.Soc SCI Med Vol 32, No 1 I, pp 1283-1289, 1991 Pnntcd m Great Bntam All nghts reserved 0277-9536/91 f3 00 + 0 00 Copynght 0 1991 Pergamon Press plc OBSTETRICAL ATTITUDES AND PRACTICES BEFORE AND AFTER THE CANADIAN CONSENSUS CONFERENCE STATEMENT ON CESAREAN BIRTH zyxwvutsrqponmlkji KARIN DOMNICK PIERRE,’EUGENE VAYDA,’ JONATHAN LLAMAS,’ MURRAY W ENKIN,~ WALTER J 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 practice, hypothetical cases, 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 ce- sarean section the mcreasmg Canadtan cesarean sec- tlon 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 strat- egies aimed at modifymg physlclan behavlour and hospital policies The results of these studies have been reported elsewhere [2-4] In this paper we focus on the reported and actual practice styles of obstetnclans and their reactlons to the Consensus Statement We are prmclpally con- cerned 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