Reviewer's report
Title:The facilitating factors and barriers encountered in the adoption of a
humanized birth care approach in a highly specialized university affiliated
hospital
Version: 1Date:2 June 2011
Reviewer: Michael C Klein
Reviewer's report:
Minor essential:
1. An important paper that needs further information as to context of the
hospital.This is obviously St. Justine Hospital in Montreal. The concept of
humanization of care is a direct translation from the French. It is a term not used
in the rest of Canada, where the closest thing to the concept is Family-Centered
Maternity Care.This difference ought to be explained. In the paper the concepts
are discussed as different.
2. In order for the reader to understand the context the authors ought to provide
the cesarean section rate for the hospital
3. Ought to provide the reality that, while the hospital is highly specialized, I
speculate that only at most 20% of the patients are at high risk. The rest are just
women who use the hospital for normal birth
4. Hence, there is little reason for the concepts to be limited to high risk or tertiary
care environments. The issue of generalizability does need to be addressed due
to the nature of the hospital, but there are many hospitals that care for a mix of
high and low risk patients--including level II facilities.
5. It would be helpful therefore to know what proportion of the women considered
themselves to be high risk or members of the community who used the facility
because of its proximity, reputation, available services, fears etc
6. I am surprised that the authors have not considered the attitudes and beliefs of
the staff to be barriers to optimal care, especially as one of the coauthors is an
author and co-investigator on this paper. I fact it is likely that attitudes of the staff
toward childbirth, and the way they see birth as inherently dangerous, may be the
greatest barrier to humanized care or truly family-centred care.
See Klein et al JOGC 2009 re attudes and beliefs of providers
The Attitudes of Canadian Maternity Care
Practitioners Towards Labour and Birth:
Many Differences but Important Similarities
Michael C. Klein, MD,1,2,3 Janusz Kaczorowski, PhD,1,2 Wendy A. Hall, RN,
PhD,4 William Fraser, MD, MSc,5 Robert M. Liston, MB, ChB,6 Sahba Eftekhary,
MD, MPH,7 Rollin Brant, PhD,1,8 Louise C. Ma#sse, PhD,1,3 Jessica Rosinski,
MA,9 Azar Mehrabadi, MSc,10 Nazli Baradaran, MD,1 Jocelyn Tomkinson,
BSc,1 Sharon Dore, RN, PhD,11 Patricia C. McNiven, RM, PhD,12 Lee Saxell,
RM, MA,13 Kathie Lindstrom, CD, LCCE,14 Jalana Grant, CD, LCCE,15 Aoife
Chamberlaine, BA16 1Developmental Neuroscience and Child Health, Child and
Family Research Institute, University of British Columbia, Vancouver BC
2Department of Family Practice, University of British Columbia, Vancouver BC
3Department of Pediatrics, University of British Columbia, Vancouver BC
4School of Nursing, University of British Columbia, Vancouver BC 5Department
of Obstetrics and Gynecology, Universite# de Montre#al, Montreal QC
6Department of Obstetrics and Gynaecology, University of British Columbia,
Vancouver BC 7Ministry of Health and Long Term Care, Government of Ontario,
Toronto ON 8Department of Statistics, University of British Columbia, Vancouver
BC 9Department of Political Science, University of British Columbia, Vancouver
BC 10School of Population and Public Health, University of British Columbia,
Vancouver BC 11Hamilton Health Sciences, Hamilton ON 12Midwifery Education
Program, Department of Family Practice, McMaster University, Hamilton ON
13Department of Midwifery, BC Women’s Hospital and Health Centre and St.
Paul’s Hospital, Vancouver BC 14Perinatal Program, Faculty of Health Sciences,
Douglas College, New Westminster BC 15South Community Birth Program,
Vancouver BC 16Midwifery Education Program, Ryerson University, Toronto ON
Abstract
Objective: Collaborative, interdisciplinary care models have the potential to
improve maternity care. Differing attitudes of maternity care providers may
impede this process. We sought to examine the attitudes of Canadian maternity
care practitioners towards labour and birth.
Methods: We performed a cross-sectional web- and paper-based survey of 549
obstetricians, 897 family physicians (400 antepartum only, 497 intrapartum), 545
nurses, 400 midwives, and 192 doulas.
Results: Participants responded to 43 Likert-type attitudinal questions. Nine
themes were identified: electronic fetal monitoring, epidural analgesia,
episiotomy, doula roles, Caesarean section benefits, factors decreasing
Caesarean section rates, maternal choice, fear of vaginal birth, and safety of
birth mode and place. Obstetrician scores reflected positive attitudes towards use
of technology, in contrast to midwives’ and doulas’ scores. Family physicians
providing only antenatal care had attitudinal scores similar to obstetricians; family
physicians practising intrapartum care and nurses had intermediate scores on
technology. Obstetricians’ scores indicated that they had the least positive
attitudes towards home birth, women’s roles in their own births, and doula care,
and they were the most concerned about the consequences of vaginal birth.
Midwives’ and doulas’ scores reflected opposing views on these issues. Although
71% of obstetricians supported regulated midwifery, 88.9% were against home
birth. Substantial numbers of each group held attitudes similar to dominant
attitudes from other disciplines.
Conclusion: To develop effective team practice, efforts to reconcile differing
attitudes towards labour and birth are needed. However, the overlap in attitudes
between disciplines holds promise for a basis upon which to begin shared
problem solving and collaboration.
Key Words: Labour, natural childbirth, attitudes of health personnel, Caesarean
section, evidence-based medicine, epidural, midwifery, home birth, episiotomy
Competing Interests: None declared. Received on April 2, 2009 Accepted on
May 19, 2009
SEPTEMBER JOGC SEPTEMBRE 2009
and Klein et al Birth Attitudes of the New Generation of Canadian Obstetricians:
How Do They Differ from Their Predecessors?
Michael C. Klein, MD, FCFP, FAAP, Robert Liston, MB, ChB, FRCSC, FRCOG,
William D. Fraser, MD, MSc, FRCPC, Nazli Baradaran, MD, Stephen J. C.
Hearps, BPsyc, PGDipPsyc, Jocelyn Tomkinson, BSc, Janusz Kaczorowski,
PhD, Rollin Brant, PhD, and The Maternity Care Research Group
ABSTRACT: Background: Attitudes drive practice, perhaps more than evidence.
The objective of this study was to determine if the new generation of Canadian
obstetricians has attitudes differing from those of their predecessors. Methods:
Employing a cross-sectional, Internet, and paper-based survey, we conducted an
in-depth study of obstetricians responding to the Canadian National Maternity
Care Attitudes Survey. Results: Of the 800 Canadian obstetricians providing
intrapartum care, 549 (68.6%) responded. Participants were stratified by age less
than or equal to 40 years compared with those over 40 years; 81 percent of
those 40 years or younger were women versus 40 percent over 40 years of age.
Younger obstetricians were significantly more likely to favor use of routine
epidural analgesia and believed that it did not interfere with labor or lead to
instrumentation; were more concerned and feared the perineal and pelvic floor
consequences of vaginal birth compared with cesarean section; and were
significantly less supportive of vaginal birth after prior cesarean section, home
birth, birth plans, routine episiotomy, and routine electronic fetal monitoring as
providing maternal or fetal benefits. They were less positive than the older
generation about a range of approaches to reducing the cesarean section rate,
the importance of maternal choice and role in their own birth, and peer review,
and they were more likely to believe that women having a cesarean section were
not missing an important experience. No significant generational differences
were found for ambivalent attitudes to vaginal breech birth. Conclusions:
Younger obstetricians were more evidence-based for some issues and less for
others. In general younger obstetricians were more supportive of the role of birth
technology in normal birth, including routine epidural analgesia, and they were
less appreciative of the role of women in their own birth. They saw cesarean
section as a solution to many perceived labor and birth problems. Results
suggest a need to examine how obstetricians acquire their favorable attitudes to
birth technology in normal birth. (BIRTH 38:2 June 2011)
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.