able to demonstrate safe, effective care but a lower use of resources, thus, less cost. This study relied on data abstraction from medical records which could potentially provide inadequate or missing data. One of the main differences noted in this study was the type of fetal monitoring: continuous versus intermittent. There have been previous studies that suggest continuous fetal monitoring does not improve fetal outcomes in most laboring women. That suggestion was true in this study. Perhaps the use of continuous fetal monitoring led to the increased numbers of cesarean sections on women in the traditional group.


The review of the literature shows that there have been studies on indications for primary cesarean sections and various authors report different indications. With cesarean deliveries rising at an alarming rate, it is time to develop nationally accepted standards for primary cesarean deliveries. Elective inductions of labor without medical necessity have a direct correlation to a higher risk of cesarean delivery. This is another area where definitions are grey. What careproviders consider a medical necessity for induction of labor varies from provider to provider. Pelvic floor integrity is a new buzz word in the medical community. Some providers claim vaginal by-pass deliveries via cesarean section will preserve pelvic floor function and decrease associated problems like incontinence. The review of the literature shows that it is pregnancy that tax these muscles and not the mode of delivery. The exception is an operative vaginal delivery, which has been associated with lack of pelvic floor integrity. Midwives tend to use less interventions like epidurals, episiotomies, and oxytocin. The use of epidurals and oxytocin has been associated with higher cesarean section rates. As far as philosophy of care, midwives view education in all areas of care and the woman's life, in general, as important. It was also found that midwives spend more time at office visits with their clients. This study will explore factors that influence the differences in primary cesarean section rates in midwife compared to physician practices.

Conceptual Framework

In the area of research, one must consider what is the driving force for the study. A conceptual framework is the driving force for a research study. Although it may not always be clearly stated, the researcher has been guided by a formal or informal conceptual framework. In understanding what a conceptual framework is, it is easiest to break it down into smaller components. A theory is an abstract idea representing a sequential path that shows how phenomenon are related (Polit, Beck & Hungler, 2001). A theory is the basis of research. A conceptual model is a loose schematic of how concepts come together. Conceptual models are often represented in a conceptual map which is simply a diagram of the conceptual model. Conceptual models may be shown by boxes, arrows, letters, or other symbols to show how concepts are related. The theory, conceptual model and conceptual map all build up to the conceptual framework which guides and directs the research process and helps researchers to develop relationships between what is known and what they are researching. Ultimately, the conceptual framework helps to develop the hypothesis and guide the study (Polit et al).

The conceptual framework that is the driving force of this research study is the midwifery model of care. Unlike the medical model of care, which is based on an illness model, the midwifery model of care focuses on the normalcy of pregnancy, childbearing, and families. Midwives are trained to intervene only if necessary. Midwifery care is centered around the whole woman. Midwives strive to know the woman as the person she is and explores how each woman fits into her family, environment, and world. Midwives explore expectations of their clients for pregnancy and childbirth and develop client-centered plans to help women meet their goals. Midwifery care is individualized care for each woman (Rooks, 1997).

In contrast to the medical model of care, in which training, education and skills focus on pathology and the diagnosing and treatment of disease, under the midwifery model of care, midwives use their training, education and skills to protect, support and enhance normal pregnancy and childbirth (Rooks, 1997). Under the midwifery model of care, pregnancy is viewed as a critical and vulnerable period but also as a very normal part of women's lives (Rooks, 1999). To begin with, certified nurse-midwives are educated in two disciplines: nursing and midwifery. Midwives receive extensive training in reproductive anatomy and physiology, health care of women, pharmacology, antepartum care, intrapartum care, postpartum care, and newborn care. While the emphasis is on the normalcy of pregnancy and childbirth, under the midwifery model of care, midwives are trained to identify abnormal conditions that may develop. The midwifery model of care provides for a system of collaboration, consultation, or referral with or to a physician if the need arises.

The midwifery model of care recognizes the pregnant women as an active participant in her own care. At each prenatal visit, midwives devote some time to teaching and education. A large part of midwifery care involves providing women with information and allowing them to make decisions related to their own health care. To do this, midwives provide their clients with information, options, and the overall authority to make their own choices (Rooks 1999). Under the midwifery model of care, the woman and her life are the central focus of care. Midwives strive to focus on each pregnant woman as a unique person, get to know her in the context of her family and lifestyle, and work to develop a plan of care that is client focused. The midwife is interested in each woman's expectation and experience of her pregnancy and birth. When armed with the knowledge of the woman's beliefs, desires, questions, worries, and lifestyle, the midwife and the client can work together to tailor an individualized plan of care (Rooks, 1999).

In childbirth, the midwifery model focuses on the normalcy of labor and delivery and uses intervention only if indicated. Midwives, as a whole, tend to have a higher tolerance for variation, within the range of normal, as long as the woman and her baby and tolerating labor well (Rooks, 1999). By treating labor as normal, interventions such as oxytocin augmentation, induction of labor, artificial rupture of membranes, and epidurals may be avoided helping to avoid stress to mom or baby and allowing the labor to stay normal. Midwives believe that women's bodies were designed to give birth and they try to protect, support, and avoid interfering with the normal processes (Rooks, 1999). Avoidance of interference, however, does not mean neglect. Midwifery care is known to be time intensive and relationship intensive (Rooks, 1999). Midwives often spend more time with their laboring clients, offering support, encouragement, coaching, and comfort. The physiology of labor is well understood by midwives and they encourage their clients to change positions, ambulate, eat small frequent meals, take in oral hydration, use hydrotherapy, and use exhalatory pushing during second stage. The midwifery model of care views pregnancy and childbirth as a healthy state and strives to protect the normalcy of this time in a woman's life.

Key concepts and relationships

The hallmark of the midwifery model of care focuses on viewing pregnancy and birth as normal physiologic and developmental processes. Non-intervention is advocated in the absence of complications. Normal is defined as occurring naturally or free from disorder. Non-intervention is a "hands off" approach to pregnancy and childbirth. The use of this simple, two-tiered approach can be applied to the current problem of the rising cesarean section rate. Review of the literature showed that clients that received midwifery care had a lower cesarean section rate. This research study will explore whether the use of midwifery care can help reduce the cesarean section rate. To do this a quantitative comparative study will be used to explore the type of care given by midwives and by physicians and the impact it has on the primary cesarean section rate. When compared to other care providers, midwives consistently had significantly lower cesarean delivery rates for their clients. What needs to be explored and quantified is the type of care that midwives deliver that get these results. Although the midwifery model of care is valued and fostered by most midwifery practitioners, other careproviders may apply this model of care to their practice.

Conceptual Map

MMOC-------(-)----------<P C/S

MMOC= Midwifery Model of Care
P C/S= Primary Cesarean Sections

Implementing the midwifery model of care can result in the lower rate of primary cesarean sections. By reducing the primary cesarean section rate the overall cesarean section rate may be impacted. For some, using the midwifery model of care would require a paradigm change, from viewing pregnancy as a catalyst for pathology to viewing pregnancy as a normal process.

Chapter 3: Methodology

Research Design

A quantitative comparative research method will be used to explore the type of care given by midwives and by physicians and the impact it has on the primary cesarean section rate. Research has shown that clients cared for by midwives had lower primary cesarean delivery rates (Butler,1993; Davis,1994; Ernst,1989; Hueston,1993; Jackson, 2003; & Rosenblatt,1997). A prospective comparative research design will compare clients receiving midwifery care to clients receiving physician (Ob/Gyn) care. Comparative research studies are often used when the parameters of the study does not meet the requirements for an experimental design (Polit, Beck & Hungler, 2001). One of the requirements for experimental design is the ability to manipulate the intervention or treatment. However, in this study, it is the differences in care practices between groups in the natural setting that are of primary interest. In this comparative study, four groups of nulliparous, pregnant clients will be followed for their delivery outcomes, vaginal or cesarean section, while also recording selected independent variables. Two control groups, one group of midwife clients and one group of physician clients, will be created by allowing clients to self-select a midwife or physician provider according to the current system set up at the study site. Prior to the first appointment, women choose which type of provider they desire for their care, which encompasses prenatal, antepartum and postpartum. Currently, about 60% choose an Ob/Gyn provider and 40% choose a midwife provider. Two more groups will be randomly assigned to either midwife or physician care by the researcher. Using the design of studying self-selecting clients and randomly assigned clients will eliminate a common critique of midwife versus physician comparative studies. It has been suggested that midwife clients are different to begin with, leading to better outcomes, because they are healthier, lower risk and desire less intervention. Independent variables that will be studied are induction of labor, use of Pitocin to augment labor, amount of time clients spent out of bed during labor and provider time spent with clients during labor. The cesarean section rate will be the dependent variable.

This research design is expressed in the following design notation form:

Group 1 X O1 Delivery Method (self-selecting midwife clients)
Group 2 X RO2 Delivery Method (randomly assigned midwife clients)
Group 3 X O3 Delivery Method (self-selecting physician clients)
Group 4 X RO4 Delivery Method (randomly assigned physician clients)

R= randomization
O= observations
X= treatment (either physician or midwife care)

Internal and External Validity

Internal validity is the degree to which it is possible to infer that the independent variable(s), rather than uncontrolled, extraneous factors, are responsible for the observed outcome(s) on the dependent variable (Polit, Beck & Hungler, 2001). Researchers must identify threats to internal validity and take measures to control them.

Threats to internal validity in this study might include:

Measures to improve internal validity include:
External validity refers to the generalizability of the research findings or how well the findings can be applied to a different setting (Polit, Beck & Hungler, 2001). The dependent variable in this study is primary cesarean sections, therefore, clients in this study will be low-risk, nulliparous pregnant women. Demographics are also important to display generalizability of the findings to other populations. This study will be conducted in Topeka, Kansas and the demographics of this city are similar to the demographics of the United States. The demographics of Topeka (Topeka Chamber of Commerce, 2000) in comparison to the United States (U.S. Census Bureau, 2000) are displayed in table 4.

Table 4: Demographics of Topeka, Kansas and the United States
Topeka, Kansas Demographics United States Demographics
White 82.9%White 75.1%
Black or African American 9%Black or African American 12.3%
Hispanic 7.3%Hispanic 12.5%
American Indian 1.2%American Indian 0.9%
Asian 1%Asian 3.6%

Sampling Methods


A sample of 280 low-risk, nulliparous pregnant women will be recruited from the offices of Topeka Ob/Gyn Associates, located in Topeka, Kansas, at their first OB intake appointment. The hospital site will be St. Francis Health Center in Topeka, Kansas. Topeka Ob/Gyn is owned and operated by St. Francis Health Center. Providers will consist of two Obstetricians/Gynecologists and two certified nurse-midwives employed by Topeka Ob/Gyn. Permission to undertake this research will be obtained from the Chief Executive Officer, the Medical Director, the Director of the New Life Center, the Clinical Coordinator of the New Life Center, the chief OB, the Ob/Gyn physicians and the certified nurse-midwives at Topeka Ob/Gyn. This researcher is currently employed at St. Francis Health Center and has access to the New Life Center, which is where the labor and delivery unit is located.

Population of interest

The target population of interest includes low-risk, nulliparous pregnant women cared for by either an Ob/Gyn or a certified nurse-midwife.

Entry to site/access to population

This researcher is a student nurse-midwife and does clinicals at Topeka Ob/Gyn with one of the midwives as a preceptor. The researcher is also employed by St. Francis Health Center as a labor and delivery nurse. Both of these avenues would allow the researcher access to the population of study and entry to the study sites. Formal access will have to be obtained.

Inclusion/exclusion criteria

All low-risk, nulliparous women will be approached, during the initial OB intake interview, by a registered nurse during the interview process. Low-risk criteria will include: first prenatal visit at, or before, 12 weeks gestation, singleton pregnancy, older than 18 years of age, no vaginal bleeding, no history of alcohol/drug abuse, no pre-existing medical conditions such as: hypertension, heart disease, severe asthma, cancer, diabetes, liver disease, kidney disease, endocrine disease (mild hypothyroidism, stable on Synthroid would be allowed), anorexia/bulimia, or obesity (BMI > 30). Subjects will be rescreened on admission to the labor and delivery unit. Subjects that meet any of the criteria for indications for primary cesarean section at the onset of labor (Appendix A) will be excluded from this study.

Sampling methods

A convenience sample of low-risk, nulliparous pregnant women who present for prenatal care at Topeka Ob/Gyn Associates will be approached by the intake registered nurse (via a short information sheet-See Appendix C) about being involved in this research study. The names, phone numbers and addresses of those interested will be forwarded (with the client's permission) to the researcher who will contact the potential participants. A convenience sample is ideal in this study because of the availability of potential subjects at this site. Convenience sampling has the potential of bias because the subjects may be atypical of the population (Polit, Beck & Hungler, 2001). It is the desire of this researcher that the inclusion and exclusion criteria and random assignment to groups will help to avoid any potential bias when it comes to subject selection.

A total of 280 study subjects that meet the criteria will be selected. Half of the subjects, 140, will self-select a careprovider, either physician (Ob/Gyn) or certified nurse-midwife. The other half of the subjects will be randomly assigned to a provider. Subjects will be informed, during the initial OB interview, that they will be placed either in the self-selecting group or the randomly assigned group. The number 280 was chosen to allow an equal distribution, of 70 subjects, among four groups. The subject number of 280 also allows for a reasonable time frame to carry out this study. The subject number chosen would allow for some attrition related to subject exclusion later in pregnancy because of development of a risk factor or pregnancy loss. The four groups to be studied would include: 70 subjects who self-selected a physician care provider, 70 subjects randomly assigned to a physician care provider, 70 subjects who self-selected a midwife care provider, and 70 subjects randomly assigned to a midwife care provider. Post-hoc power analysis will be done to determine the power of this study.

Ethical considerations

Permission and approval for this study will be sought from the Institutional Review Board of Philadelphia University and the study sites, Topeka Ob/Gyn and St. Francis Health Center, to ensure that human subjects' rights are protected. Participants will be fully informed about this research study prior to agreeing to participate and will also be informed of why this study is being done and what the researcher hopes to learn. Subjects' identifying information and medical record information extracted from the subjects medical records will be coded for data entry. Medical records will not leave the study sites. The codes will only be known by the researcher, and the research staff, and will be kept locked and secured until the study is completed, at which time the codes and all identifying data will be destroyed. Since childbirth is often a private time, the researcher and staff will not need to be present during labor and delivery. The plan will be to train the labor and delivery staff to fill out a brief data sheet during labor and delivery which will become part of the subjects' chart. After delivery, the research staff can record the data obtained from the labor and delivery nurse. All qualifying nulliparous, pregnant women will be invited to participate in this study during their intake interview. If interested, potential subjects will be given information about the study, be allowed to ask questions of the researcher, and sign an informed consent agreement prior to participation (see Appendix D). In addition, a website will be provided for subjects to obtain additional information about the study, ask questions of the researcher and to view the final results.

Data Collection procedures


The midwives in this group average 25 deliveries per month, combined, and the physicians average 50 deliveries, combined. Given the number of deliveries and the known gestation period of nine months, this study will likely need 12-15 months to collect all the data and to allow all the subjects in the study to deliver. Another factor is that the researcher desires low-risk subjects, potentially excluding many subjects, which is another rationale for the 12-15 month timeframe. It is anticipated that it will take 4-6 months to recruit all the needed study subjects.


Once subjects are recruited and have signed the informed consent document, the researcher and research staff will obtain baseline data on the subjects from the medical records available at Topeka Ob/Gyn Associates. Demographic data will be available from a face sheet in the medical record that every patient fills out at the first office visit. This information will be entered onto the Initial Data Collection Sheet (Appendix E). Demographic data collected will include: age, race, marital status, and employment. Data abstracted from the chart will be immediately coded to ensure patient confidentiality. Additional data obtained from the office chart will include: LMP/EDC, prepregnancy height/weight, and careprovider.

Labor and delivery staff at St. Francis Health Center will be educated about the research study and will be trained to collect the necessary data during labor and delivery. Data collected during labor and delivery will include: gestation, cervical exam on admission, reason for admission, complications during labor and delivery, time care provider spent in the subjects' room, time subject spent out of bed during labor, whether the labor was induced or augmented, use of epidural or intravenous pain medication, method of delivery (vaginal, cesarean section, or operative vaginal), and infant APGARs. If the labor was induced or augmented, it will be documented whether the care provider used the protocol provided for this study to administer the medications. If the patient is delivered by cesarean section, the reason for the cesarean delivery and the cervical dilatation at the time of delivery will be recorded. Time spent in the subjects' room will be documented by having the care provider, or the labor nurse, write on the paper strip on the Corometric fetal monitor upon entering and leaving the labor room. Time spent out of bed during labor will be documented by having the labor and delivery nurse write on the paper strip of the Corometric fetal monitor when the subject gets out of bed and when the subject returns to bed. These times will be calculated and entered onto the Labor and Delivery Data Collection Sheet (see Appendix E) by the labor and delivery nurse. The list of indications for primary cesarean section (Appendix A) will be on the Labor and Delivery Data Collection Sheet. The labor and delivery nurse will be trained to screen subjects and record any indications for primary cesarean section by checking the indication from the list provided.

Description of each instrument-reliability and validity

Reliability of data collection tools is very important in quantitative studies. Reliability is the consistency with which a particular tool measures an attribute (Polit, Beck & Hungler, 2001). Validity is also important when assessing tools for data collection. Validity specifically deals with the degree to which the tool measures what is supposed to be measured (Polit, 2001). Data collection instruments used in this study will consist of the Initial Data Collection sheet (Appendix E), the Labor and Delivery Data Collection Sheet (Appendix E), and use of the Corometric fetal monitor to document time. The Initial Data Collection Sheet will be filled out by the researcher and research staff, the Labor and Delivery Data Collection Sheet will be filled out by labor and delivery nurses trained to utilize the tool. Both of these tools are designed to be easy to use and take a minimal amount of time to fill out. Midwifery students at Philadelphia University, enrolled in Critical Inquiry II, a research methodology course, have critiqued the Data Collection Sheets. In addition, the Data Collection Sheets will be reviewed and evaluated by a panel of experts in obstetrics, which will include Ob/Gyn's and midwives in Topeka, KS, to help ensure that adequate content is covered and to improve content validity. Appropriate literature resources have been utilized in the construction of the data collection tools. Data collectors will be fully trained on how to fill out the data collection sheets and will undergo interrater tests on sample clients as a test of reliability. The Initial Data Collection sheets will be filled out by the researcher and the research staff which would help to minimize errors occurring from multiple data collectors. The Delivery Data Collection Sheet will be filled out by trained labor and delivery nurses. To help avoid interpretation and data extraction errors, most of the data collected is information routinely entered into the unit Delivery Record Book, on the New Life Center, for statistical purposes. The exception would be the two timed pieces: time spent out of bed and time care provider spent in patient room. This may be an area for data collection error. With this prior knowledge, the researcher will spend more time in this area educating the labor and delivery nurses on how to calculate and record this data.

Test-retest reliability will be performed on all the Corometric fetal monitors used on the labor and delivery unit to verify the reliability of these monitors to track time intervals. All Corometric fetal monitors are calibrated yearly, and as needed, by the Maintenance Department at St. Francis Health Center. Labor and delivery nurses currently document patient time out of bed, and what activity the patient is doing while out of bed, as part of their charting requirements. All patients admitted to labor and delivery routinely use continuous fetal monitoring. The physicians and midwives will need to be educated on the importance of signing the Corometric fetal monitor strip upon entering and leaving the patient room and the nurses will be educated to document this time piece on the paper strip if the careproviders neglect or are unable to do so.

Data Analysis

Data management and analysis software

The data collection for this study will be obtained by the researcher, one trained research assistant and trained labor and delivery nurses. All of the data collectors will be Registered Nurses with backgrounds in obstetrics, as well as, labor and delivery. Collected data will be compiled, organized and entered by the researcher, with the aid of a research assistant, and expressed as a statistic. The dependent variable, cesarean deliveries, will be compared to independent variables, along with the type of careprovider, to investigate the hypotheses question of which factors are associated with primary cesarean deliveries. The assumed null hypotheses would be the lack of a relationship between the independent variables and the primary cesarean delivery rate. Ten percent of the data sets will be double checked for data entry accuracy, errors will be corrected and error rate will be calculated.

The soft ware used to analyze the data will be Epi Info (Centers for Disease Control and Prevention [CDC], 2003). According to its website, Epi Info is a public domain software package designed for use by public health practitioners and researchers. It provides easy to use form and database construction, data entry, and analysis with epidemiologic statistics, maps, and graphs. Primary applications consist of: Makeview- for creating forms and questionnaires that will automatically create a data base; Enter- a program created to use forms and questionnaires created in Makeview to allow data to be entered into the database; Analysis- a program to produce statistical analyses of data, report output and graphs; EpiMap- to create GIS maps and overlay survey data; and Epi Report- a tool that allows the user to combine the information from the previous programs and present it in a professional format. Epi Info is a CDC trademark but may be freely copied, distributed, and translated in the public domain. The latest release, Epi Info, Version 3.01 will be used.


The data will be analyzed by utilizing ANOVA and independent t-tests. ANOVA (analysis of variance) will be used to analyze the timed data pieces of this study, i.e., time careprovider spent in the subjects' room and time subject spent out of bed. ANOVA statistics are often used to test mean group differences when there are three or more groups being studied. ANOVA breaks down the total variability of the dependent variable into two parts: variability attributed to the independent variable and variability related to all other sources (Polit, Beck & Hungler, 2001). By using ANOVA, the differences between the four study groups will be analyzed for the effect that the independent variables have on the dependent variable, cesarean delivery.

Independent t-tests will be used to analyze the independent variables, induction of labor and augmentation of labor. A t-test is a common research tool used to compare two groups of people on a dependent variable. T-test statistics use group means, sample size, and variability to calculate the t-value. The t-value, along with the degrees of freedom (df), is used to establish an upper limit, statistically, of what is probable if the null hypotheses is true. Independent t-tests imply that the study groups are independent of each other (Polit, Beck & Hungler, 2001). The groups compared with independent t-test analyses will be midwife clients and physician clients. Independent variables that will be analyzed are use of labor induction or augmentation and its effect on the cesarean delivery rate.

Disseminating findings

It is the hope of this researcher to distribute the outcomes of this study, both nationally and locally. The findings of this study will be submitted to the American Journal of Obstetrics and Gynecology for publishing. The researcher will also present the findings of the study at a local Ob/Gyn meeting, which is open to physicians, midwives and hospital administrators, to disseminate the information locally.



American College of Nurse-Midwives (2002, December). CNM-attended births still on the rise! Retrieved October 8, 2003, from

American College of Obstetricians and Gynecologists (2003, July). ACOG news release. Retrieved October 7, 2003,from

Bashore, R.A., Phillips, W. A., Brankman, C. R. (1990). A comparison of the morbidity of midforceps and cesarean delivery. Am J Obset Gynecol, 162, 1428-35.

Butler, J., Abrams, B., Parker, J., Roberts, J. M., Laros, R. K. (1993). Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. Am J Obstet Gynecol, 168, 1407-13.

Centers for Disease Control and Prevention (2003). Epi info 3.01. Retrieved January 12, 2004, from

Cunningham, G. C., Gant, N., Leveno, K. J., Gilstrap III, L. C., Hauth, J. C., Wenstrom, K. D. (2001). Williams obstetrics (21st ed). New York: The McGraw-Hill Companies, Inc.

Davis, L. G., Riedmann, G. L., Sapiro, M., Minogue, J. P., Kazer, R. R. (1994). Cesarean section rates in low-risk private patients managed by certified nurse-midwives and obstetricians. Journal of Nurse-Midwifery, 29(2), 91-97.

Dietz, H. P., Bennet, M. J. (2003). The effect of childbirth on pelvic organ mobility. Obstet Gynecol, 102(2), 217-9.

DiGiuseppe, D. L. (2001). Risk adjusting cesarean delivery rates: A comparison of hospital profiles based on medical record and birth certificate data. Health Services Research. Retrieved October 7, 2003, from

Ernst, K., Rooks, J., Rosen, D., Rosenfield, A., Stapleton, S., Weatherby, N. (1989). Outcomes of care in birth centers. (The national birth center study). New England Journal of Medicine, 321, 1804-11.

Fullerton, J. T., Hollenbach, K. A., Wingard, D. L. (1996). Practice styles: A comparison of obstetricians and nurse-midwives. Journal of Nurse-Midwifery, 41(3), 243-50.

Gabbe, S. G., Neibyl, J. R., Simpson, J. L. (2002). Obstetrics: normal and problem pregnancies. Philadelphia: Churchill Livingstone.

Gabay, M., Wolfe, M. D. (1994). Unnecessary cesarean sections: curing a national epidemic. Washington: Public Citizen.

Gregory, K. D., Korst, L. M., Gornbein, J. A., Platt, L. D. (2002, October). Using administrative data to identify indications for elective primary cesarean delivery. Health Services Research. Retrieved October 5, 2003, from

Greulich, B., Paine, L. L., McClain, C., Barger M. K., Edwards, N., Paul, R. (1994). Twelve years and more than 30,000 nurse-midwife-attended births: the Los Angeles County + University of Southern California women's hospital birth center experience. Journal of Nurse-Midwifery, 39(4), 185-96.

Greve, P. A. (2002). Anticipating and controlling rising malpractice insurance costs. Healthcare Financial Management. Retrieved October 7, 2003, from

Hamilton, B. E., Martin, J. A., Sutton, P. D. (2003, June). Births: preliminary data for 2002. Natl Vital Stat Rep, 51 (11),1-20.

Hueston, W., Rudy, M. (1993). A comparison of labor and delivery management between nurse midwives and family physicians. The Journal of Family Practice, 37(5), 449-454.

Jackson, D. J., Lang, J. M., Swartz, W. H., Ganiats, T. M., Fullerton, J., Ecker, J., Nguyen, U. (2003). Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Research and Practice, 93(6), 999-1006.

Lal, M. (2003). Prevention of urinary and anal incontinence: role of elective cesarean delivery. Curr Opin Obstet Gynecol, 15(5), 439-48.

MacLennan, A. H., Taylor, A. W., Wilson, D. H., Wilson, D. (2000). The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. British Journal of Obstetrics and Gynaecology, 107,1460-1470.

Polit, D., Beck, C., Hungler, B. (2001). Essentials of nursing research. Methods, appraisal, and utilization (5th ed.). Philadelphia: Lippincott.

Rooks, J. P. (1997). Midwifery and childbirth in america. Philadelphia: Temple University Press.

Rooks, J. P. (1999). The midwifery model of care. Journal of Midwifery & Women's Health, 44(4), 370-74.

Rosenblatt, R. A., Dobie, S. A., Hart, L.G., Schneeweiss, R., Gould, D., Raine, T. R., et al. (1997). Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health, 87(3), 344-51.

Roth-Kleiner, M., Wagner, B. P., Bachmann, D., Pfenniger, F. (2003). Respiratory distress syndrome in near-term babies after caesarean section. Swiss Med Wkly, 133, 283-288.

Sedev, H. M. (2002). Cesarean delivery. Retrieved September 30, 2003, from

Seyb, S. T., Berka, R. J., Socol, M. L., Dooley, S. L. (1999). Risk of cesarean delivery with elective induction of labor at term in nulliparous women. Obstetrics & Gynecology, 94(4), 600-607.

Starr, C. (2003). Elective cesarean section: a new dividing line for OBs. Contemporary OB/GYN. Retrieved September 30, 2003, from

Topeka Chamber of Commerce (2000). Demographics. Retrieved January 5, 2003 from

US Department of Health and Human Services. (2000, November). Healthy people 2010: understanding and improving health. Retrieved October 10, 2003, from

U.S. Census Bureau (2002). Geographic area: United States. Retrieved January 5, 2003 from

Yankou, D., Petersen, B. A., Oakley, D., Mayes, F. (1993). Philosophy of care: A pilot study comparing certified nurse-midwives and physicians, 38(3), 159-64.


Appendix A:
Indications for primary cesarean section.

Gregory, Korst, Gorbein &, Platt, 2002
antepartum bleed
severe hypertension
uterine scar
multiple gestation
unengaged fetal head
maternal soft tissue disorder
hypertension (other)
preterm gestation
fetal congenital anomaly


Appendix B:

Administration protocol for cervical ripening

Cytotec 25 mcg or Prostaglandin E2 gel (one applicator full) vaginally every 4 hours, maximum of four doses
discontinue if:
-hyperstimulation of the uterus
-adequate contraction pattern demonstrated by greater than 200 Montevideo units
-fetal distress
-Bishop score greater than 5

Administration protocol for Pitocin induction/augmentation

Start Pitocin at 2 milliunits/minute and increase 2 milliunits/minute every 20 minutes until adequate labor pattern is established as demonstrated by greater than 200 Montevideo units. Maximum Pitocin rate is 20 milliunits/minute.
discontinue if:
-fetal distress
-hyperstimulation of the uterus

Appendix C:


I would like to invite you to participate in a research study that will examine the kind of care women receive in labor and delivery and whether is makes a difference in the birth outcomes. Women who are pregnant with their first baby and who are considered "low-risk" from a medical point of view, are ideal candidates for this study. In this study the researcher will compare women who receive care from a physician (Ob/Gyn) to women who receive care from a certified nurse-midwife. Birth outcomes, vaginal delivery or cesarean delivery, will be compared among the groups of women observed. Different types of care provided will be observed to see how it relates to the type of delivery outcome. Willing participants will be given an informed consent document to read and sign and will be allowed to ask questions of the researcher prior to agreeing to be a part of this study. Women who agree to participate in this study will either self-select the type of provider they want for their obstetrical care or will agree to be randomly assigned to a care provider. Participants will also give permission to the researcher and research staff to have access to their medical records both in the care providers office and at the hospital during and after their delivery. Participants will not be required to fill out questionnaires or be manipulated in anyway. Your only requirements are your willingness to participate, to possibly be randomly assigned to a care provider, and to allow access to your medical records. If you would be willing to participate in this study please sign this document and include your address and phone number so the researcher can contact you.

Thank you for you time,

Kim Keen RN, BSN, SNM

I, __________________, agree to be contacted by the researcher, Kim Keen, regarding the above research study.

Signature: ___________________________

Address: ___________________________


Phone #: (s) ___________________________

Email address: _________________________

Please initial one of the following:

____ I prefer to select a Certified Nurse-Midwife for my careprovider.

____ I prefer to select and Obstetrician/Gynecologist for my careprovider.

____ I agree to be randomly appointed to a careprovider.


Appendix D:

Informed Consent


I ________________________, consent to participate in research entitled "Factors Influencing Differences in the Primary Cesarean Section Rates in Midwife Compared to Physician Practices." I understand that this study is being conducted by Kim Keen, RN, BSN, SNM as part of a Critical Inquiry Final Project in the Master's of Midwifery program at Philadelphia University. I acknowledge and fully understand that my participation is voluntary and I may resign from this study at any time without penalty. The purpose of this study is the explore factors influencing the differences in the primary cesarean section rate in midwife versus physician practices. By agreeing to be a part of this study I authorize the researcher, Kim Keen, and her research staff access to my medical records both at the Topeka Ob/Gyn Associates facility and at St. Francis Health Center. I understand that demographic information will be obtained from my medical records to be used in this study. In addition, I understand that data associated with my prenatal history, labor and delivery, and birth outcome will be obtained from my medical records. Personal contact will not have to be made between me and the researcher and I will not be required to fill out any forms or questionnaires.

My privacy will be protected and the information collected from my medical records will not be identifiable by name or in any other way. The results of this study will be submitted to the American Journal of Obstetrics and Gynecology for publication and will also be posted on a website that I will have access to. I understand that there are no identifiable risks related to my participation in this study. I fully understand that I have the right to withdraw from the study at any time that I deem necessary. I also understand that if I have any questions, I may contact the researcher at any time throughout the study.

I certify that I have read the above information and agree, without hesitation, to participate in this research study. I have received all necessary information to enable me to make an informed decision.

___________________________ _____________
Signature of Participant Date

Telephone Number

Email Address

Witness Signature


Appendix E:

Initial Data Collection Sheet


Race:(check one)

___ Caucasian (White)
___ African American (Black)
___ Hispanic
___ American Indian
___ Asian
___ Other (specify) ____________

Marital Status: (check one)

___ single (no significant other)
___ single (significant other involved)
___ married
___ divorced
___ widowed
___ estranged

Employment: (specify)_______________________

Last Menstrual Period:_________
EDC: ____________
EDC confirmed by:
___ LMP
___ Sonography

Prepregnancy Weight: ______
Height: ______


Labor and Delivery Data Collection Sheet

Reason for
Cervical Exam
on admission:
during Labor
& Delivery
Total time spent in client room by careproviderTotal time client spent out of bedLabor induced?

confirmed by sono?


___early labor
___active labor
___ bleeding
___other (describe)
___fetal distress
Hours _____

Hours ______

___Prepidil or


Labor Augmented?If labor induced or augmented, did provider use the medication protocol?Intravenous pain
medication used during labor?
Epidural used during labor?
Method of deliveryNewborn Apgars

___Other describe for other:

Cervical dilatation at time of epidural? ______
__ Forcep
___ 1-minute
___ 5-minute
___ 10-minute

Check any of the following, indications for primary cesarean section, which apply to the client.

Gregory, Korst, Gorbein &, Platt, 2002
antepartum bleed
severe hypertension
uterine scar
multiple gestation
unengaged fetal head
maternal soft tissue disorder
hypertension (other)
preterm gestation
fetal congenital anomaly

Appendix F:

Researcher salary (based on 0.2 FTE X 21 months)-------------------------------------$27,000

One research assistant (to collect data and do input: 0.2 FTE X 15 months)---------------$5,200

Paper supplies and printing costs----------------------------------------------------------$1,200

Training costs for labor and delivery nurses--------------------------------------------------$400

Assistance with statistical analysis of study data----------------------------------------------$600


The plan for obtaining funding is to apply for grants from the federal and private industry with a funding goal of $35,000.

Appendix G:

Time Table

Proposal for IRB approval, approval from St. Francis Health Center, Topeka Ob/Gyn, and the midwives and physicians---------------------------------------------------------------------------------------3 months

Recruitment of study participants-----------------------------------------------------------------4 months

Completion of data collection (allowing all subjects time to deliver after they are recruited)-------15 months

Statistical analysis of data entry and interpretation of data-------------------------------------------3 months

Writing up formal report--------------------------------------------------------------------------3 months

Total time for completion------------------------------------------28 months

. . . . . . .