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Cite this article as: Yee LM, Liu LY, Grobman WA. Relationship between obstetricians cognitive and affective traits and delivery outcomes among women with a prior
cesarean. Am J Obstet Gynecol 2015;213:413.e1-7.
413.e1
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TABLE 1
Instrument
Construct
11
14
13
Learner motivation
Tendency to engage in and enjoy
cognitive efforts
Affect in processing cognitive information
Positive self-esteem, successful adaptive
decision making
Low Need for Cognition indicates social
anxiety and difficulty with decision making
18
State-Trait Anxiety
Inventory-trait component21
20
delivery for patients delivered by providers who evidenced more adaptive decision making.14 Such ndings suggest
physician cognitive traits may inuence
outcomes in situations, such as intrapartum care, that are unpredictable. Yet,
the role of provider factors, and physicians cognitive traits specically, in the
availability and management of TOLAC
is not well understood, and remains a
critical evidence gap.15
Thus, we designed this study to investigate the association between physician
cognitive and affective traits and patient
delivery outcomes among women with 1
prior CD who were eligible to undergo
TOLAC. We hypothesized that providers
scoring in the highest quartile of cognitive
and affective assessments, representing
the most adaptive cognitive and affective
traits, would have higher frequency of
TOLAC and VBAC among their patients.
M ATERIALS
AND
M ETHODS
This was an observational study examining the relationship between obstetricians cognitive and affective traits and
their patients delivery outcomes among
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the lower 3 quartiles, an estimated 1400
participants were required. Data were
abstracted from the electronic medical
record.
The primary outcomes were frequency
of TOLAC and VBAC. Secondary outcomes included clinically signicant
uterine rupture (uterine rupture with
clinical consequence for the mother or
fetus, not including an incidentally noted
uterine window or scar dehiscence),
maternal chorioamnionitis (dened as a
temperature >100.3 F without an identied etiology other than intrauterine
infection), postpartum hemorrhage (dened as estimated blood loss >500 mL
for a vaginal delivery or >1000 mL for a
CD), major genital tract lacerations
(dened as a third- or fourth-degree
laceration), episiotomy, and maternal
ICU admission. Neonatal outcomes
included 5-minute Apgar score <4, umbilical cord artery pH <7.0, neonatal
sepsis, neonatal seizures, neonatal hypoxic ischemic encephalopathy, and
admission to the neonatal intensive care
unit.
We described patient characteristics
stratied by mode of delivery using c2
and analysis of variance tests. The psychometric scales were scored using
established scoring techniques, and
scores were categorized by quartile; top
quartiles of scores were compared to the
bottom 3 quartiles. Scores were evaluated by quartile to assess the most
extreme behavioral phenotype, which
was thought to be the most clinically
relevant exposure. For the RC, PC,
MSTAT-II, and NFC, the fourth quartile
(highest scores) represented the most
advantageous traits and was used as the
referent.14 For the STAI, lower scores
indicated the least trait anxiety, and thus
the lowest quartile scores were used as
the referent group and here are referred
to as the fourth quartile. Frequency of
TOLAC and VBAC was investigated by
cognitive and affective quartile using c2
analysis.
Hierarchical random effects multivariable logistic regression model was utilized to examine relationships between
physician cognitive and affective traits
and likelihood of undergoing TOLAC
and VBAC. The regression analysis
TABLE 2
Repeat cesarean
delivery (n [ 1310)
P value
32.4 (4.7)
34.1 (4.5)
< .001
29.5 (4.9)
30.8 (5.9)
.005
118 (61.5%)
926 (70.7%)
African American
26 (13.5%)
124 (9.5%)
Hispanic
29 (15.1%)
165 (12.6%)
Asian
13 (6.8%)
94 (7.2%)
Ethnicity
Caucasian
.066
< .001
Insurance
Private
Medicaid
Gestational age,
wk (SD)
161 (83.9%)
1228 (93.7%)
31 (16.1%)
82 (6.3%)
39.3 (1.0)
39.1 (0.7)
< .001
R ESULTS
Of the eligible 115 obstetricians, 94
(82%) signed written, informed consent
and completed the survey. During the
period of study, 1502 of their patients met
inclusion criteria. The patients mean age
was 33.9 years (SD 0.12), mean body
mass index was 30.6 kg/m2 (SD 0.15),
and mean gestational age at delivery was
39.1 weeks (SD 0.02). The population
was largely (69.5%) Caucasian and most
(91.5%) were privately insured. In all, 340
women (22.6%) underwent TOLAC, of
whom 56.5% achieved VBAC (ie, a
413.e3
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TABLE 3
Variable
Trial of labor
(n [ 340)
Reflective Copinga
.79
Q4
Q1e3
292 (77.9%)
83 (22.1%)
870 (77.2%)
257 (22.8%)
< .001
Proactive Coping
b
Q4
Q1e3
Tolerance of ambiguity
P value
217 (66.4%)
110 (33.6%)
945 (80.4%)
230 (19.6%)
.002
Q4
213 (70.8%)
Q1e3
949 (79.0%)
88 (29.2%)
C OMMENT
252 (21%)
.021
Q4b
199 (72.1%)
77 (27.9%)
Q1e3
963 (78.6%)
263 (21.5%)
Q4b
293 (72.0%)
114 (28.0%)
Q1e3
869 (79.4%)
226 (20.6%)
Trait anxietyf
.001
Q, quartile.
a
Scale measures self-efficacy and coping in setting of stress; b Indicating highest scores with most adaptive traitsefor all
scales, represents most adaptive traits on scale being measured; c Scale measures proactive goal attainment, selfconfidence, and self-regulatory behavior; d Multiple Stimulus Types Ambiguity Tolerance scale measures tolerance of
ambiguity, degree of comfort with uncertainty, and receptiveness to change; e Scale measures learner motivation,
engagement with cognitive efforts, and adaptive decision making; f Component of State-Trait Anxiety Inventory measures
stable tendencies toward anxiety and is measure of affect.
This study examined obstetrical outcomes among women with a prior cesarean from the unique perspective of
obstetrician cognitive characteristics.
Prior literature suggests provider characteristics may inuence patient delivery
outcomes; examples include ndings
that provider group was signicantly
associated with TOLAC rates7 and that
women who perceived their provider to
prefer CD were more likely to undergo
scheduled repeat CD.8 In the present
study, we found that women with 1 prior
CD were more likely to undergo TOLAC
when cared for by physicians with more
adaptive coping skills and were more
likely to achieve VBAC when delivered
by physicians with lower trait anxiety.
Given the complexity of delivery decisions for women with a prior CD, and
the public health goal of reducing the
cesarean rate, these data highlight the
importance of focusing on provider
factors that contribute to delivery
decisions.
Patient safety literature suggests that
physician cognitive and affective processes contribute to a number of patient
outcomes.9,22,23 Clinicians commonly
rely on medical heuristics to facilitate
decision making; however, under stressful settings the ability to make safe,
consistent and evidence-based decisions
can be challenging, leading to poorer care
for patients due to poorer decision and
information processing.24 For example,
in a study of cases of diagnostic error in
internal medicine, 74% of errors involved
cognitive factors.25 Literature on the role
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of cognitive processes in medical decision
making also has emerged in other elds,
including pediatrics,26 anesthesiology,27
neurology,28 and surgery.29,30 Yet, the
association between cognitive processes
and obstetric outcomes is only beginning
to be identied.
We previously identied that more
adaptive cognitive traits were associated
with decreased rate of operative vaginal
delivery among nulliparas.14 In the present analysis, we have shown that greater
PC skills, which incorporate proactive
goal attainment, self-condence, and
self-regulatory behaviors, were associated with increased likelihood of having
patients undergo TOLAC. Over 30% of
women delivered by those with the
greatest PC chose TOLAC. Similarly, less
trait anxiety was associated with an
approximately 2-fold higher VBAC rate.
These ndings are conceptually plausible, as providers who must function on
a busy labor unit, counsel patients about
risks and benets of delivery options,
and cope with uncertainty during a
TOLAC require self-efcacy, coping
skills in the setting of stress, and the
ability to manage anxiety. Our ndings
suggest that provider cognitive and affective traits may be associated with both
intrapartum decision making as well as
decisions prior to labor.
These ndings have potential educational and clinical relevance. Further
work is warranted to investigate whether
training in cognitive and emotional
competence could help improve the
quality of clinical decision making. Students and house staff are now educated
about patient safety as a routine part
of training; such education increasingly includes discussion of cognitive
biases.11,31 Education on cognitive debiasing has been proposed as a method to
improve reective problem solving and
improve patient safety.23,31 Training on
clinically relevant coping strategies may
be particularly relevant in the training of
obstetricians, given the elements of uncertainty that must be managed during
labor. Further, while much of the literature on physician cognitive skills has
focused on diagnostic error, we propose
that tools for cognitive debiasing can be
used to promote skills with regard to risk
TABLE 4
Variable
Repeat cesarean
delivery (n [ 1310)
P value
Reflective Copinga
.99
Q4
Q1e3
Proactive Coping
Q1e3
Tolerance of ambiguity
b
Q4
Q1e3
Need for Cognition
Q1e3
144 (12.8%)
983 (87.2%)
.001
Q4
Q4
327 (87.2%)
48 (12.8%)
59 (18.0%)
268 (82.0%)
133 (11.3%)
1042 (88.7%)
.026
50 (16.6%)
251 (83.4%)
142 (11.8%)
1059 (88.2%)
.18
42 (15.2%)
234 (84.8%)
150 (12.2%)
1076 (87.8%)
78 (19.2%)
329 (80.8%)
114 (10.4%)
981 (89.6%)
< .001
Trait anxietyf
Q4b
Q1e3
Q, quartile.
a
Scale measures self-efficacy and coping in setting of stress; b Indicating highest scores with most adaptive traitsefor all
scales, represents most adaptive traits on scale being measured; c Scale measures proactive goal attainment, selfconfidence, and self-regulatory behavior; d Multiple Stimulus Types Ambiguity Tolerance scale measures tolerance of
ambiguity, degree of comfort with uncertainty, and receptiveness to change; e Scale measures learner motivation,
engagement with cognitive efforts, and adaptive decision making; f Component of State-Trait Anxiety Inventory measures
stable tendencies toward anxiety and is measure of affect.
413.e5
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TABLE 5
1.12 (0.65e1.92)
1.13 (0.65e1.95)
1.86 (1.10e3.14)
1.55 (0.91e2.65)
1.35 (0.77e2.36)
1.24 (0.70e2.18)
1.29 (0.73e2.28)
1.14 (0.64e2.05)
1.53 (0.91e2.54)
2.08 (1.28e3.37)
Characteristic
Reflective Copinga Q4b
c
Proactive Coping Q4
Tolerance of ambiguity Q4
e
Random effects regression model accounting for maternal age, race/ethnicity, body mass index, gestational age, insurance
status, and physician as random effect.
CI, confidence interval; Q, quartile; TOLAC, trial of labor after cesarean; VBAC, vaginal birth after cesarean.
a
Scale measures self-efficacy and coping in setting of stress; b Indicating highest scores with most adaptive traitsefor all
scales, represents most adaptive traits on scale being measured; c Scale measures proactive goal attainment, selfconfidence, and self-regulatory behavior; d Multiple Stimulus Types Ambiguity Tolerance scale measures tolerance of
ambiguity, degree of comfort with uncertainty, and receptiveness to change; e Scale measures learner motivation,
engagement with cognitive efforts, and adaptive decision making; f Component of State-Trait Anxiety Inventory measures
stable tendencies toward anxiety and is measure of affect.
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and understanding. Adv Health Sci Educ Theory
Pract 2010;15:229-50.
14. Yee LM, Liu LY, Grobman WA. The relationship between obstetricians cognitive and
affective traits and their patients delivery outcomes. Am J Obstet Gynecol 2014;211:692.
e1-6.
15. National Institutes of Health Consensus
Development Conference Panel. National Institutes of Health Consensus Development
Conference Statement: vaginal birth after cesarean, new insights, March 8-10, 2010. Obstet
Gynecol 2010;115:1279-95.
16. Greenglass ER. Proactive coping. In:
Frydenberg E, ed. Beyond coping: meeting
goals, vision, and challenges. London: Oxford
University Press; 2002:37-62.
17. Greenglass ER, Schwarzer R, Jakubiec S,
Fiksenbaum L, Taubert S. The Proactive Coping
Inventory (PCI): a multidimensional research instrument. Paper presented at: 20th International
Conference of the STAR (Stress and Anxiety
Research Society); July 12-14, 1999 9/3/2012;
Krakow, Poland.
413.e7