June 13, 2011 Three studies by University of British Columbia and Child & Family Research Institute (CFRI) researchers are providing the closest look yet at the attitudes of women and their caregivers around the use of birth technology, and together reveal ongoing misperceptions among caregivers around the safety of vaginal births.
The latest of the studies, published in the Journal Obstetrics and Gynaecology Canada, shows women's attitudes toward the use of technology for their first childbirth -- including epidural analgesia, Caesarean section and episiotomy -- coincide with their choice of healthcare providers.
In the first study in Canada to examine women's attitudes toward labour before their first experience with childbirth, a team of researchers led by Dr. Michael Klein surveyed 1,318 low-risk women. They found that fewer than 30 per cent of women approaching their first birth attend prenatal classes, and books and the Internet are their primary sources for information about birth.
Women attending obstetricians were more favourable to the use of birth technology and were less appreciative of women's roles in their own delivery. In contrast, women attending midwives reported less favourable views toward the use of technology and were more supportive of the importance of women's roles. Family practice patients' opinions fell between the other two groups.
Even late in pregnancy, questions about epidural analgesia, Caesarean section and episiotomy solicited the most "I don't know" responses from women who took the survey. But women attending midwives appeared more knowledgeable on these issues.
"Our findings suggest that obstetricians, midwives and family physicians are caring for different populations of women, with different attitudes and expectations towards childbirth," says Klein, professor emeritus in family practice and pediatrics at UBC and senior scientist emeritus at CFRI. "But regardless of the type of care providers they attended, even late in pregnancy, many women reported uncertainty about benefits and risks of common procedures used at childbirth. This is worrisome because a lack of knowledge affects their ability to engage in informed discussions with their caregivers."
A second study, published last month in the journal Birth, compared the attitudes toward birth technology and women's role in their childbirth between the younger generation of obstetricians and their predecessors.
Klein and colleagues surveyed 800 Canadian obstetricians who include birth delivery in their practice. Out of 549 respondents, 81 per cent of those 40 years or younger were women (vs. 40 per cent over 40 years of age). The average age of Canadian obstetricians is 58.
The team found that younger obstetricians were significantly more likely to favour the use of routine epidural analgesia and were more concerned about the perceived adverse effects of vaginal birth, particularly the effect of vaginal birth on pelvic floor functioning, including urinary incontinence and sexual issues.
Compared to the older generation of obstetricians, the younger generation sees Cesarean section as a solution to many labour and birth problems, and incorrectly sees C-section as safer for both mothers and babies. The study also shows younger obstetricians are more likely to choose C-section for themselves or their partners, and are less likely to believe women missed out on an important experience by having a C-section.
In Canada, Cesarean section rates are reaching or exceeding 30 per cent in most jurisdictions. Previous studies in the U.S. and Canada have associated adverse outcomes for mothers and babies with excessively high Cesarean section rates. C-sections cost the health care system up to twice as much as vaginal birth.
"This study shows it's generation, not gender, that affects obstetricians' views about procedures like C-sections," says Klein. "And this could present a challenge to efforts to decrease C-section rates in both U.S. and Canada." As well, depending on the issue or procedure, up to a third of obstetricians were not evidence-based in their views. This creates concern about informed decision-making, especially for women who are uncertain about procedures that might be used in birth.
On the positive side, between 15-20 per cent of obstetricians have attitudes toward birth that mirror those of midwives. Thus, opportunities for collaboration certainly exist, says Klein.
A third study, published online in April in the journal Canadian Family Physician, examined whether including childbirth delivery in their practice affected family physicians' attitudes towards the use of technology.
It shows that family physicians who provide care for women during pregnancy and delivery consistently demonstrate more positive attitudes towards vaginal birth than those who don't. They are also significantly less fearful of vaginal birth for both themselves and their partners.
While all physicians surveyed supported licensed midwifery, 75 per cent thought home birth was more dangerous than hospital birth, according to the study, even though home birth by regulated midwives has been shown to be safe in Canada.
Only 7.8 per cent of family physicians who incorporate childbirth delivery in their practice would choose obstetricians for their own or their partners' maternity care. "In Canada, only 11 per cent of family physicians deliver babies as part of their practice, but they deliver 30 per cent of newborns," says Klein. "Increasing family physicians' role in overall maternity care could contribute to a more balanced attitude towards childbirth."
"Because family physicians who provide only antepartum care provide more than 50 per cent of the antepartum care in Canada, the relatively negative views of birth held by family physicians who only provide antepartum care need to be addressed in family practice education and in continuing education," says Klein.
"These three studies taken together show us that educational leaders and provincial policy-makers need to seriously examine the educational models and experiences that appear to teach the non-evidence-based view that vaginal childbirth is primarily a dangerous activity," says Klein. "If C-section rates are to fall, we need more midwives, and family physicians who will attend births, while obstetricians in training will need to have more experience with normal birth, and in the future, restrict their role to that of consultants to midwives, family physicians and nurses. In this way they can maximize the appropriateness of their surgical training.
"This means rethinking the design of the entire Canadian maternity care system. Finally, if women are to be empowered with the information that they need to dialogue with their providers, new forms of accurate information transfer will need to be developed."
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- Michael C. Klein, Robert Liston, William D. Fraser, Nazli Baradaran, Stephen J. C. Hearps, Jocelyn Tomkinson, Janusz Kaczorowski, Rollin Brant. Attitudes of the New Generation of Canadian Obstetricians: How Do They Differ from Their Predecessors? Birth, 2011; 38 (2): 129 DOI: 10.1111/j.1523-536X.2010.00462.x
- Michael C. Klein. Family physicians who provide intrapartum care and those who do not: Very different ways of viewing childbirth. Canadian Family Physician, 2011; 57 (4): e139-e147 [link]
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