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Maternity Care Attitudes & Beliefs Study
Funded By:
Four-YearNational
Study
In Association With:
Supported by:
The Society of Obstetricians and Gynaecologists of Canada
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 GroupMichael C. Klein, MD, CCFP, FAAP (Neonatal/Perinatal), FCFP, ABFP,
Principal Investigator, UBCRobert Liston, MB ChB, FRCSC, FRCOG, FACOG,
Co-Investigator – Obstetrics, UBCWilliam Donald Fraser, MD, MA, FRCSC, Co-Principal Investigator -
Obstetrics, University of MontrealJanusz Kaczorowski, PhD, Co-Principal Investigator – Medical
Sociology, UBCSharon Dore, RN, PhD, Co-Investigator – Nursing, McMasterWendy Hall, RN, PhD, Co-Investigator – Nursing, UBCPatricia McNiven, RM, PhD, Co-Investigator – Midwifery, McMasterLee Saxell, RM, MA, Co-Investigator – Midwifery, UBCKathleen A. Lindstrom, CD, Doula Educator, Co-Investigator - Doula,
Douglas CollegeJalana Grant, CD, Co-Investigator – Doula, DONA Western Canada
Director Rollin Brant, PhD,Co-Investigator – Statistics, UBCSahba Eftekhary MD, MPH, MHA, Co-InvestigatorJude Kornelsen,PhD, Co-Investigator - Medical Sociologist, UBCJessica Rosinski MA, Project ManagerAndrea Procyk, BA, Research AssistantJocelyn Tomkinson, MPH, Research AssistantOralia Gómez-Ramírez MA, Research AssistantAoife Chamberlaine, BA, Research AssistantNazli Baradaran, MD, Research Assistant
Gestation Self-Portrait © Rae Maté, 1988
www.maternitycare.ca
Perinatal Provider Crisis
Caesarean SectionTemporal Trends, Canada
Rate
YearStatistics Canada
Trends in Rate of C/S by Indication:Primary Caesarean Section
94/95 Rate (%(
2000/01 Rate (%)
Attributable Change %
RR(95% CI)
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)
JOGC 2004 - Deliveries in Canada except Que and Man
Indication 1994/95 2000/01 Attributable RR(95%CI) rate % rate % change %
Trends in Rate of C/S by Indication:Repeat Caesarean Section
Indication 94/95 Rate (%(
2000/01 Rate (%)
Attributable Change %
RR(95% CI)
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)
JOGC 2004 - Deliveries in Canada except Que and Man
Indication 1994/95 2000/01 Attributable RR(95%CI) rate % rate % Change %
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
0
5
10
15
20
25
30
35
north bc interior
2000
2005
vc fh viha
C/Section in Canada
Inter-jurisdictional difference
Inverse relationship between primary c/s and VBAC rate
Suggest care provider effect
• 553 Obstetricians• 894 Family Physicians
• 495 Provide Intrapartum Care• 399 Provide Antepartum Care Only
• 381 Midwives• 541 Nurses• 130 Doulas
2499 Maternity Care Providers Across Canada Responded
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
• 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)
Demographics
Cesarean Section & VBAC Beliefs
If a woman has had a previous cesarean section, a scheduled repeat cesarean section reduces the chance of litigation
40.9
22.6
36.5
20.526.4
53.1
21.6
35.4
43.0
23.927.8
48.3
13.9
24.5
61.6
26.2 23.1
50.8
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
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
25.018.8
56.2
14.617.8
67.5
12.8
27.4
59.8
15.8 17.7
66.5
1.67.7
90.8
1.5 2.3
96.2
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
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
7.73.7
88.7
1.2 2.2
96.5
2.8 2.8
94.4
3.0 1.7
95.4
0.5 0.3
99.2
0.0 1.6
98.4
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
Women who deliver their baby by cesarean section miss an important life experience
15.5 17.1
67.4
25.1 24.1
50.8
21.125.4
53.5
20.815.0
64.2
40.6
31.727.7
45.4
23.8
30.8
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
Cesarean section is as safe as vaginal birth for women
21.4
13.5
65.1
11.4 11.4
77.1
15.121.4
63.5
13.9 12.6
73.5
2.9 5.0
92.1
3.8 5.4
90.8
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
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:
55.9
2.6
41.5
62.4
2.7
34.9
71.7
4.2
24.1
70.9
8.0
21.1
76.0
0.5
23.5
86.9
0.0
13.1
0
20
40
60
80
100
Recommend a VBAC Recommend ascheduled cesarean
Follow the mother'srequest
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
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 battleand will end up fighting the patients over their right to decidetheir 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 theright to what is after all the safest way for their babies to beborn.
It is also far safer than many other operations they have accessto on demand such as plastic surgery or home birth.”
– All one Obstetrician
Epidural Beliefs
Epidural analgesia interferes with the normal progress of labour
28.1
16.7
5548.7
21.8
29.3
46.8
28.125
52.5
19.2
28.1
83.2
13.5
3.1
89.2
6.93.8
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP INT
FP Other
RN
RM
Doula
Epidural analgesia increases the incidence of instrumental birth
49.4
16.0
34.7
63.1
16.920.0
57.2
24.9
17.9
62.6
13.1
24.3
90.1
6.73.2
93.8
3.1 3.1
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
Obstetricians
Epidural analgesia should be routinely offered to all women in labour
58.7
12.7
28.4
38.1
17.6
44.2
56.1
14.7
2929.8
13.3
56.7
2.67.6
89.7
2.3
23
91.5
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP INT
FP Other
RN
RM
Doula
Home Birth Beliefs
Home birth is more dangerous than hospital birth, even in an uncomplicated pregnancy
88.9
5.3 5.8
74.0
15.011.0
72.6
12.115.3
53.8
13.7
32.5
0.8 1.6
97.6
3.8 5.4
90.8
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
OB Agreement analyzed by type of Payment Arrangement :Fee for Service 90.3% vs Other Payment Arrangements 82.4% p .019
Obstetricians
I support licensed / regulated midwifery services
71.0
16.512.5
65.1
23.9
11.0
68.0
18.113.9
82.2
13.6
4.1
96.9
2.3 0.8
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
Doula
Obstetricians
“Before I was an Obstetrician, I was a Midwife. Before Iwas a Midwife, I was a woman giving birth in thecapable hands of my Midwife. My Grandmother was aMidwife. I could cry, sometimes, at the direction ofmodern maternity care, and hope with all my heart thatreason and respect will prevail.”
- Obstetrician (quote used with permission)
Active Management & Post-Term Pregnancy Beliefs
“Active management of labour” improves birth outcomes
76.3
15.0
8.8
67.4
21.1
11.5
42.4
35.6
22.0
38.5
20.4
41.1
8.5
19.0
72.5
2.3 2.3
95.4
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
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:
6.5
84.0
9.511.6
67.4
21.024.7
62.6
12.6
42.848.0
9.2
57.8
5.5
36.7
78.3
0.8
20.9
0
20
40
60
80
100
Expectant management Elective induction Follow the mother's request
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
The long-term pelvic floor outcomes of physiologically managed birth will likely be better than elective cesarean section
18.9
32.1
49.0
37.042.2
20.8
31.4
45.8
22.8
51.8
32.8
15.4
62.1
30.8
7.2
76.7
20.2
3.1
0
20
40
60
80
100
Agree Neutral Disagree
Perc
ent
OB
FP Int.
FP Other
RN
RM
Doula
* 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 ?
