.Soc SCI Med Vol 32, No 1 I, pp 1283-1289, Pnntcd m Great Bntam All nghts reserved
1991 Copynght
0
0277-9536/91 f3 00 + 0 00 1991 Pergamon Press plc
OBSTETRICAL ATTITUDES AND PRACTICES BEFORE AND AFTER THE CANADIAN CONSENSUS CONFERENCE STATEMENT ON CESAREAN BIRTH KARIN DOMNICK PIERRE,’EUGENEVAYDA,’
JONATHANLLAMAS,’ MURRAYW ENKIN,~ WALTERJ HANNAH?and GEOFFM ANDERSON~ ‘Department of Health Admmlstratron, Dlvlslon of Community Health, Faculty of Medicine, Umverslty of Toronto, Toronto, Ontano, Canada, *Department of Chmcal Epldenuology and Blostatlstlcs, Faculty of Medlcme, McMaster University, Hanulton, Ontano, Canada, ‘Department of Obstetncs and Gynaecology, Faculty of Medicme, McMaster Umverslty, Hamilton, Ontano, Canada, 4Department of Obstetncs and Gynaecology, Faculty of Medicine, Umverslty of Toronto, Toronto, Ontano, Canada and 5Dlvlslon of Health Sciences, Research and Development, University of Bntlsh Columbia, Vancouver, B C , Canada Abstract-This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section m Ontario for women with a previous cesarean section or a breech presentation Using data from multiple sources-surveys of obstetnaans, and hospital admmlstrators, and hospital record statlstlcs, the authors attempt to assess the response of obstetnclans to pressure to change then practice This pressure comes pnnclpally from the Canadian Consensus Conference Statement on Cesarean Birth, released m June 1986 and subsequently endorsed by a number of professional orgamzatlons The Statement provides clear guidelines for the management of labour m women with previous cesarean section or a breech presentation The findings present a number of mterpretlve challenges Based on their response to hypothetical cases obstetnclans are favourably disposed to consldenng a tnal of labour for women with previous cesarean section and breech presentation However, both their reported practices, as well as hospital statlstlcs indicate the continued high prevalence of cesarean section, though there 1s a small decline m cesareans for previous cesarean Section There was no evidence that hospitals lacked appropnate faclhtles for a tnal of labour or had unduly restricted formal policies Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questloned on the actual details of the recommendations, obstetnclan’s recall was surpnsmgly low Respondents tended to err m the direction of choosmg more conservative measures than those recommended by the Statement The authors consider several possible mterpretatlons for the differences physlclans perceptions of the complexity of their own cases compared to the hypothetical scenarios, dd?icultles encountered m lmplementmg new procedures such as trial of labour, the mhlbltmg effect of then conservative mterpretatlon of the Consensus Statement recommendations, convemence and income Issues, fear of htlgatlon, and, patient preferences Ke~j words-physician attitudes, physIcIan behavlour change, obstetnc previous cesarean sectlon, breech presentation
INTRODUCTION This paper reports on the survey component of a provmce-wide, multl-year proJect almed at modlfymg aspects of obstetnc practice m Ontarlo In the face of a growing controversy regarding mdlcatlons for cesarean section the mcreasmg Canadtan cesarean sectlon rate provided the Impetus for the 1985 Canadian Consensus Conference on Aspects of Cesarean Birth The Consensus Conference Statement developed and released m 1986 made defimtlve recommendations concerning the management of patients with previous cesarean section and breech presentation (11 To track obstetnaans attitudes, practice patterns, and reactions to the Statement we used both survey and hospital utlhzatlon data before and after the release of the Statement In addltlon, the research team implemented and evaluated mterventlon strategies aimed at modifymg physlclan behavlour and hospital policies The results of these studies have been reported elsewhere [2-4]
practice, hypothetical
cases,
In this paper we focus on the reported and actual practice styles of obstetnclans and their reactlons to the Consensus Statement We are prmclpally concerned with assessing what happens when physlclans are faced with pressures to change an estabhshed chmcal practice pressures which came from the Consensus Statement, Its endorsement by the Society of Obstetnclans and Gynaecologlsts of Canada and the Canadian Assoclatlon of Professors of Obstetncs and Gynaecology, and an mterventlon study The data highlight dlscrepancles between knowledge and practxe, both reported and actual, and allow us to ldentlfy some possible barriers to change m obstetric practices METHODS
Data for this study came from self-administered mailed surveys of Ontano obstetnaans* one before and two after the release of the 1986 Canadian Consensus Conference on Aspects of Cesarean Bxth.
1283
KAIUNDOMNICK
1284
In addltlon, pre and post Consensus Conference surveys of Ontano hospitals identified formal hospltal pohcles regarding previous cesarean section and breech presentation Ontano hospital discharge data from the Hospital Medical Records Institute from 1982 through 1988 provided data on the overall provmclal cesarean section rates and rates by specific diagnosis [3] (see Appendix) A summary of the timing, sample frame, content and response rate of each of the surveys 1s shown m Table 1 By using an mltlal and two follow-up mallmgs we achieved response rates greater than 74% m each of the five surveys Two separate sets of obstetnaan/gynaecologlst samples were selected from the mailing list of the Ontario Medical Assoclatlon The first (Survey 1) was a 40% random sample, drawn m 1985/86 It collected baseline mformatlon on pre-Consensus Conference attitudes and practices of obstetnclans regarding breech and previous cesarean section, using hypothetical cases and self reported data (See Appendix for actual questions ) The two hypothetical cases descnbmg an uncomplicated pregnancy with a breech presentation, and the other a routine pregnancy m a woman with one low traverse previous cesarean section, were developed m consultation with the Soc:ety of Obstetnclans and Gynaecologlsts of Canada and the Canadian Assoclatlon of Professors of Obstetncs and Gynaecology Details of these cases have been published elsewhere [4] In 1988, two years after the release of the Consensus Statement this group of obstetricians was resurveyed using the same hypothetical cases, and practice questions, but with new questions about awareness of the Consensus Statement and its impact on then practice (Survey 2) All physicians who practiced m any of Table Survey number and date
I
PIERRE er al
sixteen community hospitals involved m a concurrent study designed to evaluate the impact of different mterventlons on physicians behavlour [5], were excluded from the Survey 2 sample. In addition a 40% sample of new members (1 e since the 1986 survey) from the Ontano Medical Assoclatlon list was meluded A cohort of 93 obstetnaans/gynaecologlsts responded to both Surveys 1 and 2 (the Companson Cohort) Earlier, m 1987, a survey of all the obstetnclans (60%) not included m Survey 1 was conducted (Survey 3) This survey measured levels of awareness, sources of mformatlon, detailed knowledge and Impact of the Consensus Statement one year after its release These data were pnmanly used for companson with all 130 Survey 2 responses Surveys of all Ontario hospitals with obstetnc departments m 1985 and 1988 identified the extent and nature of pohcles for breech presentation and previous cesarean section Questlonnalres were sent to the Chiefs of Obstetncs In those hospitals where a Chief could not be identified, the Hospital Admmlstrator was asked to have the questionnaire completed by an appropnate member of the medical staff The 1988 resurvey of these hospitals also excluded the sixteen hospitals which were involved m the concurrent intervention study The number of hospitals m the 1988 survey was further reduced by hospital mergers, hospital closures or the closure of obstetnc departments FINDINGS
The charactenstlcs of the respondents to Surveys 1-3, and the Comparison Cohort are summarized m Table 2 The survey data compare obstetnaans
Summary
of surveys
Survey name
Sample
Questlo”
I 1985186
Obstetruan basehne survey
40% random sample of obstetrlclans I” OMA’
2 1988
Obstetnclan follow up survey
. respondents to 1985 survey . plus 40% sample of new OMA’ members . minus obstetruans I” mterventlon hospital?
l
3 1987
Obstetnua” awareness survey
4 1985
Hospital survey
5 1988
Hospital follow up survey
basehne
Respondents samples (response rate)
content
l
hypothetrcal cases l atutudes l reported practice
156/l92(81%) Comparison Cohort’ N = 93
hypothetlcal cases attitudes, l reported practice . awareness and Impact of CS
130/175 (74%) Comparison Cohort’ N = 93
60% of obstetrwdns on OMA’ hst not surveyed m 1985
. detaded awareness of CS’ l lmpdct of CS’ . sources of mformatlo”
160/200 (80%)
Ontario hospitals wth obstetrx facihtles
. pollcles l faclhtles
140/154(91%)
@as above . minus mterventlon hospitals’
.
120/122(98%)
l
pohcres . facacrhtles l awareness of CS’ l Impact of CS
‘Ontano Medvcal Assoclatlon (provmaal branch of the Canadian MedIcal Assoclatlon) ‘Sixteen commumty hospitals which were randomly selected to partupate I” a concurrent ‘Consensus Statement ‘Comparison Cohort -93 ehglble physlclans who responded to surveys I and 2
mterventlon
study
Obstetrical attitudes and practices regardmg cesarean bu-th Table 2 Charactenstxs
of samples
Companson’ Survey 1 Survey 2 Cohort (%) (%) (%) Sex Male Female
Survey 3 (%)
96 4
88 12
94 6
87 13
1960-1969 1970 o* later
42 31 27
31 28 41
38 30 32
31 41 28
Tramed m Canada
70
70
70
76
Commumty Hospital Teachmg Hospital
69 31
61 39
64 36
56 44
Mean number of dehvenes m previous 12 months
206
209
21612 2102
200
(156)
(130)
(93)
(160)
Year of from
graduorron
medrcol
school
1959 or earlter
Hospttol
@ihotron
(N)
attitudes and practices regardmg cesarean section at two points m time (Survey 1 and Survey 2), identify changes m hospital policies over trme and m response to the Consensus Statement (Survey 4 and Survey 5), and measure obstetnaans levels of awareness and knowledge of the Consensus Statement and Its impact on obstetnclans (Survey 2 and Survey 3) 1 Comparison Cohort The Companson Cohort of 93 obstetnclans was surveyed Just pnor to the completion of the Consensus Statement m late 1985/early 1986 and approxlmately two years after Its release m early 1988 (Table 3) Their responses to the breech presentation hypothetical case were unchanged over time 99% and then 97% chose to continue labour For the hypothetical previous cesarean section case there was also no slgmficant difference 89% chose a trial of labour m 1985 compared to 96% m 1988 Table 3 Comparrson cohort hypothetIca cases and reported attltudes and practice Survey 1 1985/86 (%)
Survey 2 1988 (%)
presentatton
Tnal of labour for HypothetIcal Case
99
97
% of patients wth breech prewntatlon delwered by cesarean section (Reported)
57
54
Cesarean Sectlon Rate for breech presentation’ m Ontario (Actual)’
69
69
of labour for Hypothetwl
Case
89
96
% of patients wth prewous cesarean sectton dehvered by cesarean sectlon (Reported)
68
60’
Cesarean SectIon Rate for prewous cesarean sectlon m Ontario (Actual)’
94
91
(93)
(93)
Trrrl
In 1985/86, the Companson Cohort reported that, on average, 57% of the women they saw mth a breech presentation were delivered by cesarean section and they reported almost no change m 1988 (54%) However, their practices for previous cesarean section had changed They reported that on average 68% of women with previous cesarean sectlon had repeat cesarean section m 1985/86, this average fell to 60% m 1988 (t = 2 86, P -=z0 05) However, actual Ontano hospital obstetrical data collected by the Hospital Medical Records Institute showed that m both 1985/1986 and 1988 69% of women with breech presentation were delivered by cesarean sectlon, but 94% of patients urlth previous cesarean sectlon were delivered by cesarean section m 1985/1986 and 91% m 1988 [3] 2 Consensus Statement
‘93 obstetnclans who responded to both Survey I and Survey 2 *Mean of responses of the Comparison Cohort to Surveys I and 2
Breech
1285
(N) ‘Hospital Medrcal Records lnstxtute data *P 5 0 05
awareness, knowledge and reported effect on practrce (comparuon of Survey 2 and Survey 3)
Awareness of the Consensus Statement and its recommendations was measured on two occasions the 1987 Awareness Survey (Survey 3) and the 1988 follow-up survey (Survey 2) In 1987 94% and m 1988 87% of obstetnclans reported that they were aware of the Consensus Statement and were m general agreement with Its overall recommendations. The impact of the Consensus Statement on reported obstetnc practices was measured somewhat differently m Surveys 3 and 2 In Survey 3 ninety percent of respondents reported formally dlscussmg the posslblhty of a tnal of labour wrth patients who had a previous cesarean section before the release of the Statement This increased to 97% after the Statement’s release In Survey 2 obstetnclans were asked if they had made any changes to their obstetric practice as a direct result of the Consensus Statement Thirty-four percent of the respondents reported changes, pnmanly m the direction of encouraging trial of labour As well, 34% indicated that there had been changes m the policies of their hospitals which encouraged trial of labour and vaginal birth after cesarean section Survey 3 also included detalled questions on the source(s) of mformatlon about the Consensus Statement Three quarters of the obstetnclans reported that they had a copy of the statement They had learned about the Consensus Statement from multiple sources the Society of Obstetnclans and Gynaecologlsts of Canada Bulletrn (94%), colleagues (56%) and the Canadian Medical Association Journal (52%) were the most frequently reported sources Survey 3 also assessed knowledge of the Statement’s basic recommendations In the case of breech presentation respondents were asked to identify which of four birth weight ranges had been recommended as safe for a planned vagmal delivery The questions relating to previous cesarean sectlon (with a low traverse scar and singleton vertex presentation) hsted four condltlons pertammg to the management of the antenatal period, labour and delivery For both previous cesarean section and breech presentation two of the statements were recommendations of the Consensus Conference and two were not (Table 4). Although over 90% of the obstetricians who were aware of the statement reported that they recalled its
&KIN
1286 Table 4 questrons
Knowledge of recommendatmns on the contents of the consensus datlons’
DOMNICK
responses to yes-no statement’s recommenPercentage of respondents COIWCllJ’ answenng knowledge test questton (A’ = 160)
“Inchcate whtch of the followmg actIons were recommended m the consensus statement” A Breech
F’mseatahon
Recommendation
of the Con.wnsus
Staremenr
*Planned vagmal d&very twth weight 1500-2500 g
m frank
breech
If
33
*Planned vagmal d&very buth we&t 2500-4000 g
m frank
breech
If
a9
Not
o Recommendarlon
of Ihe Con.wws
Stakvnenr
lPlanned
vagmal debvery birth weight < I500g
m frank
breech
If
a7
*Planned vagmal dehvery btrth uwght > 4000 g
m frank
breech
If
96
The set of 4 Statements about breech presentauon correctly ldentlfied as recommendations/ not recommendations of the Consensus Statement B. P~~~MXLSCeaareaa
Seehon
Recommendarron
of the Consensus
Tnal of labour sectIon
only after 1 prewous
.
. Antenatal
obstetrical
26
Smtement
cesarean
evaluation
72 77
Nor Recommendatrons m the Consensus Stotemem . Constant Obstetnclan attendance durmg tnal of labour for prewous cesarcan sewon
46
lElectromc
of
36
The set of 4 statements about Prewous Cesarean Se&on correctly ldentrfied as recommendations! not recommendanons of the Consensus Statement
9
Both sets of statements (total 8 statements) Correctly tdentrfied as recommendatlonsinot recommendations of the Consensus Statement
3
labour
fetal momtonng durmg for prewous cesarean secbon
‘See Appenchx
tnal
PIERRE
et d
m 1988 (Survey 5) were aware of the Consensus Statement, and 33% stated that hospital pohcy had changed m response to the Statement Just over one quarter of hospitals m both 1985/86 and 1988 had formal pohcles for breech presentation, but more hospitals had pohcles for the management of prevlous cesarean section 40% m 1985 and 46% m 1988 (Table 5) The policies appear to correspond to the recommendations of the Consensus Statement In 1985 9% of hospitals had a pohcy requlrmg a cesarean section for a breech presentation, and 24% for a previous cesarean section In 1988, 11% of the hospitals surveyed still mandated cesarean section for breech presentation, but only 15% required a cesarean section for a previous cesarean section More than one-fifth of the hospitals routinely transfer a woman with either a previous cesarean section or a breech presentation to a tertiary centre In response to a set of questions concernmg the ‘usual hospital reqmrements’ for permitting a tnal of labour, 17% of hospitals required the constant attendance of an obstetnclan and 72% required routme fetal momtonng As m the obstetnclan survey, these responses mdlcate a more conservative approach than that recommended by the Consensus Statement In keeping with the Statement’s recommendations. 83% of hospitals require an antenatal obstetric evaluation and 84% had anaesthesla available within 30mm However, the malonty of hospitals have no pohczes for previous cesarean section or breech presentation Neither lmphclt nor explicit policies inhibit the lmplementatlon of the Consensus Statement DISCUSSION
for actual Question
recommendations and over 90% agreed with these recommendations for both breech presentation and previous cesarean section, then detailed knowledge was lower then might have been expected Only 26% were able to answer all four questions for planned vaginal dehvery with breech presentation correctly Nme percent answered all four questions for previous cesarean section correctly Only 3% were able to answer all eight questions correctly (Table 4) The respondents erred m the dlrectlon of choosing more conservative measures than those included m the Consensus Statement For example, more than half opted for constant obstetric supervlslon and the use of fetal momtonng although neither were recommendatlons of the Consensus Statement
These data ldentlfy a number of differences which require interpretation Why IS there such discrepancy between responses to the hypothetical cases, reported behavlour and ObJectively measured behavlour? Why, despite the positive acceptance of the Consensus Statement’s recommendations, IS actual knowledge of the recommendations limited? It appears that obstetricians, faced with pressures to change will accept the intellectual rationale, while m practice they remam constrained by established patterns and behavlours The two hypothetical cases were clear and unambiguous (Appendix A) Not surpnsmgly, almost all of Table 5 Hospital
Breech
Formal
Preurous
3 Hosprtal polrcres The proportion of Ontario hospitals with formal pohcies for the management of breech presentation and previous cesarean section remained essentially the same after the release of the Consensus Statement Respondents m 79% of the hospitals surveyed
pohcy
Cesorean
Survey 5 I988 (%)
26
28
9 39 14
38 25
40
46
24 IO 29
15 I8 21
Anaesthesla
wthm
II
Secrron
pohcy
Nature of pohcy Ceqarean sectlo” required Consultation requred Transfer to tertiary centre
0’)
Survey 4 1985186 (%) Presenrarlon
Nature of pohcy Cesarean sectloo reqwred Consultatron reqwred Referral to tertury centre Formal
polues
30 mm
84
84
140
119
Obstetrical attitudes and practices regarding cesarean bn-th the obstetnclans surveyed chose to continue labour or offer a tnal of labour for both cases However, their reported practices mdlcated that they selected tnal of labour far less frequently This discrepancy may be explamed by the perceptlon that the pregnancles m their practices are more complex than the hypothetical cases Studies which have used hypothetical cases to estimate physlclan behavlour have concluded that there 1s little correlation between physlclan choices for hypothetical cases and their actual practices [6] Physlclans apparently view hypothetical cases as example of ‘the Ideal’ and their responses as answers to ‘test questions’ rather than as mdlcators of their practical choices The quality of care literature offers examples where physlclans ldentlfy acceptable standards of care for particular diseases (process cntena) but fall, m large part, to follow these standards m their own practices, although they are convmced that they have made modlficatlons or followed their predetermined cntena or standards [7,8] Physlclans are also convinced of the value of the medical and surgical treatments they provide A Cahforma study found that physlaans famlhes had higher surgical rates for common procedures than the famlhes of other comparable groups [9] Studies of physlclan responses to Consensus Statements developed m the United States also indicate the discrepancy between what physlclans say they do and what they actually do m their practices [lo] The failure of the obstetnclans reported tnal of labour rates to increase slgmficantly for breech presentation may be due to their lack of trammg and/or experience m dehvenng breech presentation patients vagmally Changes m residency trammg and effective ‘hands-on’ contmumg education would be necessary to increase obstetnclans ‘comfort level’ and competence On the other hand, they reported a slgmficant increase m the frequency with which tnal of labour was offered for previous cesarean sectlon, but this IS more a change m practrce style than a change to an unfamthar or infrequently used procedure However, m neither previous cesarean section nor breech presentation do the practices reported by the Companson Cohort match the actual data regarding cesarean section in Ontario In 1985 when obstetrlclans said they were offenng trial of labour to 60% of their previous cesarean section patients, 95% were being delivered by cesarean section In 1988, although the Comparison Cohort reported offering tnal of labour to 68% of previous cesarean section patients, the provmclal cesarean section rate for women with previous cesarean section had only decreased to 91% The hterature mdlcates that approximately twothirds of trials of labour for previous cesarean section will result m vaginal dehverles [ 111 If the women with previous cesarean section had actually been offered a trial of labour and If success was at the reported rate, the cesarean section rate m Ontario would have dropped by approximately one sixth This discrepancy may be explained by tnals of Iabour which are brief and inadequate, possibly due to the obstetnaans lack of confidence or the women’s anxiety and discomfort Obstetnclans may have also overstated the frequency with which they offered trial of labour This overstatement 1s not
1287
deliberate, It probably represents what the physlclans actually believed happened For many a tnal of labour will be a new and dehberately planned expenence and remembered more readily than a routme cesarean section. These factors point to the maJor problems associated with self reportmg respondents tend to overestimate what they perceive to be acceptable practice behavlour Although self reporting 1s not reliable quantitatively, rt may be useful m detectmg the presence or absence and the direction of trends The actual rate of cesarean sectlon for women with previous cesarean sectlon decreased four percentage points although the reported rate was down eight percentage points. The actual rate of cesarean section for women with breech presentation remained the same and higher than the reported rate but the reported rate, also remained unchanged The trend toward tnal of labour with previous cesarean section, may contmue and increase If attltude changes precede behavlour changes for previous cesarean section, but once behavlour changes begm they may progress rapidly [12] The dechne m tonslllectomles m the 1970’s m Canada encouraged by studies which challenged the necessity for the procedure, occurred at a more rapid rate than early data would have suggested Although most obstetnclans reported that they knew about the Consensus Statement and agreed with Its recommendations, their answers to specific questions regarding the Statements’s recommendations were frequently mcorrect Then answers (and their actual behanour) were more conservative than the recommendations of the Consensus Statement If obstetnclans believe that m order to perform a tnal of labour, they must be constantly m attendance durmg a woman’s labour (as over half of them did), practical Issues come mto play More physlclan time would be required to attend a tnal of labour than to perform an elective cesarean section This mconvemence and the addltlonal hours would, m a fee for service system, take obstetnclans away from other patients and potential earnmgs Perhaps, as has been suggested m Quebec, the fee for a tnal of labour should be greater than that for an elective cesarean section followmg a previous cesarean section The more conservative answers to the Consensus Statement questlons may be seen to predict the slow actual rate of decrease m cesarean section rates for women with previous cesarean section If so, regular reinforcement of the recommendations ~111be necessary to overcome the tendency to resist change because of established practices, peer pressure, and trammg and experience Resistance 1s also due, m part, to a growing concern regarding htlgatlon and malpractice In thrs regard, the recent recommendation of the Canadian Medical Protective Assocration about previous cesarean section should prove helpful In a recent Information Letter the Assoclatlon stated, “At the present time the Report of the Panel of the National Consensus Conference on Aspects of Cesarean Birth IS the bench-mark reference” [ 131 The Information Letter also clarifies and reinforces the Consensus Statement’s recommendations for previous cesarean section
KARIN DOMNICK PIERRE ef al
1288
Many obstetnclans have been condItIoned to beheve ‘once a cesarean-always a cesarean’ even though this belief 1s a vestige from the days when vertical utenne mclslons were used Although they may be mtellectually convinced that a tnal of labour 1s safe, sltuatlonal pressures such as concerns regardmg legal hablhty, a patlent’s anxiety or ambivalence, the mconvemence of a lengthy labour, peer pressure and general resistance to change may predispose obstetnclans to retam familiar patterns of behavlour There 1s no mdlcatlon that hospitals and their policies are deterrents to tnal of labour for previous cesarean sectlon or breech presentation Most hospltals do not have pohcles and, when pohcles exist, the vast majonty are not restnctlve However, unstated negative attitudes toward trial of labour m hospitals could be operating, even without stated pohaesheld by obstetnaans, obstetrical nurses or admmlstrators For the Statement’s recommendations to be translated mto lower rates such attitudes must be identified and confronted The attrtudes of women have not been adequately studled Anecdotal evidence and quahtatlve research findmgs suggest [14, 151 that some women prefer elective cesarean section to the potenttal discomfort of a tnal of labour, especially after a previous expenence with prolonged labour and eventual cesarean sectlon Negative attitudes of obstetnclans toward tnal of labour, fear of a falled tnal of labour or the mconvemence of a scheduled delivery have ail been reported as factors predlsposmg women to choose elective cesarean section Women also need to understand the recommendations of the Consensus Statement, d they are to make informed choices Acknowledgements-Thus research was supported by grants from the Physzczans’ Services Incorporated Foundation and the Nattonal Health Research and Development Program of Health and Welfare Canada
7
8
9
10
11 12
13 14 15
Hare R L and Bamoon S Medical care appraisal and quahty assurance m the office practzce of internal medzcme, San Franctsco Am Soczery znrern Med 138-141, July, 1973 Szbley J C , Spitzer W 0 , Rudmck K V , Bell J D , Bethune R D , Sackett D L and Wrzght K Quahty of care apprazsal m pnmary care a qualitative method Ann zntern Med 83, 46-52, 1975 Bunker J P and Brown B W The phystclan as an informed consumer of surgical services New Engl J Med 290, 1051-1055, 1974 Jacoby I The Consensus Development Program of the Natzonal Institutes of Health current practices and hzstoncal perspectives Inr J Tech Ass Hlth Care 2, 420-432, 1985 Hemmmkz E Pregnancy and birth after cesarean section Bzrrh 14, 12-17, 1987 Mmdell W R, Vayda E and Cordzllo B Ten year trends m Canada for selected operations Can Med Assn J 127, 23-21, 1982 Obstetncs Vagmal berth after cesarean section Can Med Proteczzve Assoc Informatzon Lert 4, l-2, 1989 Lzpson J G Repeat cesarean births Social and psychologzcal issues JOG Nurszng 13, 157-162, 1984 McClam C S Why women choose trial of labour or repeat cesarean section J Fumzly Pracrzce 21, 210-216. 1985 APPENDIX Hypozhetzcal
Cases Used zn Surveys
For each of the two hypothetical cases presented below, please mdzcate how you would manage the patient described by checkmg the appropriate space A 22 year old woman, para 1 gravzda 2. at 36 completed weeks gestatzon, has had an uneventful pregnancy to date The fetus zs m vertex presentatzon, average size for dates Her first dehvery was by lower segment cesarean section for breech presentation She would prefer a vagmal delivery on this occaszon Would
you permit
a trial labour
for this patlent?
OR
REFERENCES
Would Consensus Panel members, Consensus Conference Report Indzcatzons for cesarean section final statement of the panel of the NatIonal Consensus Conference on Aspects of cesarean berth Can Med Assn J 134, 1348-1352, 1986 Lomas J , Anderson G M , Enkm M W . Vayda E , Roberts R and MacKmnon B A The role of evidence m the consensus process J Am Med Assn 259, 3001-3005, 1988 Lomas J , Anderson G M . Domnzck Pierre K , Vayda E, Enkm M W and Hannah W J Do practice guidelines guide practice” N Engl J Med 321, 13061311, 1989 Barnsley J , Vayda E . Lomas J , Enkzn M . Domnzck Pierre K, Anderson G M and MacKmnon B A Cesarean section m Ontarzo practzce patterns and responses to hypothetical cases Can J Surg 33, 128-132, 1990 Lomas J , Enkm M W . Anderson G M , Hannah W J , Vayda E and Singer J Changing inappropriate surgzcal rates m communzty hospitals A randomized controlled trial of strategies to implement practice guidelines processed McMaster Unzverszty, p 16 plus tables and appendicrs Vayda E , Mmdell W R . Mueller C B and Yaffe B Measuring surgical deczszon makmg with hypothetical cases Can Med Assn J 127, 287-290, 1982
A
you schedule
her for elective cesarean?
L A 34 year old woman, para 1 gravzda 2, enters hospital zn active labour Her cervix IS 4 cm dzlated, membranes intact X-ray confirms the exammatzon findings of breech presentatzon and shows that zt IS a frank breech wzth well flexed head The fetus 1s average szze Her first baby weighed 71b and vaginal dehvery was uneventful Would
you allow this woman
to continue
zn labour”
OR Would
you schedule
her for an emergency
APPENDIX
cesarean
section?
B
Questzons on Self-Reported Behauour (Surveys I and 2) What proportion of breeches deliver by cesarean section
that you see at present
do you _%
What proportion of patients with previous cesarean that you see at present do you deliver by cesarean
sections section7 _%
Obstetrical attitudes and practices regardmg cesarean birth APPENDIX
C
QueStlons Testing Knowledge of Consensus Statement (Survey 2 and 3)
interested m your recollectlon of some of the Statement’s recommendations PLEASE CHECK EVERY ITEM THAT YOU RECALL AS BEING A RECOMMENDATION CONTAINED IN THE CONSENSUS STATEMENT
We are
the appropriate skdl and trammg of the attendmg physIcIan and no other comphcatmg factors, vagmal dehvery should be offered or recommended wth frank breech presentauon, when the estimated blrthwerght IS (CHECK ONLY THOSE THAT APPLY)
(a) Given
[ ] less than 1500 g
[ ] between 1500 and 2500 g [ ] between 2500 and 4000g [ ] greater than 400 g [ ] Do not recall (b) A trial of labour should be offered to all women with a low transverse previous cesarean sectron and smgleton vertex presentation, as long as
1289
(CHECK ONLY THOSE THAT APPLY)
[ ] an obstetnclan IS m constant physlcal attendance dunng labour [ ] there has been only one previous cesarean sectlon [ ] there IS contmuous electromc fetal momtonng [ ] there 1san antenatal evaluation by an obstetncran
[ ] Do not recall APPENDIX
D
Hosplral Medtcal Records Insrrrute
Each hospital m Ontano IS reqmred to complete a discharge summary for every discharged patlent The Hospital Medlcal Records Institute, an mdependent orgamzatlon, supported by the Ontano Mmlstry of Health, collects mformatlon from this document on dlagnosls, length of stay, outcome, procedures, transfusrons and medrcatlons and other variables The Institute prepares regular reports on mdlvldual physIclans, on services used, and on hospitals, as well as provedmg comparison data and reaonal summanes or special tabulations The vahdlty of the mformatlon 1s assessed by both the hospital and the Hospital MedIcal Records Institute
1991 Copynght
0
0277-9536/91 f3 00 + 0 00 1991 Pergamon Press plc
OBSTETRICAL ATTITUDES AND PRACTICES BEFORE AND AFTER THE CANADIAN CONSENSUS CONFERENCE STATEMENT ON CESAREAN BIRTH KARIN DOMNICK PIERRE,’EUGENEVAYDA,’
JONATHANLLAMAS,’ MURRAYW ENKIN,~ WALTERJ HANNAH?and GEOFFM ANDERSON~ ‘Department of Health Admmlstratron, Dlvlslon of Community Health, Faculty of Medicine, Umverslty of Toronto, Toronto, Ontano, Canada, *Department of Chmcal Epldenuology and Blostatlstlcs, Faculty of Medlcme, McMaster University, Hanulton, Ontano, Canada, ‘Department of Obstetncs and Gynaecology, Faculty of Medicme, McMaster Umverslty, Hamilton, Ontano, Canada, 4Department of Obstetncs and Gynaecology, Faculty of Medicine, Umverslty of Toronto, Toronto, Ontano, Canada and 5Dlvlslon of Health Sciences, Research and Development, University of Bntlsh Columbia, Vancouver, B C , Canada Abstract-This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section m Ontario for women with a previous cesarean section or a breech presentation Using data from multiple sources-surveys of obstetnaans, and hospital admmlstrators, and hospital record statlstlcs, the authors attempt to assess the response of obstetnclans to pressure to change then practice This pressure comes pnnclpally from the Canadian Consensus Conference Statement on Cesarean Birth, released m June 1986 and subsequently endorsed by a number of professional orgamzatlons The Statement provides clear guidelines for the management of labour m women with previous cesarean section or a breech presentation The findings present a number of mterpretlve challenges Based on their response to hypothetical cases obstetnclans are favourably disposed to consldenng a tnal of labour for women with previous cesarean section and breech presentation However, both their reported practices, as well as hospital statlstlcs indicate the continued high prevalence of cesarean section, though there 1s a small decline m cesareans for previous cesarean Section There was no evidence that hospitals lacked appropnate faclhtles for a tnal of labour or had unduly restricted formal policies Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questloned on the actual details of the recommendations, obstetnclan’s recall was surpnsmgly low Respondents tended to err m the direction of choosmg more conservative measures than those recommended by the Statement The authors consider several possible mterpretatlons for the differences physlclans perceptions of the complexity of their own cases compared to the hypothetical scenarios, dd?icultles encountered m lmplementmg new procedures such as trial of labour, the mhlbltmg effect of then conservative mterpretatlon of the Consensus Statement recommendations, convemence and income Issues, fear of htlgatlon, and, patient preferences Ke~j words-physician attitudes, physIcIan behavlour change, obstetnc previous cesarean sectlon, breech presentation
INTRODUCTION This paper reports on the survey component of a provmce-wide, multl-year proJect almed at modlfymg aspects of obstetnc practice m Ontarlo In the face of a growing controversy regarding mdlcatlons for cesarean section the mcreasmg Canadtan cesarean sectlon rate provided the Impetus for the 1985 Canadian Consensus Conference on Aspects of Cesarean Birth The Consensus Conference Statement developed and released m 1986 made defimtlve recommendations concerning the management of patients with previous cesarean section and breech presentation (11 To track obstetnaans attitudes, practice patterns, and reactions to the Statement we used both survey and hospital utlhzatlon data before and after the release of the Statement In addltlon, the research team implemented and evaluated mterventlon strategies aimed at modifymg physlclan behavlour and hospital policies The results of these studies have been reported elsewhere [2-4]
practice, hypothetical
cases,
In this paper we focus on the reported and actual practice styles of obstetnclans and their reactlons to the Consensus Statement We are prmclpally concerned with assessing what happens when physlclans are faced with pressures to change an estabhshed chmcal practice pressures which came from the Consensus Statement, Its endorsement by the Society of Obstetnclans and Gynaecologlsts of Canada and the Canadian Assoclatlon of Professors of Obstetncs and Gynaecology, and an mterventlon study The data highlight dlscrepancles between knowledge and practxe, both reported and actual, and allow us to ldentlfy some possible barriers to change m obstetric practices METHODS
Data for this study came from self-administered mailed surveys of Ontano obstetnaans* one before and two after the release of the 1986 Canadian Consensus Conference on Aspects of Cesarean Bxth.
1283
KAIUNDOMNICK
1284
In addltlon, pre and post Consensus Conference surveys of Ontano hospitals identified formal hospltal pohcles regarding previous cesarean section and breech presentation Ontano hospital discharge data from the Hospital Medical Records Institute from 1982 through 1988 provided data on the overall provmclal cesarean section rates and rates by specific diagnosis [3] (see Appendix) A summary of the timing, sample frame, content and response rate of each of the surveys 1s shown m Table 1 By using an mltlal and two follow-up mallmgs we achieved response rates greater than 74% m each of the five surveys Two separate sets of obstetnaan/gynaecologlst samples were selected from the mailing list of the Ontario Medical Assoclatlon The first (Survey 1) was a 40% random sample, drawn m 1985/86 It collected baseline mformatlon on pre-Consensus Conference attitudes and practices of obstetnclans regarding breech and previous cesarean section, using hypothetical cases and self reported data (See Appendix for actual questions ) The two hypothetical cases descnbmg an uncomplicated pregnancy with a breech presentation, and the other a routine pregnancy m a woman with one low traverse previous cesarean section, were developed m consultation with the Soc:ety of Obstetnclans and Gynaecologlsts of Canada and the Canadian Assoclatlon of Professors of Obstetncs and Gynaecology Details of these cases have been published elsewhere [4] In 1988, two years after the release of the Consensus Statement this group of obstetricians was resurveyed using the same hypothetical cases, and practice questions, but with new questions about awareness of the Consensus Statement and its impact on then practice (Survey 2) All physicians who practiced m any of Table Survey number and date
I
PIERRE er al
sixteen community hospitals involved m a concurrent study designed to evaluate the impact of different mterventlons on physicians behavlour [5], were excluded from the Survey 2 sample. In addition a 40% sample of new members (1 e since the 1986 survey) from the Ontano Medical Assoclatlon list was meluded A cohort of 93 obstetnaans/gynaecologlsts responded to both Surveys 1 and 2 (the Companson Cohort) Earlier, m 1987, a survey of all the obstetnclans (60%) not included m Survey 1 was conducted (Survey 3) This survey measured levels of awareness, sources of mformatlon, detailed knowledge and Impact of the Consensus Statement one year after its release These data were pnmanly used for companson with all 130 Survey 2 responses Surveys of all Ontario hospitals with obstetnc departments m 1985 and 1988 identified the extent and nature of pohcles for breech presentation and previous cesarean section Questlonnalres were sent to the Chiefs of Obstetncs In those hospitals where a Chief could not be identified, the Hospital Admmlstrator was asked to have the questionnaire completed by an appropnate member of the medical staff The 1988 resurvey of these hospitals also excluded the sixteen hospitals which were involved m the concurrent intervention study The number of hospitals m the 1988 survey was further reduced by hospital mergers, hospital closures or the closure of obstetnc departments FINDINGS
The charactenstlcs of the respondents to Surveys 1-3, and the Comparison Cohort are summarized m Table 2 The survey data compare obstetnaans
Summary
of surveys
Survey name
Sample
Questlo”
I 1985186
Obstetruan basehne survey
40% random sample of obstetrlclans I” OMA’
2 1988
Obstetnclan follow up survey
. respondents to 1985 survey . plus 40% sample of new OMA’ members . minus obstetruans I” mterventlon hospital?
l
3 1987
Obstetnua” awareness survey
4 1985
Hospital survey
5 1988
Hospital follow up survey
basehne
Respondents samples (response rate)
content
l
hypothetrcal cases l atutudes l reported practice
156/l92(81%) Comparison Cohort’ N = 93
hypothetlcal cases attitudes, l reported practice . awareness and Impact of CS
130/175 (74%) Comparison Cohort’ N = 93
60% of obstetrwdns on OMA’ hst not surveyed m 1985
. detaded awareness of CS’ l lmpdct of CS’ . sources of mformatlo”
160/200 (80%)
Ontario hospitals wth obstetrx facihtles
. pollcles l faclhtles
140/154(91%)
@as above . minus mterventlon hospitals’
.
120/122(98%)
l
pohcres . facacrhtles l awareness of CS’ l Impact of CS
‘Ontano Medvcal Assoclatlon (provmaal branch of the Canadian MedIcal Assoclatlon) ‘Sixteen commumty hospitals which were randomly selected to partupate I” a concurrent ‘Consensus Statement ‘Comparison Cohort -93 ehglble physlclans who responded to surveys I and 2
mterventlon
study
Obstetrical attitudes and practices regardmg cesarean bu-th Table 2 Charactenstxs
of samples
Companson’ Survey 1 Survey 2 Cohort (%) (%) (%) Sex Male Female
Survey 3 (%)
96 4
88 12
94 6
87 13
1960-1969 1970 o* later
42 31 27
31 28 41
38 30 32
31 41 28
Tramed m Canada
70
70
70
76
Commumty Hospital Teachmg Hospital
69 31
61 39
64 36
56 44
Mean number of dehvenes m previous 12 months
206
209
21612 2102
200
(156)
(130)
(93)
(160)
Year of from
graduorron
medrcol
school
1959 or earlter
Hospttol
@ihotron
(N)
attitudes and practices regardmg cesarean section at two points m time (Survey 1 and Survey 2), identify changes m hospital policies over trme and m response to the Consensus Statement (Survey 4 and Survey 5), and measure obstetnaans levels of awareness and knowledge of the Consensus Statement and Its impact on obstetnclans (Survey 2 and Survey 3) 1 Comparison Cohort The Companson Cohort of 93 obstetnclans was surveyed Just pnor to the completion of the Consensus Statement m late 1985/early 1986 and approxlmately two years after Its release m early 1988 (Table 3) Their responses to the breech presentation hypothetical case were unchanged over time 99% and then 97% chose to continue labour For the hypothetical previous cesarean section case there was also no slgmficant difference 89% chose a trial of labour m 1985 compared to 96% m 1988 Table 3 Comparrson cohort hypothetIca cases and reported attltudes and practice Survey 1 1985/86 (%)
Survey 2 1988 (%)
presentatton
Tnal of labour for HypothetIcal Case
99
97
% of patients wth breech prewntatlon delwered by cesarean section (Reported)
57
54
Cesarean Sectlon Rate for breech presentation’ m Ontario (Actual)’
69
69
of labour for Hypothetwl
Case
89
96
% of patients wth prewous cesarean sectton dehvered by cesarean sectlon (Reported)
68
60’
Cesarean SectIon Rate for prewous cesarean sectlon m Ontario (Actual)’
94
91
(93)
(93)
Trrrl
In 1985/86, the Companson Cohort reported that, on average, 57% of the women they saw mth a breech presentation were delivered by cesarean section and they reported almost no change m 1988 (54%) However, their practices for previous cesarean section had changed They reported that on average 68% of women with previous cesarean sectlon had repeat cesarean section m 1985/86, this average fell to 60% m 1988 (t = 2 86, P -=z0 05) However, actual Ontano hospital obstetrical data collected by the Hospital Medical Records Institute showed that m both 1985/1986 and 1988 69% of women with breech presentation were delivered by cesarean sectlon, but 94% of patients urlth previous cesarean sectlon were delivered by cesarean section m 1985/1986 and 91% m 1988 [3] 2 Consensus Statement
‘93 obstetnclans who responded to both Survey I and Survey 2 *Mean of responses of the Comparison Cohort to Surveys I and 2
Breech
1285
(N) ‘Hospital Medrcal Records lnstxtute data *P 5 0 05
awareness, knowledge and reported effect on practrce (comparuon of Survey 2 and Survey 3)
Awareness of the Consensus Statement and its recommendations was measured on two occasions the 1987 Awareness Survey (Survey 3) and the 1988 follow-up survey (Survey 2) In 1987 94% and m 1988 87% of obstetnclans reported that they were aware of the Consensus Statement and were m general agreement with Its overall recommendations. The impact of the Consensus Statement on reported obstetnc practices was measured somewhat differently m Surveys 3 and 2 In Survey 3 ninety percent of respondents reported formally dlscussmg the posslblhty of a tnal of labour wrth patients who had a previous cesarean section before the release of the Statement This increased to 97% after the Statement’s release In Survey 2 obstetnclans were asked if they had made any changes to their obstetric practice as a direct result of the Consensus Statement Thirty-four percent of the respondents reported changes, pnmanly m the direction of encouraging trial of labour As well, 34% indicated that there had been changes m the policies of their hospitals which encouraged trial of labour and vaginal birth after cesarean section Survey 3 also included detalled questions on the source(s) of mformatlon about the Consensus Statement Three quarters of the obstetnclans reported that they had a copy of the statement They had learned about the Consensus Statement from multiple sources the Society of Obstetnclans and Gynaecologlsts of Canada Bulletrn (94%), colleagues (56%) and the Canadian Medical Association Journal (52%) were the most frequently reported sources Survey 3 also assessed knowledge of the Statement’s basic recommendations In the case of breech presentation respondents were asked to identify which of four birth weight ranges had been recommended as safe for a planned vagmal delivery The questions relating to previous cesarean sectlon (with a low traverse scar and singleton vertex presentation) hsted four condltlons pertammg to the management of the antenatal period, labour and delivery For both previous cesarean section and breech presentation two of the statements were recommendations of the Consensus Conference and two were not (Table 4). Although over 90% of the obstetricians who were aware of the statement reported that they recalled its
&KIN
1286 Table 4 questrons
Knowledge of recommendatmns on the contents of the consensus datlons’
DOMNICK
responses to yes-no statement’s recommenPercentage of respondents COIWCllJ’ answenng knowledge test questton (A’ = 160)
“Inchcate whtch of the followmg actIons were recommended m the consensus statement” A Breech
F’mseatahon
Recommendation
of the Con.wnsus
Staremenr
*Planned vagmal d&very twth weight 1500-2500 g
m frank
breech
If
33
*Planned vagmal d&very buth we&t 2500-4000 g
m frank
breech
If
a9
Not
o Recommendarlon
of Ihe Con.wws
Stakvnenr
lPlanned
vagmal debvery birth weight < I500g
m frank
breech
If
a7
*Planned vagmal dehvery btrth uwght > 4000 g
m frank
breech
If
96
The set of 4 Statements about breech presentauon correctly ldentlfied as recommendations/ not recommendations of the Consensus Statement B. P~~~MXLSCeaareaa
Seehon
Recommendarron
of the Consensus
Tnal of labour sectIon
only after 1 prewous
.
. Antenatal
obstetrical
26
Smtement
cesarean
evaluation
72 77
Nor Recommendatrons m the Consensus Stotemem . Constant Obstetnclan attendance durmg tnal of labour for prewous cesarcan sewon
46
lElectromc
of
36
The set of 4 statements about Prewous Cesarean Se&on correctly ldentrfied as recommendations! not recommendanons of the Consensus Statement
9
Both sets of statements (total 8 statements) Correctly tdentrfied as recommendatlonsinot recommendations of the Consensus Statement
3
labour
fetal momtonng durmg for prewous cesarean secbon
‘See Appenchx
tnal
PIERRE
et d
m 1988 (Survey 5) were aware of the Consensus Statement, and 33% stated that hospital pohcy had changed m response to the Statement Just over one quarter of hospitals m both 1985/86 and 1988 had formal pohcles for breech presentation, but more hospitals had pohcles for the management of prevlous cesarean section 40% m 1985 and 46% m 1988 (Table 5) The policies appear to correspond to the recommendations of the Consensus Statement In 1985 9% of hospitals had a pohcy requlrmg a cesarean section for a breech presentation, and 24% for a previous cesarean section In 1988, 11% of the hospitals surveyed still mandated cesarean section for breech presentation, but only 15% required a cesarean section for a previous cesarean section More than one-fifth of the hospitals routinely transfer a woman with either a previous cesarean section or a breech presentation to a tertiary centre In response to a set of questions concernmg the ‘usual hospital reqmrements’ for permitting a tnal of labour, 17% of hospitals required the constant attendance of an obstetnclan and 72% required routme fetal momtonng As m the obstetnclan survey, these responses mdlcate a more conservative approach than that recommended by the Consensus Statement In keeping with the Statement’s recommendations. 83% of hospitals require an antenatal obstetric evaluation and 84% had anaesthesla available within 30mm However, the malonty of hospitals have no pohczes for previous cesarean section or breech presentation Neither lmphclt nor explicit policies inhibit the lmplementatlon of the Consensus Statement DISCUSSION
for actual Question
recommendations and over 90% agreed with these recommendations for both breech presentation and previous cesarean section, then detailed knowledge was lower then might have been expected Only 26% were able to answer all four questions for planned vaginal dehvery with breech presentation correctly Nme percent answered all four questions for previous cesarean section correctly Only 3% were able to answer all eight questions correctly (Table 4) The respondents erred m the dlrectlon of choosing more conservative measures than those included m the Consensus Statement For example, more than half opted for constant obstetric supervlslon and the use of fetal momtonng although neither were recommendatlons of the Consensus Statement
These data ldentlfy a number of differences which require interpretation Why IS there such discrepancy between responses to the hypothetical cases, reported behavlour and ObJectively measured behavlour? Why, despite the positive acceptance of the Consensus Statement’s recommendations, IS actual knowledge of the recommendations limited? It appears that obstetricians, faced with pressures to change will accept the intellectual rationale, while m practice they remam constrained by established patterns and behavlours The two hypothetical cases were clear and unambiguous (Appendix A) Not surpnsmgly, almost all of Table 5 Hospital
Breech
Formal
Preurous
3 Hosprtal polrcres The proportion of Ontario hospitals with formal pohcies for the management of breech presentation and previous cesarean section remained essentially the same after the release of the Consensus Statement Respondents m 79% of the hospitals surveyed
pohcy
Cesorean
Survey 5 I988 (%)
26
28
9 39 14
38 25
40
46
24 IO 29
15 I8 21
Anaesthesla
wthm
II
Secrron
pohcy
Nature of pohcy Ceqarean sectlo” required Consultation requred Transfer to tertiary centre
0’)
Survey 4 1985186 (%) Presenrarlon
Nature of pohcy Cesarean sectloo reqwred Consultatron reqwred Referral to tertury centre Formal
polues
30 mm
84
84
140
119
Obstetrical attitudes and practices regarding cesarean bn-th the obstetnclans surveyed chose to continue labour or offer a tnal of labour for both cases However, their reported practices mdlcated that they selected tnal of labour far less frequently This discrepancy may be explamed by the perceptlon that the pregnancles m their practices are more complex than the hypothetical cases Studies which have used hypothetical cases to estimate physlclan behavlour have concluded that there 1s little correlation between physlclan choices for hypothetical cases and their actual practices [6] Physlclans apparently view hypothetical cases as example of ‘the Ideal’ and their responses as answers to ‘test questions’ rather than as mdlcators of their practical choices The quality of care literature offers examples where physlclans ldentlfy acceptable standards of care for particular diseases (process cntena) but fall, m large part, to follow these standards m their own practices, although they are convmced that they have made modlficatlons or followed their predetermined cntena or standards [7,8] Physlclans are also convinced of the value of the medical and surgical treatments they provide A Cahforma study found that physlaans famlhes had higher surgical rates for common procedures than the famlhes of other comparable groups [9] Studies of physlclan responses to Consensus Statements developed m the United States also indicate the discrepancy between what physlclans say they do and what they actually do m their practices [lo] The failure of the obstetnclans reported tnal of labour rates to increase slgmficantly for breech presentation may be due to their lack of trammg and/or experience m dehvenng breech presentation patients vagmally Changes m residency trammg and effective ‘hands-on’ contmumg education would be necessary to increase obstetnclans ‘comfort level’ and competence On the other hand, they reported a slgmficant increase m the frequency with which tnal of labour was offered for previous cesarean sectlon, but this IS more a change m practrce style than a change to an unfamthar or infrequently used procedure However, m neither previous cesarean section nor breech presentation do the practices reported by the Companson Cohort match the actual data regarding cesarean section in Ontario In 1985 when obstetrlclans said they were offenng trial of labour to 60% of their previous cesarean section patients, 95% were being delivered by cesarean section In 1988, although the Comparison Cohort reported offering tnal of labour to 68% of previous cesarean section patients, the provmclal cesarean section rate for women with previous cesarean section had only decreased to 91% The hterature mdlcates that approximately twothirds of trials of labour for previous cesarean section will result m vaginal dehverles [ 111 If the women with previous cesarean section had actually been offered a trial of labour and If success was at the reported rate, the cesarean section rate m Ontario would have dropped by approximately one sixth This discrepancy may be explained by tnals of Iabour which are brief and inadequate, possibly due to the obstetnaans lack of confidence or the women’s anxiety and discomfort Obstetnclans may have also overstated the frequency with which they offered trial of labour This overstatement 1s not
1287
deliberate, It probably represents what the physlclans actually believed happened For many a tnal of labour will be a new and dehberately planned expenence and remembered more readily than a routme cesarean section. These factors point to the maJor problems associated with self reportmg respondents tend to overestimate what they perceive to be acceptable practice behavlour Although self reporting 1s not reliable quantitatively, rt may be useful m detectmg the presence or absence and the direction of trends The actual rate of cesarean sectlon for women with previous cesarean sectlon decreased four percentage points although the reported rate was down eight percentage points. The actual rate of cesarean section for women with breech presentation remained the same and higher than the reported rate but the reported rate, also remained unchanged The trend toward tnal of labour with previous cesarean section, may contmue and increase If attltude changes precede behavlour changes for previous cesarean section, but once behavlour changes begm they may progress rapidly [12] The dechne m tonslllectomles m the 1970’s m Canada encouraged by studies which challenged the necessity for the procedure, occurred at a more rapid rate than early data would have suggested Although most obstetnclans reported that they knew about the Consensus Statement and agreed with Its recommendations, their answers to specific questions regarding the Statements’s recommendations were frequently mcorrect Then answers (and their actual behanour) were more conservative than the recommendations of the Consensus Statement If obstetnclans believe that m order to perform a tnal of labour, they must be constantly m attendance durmg a woman’s labour (as over half of them did), practical Issues come mto play More physlclan time would be required to attend a tnal of labour than to perform an elective cesarean section This mconvemence and the addltlonal hours would, m a fee for service system, take obstetnclans away from other patients and potential earnmgs Perhaps, as has been suggested m Quebec, the fee for a tnal of labour should be greater than that for an elective cesarean section followmg a previous cesarean section The more conservative answers to the Consensus Statement questlons may be seen to predict the slow actual rate of decrease m cesarean section rates for women with previous cesarean section If so, regular reinforcement of the recommendations ~111be necessary to overcome the tendency to resist change because of established practices, peer pressure, and trammg and experience Resistance 1s also due, m part, to a growing concern regarding htlgatlon and malpractice In thrs regard, the recent recommendation of the Canadian Medical Protective Assocration about previous cesarean section should prove helpful In a recent Information Letter the Assoclatlon stated, “At the present time the Report of the Panel of the National Consensus Conference on Aspects of Cesarean Birth IS the bench-mark reference” [ 131 The Information Letter also clarifies and reinforces the Consensus Statement’s recommendations for previous cesarean section
KARIN DOMNICK PIERRE ef al
1288
Many obstetnclans have been condItIoned to beheve ‘once a cesarean-always a cesarean’ even though this belief 1s a vestige from the days when vertical utenne mclslons were used Although they may be mtellectually convinced that a tnal of labour 1s safe, sltuatlonal pressures such as concerns regardmg legal hablhty, a patlent’s anxiety or ambivalence, the mconvemence of a lengthy labour, peer pressure and general resistance to change may predispose obstetnclans to retam familiar patterns of behavlour There 1s no mdlcatlon that hospitals and their policies are deterrents to tnal of labour for previous cesarean sectlon or breech presentation Most hospltals do not have pohcles and, when pohcles exist, the vast majonty are not restnctlve However, unstated negative attitudes toward trial of labour m hospitals could be operating, even without stated pohaesheld by obstetnaans, obstetrical nurses or admmlstrators For the Statement’s recommendations to be translated mto lower rates such attitudes must be identified and confronted The attrtudes of women have not been adequately studled Anecdotal evidence and quahtatlve research findmgs suggest [14, 151 that some women prefer elective cesarean section to the potenttal discomfort of a tnal of labour, especially after a previous expenence with prolonged labour and eventual cesarean sectlon Negative attitudes of obstetnclans toward tnal of labour, fear of a falled tnal of labour or the mconvemence of a scheduled delivery have ail been reported as factors predlsposmg women to choose elective cesarean section Women also need to understand the recommendations of the Consensus Statement, d they are to make informed choices Acknowledgements-Thus research was supported by grants from the Physzczans’ Services Incorporated Foundation and the Nattonal Health Research and Development Program of Health and Welfare Canada
7
8
9
10
11 12
13 14 15
Hare R L and Bamoon S Medical care appraisal and quahty assurance m the office practzce of internal medzcme, San Franctsco Am Soczery znrern Med 138-141, July, 1973 Szbley J C , Spitzer W 0 , Rudmck K V , Bell J D , Bethune R D , Sackett D L and Wrzght K Quahty of care apprazsal m pnmary care a qualitative method Ann zntern Med 83, 46-52, 1975 Bunker J P and Brown B W The phystclan as an informed consumer of surgical services New Engl J Med 290, 1051-1055, 1974 Jacoby I The Consensus Development Program of the Natzonal Institutes of Health current practices and hzstoncal perspectives Inr J Tech Ass Hlth Care 2, 420-432, 1985 Hemmmkz E Pregnancy and birth after cesarean section Bzrrh 14, 12-17, 1987 Mmdell W R, Vayda E and Cordzllo B Ten year trends m Canada for selected operations Can Med Assn J 127, 23-21, 1982 Obstetncs Vagmal berth after cesarean section Can Med Proteczzve Assoc Informatzon Lert 4, l-2, 1989 Lzpson J G Repeat cesarean births Social and psychologzcal issues JOG Nurszng 13, 157-162, 1984 McClam C S Why women choose trial of labour or repeat cesarean section J Fumzly Pracrzce 21, 210-216. 1985 APPENDIX Hypozhetzcal
Cases Used zn Surveys
For each of the two hypothetical cases presented below, please mdzcate how you would manage the patient described by checkmg the appropriate space A 22 year old woman, para 1 gravzda 2. at 36 completed weeks gestatzon, has had an uneventful pregnancy to date The fetus zs m vertex presentatzon, average size for dates Her first dehvery was by lower segment cesarean section for breech presentation She would prefer a vagmal delivery on this occaszon Would
you permit
a trial labour
for this patlent?
OR
REFERENCES
Would Consensus Panel members, Consensus Conference Report Indzcatzons for cesarean section final statement of the panel of the NatIonal Consensus Conference on Aspects of cesarean berth Can Med Assn J 134, 1348-1352, 1986 Lomas J , Anderson G M , Enkm M W . Vayda E , Roberts R and MacKmnon B A The role of evidence m the consensus process J Am Med Assn 259, 3001-3005, 1988 Lomas J , Anderson G M . Domnzck Pierre K , Vayda E, Enkm M W and Hannah W J Do practice guidelines guide practice” N Engl J Med 321, 13061311, 1989 Barnsley J , Vayda E . Lomas J , Enkzn M . Domnzck Pierre K, Anderson G M and MacKmnon B A Cesarean section m Ontarzo practzce patterns and responses to hypothetical cases Can J Surg 33, 128-132, 1990 Lomas J , Enkm M W . Anderson G M , Hannah W J , Vayda E and Singer J Changing inappropriate surgzcal rates m communzty hospitals A randomized controlled trial of strategies to implement practice guidelines processed McMaster Unzverszty, p 16 plus tables and appendicrs Vayda E , Mmdell W R . Mueller C B and Yaffe B Measuring surgical deczszon makmg with hypothetical cases Can Med Assn J 127, 287-290, 1982
A
you schedule
her for elective cesarean?
L A 34 year old woman, para 1 gravzda 2, enters hospital zn active labour Her cervix IS 4 cm dzlated, membranes intact X-ray confirms the exammatzon findings of breech presentatzon and shows that zt IS a frank breech wzth well flexed head The fetus 1s average szze Her first baby weighed 71b and vaginal dehvery was uneventful Would
you allow this woman
to continue
zn labour”
OR Would
you schedule
her for an emergency
APPENDIX
cesarean
section?
B
Questzons on Self-Reported Behauour (Surveys I and 2) What proportion of breeches deliver by cesarean section
that you see at present
do you _%
What proportion of patients with previous cesarean that you see at present do you deliver by cesarean
sections section7 _%
Obstetrical attitudes and practices regardmg cesarean birth APPENDIX
C
QueStlons Testing Knowledge of Consensus Statement (Survey 2 and 3)
interested m your recollectlon of some of the Statement’s recommendations PLEASE CHECK EVERY ITEM THAT YOU RECALL AS BEING A RECOMMENDATION CONTAINED IN THE CONSENSUS STATEMENT
We are
the appropriate skdl and trammg of the attendmg physIcIan and no other comphcatmg factors, vagmal dehvery should be offered or recommended wth frank breech presentauon, when the estimated blrthwerght IS (CHECK ONLY THOSE THAT APPLY)
(a) Given
[ ] less than 1500 g
[ ] between 1500 and 2500 g [ ] between 2500 and 4000g [ ] greater than 400 g [ ] Do not recall (b) A trial of labour should be offered to all women with a low transverse previous cesarean sectron and smgleton vertex presentation, as long as
1289
(CHECK ONLY THOSE THAT APPLY)
[ ] an obstetnclan IS m constant physlcal attendance dunng labour [ ] there has been only one previous cesarean sectlon [ ] there IS contmuous electromc fetal momtonng [ ] there 1san antenatal evaluation by an obstetncran
[ ] Do not recall APPENDIX
D
Hosplral Medtcal Records Insrrrute
Each hospital m Ontano IS reqmred to complete a discharge summary for every discharged patlent The Hospital Medlcal Records Institute, an mdependent orgamzatlon, supported by the Ontano Mmlstry of Health, collects mformatlon from this document on dlagnosls, length of stay, outcome, procedures, transfusrons and medrcatlons and other variables The Institute prepares regular reports on mdlvldual physIclans, on services used, and on hospitals, as well as provedmg comparison data and reaonal summanes or special tabulations The vahdlty of the mformatlon 1s assessed by both the hospital and the Hospital MedIcal Records Institute
