Implementation of a calculator to predict cesarean delivery during labor induction: a qualitative evaluation of the clinician perspective

BACKGROUND: We previously conducted a prospective cohort study (n=1610) demonstrating that the implementation of a validated calculator to predict likelihood of cesarean delivery during labor induction was associated with reduced maternal morbidity, reduced cesarean delivery rate, and improved birth satisfaction. OBJECTIVE: To optimize future implementation, we used qualitative interviews to understand the clinician perspective on: (1) the cesarean delivery risk calculator implementation and (2) the mechanisms by which the use of the calculator resulted in the observed improved outcomes. STUDY DESIGN: After completion of the prospective study (June 30, 2019), 20 trainees and attending clinicians (including nurse-midwives, obstetrical physicians, and family medicine physicians) at the study site participated in a single, brief semistructured interview from March 1, 2020, to June 30, 2020. Transcriptions were coded using a systematic approach. RESULTS: Overall, clinicians had favorable perspectives regarding the cesarean delivery risk calculator. Clinicians described the calculator as offering “objective data” and a “standardized snapshot of the labor trajectory.” Concerns were raised regarding “overreliance” on calculator output. Barriers to use included time for patient counseling and “awkwardness” around the interactions and perceived patient misunderstanding of the calculator result. Although most senior clinicians (n=8) reported that the calculator did not impact patient management, trainee clinicians (n=12) more often felt that the calculator influenced care at the extremes of cesarean delivery risk. Furthermore, more senior clinicians felt “neutral” regarding any impact of counseling patients on cesarean delivery risk compared with trainee clinicians, who felt that the counseling “built [patient-clinician] trust.” CONCLUSION: This qualitative evaluation characterized the generally positive clinician perspective around the cesarean delivery risk calculator, while identifying specific facilitators and barriers to implementation. In addition, we elucidated potential mechanisms by which the calculator may have been related to clinician decision making and patient-clinician interactions, leading to reduced maternal morbidity and improved patient birth satisfaction. This information is important as widespread implementation of the cesarean delivery risk calculator begins.