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Relationship between obstetricians cognitive

and affective traits and delivery outcomes
among women with a prior cesarean
Lynn M. Yee, MD, MPH; Lilly Y. Liu, BA; William A. Grobman, MD, MBA
OBJECTIVE: We sought to investigate the relationship between ob-

stetricians cognitive traits and delivery outcomes among women with

a prior cesarean delivery.
STUDY DESIGN: A total of 94 obstetricians completed 5 standardized
psychometric scales: Reflective Coping, Proactive Coping, Multiple
Stimulus Types Ambiguity Tolerance (MSTAT), Need for Cognition, and
State-Trait Anxiety Inventory. Scores were analyzed by quartile. Delivery data were collected for primiparas with 1 prior low transverse
cesarean delivery and a term, cephalic singleton. We used c2 tests and
random effects logistic regression to examine the relationship between
obstetricians cognitive traits and their patients frequency of trial of
labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC).
RESULTS: Of 1502 eligible patients, 22.6% underwent TOLAC.

Women were more likely to undergo TOLAC when cared for by

physicians with scores in the highest quartile of the proactive coping
(33.6% vs 19.6%; P < .001), MSTAT (29.2% vs 21.0%; P .002),

and Need for Cognition (27.9% vs 21.5%; P .02) assessments, or

in the lowest quartile for anxiety assessment (28.0% vs 20.6%; P
.001). Similarly, those with high proactive coping (18.0% vs 11.3%;
P .001), high MSTAT (16.6% vs 11.8%; P .03), and low anxiety
(19.2% vs 10.4%; P < .001) had greater VBAC rates. Random effects regression analyses revealed physicians with high proactive
coping remained significantly more likely to have patients undergo
TOLAC (adjusted odds ratio, 1.86; 95% confidence interval,
1.10e3.14) and those with low anxiety remained significantly more
likely to have patients experience VBAC (adjusted odds ratio, 2.08;
95% confidence interval, 1.28e3.37).
CONCLUSION: There is an increased likelihood of TOLAC and VBAC for
women delivered by physicians with more proactive coping and less
anxiety.

Key words: physician cognitive skills, physician coping, trial of labor

after cesarean, vaginal birth after cesarean

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.

n the United States, nearly one third

of births occur via cesarean delivery
(CD) and approximately 90% of lowrisk women with a prior cesarean undergo a repeat CD.1-3 The rising cesarean
rate is of signicant public health
concern due to the associated maternal
morbidity. As a result, reducing primary
and repeat CD, the latter of which
From the Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology,
Feinberg School of Medicine, Northwestern
University, Chicago, IL.
Received March 7, 2015; revised April 13, 2015;
accepted May 10, 2015.
The authors report no conict of interest.
Presented in poster format at the 35th annual
meeting of the Society for Maternal-Fetal
Medicine, San Diego, CA, Feb. 2-7, 2015.
Corresponding author: Lynn M. Yee, MD, MPH.
lynn.yee@northwestern.edu
0002-9378/$36.00
2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2015.05.023

account for half of the increase in

cesarean rate, is a goal of numerous
professional organizations and the US
Department of Health and Human Services.1,2,4 While many patient- and
system-based factors contribute to the
cesarean rate, little work has focused on
provider contributions to delivery approach and mode.
The dramatic decrease in the vaginal
birth after cesarean (VBAC) rate has been
attributed largely to a decrease in the
likelihood of choosing a trial of labor after
cesarean (TOLAC),5 yet evidence suggests
a majority of women with 1 prior low
transverse cesarean are TOLAC candidates.6 While the American Congress of
Obstetricians and Gynecologists notes
that after appropriate counseling, the
ultimate decision to undergo TOLAC or a
repeat CD should be made by the patient
in consultation with her health care provider,6 some evidence suggests provider
factors can inuence patient decisions in
this regard.7,8

Patient safety and quality improvement initiatives increasingly reect the

concept that provider traits are associated with patient outcomes. Beyond demographic or training characteristics,
provider cognitive traits are one type of
characteristic thought to affect clinical
decisions. Cognitive traits include cognitive biases and clinical reasoning skills,
coping ability, analytical skills, cognitive
efciency, and learner motivation.9-12
Provider emotional inuences and affective traits, or predisposition toward types
of emotional responses, have additionally
been proposed to affect clinical decisions.9-12 In a small study of 12 obstetricians, Dunphy et al13 found that
physicians with better coping skills and
lower trait anxiety were more likely to
care for women who achieved spontaneous vaginal deliveries. In previous
work, our group studied the relationship between obstetrician cognitive traits
and delivery outcomes for nulliparas,
nding decreased risk of operative vaginal

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TABLE 1

Cognitive and affective scales used to assess physician traits

No. of
items

Instrument

Construct

Reflective Coping scale of

Proactive Coping Inventory16,17

 Coping in setting of stress and distress

 Self-efficacy
 Affect and proactive attitude

11

Proactive Coping scale of

Proactive Coping Inventory16,17

 Proactive goal attainment/orientation

 Self-confidence
 Self-regulatory cognition and behavior

14

Multiple Stimulus Types

Ambiguity Tolerance-II13,18,19

 Tolerance for ambiguity

 Degree of comfort with uncertainty
and/or complexity
 Receptiveness to change

13

Need for Cognition13,20

 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

 Stable individual tendencies toward

anxiety in range of threatening situations
 Measure of affect

20

Yee. Obstetrician cognition and VBAC. Am J Obstet Gynecol 2015.

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

women with 1 prior CD. Methods for

assessment of cognitive and affective
traits have been described previously.14 In
brief, providers of obstetric care at a single academic institution were surveyed
using 5 standardized psychometric measures. Their patient outcomes were then
retrospectively reviewed to identify differences in delivery outcomes associated
with provider cognitive characteristics.
Institutional review board approval from
Northwestern University was obtained
prior to initiation of the study.
Eligible participants included all
attending obstetricians practicing at a
single institution and their eligible
patients. General obstetricians and
maternal-fetal medicine specialists were
included. Trainees and midlevel providers were not surveyed in this study, as
all delivery decisions are ultimately the
responsibility of the attending physician.
Attending physicians directly participate
in all births, including those of patients
who received prenatal care in the
hospital-based clinic staffed by residents
with faculty supervision. From 2012
through 2013, obstetricians completed a

413.e2 American Journal of Obstetrics & Gynecology SEPTEMBER 2015

written survey that included demographic characteristics and 5 established,

validated scales: Reective Coping
(RC),16,17 Proactive Coping (PC),16,17
Multiple Stimulus Types Ambiguity
Tolerance (MSTAT)-II,18,19 Need for
Cognition (NFC),20 and the trait component of the State-Trait Anxiety Inventory (STAI).21 The RC, PC, MSTAT,
and NFC largely measure cognitive
traits, whereas the STAI is a measure of
an affective trait. These scales were
chosen on the basis of use in prior work,
their high construct validity, and the
theoretical basis of these traits relationships to medical decision making.13,14
Details of each instrument can be
found in Table 1.
Patients eligible for study inclusion
were primiparas age 18 years with 1
prior low transverse CD and a term, cephalic singleton who were delivered by a
physician who completed the survey. All
deliveries meeting criteria from January
2008 through June 2013 were reviewed
to provide a nal population for analysis
that would allow for adequate power (see
below). The population was limited to
women with 1 prior CD (and no prior
vaginal deliveries) to limit the possibility
that provider decisions would have been
inuenced by prior vaginal birth(s) or
the number of prior CD. Women with
fetuses with major anomalies, who had a
fetal demise, or who were otherwise
ineligible for vaginal birth (placenta
previa, prior classical CD, prior cavityentering myomectomy) were excluded.
Sample size was determined based
on the number of patients needed to
demonstrate a difference in TOLAC rate
between patients delivered by providers
scoring in the highest quartile compared
to providers scoring in the lower 3
quartiles. Prior work has suggested that
women delivered by providers with
coping scores in the highest quartile
had a 30% lower risk of operative vaginal
delivery.14 If approximately 30% of
women undergo TOLAC when cared
for by physicians with cognitive trait
scores in the highest quartile of cognitive
scores, to have 80% power at an
alpha 0.05 to detect a 30% difference
in the proportion of women undergoing
TOLAC among providers with scores in

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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

Patient characteristics by mode of delivery

Characteristic

Vaginal birth after

cesarean (n [ 192)

Repeat cesarean
delivery (n [ 1310)

P value

Age, y, mean (SD)

32.4 (4.7)

34.1 (4.5)

< .001

Body mass index,

mean (SD)

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

Yee. Obstetrician cognition and VBAC. Am J Obstet Gynecol 2015.

adjusted for potential confounders, including patient characteristics identied

to be signicantly associated with mode
of delivery and delivering physicians as
random effect terms that accounted for
the effect of nonindependence due to
clustering by physician. This method accounts for clustering of patients by
physician. Finally, additional regression
analyses were performed to investigate
the secondary outcomes by quartile of
physician cognitive and affective traits.
Statistical analyses were undertaken using
software (STATA, version 13; StataCorp,
College Station, TX). All analyses were 2tailed and P < .05 was used to dene
statistical signicance.

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

12.8% VBAC rate). The majority (78.7%)

of VBACs occurred spontaneously, with
the remainder being operative vaginal
deliveries. Patient characteristics differed
signicantly based on delivery mode
(Table 2).
Multiple obstetrician cognitive and
affective traits were signicantly associated with likelihood of undergoing
TOLAC (Table 3). Women were more
likely to undergo TOLAC when cared for
by physicians with PC (33.6% vs 19.6%;
P < .001), ambiguity tolerance (29.2% vs
21.0%; P .002), and NFC (27.9% vs
21.5%; P .02) in the highest quartile.
Women also were more likely to experience TOLAC (28.0% vs 20.6%; P .001)
when delivered by physicians with the
least trait anxiety. There were no differences in TOLAC rates based on physicians RC. Similarly, obstetrician traits
were found to be associated with likelihood of experiencing VBAC (Table 4).
Women delivered by physicians with high
PC (18.0% vs 11.3%; P .001), high
tolerance of ambiguity (16.6% vs 11.8%;
P .03), and low anxiety (19.2% vs
10.4%; P < .001) had a higher chance of
VBAC. There were no differences in
VBAC rate based on physician RC or
NFC. Among the population of women
undergoing TOLAC, low anxiety among

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TABLE 3

Frequency of trial of labor after cesarean based on physician

characteristics
No trial of labor
(n [ 1162)

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%)

Need for Cognitione

.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.

Yee. Obstetrician cognition and VBAC. Am J Obstet Gynecol 2015.

their physicians remained signicantly

associated with VBAC (68.4% vs 50.4%;
P .002).
Random effects multivariable logistic
regression analyses were then performed
to adjust for potential confounding factors and assess the independent association between likelihood of TOLAC and
VBAC and physician traits (Table 5).
These analyses demonstrated that
women were more likely to undergo
TOLAC (adjusted odds ratio [aOR],
1.86; 95% condence interval [CI],
1.10e3.14), even after adjusting for
physician clustering and patient characteristics (age, race/ethnicity, body mass
index, insurance status, and gestational
age), when cared for by those with higher
PC. In addition, patients remained
signicantly more likely to experience
VBAC (aOR, 2.08; 95% CI, 1.28e3.37)
when cared for by providers with low

anxiety. This increase in VBAC not only

was a result of women undergoing
TOLAC more often; women who were
cared for by providers with low anxiety,
once they did undertake TOLAC, were
more likely to ultimately achieve a
vaginal birth (aOR, 2.34; 95% CI,
1.33e4.11). No other physician traits
remained statistically signicantly associated with likelihood of TOLAC, vaginal
delivery if TOLAC is undertaken, or
VBAC.
Maternal and neonatal secondary
outcomes were assessed as well. Physicians scoring highest in PC were more
likely to have patients with chorioamnionitis (4.9% vs 2.0%; P .005),
an association that persisted in multivariable analysis (aOR, 2.13; 95% CI,
1.1e4.3). Signicant differences in other
outcomes were not observed. Specically,
there were no differences in uterine

413.e4 American Journal of Obstetrics & Gynecology SEPTEMBER 2015

rupture, postpartum hemorrhage, or

maternal intensive care unit admission
based on provider characteristics. Among
women delivering vaginally, there were
no differences in episiotomy or major
perineal laceration. Neonatal admission
to the neonatal intensive care unit,
5-minute Apgar score <4, cord umbilical
artery pH <7.0, and neonatal hypoxic
ischemic encephalopathy were infrequent
events and signicant differences in these
outcomes by obstetrician cognitive or
affective traits were not identied (data
not shown). There were no cases of
neonatal sepsis or seizure.

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

Mode of delivery by physician cognitive characteristics

Vaginal birth after
cesarean (n [ 192)

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.

Yee. Obstetrician cognition and VBAC. Am J Obstet Gynecol 2015.

tolerance and coping in the setting of

uncertainty or ambiguity. Moreover, the
teaching of coping skills and strategies
to reduce anxiety in a clinical setting
may be benecial to learners at all levels,
beyond formal training. Ongoing physician education about coping skills, anxiety reduction, and cognitive biases, with
routine feedback on these skills alongside
feedback about patient outcomes, may
be a potential point of intervention in the
effort to enhance obstetric care.
A signicant strength of this study is
the large number of physicians who
participated in surveys of their cognitive
and affective traits using validated measures. The use of a random effects
regression allowed us to account for
clustering of patients by physician and
for differences in physician characteristics that might have confounded the
observed association. However, there are
also a number of limitations. First, there

is possible selection bias from nonresponders to the survey, although this is

likely to be minimal, since such a high
proportion of eligible providers responded. Second, it is possible that providers
were affected by social desirability bias,
in which they chose survey answers they
thought to be desirable traits; however, if
this were to have occurred, it would bias
toward the null hypothesis. Further, patient factors beyond physician control
may have confounded results; although
we attempted to control the most relevant and likely covariates in the regression analysis, it is possible that additional
factors were not captured. In addition,
we did not identify signicant differences in secondary maternal and
neonatal outcomes, which may be due to
the infrequent occurrence of adverse
outcomes and corresponding lack of
statistical power to detect such differences. It is possible a larger study with

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TABLE 5

Likelihood of experiencing trial of labor after cesarean and vaginal birth

after cesarean by physician cognitive characteristics
Adjusted odds ratio
of TOLAC (95% CI)

Adjusted odds ratio

of VBAC (95% CI)

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)

Need for Cognition Q4

1.29 (0.73e2.28)

1.14 (0.64e2.05)

Trait anxietyf Q4b

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.

Yee. Obstetrician cognition and VBAC. Am J Obstet Gynecol 2015.

sufcient power to detect differences in

secondary outcomes may identify relationships between provider traits and
perinatal outcomes that warrant further
discussion regarding which provider
traits are associated with the greatest
overall benet for patients.
In addition, the provider for each
patient in the analysis was considered to
be the delivering provider. Yet, each
provider exists within a group practice,
and while members of a group are more
likely to practice similarly to each other,
it is possible a patient may have been
managed by multiple providers during
her labor or during the antepartum
period. Nevertheless, it is the provider
who is present at delivery who is most
acutely responsible for and whose
cognitive characteristics are most likely
to inuence delivery decisions. Thus,
assignment of the delivering physician to
the patient is thought to be the most
appropriate relationship for investigation of the role of cognitive and affective
traits and delivery outcomes. Any contribution to this decision from other
sources would only serve to bias toward
the null hypothesis and weaken any
observed association.
This study was performed at an academic medical center where patients and
providers have around-the-clock access

to obstetrical anesthesiology services,

blood bank resources, and surgical staff,
and house staff are a routine part of care
on the labor and delivery unit. All providers on this unit work with resident
physicians in the management of women
undergoing TOLAC and repeat CD. In
addition, resident physicians are
involved in the care of all patients undergoing TOLAC. Thus, these ndings
may not be generalizable to other
obstetrical settings. However, we believe
that the tertiary care study setting is
actually the most appropriate setting to
investigate the role of provider cognitive
and affective traits, as all providers have
equal access to resources. Future work
can investigate these associations further
in the community setting.
Determining factors that contribute to
the rising CD rate is central to developing interventions that reduce the
cesarean rate. Increasingly, provider
factors are recognized as important
contributors to clinical and patient safety
outcomes. Our ndings demonstrate
that obstetrician coping and anxiety are
associated with patient delivery outcomes in the setting of care for women
with a prior CD. Additional work is
required to investigate relationships between provider traits and less common
adverse perinatal outcomes. Future work

413.e6 American Journal of Obstetrics & Gynecology SEPTEMBER 2015

must also explore the mechanism by

which these traits inuence provider
decision making. Ultimately, we must
consider whether incorporating training
in coping strategies, cognitive debiasing,
and anxiety reduction techniques could
aid in improving patient outcomes in
obstetrics.
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