Obstetric Anesthesia Workforce Survey

Abstract

“THE position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged by the care given her at the birth of her child.”1Although many developments have occurred in obstetric anesthesia since this quote's first publication in 1929, advances in the subspecialty have been complicated by medicolegal, financial, maternal, and fetal considerations. In addition to these concerns, recent economic pressures, variations in payment, patient expectations, and the technical aspects of providing these services have challenged obstetric anesthesia practice.Surveys are frequently used to define and detect changes in practice. Since data were collected more than 20 yr ago for the first obstetric anesthesia workforce survey,2there have been improvements in delivery of obstetric analgesia and anesthesia. Many factors affect the number and type of available anesthesia care providers and the services they provide. The most recent obstetric anesthesia survey reported that although the availability of both regional analgesia and anesthesia for labor and delivery had improved in the previous decade, improvement was still needed in staffing patterns and availability of personnel.3Organizations outside the practice of anesthesiology (e.g. American College of Obstetricians and Gynecologists [ACOG], Association of Women's Health Obstetric and Neonatal Nurses [AWHONN]) have published their own guidelines,4–6∥which impact the management of pain relief. Newer approaches to regional analgesia for labor (e.g. , patient-controlled epidural analgesia, combined spinal–epidural [CSE] analgesia) may aid practitioners in meeting the increased demands of obstetric anesthesia practice, but whether these newer approaches are used substantially is unknown.The 2001 obstetric anesthesia workforce survey was performed in conjunction with the Society for Obstetric Anesthesia and Perinatology to estimate and assess current trends in obstetric anesthesia practice as well as to identify potential areas needing improvement.In 1981 and 1992,2,3workforce surveys were conducted to assess trends in obstetric anesthesia practice. The survey was repeated in 2001, modifying the 1992 instrument to include newer questions to define contemporary practice patterns. The 2001 survey instrument differed from previous surveys by separating the questionnaire into three parts to direct questions to the three key labor and delivery personnel (Chief of Anesthesiology, Chief of Obstetrics, Labor and Delivery Manager) that were most likely to provide the most accurate information. Questionnaires were developed using TELEform® technology (Verity, Inc., Sunnyvale, CA), which simplified the process of data entry and quality control by converting information written on paper documents directly into an electronic database. Each draft survey was distributed to a four- or five-participant focus group to obtain feedback about the survey (e.g. , validity of questions, ease of use) before distribution.The primary focus of the survey was to obtain data on obstetric anesthesia practice from obstetrics and anesthesia providers as well as labor and delivery managers in groups of hospitals defined by the annual number of births and to compare these data across these hospital strata. Using the response rates known from previous surveys, the number of individuals contacted within each stratum was determined with the expectation that approximately 170 respondents would complete and return the survey.A stratified random sample frame of 1,300 hospitals was selected from the American Hospital Association's 2001 Guide to the Health Care Field . Hospitals were stratified based on geographic region (Northeast, Mid-Atlantic, South Atlantic, East North Central, East South Central, West North Central, West South Central, Mountain, and Pacific) and number of births for that year: stratum I (> 1,500 births), stratum II (500–1,499 births), and stratum III (100–500 births).During the presurvey time period, letters were sent to each hospital administrator in the sample (stratum I: n = 336; stratum II: n = 492; stratum III: n = 473) asking them to identify and provide contact information for the three key labor and delivery personnel at their institution: Chief of Anesthesiology, Chief of Obstetrics, and Labor and Delivery Manager. Administrators who did not respond received a second mailing. Following the methods outlined by Dillman,7a survey introductory letter was mailed to the three key personnel at each responding institution, followed by the survey instrument 1 week later. Each of the personnel was contacted periodically up to five times during the survey. Incentives or inducements for completion of the survey were not offered. The identity of all survey respondents remained confidential. Returned questionnaires were scanned using TELEform® software. Response tabulation and statistical analysis (by strata) were completed using SAS® software (SAS Institute, Inc., Cary, NC). Responses were analyzed by strata.A brief follow-up telephone survey of nonresponding hospitals was conducted to identify potential differences between responders and nonresponders. This brief survey focused on several key characteristics, including anesthesia procedures and personnel.Table 1contains data aggregated from the American Hospital Association's Annual Survey Database for the fiscal year 2001. Compared with their 1981 and 1992 data, the number of hospitals providing obstetric care decreased from 4,163 in 1981 and 3,545 in 1992 to 3,160 in 2001. A substantial decrease was observed in the number of stratum III hospitals (100–500 births) providing obstetric care compared with 1992 data (1,603–1,081), and there was a considerable increase in the number of the largest stratum I facilities (824–889).Table 2describes survey respondents, profiles of responding hospitals, and total number of births at responding hospitals for 2001. A total of 378 of the 1,300 initially sampled hospitals responded to the request for contact information on their key labor and delivery personnel (29% overall response). In the Anesthesiology survey, responses were received from 57% of the contacted anesthesiologists and certified registered nurse anesthetists. In the Obstetrics survey, responses were received from 45% of the contacted obstetricians, nurse midwives, and family practitioners. In the Labor and Delivery Manager survey, responses were received from 75% of the registered nurses and other labor and delivery management personnel.Stratum I hospitals (> 1,500 births) were more likely to be regional referral centers for high-risk obstetrics and to have anesthesiology residency and Clinical Anesthesiology year 4 programs. Nevertheless, 20% of hospitals with 500–1,500 deliveries per year consider themselves regional referral centers for high-risk obstetrics (i.e. , high-risk referral center).Compared with previous surveys, there was an overall increase in the percent of maternity cases using regional analgesia for labor across all strata (table 3). There were decreases in the percent of parturients receiving either parenteral analgesia or no analgesia at all compared with 1981 and 1992 survey data. In all hospitals, the use of epidural analgesia increased compared with previous surveys, with the sharpest increase occurring in stratum III hospitals. Spinal analgesia (either with or without local anesthetics) was used in less than 10% of cases. Similarly, CSE was administered in a small number of maternity cases across all strata. Patient-controlled epidural analgesia was used in nearly one-third of stratum I and II hospitals, but only 18% of stratum III hospitals reported its use.The use of spinal anesthesia for cesarean delivery increased across all strata, whereas the use of epidural anesthesia decreased across all strata compared with 1992 survey data (table 3). General anesthesia was used in 5% or less of elective cesarean deliveries. However, general anesthesia was used in 15% of urgent–emergent cases in stratum I hospitals (> 1,500 births), 30% in stratum II hospitals (500–1,499 births), and 25% in stratum III hospitals (100–500 births). CSE anesthesia was used in less than 10% of cesarean deliveries across all strata.Eighty percent of stratum I hospitals reported in-house availability of regional analgesia during labor (table 4). In the smallest hospitals, only 3% reported in-house coverage for regional analgesia for labor. Compared with 1992, stratum II hospitals reported a decrease in in-house coverage from 27% to 20% in 2001. Seventy-seven percent of stratum II hospitals reported on-call coverage for regional analgesia. Compared with 20% provider unavailability in 1992, only 3% of stratum III hospitals reported that regional analgesia for labor was not available. In all hospital categories, the provider availability of regional anesthesia for cesarean delivery was similar to that available during labor.In 2001, across all strata, an anesthesiologist was slightly more often directly involved in the care of patients receiving regional analgesia for labor compared with 1981 and 1992 survey data (table 5). Less than 6% of regional analgesics were administered by obstetricians for labor across all strata, compared with 30% in 1981. In stratum III hospitals, 34% of regional analgesics for labor were administered by independently practicing certified registered nurse anesthetists, and 14% of these anesthetics were administered by certified registered nurse anesthetists under the medical direction of nonanesthesiologist physicians.Respondents were asked for the percentage of various personnel performing newborn resuscitation in their hospitals. In stratum I and II hospitals, pediatricians performed an average of 42% and 48% of neonatal resuscitations during cesarean deliveries, respectively. This was offset by a large increase in the average percentage of resuscitations performed by nursing personnel (e.g. , nurse specialist trained in neonatal resuscitation, labor nurse).Respondents were asked whether their hospitals allowed vaginal birth after cesarean delivery (VBAC) (table 6). Vaginal birth after cesarean delivery was allowed in 98% of stratum I and 92% of stratum II hospitals but was allowed in only 68% of stratum III hospitals. Regardless, only 25–30% of all patients attempted it across all strata. Forty percent of the stratum III hospitals reported that since the introduction of the July 1999 American College of Obstetrics and Gynecology Practice Bulletin on Vaginal Birth after Cesarean Delivery,5VBAC was no longer performed. Both stratum I and II hospitals also indicated a decrease in VBAC attempts since introduction of the practice bulletin. Across all strata, at least 60% of attempted VBACs were successful.Respondents were asked about in-house anesthesia provider coverage during epidural infusions, and VBAC with and without regional analgesia (table 6). During epidural infusions, the majority of institutions in all three strata required anesthesia providers to be in-house. Across all strata, between 63% (stratum III) and 94% (stratum I) of institutions required providers to be in-house when parturients were attempting VBAC with regional analgesia. Eighty-six percent of stratum I hospitals required anesthesia providers to be in-house during attempted VBAC even if regional analgesia was not used. In the smallest hospitals, 33% of respondents stated that in-house anesthesia providers were required during VBAC attempts without regional analgesia.Almost all hospitals allowed ambulation during spinal opioid administration (table 6). Although approximately 50% of hospitals allowed ambulation during epidural or CSE analgesia, a much smaller percentage of patients actually ambulated.Less than 10% of institutions allowed nurses to reinstitute (i.e. , restart) epidural infusions across all strata (table 6). Twenty-eight percent of stratum II hospitals reported that nurses were allowed to adjust infusion rates, but only 7% of stratum I hospitals permitted nursing staff to adjust epidural infusion rates. Nurses were allowed to administer epidural boluses in 13% of stratum II hospitals, but only 3% of stratum I hospitals allowed nurses to administer boluses.The collection rates for professional fees for anesthesia for labor and vaginal delivery as well as cesarean delivery and for other surgical procedures steadily decreased from 1981 to 2001 (table 7).Stratum I hospitals had the largest percentage of health maintenance organization payers, and stratum II and III hospitals had the largest percentage of Medicaid payers. Stratum III hospitals had the highest percentage of Medicaid and private insurer categories but had the smallest percentage of health maintenance organization payers. Percentage payment of actual charges was similar among all groups of payers across all sizes of hospitals.Responses were obtained from 43 hospital administrators (16 stratum I, 13 stratum II, and 14 stratum III) of institutions that did not respond to the initial survey. Collectively, there were no significant differences (P = 0.05) in responses obtained from initial survey respondents compared with nonrespondents.More than 4 million deliveries occur in the United States each year. During the past 20 yr, there has been an increasing trend toward the use of regional analgesia/anesthesia for labor and delivery. Current survey results suggest that there has been improvement in availability as well as staffing of regional analgesia/anesthesia for labor and delivery. These results are particularly notable because the number of anesthesia providers has not kept pace with increasing demand for services.8–10In a report published in 2003, the number of American anesthesia residency graduates decreased by 75% from a high of 1,511 in 1994 to only 400 in 2000.11Although the number increased to 783 in 2003, several factors will continue to intensify and prolong the shortage of anesthesiologists. The number of nurse anesthetists is also expected to decrease because the average age of nurses is increasing and nonhospital jobs are multiplying.12While the availability of trained anesthesiologists has declined,10,13surgical volumes have increased and the of practice has to surgical care pain and demand for anesthesia services and availability of anesthesia providers will the of obstetric anesthesia 2001 survey that in the United the total number of hospitals as well as the number of stratum III hospitals (100–500 births) providing obstetric care decreased by and compared with the previous (table In both the number of stratum I (> 1,500 and II (500–1,499 births) hospitals providing obstetric care The increased number of stratum I and decreased number of stratum III hospitals providing obstetric care is with in the 1992 survey and of obstetric services to obstetric or of smaller labor and delivery Both the American Society of and of obstetric care as stated in the for Anesthesia Care in Although only of deliveries occurred in hospitals with obstetric services between and deliveries per these hospitals of the hospitals providing obstetric percent of all deliveries occur in hospitals with more than 1,500 deliveries per for to anesthesia Many of these hospitals are also with medical and residency programs. 20% of stratum II and of stratum III hospitals are regional referral centers for high-risk obstetrics (table likely that facilities are referral in to a by the American Society of and for Anesthesia Care in in-house and neonatal are in large maternity and as high-risk subspecialty care centers have a anesthesiologist with or in anesthesia in of obstetric anesthesia and personnel in administration of obstetric anesthesia be available in the hospital a survey results suggest that use of regional analgesia for labor increased across all strata, in stratum III hospitals (table 3). In parturients received parenteral or no analgesia compared with 1981 and 1992 factors labor analgesia family and past and expectations, of the or and the and medical providing labor pain management affect of pain a between a birth epidural analgesics and the of a receiving The also reported that of who to a labor epidural a of pain during that and of the are more for than the of pain and medical the about of epidural analgesia on the of cesarean delivery has been of regional analgesia in the of a American Society of the that for many regional anesthesia or will be the most Although the overall availability of anesthesia providers has and availability of regional analgesia for labor in all hospitals has in stratum III hospitals. this not all hospitals anesthesia groups to provide this and hospitals only provide services for cesarean epidural infusions were improvements in the administration of regional analgesia for labor compared with (i.e. , patient-controlled epidural analgesia) have allowed for of local anesthetics and for or of Although patient-controlled epidural analgesia total epidural and decreases anesthesia personnel of hospitals used patient-controlled epidural analgesia (table 3). for a of use are but may be or of the publication of the obstetric anesthesia workforce survey, CSE is other that is to obstetric anesthesia practice. its spinal analgesia the of administration of of spinal anesthetics without the with epidural The spinal has been used in smaller hospitals because it be administered by obstetric care providers with or by anesthesia personnel who not in the survey results suggest that spinal were used in a small number of hospitals across all the strata. In to the of CSE labor analgesia the of both spinal and epidural these data suggest that CSE was used in less than 10% of all hospitals in 2001. Although CSE to be a it is more complicated than either spinal or epidural the of the the epidural has not been to after the of spinal analgesia, if an is these potential for CSE have been to at the as epidural actual not to be between the use also be by about potential use of regional anesthesia and spinal anesthesia for cesarean delivery has increased since publication of the 1992 survey results (table 3). epidural or spinal anesthetics the to be or with The current survey results also suggest that spinal anesthesia was used in approximately 50% of urgent–emergent cesarean deliveries. These results are not because spinal anesthesia many epidural and the for its use in many urgent–emergent cesarean deliveries. about the decreased use of general anesthesia for cesarean delivery and no longer in providing general anesthesia for obstetric results suggest that general anesthesia was still used in of urgent–emergent cesarean deliveries in 2001. However, in elective cesarean deliveries, general anesthesia was used in less than 5% of cases in all sizes of previous workforce surveys stated that availability of regional analgesia be changes were observed in the 2001 survey provider availability and personnel providing regional anesthesia for In stratum III hospitals (100–500 births), providers were available on-call for labor and cesarean deliveries in more than of In 20% of these small services had no regional analgesia for labor in Although epidural analgesia is often as several factors may have to its increased use of epidural analgesia to overall patient with the labor and delivery In an epidural during labor the with general anesthesia and cesarean delivery. However, with current payment and an between and demand for anesthesia staffing of obstetric anesthesia services will continue to be a changes in personnel performing newborn resuscitation at the time of cesarean delivery were observed in stratum I and II hospitals in 2001, approximately 45% of resuscitations were performed by pediatricians compared with in In stratum III hospitals, the percentage of resuscitations performed by family practitioners decreased from in 1992 to 13% in 2001. performed by practice or labor nursing personnel increased in all sizes of hospitals. Anesthesia providers or certified registered nurse are involved in newborn resuscitation This is with previous publication of the most recent obstetric anesthesia workforce survey in VBAC has a more of obstetric practice. Although for VBAC attempts increased from to of and with of labor in patients with previous cesarean decreased the number of VBAC attempts by to in a practice for VBAC the availability of anesthesia and personnel for cesarean followed this and many anesthesiologists to the VBAC because they for in-house coverage of labor and delivery in hospitals. a VBAC practice the for availability of anesthesia and personnel during attempted the has not been defined in VBAC practice VBAC be attempted in institutions to respond to with available to provide results decreased of VBAC attempts in all sizes of maternity services (table 6). These results are with the on results suggest that small hospitals attempted and anesthesia providers remained during attempted Although VBAC attempts be performed in smaller hospitals if they have the personnel and to respond to obstetric (e.g. , the of VBAC is less well in these on of have also position that the of availability of personnel and facilities a local based on each availability of and geographic much was after publication of a large the survey results that in hospitals that ambulation during spinal or epidural labor analgesia, the average percentage of patients using ambulation from only 3% in the largest hospitals to in stratum III hospitals (table 6). Stratum III hospitals were more likely to ambulation and for patients to the and fetal of ambulation after regional administration during it is to which patients are to the of ambulation during labor the practice of a has been the delivery of obstetric anesthesia care that likely regional analgesia delivery. In 2001, published an position that registered nurses not adjust epidural infusion rates, or reinstitute epidural infusions, administer epidural or patient-controlled epidural analgesia nurses have infusions it was to the to which labor and delivery nurses to position results that nurses in stratum II (500–1,499 births) and III (100–500 births) hospitals were more likely to adjust epidural infusion rates (table 6). However, less than 10% of stratum I hospitals (> 1,500 births) allowed nurses to adjust epidural infusion rates, administer epidural or reinstitute epidural Although the Society for Obstetric Anesthesia and Perinatology and the American Society of have to their and have labor nurses to an in pain during has been in their However, most recent on during Labor that labor and delivery nursing personnel who have been and have current be to in the management of epidural infusions, including of and of or whether this will affect position is respondents were asked is the collection of professional fees for and the results are in Although not whether responders to or collection rates are similar between surgical and obstetric cases. also determined patient categories and percentage of actual charges for cesarean delivery and labor epidural analgesia in all sizes of hospitals. Stratum I hospitals had the largest percentage of health maintenance organization payers, and stratum II and III hospitals had the largest percentage of Medicaid payers. Stratum III hospitals had the highest percentage of Medicaid and private insurer categories but had the smallest percentage of health maintenance organization payers. The number of practitioners that they had been payment increased from 25% in 1992 to in 2001. percent of respondents reported that had payment, but only responded that payment was by to previous obstetric anesthesia workforce surveys, there are several to the current A number of are required for the of a sample of the most for a survey is a complete frame that response by that the sample the of of the of this was in contact with key personnel in institutions in the of institutions were but initial were with a high although used the most recent 2001 American Hospital Association's Annual Survey Database to a current and accurate of hospitals, publication of the process of and of hospitals in the United sample sizes are also required for Although sample sizes were based on response rates known from previous of the of surveys is to the number of including by hospital administrators and responses did not rates. The survey instrument was to obtain from the most in to increase survey This the of the survey for each the potential of performed a follow-up telephone survey of nonresponders. these results were not from initial survey providing that results are medical surveys are often by response to a survey is the survey instrument In addition to questions from the previous survey, newer questions were to the 2001 survey to addition of the most recent developments in obstetric anesthesia practice. survey the and validity of the instrument by draft to or five in each focus group (i.e. , anesthesia obstetrics labor and delivery management to obtain feedback about survey questions and its ease of These as survey to the a number of substantial changes have occurred in the practice of obstetric anesthesia since publication of the 1992 survey the number of hospitals providing obstetric care but the number of stratum I hospitals the potential in anesthesia provider there was an overall increase in the use of regional analgesia for labor across all strata, and more parturients used type of analgesia for labor. In regional anesthesia for cesarean delivery increased across all sizes of delivery but general anesthesia is still used in many urgent–emergent cesarean deliveries. Collectively, the 2001 survey results suggest that staffing and payment availability of services and anesthesia personnel have