Obstetrical attitudes and practices before and after the Canadian consensus conference statement on cesarean birth

This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section in Ontario for women with a previous cesarean section or a breech presentatio. Using data from multiple sources--surveys of obstetricians, and hospital administrators, and hospital record statistics, the authors attempt to assess the response of obstetricians to pressure to change their practice. This pressure comes principally from the Canadian Consensus Conference Statement on Cesarean Birth, released in June 1986 and subsequently endorsed by a number of professional organizations. The Statement provides clear guidelines for the management of labour in women with previous cesarean section or a breech presentation. The findings present a number of interpretive challenges. Based on their response to hypothetical cases obstetricians are favourably disposed to considering a trial of labour for women with previous cesarean section and breech presentation. However, both their reported practices, as well as hospital statistics indicate the continued high prevalence of cesarean section, though there is a small decline in cesareans for previous cesarean section. There was no evidence that hospitals lacked appropriate facilities for a trial of labour or had unduly restricted formal policies. Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questioned on the actual details of the recommendations, obstetrician's recall was surprisingly low. Respondents tended to err in the direction of choosing more conservative measures than those recommended by the Statement. The authors consider several possible interpretations for the differences: physicians perceptions of the complexity of their own cases compared to the hypothetical scenarios; difficulties encountered in implementing new procedures such as trial of labour; the inhibiting effect of their conservative interpretation of the Consensus Statement recommendations; convenience and income issues; fear of litigation; and, patient preferences.