Your Care Provider's Attitude About Birth Increases C-section Chance, Study Says

Does your attitude about food ingredients influence what you buy on your weekly grocery shopping trip (organic or standard, carbs, vegetarian or meat, natural, low fat, etc.)? Of course it does! Well, what if you could get an inside look into your doctor/midwife/practitioner's attitude and views on vaginal birth vs. c-section? Do you think that could influence your care and outcome in labor and birth?

A new study published in BMC Pregnancy & Childbirth says yes.

Researchers collected survey data from a random sample of 209 maternal care providers in California, including maternal fetal medicine physicians (MFM), obstetricians (OB), family medicine physicians, certified nurse midwives (CNM), and licensed midwives (LM). The birth attitudes survey (used and validated by a prior study in 2009) looked at six different areas that were most likely to affect whether or not a first-time parent carrying only one baby at term and who presented at birth in the head-down position (otherwise known as "nulliparous, term, singleton, vertex" or NTSV), would end up having a cesarean.

The six questionnaire topics were:

• attitudes regarding use of electronic fetal monitoring
• factors that increase cesarean rates
• fears of birth mode by respondents or their partners/spouses
• factors that decrease cesarean rates
• maternal choice and mothers' roles in birth
• safety by mode or place of birth

Doctors and midwives who scored low on the scale of questions were classified as more in favor of vaginal birth. Those who scored high were marked as more in favor of cesarean birth.

What researchers found -- perhaps not surprising, considering my crude grocery store example -- was that those who scored high or more in favor of c-section, also had higher rates of performing NTSV c-sections. In other words, their attitudes correlated with how they practiced and the resulting outcomes. This is in spite of current evidence and best practices research that says a lower c-section rate is better and healthier for families. Currently in the United States, the c-section rate is 31.9%, or 1 in 3, and some hospitals have a c-section rate as high as 69%! The Healthy People 2020 (a U.S. government health initiative) has set the c-section rate goal of 23.9%, and the World Health Organization (WHO) recommends a country's cesarean rate not exceed 15%.

Graph image source: BMC Pregnancy & Childbirth

In taking a closer look at the study's results by the type of care provider who responded, researchers founds that attitudes varied widely. On the lowest end of the scale (those whose attitudes favored vaginal birth) were licensed midwives, followed closely by certified nurse midwives or CNMs. Highest on the scale (those whose attitudes favored cesarean birth) were OBs. Family medicine physicians fell somewhere between midwives and OBs, or aligned more closely with midwives. Maternal fetal medicine physicians were similar to low-risk OBs, or fell between OBs and family medicine physicians. Researchers were most surprised to find that OBs had the widest ranging attitudes, the bottom range of which aligned with midwives all the way up to those who were more pro-cesarean than maternal fetal medicine physicians.

So what does this all mean for you -- why are these findings important? This one line in the study sums it up nicely:

"These findings suggest that a provider's underlying attitudes, values, and beliefs play an important role in intrapartum [childbirth] decisions that ultimately affect birth outcomes."

If your care provider's attitudes, values, and beliefs play a big role in what kind of birth you will end up with, then it makes sense for you to do all that you can to learn about your doctor or midwife long before you encounter their care in childbirth. What that means is ask questions -- lots of them and often. It's ideal to make an appointment with a prospective provider before beginning your prenatal care (referred to as a consultation appointment or interview), and start with a list of questions that will better inform you of your provider's stance on birth practices that support either vaginal birth or cesarean birth.

It also helps to find out their NTSV cesarean rate. If you're already under the care of a midwife or doctor, it's almost never too late to start asking questions -- and perhaps make a change.

The kind of care your receive in birth matters. Cesarean can be life-saving, of course. But when it's over-used and used unnecessarily, it poses dangerous risks for parents and babies. Until we can get all practitioners on board with what is best and safest for families, including a lower c-section rate, the best thing you can do is to learn about best practices in birth and choose your care provider wisely. Taking an early pregnancy class or pre-pregnancy class can help you learn more about birth choices and choose a better care provider earlier on. Taking a good childbirth class later in pregnancy can help you determine if the care provider you have will serve you best in childbirth -- and what to do if you are considering making a switch.