• Emily C White VanGompel, Susan L Perez, Avisek Datta, Francesca R Carlock, Valerie Cape, and Elliott K Main.
• Department of Family Medicine, University of Chicago, Pritzker School of Medicine, Chicago, Illinois ewhitevangompel@northshore.org.
• Ann Fam Med. 2021 May 1; 19 (3): 249-257.

PurposeLarge-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals' success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not.MethodsA mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals' net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators.ResultsOut of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians' individual attitudes differed by hospital success on 5 scales: best practices (P = .003), fear (P = .001), cesarean safety (P = .014), physician oversight (P <.001), and microculture (P = .044) scales. Patient ability to make informed decisions showed poor agreement across all hospitals, but was higher at successful hospitals (38% vs 29%, P = .01). Important qualitative themes included: ease of access to shared resources on best practices, fear of bad outcomes, personal resistance to change, collaborative practice and effective communication, leadership engagement, and cultural flexibility.ConclusionsSuccessful hospitals' culture and context was measurably different from nonresponders. Leveraging these contextual factors may facilitate success.© 2021 Annals of Family Medicine, Inc.

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