摘要：Objectives. We examined whether interpersonal processes of care (IPC) were associated with cesarean delivery. Methods. We performed a cross-sectional study of 1308 postpartum women at Kaiser Permanente Medical Center in Walnut Creek, CA (KP-WC), and San Francisco General Hospital (SFGH) from 2004 to 2006. Using interview and medical record data, logistic regression analyses estimated the odds of cesarean delivery as a function of IPC domains. Results. After adjustment for demographic and reproductive factors, women at KP-WC who reported higher scores for their provider’s “elicitation of patient concerns and responsiveness” were less likely to have delivered by cesarean, whereas women who reported higher scores for “empowerment and self-care” were more likely. At KP-WC, women who reported low English proficiency were less likely to have delivered by cesarean than women who reported high proficiency. At SFGH, none of the IPC measures were significant; however, younger age was associated with a lower risk of cesarean delivery, whereas higher educational attainment was associated with an increased risk. Conclusions. To reduce record-high rates of cesarean delivery, more emphasis should be placed on addressing the nonmedical factors associated with operative delivery. In the last 13 years, the rate of cesarean delivery in the United States increased by 59%, from 20.7% in 1996 to an all-time high of 32.9% in 2009. 1,2 This increase was observed among all groups of women, regardless of age, race/ethnicity, or state of residence. Compared with vaginal delivery, cesarean delivery is associated with increased morbidity and mortality as well as higher costs, and there are little data to suggest that perinatal outcomes have improved as cesarean rates have increased. 3 Although there are clinical indications for performing a cesarean delivery, several nonmedical factors have been associated with its use, such as patient preferences, health insurance status, physician and institutional practice patterns, practice guidelines, and liability concerns. 4–6 In the early 1990s, the Department of Health and Human Services identified the need to reduce the cesarean rate. Despite national goals 7,8 and recommendations from the American College of Obstetricians and Gynecologists, 9 the national cesarean delivery rate has steadily increased since 1996; in 2009, one third of all women who gave birth had a cesarean delivery. 2 To achieve the overall goal of reducing unwarranted cesarean deliveries, we need a more comprehensive understanding of the influence of medical and nonmedical factors on operative delivery. We focused on the role of interpersonal processes of care (IPCs) and the likelihood of cesarean delivery. IPCs describe various aspects of the provider–patient relationship, including communication, patient-centered decision-making, and interpersonal style. IPCs could influence the decision to deliver by cesarean, yet very few studies have analyzed these issues. For example, better provider–patient communication could help educate patients about the risks vs benefits of operative delivery and reduce the number of women who request an elective or repeat cesarean delivery.
