Planetary Confusion: Where is Captain Kirk when we need him?

Edmonton May 7th 2011 Building Partnerships With Women, their

Families and Care Providers based on what providers and women believe about childbirth

How can evidence shape a new relationship?

Michael C. KleinEmeritus Professor of Family Practice UBC and

Child and Family Research Institute

Maternity Care Attitudes & Beliefs Study

Funded By:

Four-YearNational

Study

In Association With:

Supported by:

•College Family Physicians of Canada (CFPC)•Society of Obstetricians and Gynaecologists of Canada • Association of Obstetricians and Gynecologists of Quebec (AOGQ)•The Canadian Association of Midwives (CAM)•Association des omnipraticiens en périnatalité du Québec (AOPQ) --Various Provincial & National Nurses Associations

--DONA International

Maternity Care Research GroupMichael C. Klein, MD, CCFP, FAAP (Neonatal/Perinatal), FCFP, ABFP,

Principal Investigator, UBCJanusz Kaczorowski, PhD, Co-Principal Investigator –

Medical Sociology, UBCWilliam Donald Fraser, MD, MA, FRCSC, Co-Principal Investigator -

Obstetrics, University of MontrealRobert Liston, MB ChB, FRCSC, FRCOG, FACOG,

Co-Investigator – Obstetrics, 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, UBCJocelyn Tomkinson, MPH, Project Manager Jessica Rosinski MA,Research AssistantAndrea Procyk, BA, Research AssistantNazli Baradaran, MD, Research AssistantOralia Gómez-Ramírez MA, Research AssistantAoife Chamberlaine, BA, Research Assistant

Gestation Self-Portrait © Rae Maté, 1988

www.maternitycare.ca

National Study Background:

•Differences in beliefs and attitudes toward birth among different maternity care providers doing similar work can be a source of conflict and confusion in the workplace

•And can create inter-professional difficulties and problems for pregnant and laboring women to build partnerships with their provider.

•As well as creating confusion for undergraduate and postgraduate trainees

The Ground is Shifting

• The profession of OB/GYN is changing—aging and feminizing

• Demographics of the other maternity care providers are changing

• Demographics of the childbearing population are changing—older, heavier etc

• Birth technology is changing, ?? improving • EBM approach is changing—more EBM in maternity

care• Hence, every reason to expect changes in attitudes of

providers and women in the new generation of each

• 553 Obstetricians• 894 Family Physicians

• 495 Provide Intrapartum Care• 399 Provide Antepartum Care Only

• 381 Midwives• 541 Nurses• 130 Doulas• 1350 Nulliparous Women

2499 Maternity Care Providers Across Canada Responded Both Languages

The responses for each group represented every region in Canada, Rural and Urban and paralleled actual distribution providers, with the exception of some weakness in Quebec for nurses, midwives, doulas and women

Midwifery and Home Birth

Post-Term Pregnancy Beliefs

In-Depth Study of Obstetricians

This generational analysis encapsulates many of these changes and was most revealing and predictive of the future of maternity care

•Areas of Agreement and disagreement between Obstetricians <=40 and >40

Demographics OBs <=40 and >40 age

• Female: 81% younger vs 40% older

• Generation NOT gender

• Regional, Level, and type of practice similar

• Mean deliveries/year: – 169 younger vs 109 older

Some areas of intergenerational agreement

Could consider them core values

20 21.7

70.9

21.717.2

21.3

70.6

22.7

0

10

20

30

40

50

60

70

80

90

100

is safer for the baby than vaginal birth

is as safe as vaginal birth for women

costs more for the health system than

vaginal birth

Women who want C/S in the absence of

medical indication should have to pay

for it

% A

gree

men

tCesarean Section:

40 and Under

Over 40

Some ways to reduce the Cesarean section

rate

25.921.7

27.5

21.3

0

10

20

30

40

50

60

70

80

90

100

Providing more midwifery services Encouraging more family physicians to provide intrapartum maternity care

% A

gree

men

tApproaches to reducing Cesarean Section rate:

40 and Under

Over 40

7.5 9.1

44.3

5.4 7.1

49.2

0

10

20

30

40

50

60

70

80

90

100

Because of the unpredictability of vaginal

birth, I would prefer a scheduled C/S for myself or

partner

If my partner or I were pregnant with an apparently normal pregnancy, I would

prefer an elective C/S instead of a vaginal birth

For single term frank breech, women should be

offered the choice of vaginal birth

% A

gree

men

tChoosing Cesarean:

40 and Under

Over 40

70.3 71.5

0

10

20

30

40

50

60

70

80

90

100

I support licensed/regulated midwifery services

% A

gree

men

tRegulated Midwifery:

40 and Under

Over 40

Positive attitudes toward doulas

Strongly Agree

Neutral

Strongly Disagree

29.5

52.6

28.528.1

60.1

34.9

0

10

20

30

40

50

60

70

80

90

100

There is a need for doula services in maternity care

In my practice, doulas are welcome

Doulas improve birth outcomes

% A

gree

men

tDoulas:

40 and Under

Over 40

In-Depth Study of Obstetricians

Areas of Disagreement between Obstetricians

<=40 and >40

All statistically significant at p <.05 or usually <.01 to <.001

But keep in mind areas or zones of interdisciplinary agreement

Positive attitudes toward electronic fetal monitoring

Strongly Agree

Neutral

Strongly Disagree

9.8

41.4

19.3

48.6

0

10

20

30

40

50

60

70

80

90

100

provides important benefits for the fetus* elimination as an approach to reducing C/S rate

% A

gree

men

tRoutine Electronic Fetal Monitoring:

40 and Under

Over 40

Positive attitudes regarding epidural analgesia

Strongly Agree

Neutral

Strongly Disagree

21.1

41.0

72.6

31.4

53.7

60.1

0

10

20

30

40

50

60

70

80

90

100

interferes with the normal progress of labour*

increases the incidence of instrumental birth*

should be administered whenever a patient requests

it*

% A

gree

men

tEpidural Analgesia:

40 and Under

Over 40

Positive attitudes regarding routine episiotomy

Strongly Agree

Neutral

Strongly Disagree

0.6

7.4

92.0

6.3

15.6

73.8

0

10

20

30

40

50

60

70

80

90

100

if done routinely, can prevent pelvic floor

relaxation*

should be used for all instrumental vaginal births*

if done routinely, leads to more harm than good*

% A

gree

men

tEpisiotomy:

40 and Under

Over 40

93.7

33.1

86.7

21.3

0

10

20

30

40

50

60

70

80

90

100

Home birth is more dangerous than hospital birth, even in an uncomplicated

pregnancy*

If a woman has had a previous C/S, a scheduled repeat C/S can improve

newborn outcomes*

% A

gree

men

tSafety by place and mode of birth:

40 and Under

Over 40

Woman’s role in her own birth

Positive attitudes toward the importance of maternal choices and the role played by the mother in her own

birth Strongly Agree

Neutral

Strongly Disagree

25.7 25.120.2

45.7

91.4

38.7 40.1

10.7

41.0

79.3

0

10

20

30

40

50

60

70

80

90

100

For a woman, having a vaginal birth is a more empowering

experience then delivering by

C/S*

Women should be encouraged

to develop a birth plan*

C/S is like any other birth*

It is a woman's right to choose C/S for herself,

even in the absence of

medical indication

A woman's history of sexual abuse can have

an important impact on the course of her

labour and birth*

% A

gree

men

tMother's choice and role in her own birth:

40 and Under

Over 40

Fear/Concern about vaginal birth compared with Cesarean

Positive attitudes toward provider/spouse fears about birth mode

Strongly Agree

Neutral

Strongly Disagree

21.1

12.6

22.3 24.3

12.6

5.49.0 10.9

0

10

20

30

40

50

60

70

80

90

100

may lead to urinary incontinence*

may comprimise sexual functioning*

may lead to fecal or flatal incontinence*

could lead to perineal and/or

pelvic floor damage*

% A

gree

men

tI fear vaginal birth for myself or my partner as it:

40 and Under

Over 40

The Attitudes of Family Physicians Providing Intrapartum Care vs. Those That Do Not:

• More than 50% of antenatal care in Canada provided by FPs who do not provide intrpartum care

• Only 11% of Canadian FPs attend births

• Yet 1/3 Canadian births attended by FPs

• Canadian FPs important providers of maternity care and influential on women’s perceptions and expectations about birth

897 Family Physicians

503 Provide Intrapartum Care

394 Provide Antepartum Care Only

Cesarean Section as preventive strategy strategy

p<.001 p=.011

Woman’s Role in her own birth

p=.042

Summary Summary

• Intrapartum FPs consistently hold more positive views about normal vaginal birth than FPP and especially FFN.

• Many antepartum only FPs seem to have a technological view of birth and potentially influence their patients to that view before transfer usually to OBs, and less likely FPs and occasionally to midwives. They decide when and to whom to refer their patients

• Therefore, we can’t neglect them as they provide more than 50% of the antenatal care in Canada

Summary:

• Many antepartum only FPs seem to distrust birth and likely influence their patients to that view. Therefore, we can’t neglect them as they provide 50% of the antenatal care in Canada

• Our postgraduate FP curriculum and CME activities for FPs need to acknowledge this problem and adjust accordingly.

• We need to encourage antenatal only FPs to refer to other FPs attending births and to engage in evidence-based counselling of their patients.

• Regardless of whether FPs attend births or not, we as a discipline need to engage in a national discussion about evidence-based, optimal birth.

And the Women Approaching Their First

Birth—what do they believe and know?---stratified by type of maternity provider

Some outcomes from the women’s study

•1355 Nulliparous women attending three types of providers•By demographics•And by trimester

Theme A:Woman’s Role in Her Own Birth

Theme C:Compared with Vaginal Birth, Cesarean Section:

Theme C:Cesarean Section (cont).

0.1 1 10

PROVIDER TYPEOB

*FP*RM

REGIONBC/AB

*SK/MBOntario

*Quebec*Atlantic

Territories

INCOMELess than 40K

40 to 60K60 to 100KOver 100K

*Prefer not to say

PLAN TO GIVE BIRTHCity

Small townRural/remote region

TRIMESTER12

*3

Evidence-Based Knowledge(10 items, KR20 = .822)

* indicates significance, p<.05

(Ordinal Logistic Regression Odds Ratios & 95% C.I.)

More Knowledgeable | . | Less Knowledgeable

% “I Don’t Know“ (IDK) Responses 3rd Trimster

% “I don’t know” (IDK) Responses 3rd Trimester

“

Proportion of IDK Responses Stratified by Trimester and Provider

Meaning

• It appears that three different populations of women are attending the three provider groups

• Women attending midwives have a greater fund of evidence-based knowledge even before their first visit with a midwife

• Many women even late in pregnancy are lacking information that they should know

Overall Summary:

• Younger Canadian obstetricians <40, 81%who are women, more fearful/concerned about vaginal childbirth than older usually male colleagues

• Younger are sometimes evidence-based in their attitudes, sometimes not

• But it is about generation not gender• 30% of OBs do or would consider limiting their practice

to consultation not primary care

Summary• While great similarities within the OB discipline as a

group, – Some important differences amongst Obstericians—not only

by generation• More importantly, on most issues (even contentious

ones), 15-20% of OBs align with midwives (BOXPLOTS)• We need to know more about the underlying issues that divide

the disciplines. • We need to put ourselves in the shoes of each discipline—to

appreciate the why the differences

TOWARD BETTER CARE• Grow regulated midwifery in Canada• Rebuild FP Maternity Care• Encourage further doula development and

availability• If change is to happen, we need to understand

where each discipline is coming from and…• We need to appreciate the different value

systems in operation for each provider group—and why!

• Better is also cheaper

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 and Normal Birth

Summary: All Providers• RNs vary according to the issue, aligning with OBs or

Midwives or FPs—or independent.– Nurses have to adapt to the attitudes/beliefs of the other

providers• Doulas align with midwives• Many providers have strongly held beliefs that

may not be evidence-based• Truly informed consent cannot take place in

such an environment—especially for nulliparous women who are frightened and confused

WHAT DOES THIS TELL US?• We need to know more about the underlying issues that divide

the disciplines and motivate women• This requires attentive listening and the acquisition of deep

understanding of the underlying motivations of both providers and women.

• Small interventions and fixes are not likely to lead to enhanced partnerships.

• The care system and the education for truly collaborative care and true partnerships between maternity care providers and women will require development of trust and reciprocal understanding

• This a huge and long-term commitment between educators, professional organizations consumers and government

TOWARD BETTER CARE ?

• Inter-professional Education?• Redesign maternity care curriculum for OBs and FPs, Nurses

and Midwives too• Collaborative Practice/collaborative education? New Models of

Care?????– South Health only real model in Canada

• Altered Remuneration?• We must engage with antepartum FPs who do not do

intrapartum maternity! • We need to recognize the power imbalance that exists in

maternity care and do something to reduce it.

TOWARD BETTER CARE ?• Informed choice is a right• It is about acknowledging that women loose control when they

come to the hospital and doing something about it.• It is about paying attention to the woman’s value systems and

integrating them into the plan• It is about acknowledging that doing all this takes time—so we

have to design systems that provide the time• COMPASSION and understanding is at the core of any

contemplated change