Abstract / Summary
Background: The requirement that a surgical team be “immediately available” is a barrier to VBAC access. Through continuous L&D staffing, obstetric hospitalists may facilitate VBAC access. We clarified the role of hospitalists in addressing barriers and facilitators to VBAC implementation. Methods: The multi-hospital sample (N=11) included sites that resumed VBAC services or had low utilization of VBAC. We conducted interviews with clinicians (N=19), including obstetricians, family practitioners, nurses, and midwives. We used the five domains from the consolidated framework for implementation research (CFIR 2.0) to deductively identify implementation determinants. Findings: The sites represented a range of practice settings. Sites included 7 rural hospitals and 8 with <1000 births/year. One site did not offer VBAC. Hospitalists worked at 3 sites; 4 others had alternative 24/7 models. All VBAC-offering sites required immediate availability, with 7 requiring in-house presence throughout labor and 3 only during active labor. Hospitalists functioned primarily as a workforce solution to address provider burnout and improve patient safety, secondarily facilitating VBAC access. In high-volume units, hospitalists relieved overstretched outpatient providers from inpatient duties, eliminating the burden posed by the immediately available VBAC standard (Inner setting: work infrastructure). In low-volume or rural hospitals, hospitalists provided 24/7 backup for complex cases, enabling family practitioners and midwives to provide VBAC (Innovation: complexity). However, hospitalists facilitated VBAC only under specific conditions. In high-volume, multi-practice units, lack of clear role definition created confusion about patient assignments, and one hospitalist expressed concern about other services “dumping” VBAC cases onto hospitalists (Inner setting: work infrastructure; communication). While the institution of a hospitalist program was a facilitator to VBAC access, a coordinated set of actions were still needed, like communicating the new availability of VBAC services to the public or ensuring that outpatient clinicians were consistently offering VBAC to all eligible candidates (Outer setting: local conditions). Conclusions: Obstetric hospitalists facilitated VBAC access by addressing provider burnout from unsustainable on-call demands posed by the immediately available. The CFIR effectively identified multi-level determinants requiring simultaneous intervention to support VBAC access. Implementation success depends not only on hospitalist presence, but on complementary organizational actions addressing workflow clarity, public awareness, and outpatient provider commitment to VBAC.