Transcript Slide 1

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. Klein
Emeritus Professor of Family Practice UBC and
Child and Family Research Institute
Maternity Care
Attitudes & Beliefs Study
Funded
By:
Four-Year
National
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 Group
Michael C. Klein, MD, CCFP, FAAP (Neonatal/Perinatal), FCFP, ABFP,
Principal Investigator, UBC
Janusz Kaczorowski, PhD, Co-Principal Investigator –
Medical Sociology, UBC
Gestation Self-Portrait
© Rae Maté, 1988
www.maternitycare.ca
William Donald Fraser, MD, MA, FRCSC, Co-Principal Investigator Obstetrics, University of Montreal
Robert Liston, MB ChB, FRCSC, FRCOG, FACOG,
Co-Investigator – Obstetrics, 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
Jocelyn Tomkinson, MPH, Project Manager
Jessica Rosinski MA,Research Assistant
Andrea Procyk, BA, Research Assistant
Nazli Baradaran, MD, Research Assistant
Oralia Gómez-Ramírez MA, Research Assistant
Aoife Chamberlaine, BA, Research Assistant
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
2499 Maternity Care Providers
Across Canada Responded Both Languages
• 553 Obstetricians
• 894 Family Physicians
• 495 Provide Intrapartum Care
• 399 Provide Antepartum Care Only
• 381 Midwives
• 541 Nurses
• 130 Doulas
• 1350 Nulliparous Women
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
Cesarean Section:
100
90
80
70.9 70.6
% Agreement
70
60
50
40
40 and Under
30
Over 40
20
20
17.2
21.7 21.3
21.7 22.7
10
0
is safer for the baby is as safe as vaginal
than vaginal birth
birth for women
costs more for the Women who want
health system than C/S in the absence of
vaginal birth
medical indication
should have to pay
for it
Some ways to reduce
the Cesarean section
rate
Approaches to reducing Cesarean Section rate:
100
90
80
% Agreement
70
60
50
40 and Under
Over 40
40
30
25.9
27.5
21.7
21.3
20
10
0
Providing more midwifery services
Encouraging more family physicians to
provide intrapartum maternity care
Choosing Cesarean:
100
90
80
% Agreement
70
60
49.2
50
44.3
40
40 and Under
30
Over 40
20
10
7.5
5.4
9.1
7.1
0
Because of the
If my partner or I were
For single term frank
unpredictability of vaginal pregnant with an apparently breech, women should be
birth, I would prefer a
normal pregnancy, I would offered the choice of vaginal
scheduled C/S for myself or
prefer an elective C/S
birth
partner
instead of a vaginal birth
Regulated Midwifery:
100
90
80
70.3
71.5
% Agreement
70
60
50
40 and Under
Over 40
40
30
20
10
0
I support licensed/regulated midwifery services
Positive attitudes toward doulas
Strongly Agree
Neutral
Strongly Disagree
Doulas:
100
90
80
70
% Agreement
60.1
60
52.6
50
40 and Under
40
30
34.9
29.5
28.5
28.1
20
10
0
There is a need for doula
services in maternity care
In my practice, doulas are
welcome
Doulas improve birth
outcomes
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
Routine Electronic Fetal Monitoring:
100
90
80
70
% Agreement
60
48.6
50
41.4
40
30
19.3
20
10
9.8
0
provides important benefits for the fetus*
elimination as an approach to reducing C/S rate
40 and Under
Over 40
Positive attitudes regarding epidural analgesia
Strongly Agree
Neutral
Strongly Disagree
Epidural Analgesia:
100
90
80
72.6
70
% Agreement
60.1
60
53.7
50
41.0
40
Over 40
31.4
30
21.1
20
10
0
interferes with the normal
progress of labour*
40 and Under
increases the incidence of
should be administered
instrumental birth*
whenever a patient requests
it*
Positive attitudes regarding routine episiotomy
Strongly Agree
Neutral
Strongly Disagree
Episiotomy:
100
92.0
90
80
73.8
% Agreement
70
60
50
40 and Under
40
Over 40
30
20
15.6
6.3
10
7.4
0.6
0
if done routinely, can
prevent pelvic floor
relaxation*
should be used for all
if done routinely, leads to
instrumental vaginal births* more harm than good*
Safety by place and mode of birth:
100
90
93.7
86.7
80
% Agreement
70
60
50
40 and Under
40
Over 40
33.1
30
21.3
20
10
0
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*
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
Mother's choice and role in her own birth:
100
91.4
90
79.3
80
% Agreement
70
60
45.7
50
40
30
40.1
38.7
25.7
41.0
25.1
40 and Under
20.2
20
Over 40
10.7
10
0
For a woman, Women should
having a vaginal be encouraged
birth is a more
to develop a
empowering
birth plan*
experience then
delivering by
C/S*
C/S is like any
other birth*
It is a woman's
A woman's
right to choose history of sexual
C/S for herself, abuse can have
even in the
an important
absence of
impact on the
medical
course of her
indication
labour and
birth*
Fear/Concern about vaginal
birth compared with Cesarean
Positive attitudes toward provider/spouse fears
about birth mode
Strongly Agree
Neutral
Strongly Disagree
I fear vaginal birth for myself or my partner as it:
100
90
80
% Agreement
70
60
50
40 and Under
40
Over 40
30
20
10
24.3
22.3
21.1
12.6
12.6
5.4
9.0
10.9
0
may lead to urinary
may comprimise
may lead to fecal or
incontinence*
sexual functioning* flatal incontinence*
could lead to
perineal and/or
pelvic floor damage*
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
Proportion of agreement (%)
100
80
60
FPI
40
FPP
30.7
FPN
23.5
20
15.6
12.0
13.5
6.8
0
Cesarean section prevents
urinary incontinence.
p<.001
Cesarean section prevents sexual
dysfunction.
p=.011
Woman’s Role in her own birth
Proportion of agreement (%)
100
80
60
50.8
42.6
41.8
40
FPI
FPP
FPN
20
0
For a woman, having a vaginal birth is a more empowering experience than
delivering by Cesarean section
p=.042
Routine EFM: Provides important benefits
for the fetus. *
100
90
80
70
60
%
50
40
30
25.9
20
10
14.7
6.4
0
FPI
FPP
FPN
EFM: Reduces the chance of litigation. *
100
90
80
70
60
%
50
39.7
40
31.6
30
20
12.4
10
0
FPI
FPP
FPN
Approaches to reducing the cesarean
section: Eliminating routine electronic fetal
monitoring (EFM). *
100
90
80
70
60
57.1
% 50
40
35.0
30
25.0
20
10
0
FPI
FPP
FPN
Epidural Analgesia: Should be routinely offered to
all women in labour. *
100
90
80
67.6
70
60
51.2
%
50
40
37.8
30
20
10
0
FPI
FPP
FPN
Episiotomy: Should be used for all
instrumental vaginal births. *
100
90
80
70
60
%
50
40
30
24.5
23.0
FPP
FPN
20
10
5.4
0
FPI
Episiotomy: If done routinely, can prevent
3rd/4th degree tears. *
100
90
80
70
60
% 50
40
30
21.4
20
12.6
10
4.2
0
FPI
FPP
FPN
100
90
Doulas improve birth outcome. *
80
70
60
51.1
% 50
40
29.8
30
20.0
20
10
0
FPI
FPP
FPN
There is a need for doula services in
maternity care. *
100
90
80
70
60
%
50
45.0
40
36.0
29.8
30
20
10
0
FPI
FPP
FPN
Women should be encouraged to develop a
birth plan.
100
90
80
70
60
59.8
58.6
FPP
FPN
54.3
% 50
40
30
20
10
0
FPI
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
90
80
74.7
70.7
70
% Agreement
60
59.0
54.4
53.9
54.7
50
45.0
OB
40
FP
RM
30
22.0
23.9
20
10
0
I believe that having a vaginal
The most important thing in Women who deliver their baby
birth is a more empowering
by cesarean section miss an
having a normal birth is the
experience than delivering by woman’s own confidence in her
important life experience.
cesarean section.
ability to give birth.
Theme C:
Compared with Vaginal Birth, Cesarean Section:
18
16.9
16
14.9
15.4
14
11.7
% Agreement
12
10.5
10.1
10
8
6
7.9
OB
8.1
FP
5.4
RM
5.9
4.5
4
1.6
2
0
prevents bladder
prevents future sexual is more convenient for
problems in the future.
problems for the
mothers.
mother.
is safer for the baby.
Theme C:
Cesarean Section (cont).
30
27.9
25
21.5
% Agreement
20
18.1
17.0
15.8
15
OB
FP
RM
10
6.5
5
1.8
2.4
1.4
0
I believe that a woman recovers Cesarean section is a less For women, cesarean section is
faster after a cesarean section painful method of delivery than
as safe as vaginal birth.
than after vaginal birth.
vaginal birth.
Evidence-Based Knowledge
(10 items, KR20 = .822)
PROVIDER TYPE
OB
*FP
*RM
REGION
BC/AB
*SK/MB
Ontario
*Quebec
*Atlantic
Territories
INCOME
Less than 40K
40 to 60K
60 to 100K
Over 100K
*Prefer not to say
PLAN TO GIVE BIRTH
City
Small town
Rural/remote region
TRIMESTER
1
2
*3
0.1
1
| Less Knowledgeable
10
More Knowledgeable |
* indicates significance, p<.05
(Ordinal Logistic Regression Odds Ratios & 95% C.I.)
.
% “I Don’t Know“ (IDK) Responses 3rd Trimster
% IDK
0
Childbirth usually requires medical technology.
20
5.6
3.7
Women who deliver their baby by cesarean section miss an
important life experience.
6.5
Having a birth plan (written outline of preferences for labour and
birth) is a good idea for a pregnant women.
1.9
It is a woman's right to choose a cesarean section for herself, even
if there are no medical reasons to have it.
2.5
An epidural should be routinely offered to all women in labour.
60
2.9
I believe that having a vaginal birth is a more empowering
experience than delivering by cesarean section.
The most important thing in having a normal birth is the woman’s
own confidence in her ability to give birth.
40
3.1
An epidural increases the use of forceps and vacuum extractors.
33.8
Epidurals interfere with the normal progress of labour.
18.1
Compared with vaginal birth, cesarean section prevents bladder
problems (such as urine frequency, urgency or loss of urine) in the
future.
49.4
Compared with vaginal birth, cesarean section prevents future
sexual problems for the mother.
I believe that a woman recovers faster after a cesarean section
than after vaginal birth.
33.6
7.4
% “I don’t know” (IDK) Responses 3rd Trimester
% IDK
0
10
Compared with vaginal birth, cesarean section is
more convenient for mothers.
20
30
8.6
Cesarean section is a less painful method of
delivery than vaginal birth.
13.7
Compared with vaginal birth, cesarean section is
safer for the baby.
18.9
For women, cesarean section is as safe as vaginal
birth.
18.1
“
Episiotomy prevents sexual problems in the
future.
34.3
Episiotomy causes more problems than it
prevents.
Home birth is more dangerous than hospital birth,
even in an uncomplicated pregnancy.
If available, out-of-hospital birth centers can
provide safe maternity care for women with no
pregnancy problems.
There is a need for doula services in maternity
care.
40
27.0
2.7
9.2
14.1
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