Maternity Care
Attitudes & Beliefs Study
Funded
By:
In Association
With:
Supported
by:
The Society of Obstetricians and Gynaecologists of Canada
Four-Year
National
Study
The Association of Obstetricians and Gynecologists of Quebec (AOGQ)
The College of Family Physicians of Canada (CFPC)
The Canadian Association of Midwives (CAM)
Association des omnipraticiens en périnatalité du Québec (AOPQ)
Various Nurses Associations
DONA International
Maternity Care Research Group
Gestation Self-Portrait
© Rae Maté, 1988
www.maternitycare.ca
Michael C. Klein, MD, CCFP, FAAP (Neonatal/Perinatal), FCFP, ABFP,
Principal Investigator, UBC
Robert Liston, MB ChB, FRCSC, FRCOG, FACOG,
Co-Investigator – Obstetrics, UBC
William Donald Fraser, MD, MA, FRCSC, Co-Principal Investigator Obstetrics, University of Montreal
Janusz Kaczorowski, PhD, Co-Principal Investigator – Medical
Sociology, UBC
Sharon Dore, RN, PhD, Co-Investigator – Nursing, McMaster
Wendy Hall, RN, PhD, Co-Investigator – Nursing, UBC
Patricia McNiven, RM, PhD, Co-Investigator – Midwifery, McMaster
Lee Saxell, RM, MA, Co-Investigator – Midwifery, UBC
Kathleen A. Lindstrom, CD, Doula Educator, Co-Investigator - Doula,
Douglas College
Jalana Grant, CD, Co-Investigator – Doula, DONA Western Canada
Director
Rollin Brant, PhD,Co-Investigator – Statistics, UBC
Sahba Eftekhary MD, MPH, MHA, Co-Investigator
Jude Kornelsen,PhD, Co-Investigator - Medical Sociologist, UBC
Jessica Rosinski MA, Project Manager
Andrea Procyk, BA, Research Assistant
Jocelyn Tomkinson, MPH, Research Assistant
Oralia Gómez-Ramírez MA, Research Assistant
Aoife Chamberlaine, BA, Research Assistant
Nazli Baradaran, MD, Research Assistant
Perinatal Provider Crisis
Caesarean Section
Temporal Trends, Canada
Rate
Year
Statistics Canada
Trends in Rate of C/S by Indication:
Primary Caesarean Section
94/95
2000/01
1994/95
2000/01
Rate (%( Rate (%)
rate %
rate %
Attributab RR
Attributable
RR(95%CI)
le Change (95% CI)
change %
%
Breech
2.8
3.1
8.3
1.10 (1.06-1.13)
Dystocia
6.9
9.2
63.9
1.33 (1.31-1.36)
Fetal
Distress
1.6
2.3
19.5
1.44 (1.38-1.50)
Other
1.4
1.7
8.3
1.25 (1.19-1.30)
Total
12.7
16.3
100
1.29 (1.27-1.30)
Indication
JOGC 2004 - Deliveries in Canada
except Que and Man
Trends in Rate of C/S by Indication:
Repeat Caesarean Section
Indication
Indication
94/95
1994/95 2000/01
2000/01
Rate (%( Rate (%)
Attributab
Attributable RRRR(95%CI)
le Change (95% CI)
Change %
%
Breech
3.9
3.7
-4.2
0.95 (0.87-1.04)
Dystocia
15.1
14.9
-4.2
0.98 (0.95-1.03)
Fetal
Distress
2.2
2.4
4.2
1.10 (0.98-1.23)
Other
7.8
10.2
50
1.31 (1.24-1.38)
Elective
Repeat
37.7
40.3
54
1.07 (1.05-1.09)
Total
66.7
71.5
100
1.07 (1.05-1.09)
rate %
rate %
JOGC 2004 - Deliveries in Canada
except Que and Man
Caesarean Section Rate;
Contributing Factors
•
•
•
•
•
•
•
•
Maternal Age
Maternal Obesity
Change in VBAC practice
Decrease in assisted vaginal births
Analgesic use
Induction
Maternal Choice ?
Logistics, Compensation, Liability.
C/S Rate by Prov / Ter. 2005/06
Caesarean Sections per 100 hospital Births
CIHI 2007
C/S by HA, 2000/05
35
30
25
20
2000
2005
15
10
5
0
north
vc
bc
fh
interior viha
C/Section in Canada
Inter-jurisdictional difference
Inverse relationship between primary c/s
and VBAC rate
Suggest care provider effect
2499 Maternity Care Providers
Across Canada Responded
• 553 Obstetricians
• 894 Family Physicians
• 495 Provide Intrapartum Care
• 399 Provide Antepartum Care Only
• 381 Midwives
• 541 Nurses
• 130 Doulas
The responses for each provider group represent every
region in Canada, in both Rural and Urban locations that
parallel the actual distribution of those providers
Demographics
• The majority of respondents completed the
questionnaire in English (86.5%)
• The majority of Obstetricians (52.5%) and Family
Physicians (68%) who responded were women
• On average, Obstetricians were the oldest
respondents (47 years old – mean/median)
Cesarean Section & VBAC
Beliefs
If a woman has had a previous cesarean section, a scheduled repeat
cesarean section reduces the chance of litigation
100
OB
80
FP Int.
Percent
6 1.6
60
5 3 .1
4 8 .3
5 0 .8
4 3 .0
4 0 .9
2 0 .5 2 1.6
2 6 .2
2 3 .9
20
2 2 .6
2 6 .4
2 7 .8
RM
2 4 .5 2 3 .1
Doula
13 .9
0
Agree
RN
3 6 .5
3 5 .4
40
FP Other
Neutral
Disagree
By Chi Square, all differences p<.001 this and all subsequent slides
Obstetricians
If a woman has had a previous cesarean section, a scheduled repeat
cesarean section can improve newborn outcome
96.2
100
90.8
80
OB
Percent
67.5
56.2
60
66.5
59.8
FP Other
RN
40
27.4
25.0
20
FP Int.
18 . 8 17 . 8
14 . 6 12 . 8 15 . 8
RM
17 . 7
Doula
7.7
2.3
1. 6 1. 5
0
Agree
Neutral
Disagree
OB Agreement analyzed by type of Payment Arrangement :
Fee for Service 27.2% vs Other Payment Arrangements 16.7% p.014
Obstetricians
Thoughts on the Rising Cesarean Section Rate:
“On a per hour basis, elective CS is infinitely more
lucrative than vaginal birth and infinitely more convenient
for physicians.” – An Obstetrician who filled out the study
questionnaire
“No opportunity for medical students or nursing students
or obstetrics residents to experience anything other than
over-medicalized labour and birth.” – Obstetrician
If my partner or I were pregnant with an apparently normal
pregnancy, I would prefer an elective cesarean section instead of a
vaginal birth
9 6 .5 9 4 .4 9 5 .4
100
9 9 .2 9 8 .4
8 8 .7
OB
80
Percent
FP Int.
60
FP Other
RN
40
RM
20
7 .7
1.2 2 .8 3 .0 0 .5 0 .0
Doula
3 .7 2 .2 2 .8 1.7
0 .3 1.6
0
Agree
Neutral
Disagree
Women who deliver their baby by cesarean section miss an important
life experience
100
80
OB
Percent
6 7 .4
60
6 4 .2
5 0 .8
FP Int.
5 3 .5
FP Other
4 5 .4
4 0 .6
40
3 1.7
2 5 .1
20
2 1.1 2 0 .8
15 .5
2 4 .1 2 5 .4
17 .1
2 3 .8
2 7 .7
15 .0
Neutral
RN
RM
Doula
0
Agree
3 0 .8
Disagree
Cesarean section is as safe as vaginal birth for women
100
9 2 .1 9 0 .8
7 7 .1
80
Percent
6 5 .1
7 3 .5
6 3 .5
60
FP Int.
FP Other
RN
40
2 1.4
20
OB
RM
2 1.4
11.4
15 .1 13 .9
13 .5 11.4
Doula
12 .6
5 .0 5 .4
2 .9 3 .8
0
Agree
Neutral
Disagree
OB Agreement analyzed by type of Payment Arrangement :
Fee for Service 23.7% vs Other Payment Arrangements 11.2% p .002
When a woman has had a previous cesarean section and has no
recurring indication, most of the time, my preferred approach is to:
100
8 6 .9
80
7 1.7 7 0 .9
7 6 .0
OB
Percent
6 2 .4
60
FP Int.
5 5 .9
FP Other
4 1.5
3 4 .9
40
RN
2 4 .1
20
2 1.1 2 3 .5
RM
13 .1
2 .6 2 .7 4 .2
8 .0
Doula
0 .5 0 .0
0
Recommend a VBAC
Recommend a
scheduled cesarean
Follow the mother's
request
Thoughts on the Rising Cesarean Section Rate:
“Poor training of residents: fewer forceps, no breeches, CS for
anything out of the ordinary.
Decreasing role of generalist teaching OB vs. FME/Perinatologist
most of whom do not practice good Obstetrics.
Decreased tolerance of risk vis a vis [medical-legal] consideration
by new grads(can it ride out tracing showing decline).
If our current trend continues, all deliveries will be CS, will be no
need for skilled attendant, only a robot to do CS!”
– An Obstetrician
Thoughts on the Rising Cesarean Section Rate:
“A high CS rate is here to stay. You are fighting a loosing battle
and will end up fighting the patients over their right to decide
their own "birth experience".
Many of them want that to be an elective CS so why not?
The medical-legal risks are just too high to deny women the
right to what is after all the safest way for their babies to be
born.
It is also far safer than many other operations they have access
to on demand such as plastic surgery or home birth.”
– All one Obstetrician
Epidural Beliefs
Epidural analgesia interferes with the normal progress of
labour
100
89.2
83.2
OB
80
Percent
FP INT
60
48.7 46.8
55
52.5
FP Other
RN
40
28.1
29.3
28.1
21.8
16.7
20
25
28.1
19.2
13.5
Doula
6.9
3.1 3.8
0
Agree
RM
Neutral
Disagree
Epidural analgesia increases the incidence of instrumental birth
100
90.1
93.8
80
OB
Percent
63.1
60
62.6
FP Int.
57.2
FP Other
49.4
RN
34.7
40
24.9
16 . 0 16 . 9
20
RM
24.3
2 0 . 0 17 . 9
13 . 1
Doula
6.7
3.1
3.2 3.1
0
Agree
Neutral
Disagree
Obstetricians
Epidural analgesia should be routinely offered to all women in
labour
100
8 9 . 7 9 1. 5
OB
80
Percent
FP INT
60
58.7
56.7
56.1
FP Other
44.2
40
RN
38.1
29.8
28.4
29
RM
23
17 . 6
20
12 . 7
14 . 7 13 . 3
Doula
7.6
2.6 2.3
0
Agree
Neutral
Disagree
Home Birth Beliefs
Home birth is more dangerous than hospital birth, even in an
uncomplicated pregnancy
100
80
97.6
90.8
88.9
OB
74.0 72.6
Percent
FP Int.
60
53.8
FP Other
40
32.5
RN
RM
15 . 0
20
0.8
3.8
15 . 3
12 . 1 13 . 7
5.3
11. 0
1. 6
5.4
5.8
0
Agree
Neutral
Disagree
OB Agreement analyzed by type of Payment Arrangement :
Fee for Service 90.3% vs Other Payment Arrangements 82.4% p .019
Doula
Obstetricians
I support licensed / regulated midwifery services
9 6 .9
100
8 2 .2
80
7 1.0
Percent
6 5 .1
6 8 .0
OB
FP Int.
60
FP Other
40
RN
2 3 .9
16 .5
20
Doula
18 .1
12 .5 11.0 13 .9
13 .6
2 .3
4 .1
0
Agree
Neutral
Disagree
0 .8
Obstetricians
“Before I was an Obstetrician, I was a Midwife. Before I
was a Midwife, I was a woman giving birth in the
capable hands of my Midwife. My Grandmother was a
Midwife. I could cry, sometimes, at the direction of
modern maternity care, and hope with all my heart that
reason and respect will prevail.”
- Obstetrician (quote used with permission)
Active Management &
Post-Term Pregnancy Beliefs
“Active management of labour” improves birth outcomes
95.4
100
80
76.3
72.5
67.4
OB
Percent
FP Int.
60
FP Other
42.4
40
4 1. 1
38.5
35.6
RN
RM
2 1. 1
20
22.0
2 0 . 4 19 . 0
Doula
15 . 0
8.5
8.8
2.3
11. 5
2.3
0
Agree
Neutral
Disagree
Obstetricians
In the management of an uncomplicated post term pregnancy (e.g. normal
amniotic fluid, NST etc) at or after 41 and 3/7 weeks, most of the time, I prefer:
100
84.0
78.3
80
OB
67.4
Percent
62.6
FP Int.
57.8
60
FP Other
48.0
42.8
RN
36.7
40
RM
24.7
20
21.0
11.6
6.5
9.5
5.5
20.9
12.6
9.2
0.8
0
Expectant management
Elective induction
Follow the mother's request
Doula
The long-term pelvic floor outcomes of physiologically managed birth*
will likely be better than elective cesarean section
100
OB
76.7
80
FP Int.
Percent
62.1
60
FP Other
5 1. 8
42.2
37.0
40
20
3 1. 4
32.1
49.0
45.8
RN
32.8
RM
30.8
20.2
18 . 9
20.8 22.8
Doula
15 . 4
7.2
3.1
0
Agree
Neutral
Disagree
* Defined in the survey question as: “for example, use of non-lithotomy positions, avoidance
of prolonged closed-glottis pushing in the second stage, and limiting episiotomy”
Summary: All Providers
• Intrapartum FPs more likely to disagree with OBs
than those who have left or never practiced
intrapartum.
• RNs vary according to the issue, aligning with OBs or
independent.
• Often FPs align with OBs. However on issues
concerning the effectiveness of CS as a means of
improving a range of outcomes, they are in relative
disagreement
– This is especially true for FPs practicing intrapartum
maternity care
Summary: All Providers
• 71% of OBs support regulated/licensed midwifery, but
89% of OBs believe that home birth is more
dangerous than hospital birth
• The majority of OBs are in disagreement with most
beliefs held by RMs
• This dissonance has importance for the SOGC’s
position on collaborative and team practice
Summary: Obstetricians
• While OBs are often cohesive in their opinions
relative to other maternity care providers, it is
clear that:
– OBs vary in their belief systems, based on
demographic variables such as age,
gender, location of practice, and payment
arrangement
WHAT DOES THIS TELL US?
• Great similarities amongst most OBs
• But some important differences amongst OBs
• Wide Differences between OBs and Other
Providers
• We need to know more about the underlying
issues:
• Focus Groups
• Developing Attitudes
Focus Groups:
• We need your help in understanding reasons
behind opinions/beliefs—how providers have come
to their beliefs as reflected in the survey
• Focus Groups will be held in the Fall/Winter of 2008
in Montreal, Toronto/Hamilton, Winnipeg, and
Vancouver, ?Halifax
• Focus Groups will include a mix of all maternity care
providers and women (some homogenous focus
groups will also likely be held)
TOWARD BETTER CARE ?
• Inform our educational programs?
(Upcoming National Trainee Grant)
• Interprofessional Education?
• Collaborative Practice?
• Altered Remuneration ?