VIEWS OF OBSTETRICIANS AND PHYSIOTHERAPISTS ON ANTE-NATAL PREPARATION FOR CHILDBIRTH B Fish, B Chalmers and D Meyer* SUMMARY Obstetricians’ and physiotherapists' views of ante-natal child­ birth preparation classes were examined by means of a postal q u e s tio n n a ir e . R e s p o n s e s o f 1 0 8 o b s t e t r ic ia n s a n d 5 7 physiotherapists revealed some marked differences in percep­ tions of childbirth classes offered by physiotherapists. In general physiotherapists' views were most favourable while obstetri­ cians views were less so. Differences between physiotherapists’ and obstetricians’ views regarding the relevance of, and e m ­ phasis placed on, topics in childbirth preparation courses were also revealed. Data must, however, be viewed with caution due to the low response rate obtained. OPSOMM ING Die menings van verloskundiges en fisioterapeute ten opsigte van voorgeboorte klasse was deur middel van posvraelyste ondersoek. Vanuit die antwoorde van 108 verloskundiges en 57 fisioterapeute is verskeie sienswyses geopenbaar. In die algem een is die fisioterapeute se menings meer gunstig daar- toe. Verskille tussen die menings van verloskundiges en.-_.fi- sioterapeute ten opsigte van die tersaaklikheid en klem 'v a n s e k ere o n d e rw e rp e in g e b o o rte v o o rb e re id in g s k la s s e w as ook gevind. As gevolg van die swak reaksie op vraelyste moet gegewens versigtig bekyk word. ' J INTRODUCTION W hile much has been w ritten on the historical rift that- has developed between do cto rs and midwives over the past century o r even lo n g e r'’ , few empirical studies a p p ea r .to have been conducted exploring the specific param eters o f these d iffere n ce s.. Studies - by Cogan and Hayward and C halm ers do shed som e light o n 1 these issues but much still rem ains to be done to explore the possible differences o f opinions that may exist between obstetricians and 'b th e r professionals working in the area of childbirth. : . T he present study, initiated by the O bstetric Association of the South African Society of Physiotherapy, (O A SA SP) em erged Jas a result o f perceived differences o f opinions between obstetricians and physiotherapists regarding the value o f ante-natal childbirth p re p a ra ­ tion classes. R ep o rts subm itted to the OASASP from physiotherapists sug­ gested that obstetricians were perceived as having somewhat negative views towards ante-natal preparation courses run by physiotherapists. Such perceptions were based on an apparent lack of support by obstetricians for their patients' attendance at courses. In consequence, a survey of the views o f both obstetricians and physiotherapists towards physiotherapist run childbirth preparation classes was undertaken to ascertain the validity and extent o f the perceived differences of opinion. It was hoped that possible problem areas regarding childbirth education courses would be highlighted by the survey as well as any perceived inadequacies in the preparation of couples for childbirth. PROCEDURE Subjects: In total 527 questionnaires were mailed to obstetricians listed in the Medical and D ental Council register of South Africa, (Total N = 527; T V L N = 246; Cape N = 162; Natal N = 83; O FS N = 26; N amihia N = 5;) and the Southern African Independent o r Self Governing States o r homeland areas (N = 5; T ranskei N = 2; Kwazulu N = 2; Bophuthatsw ana N =21). Initially approximately 15% o f obstetricians com pleted q u e s­ tionnaires. A second copy o f the questionnaire was then sent to a random sam ple o f 250 of the non-responding obstetricians situated in m ajor cities. D octors residing in Nam ibia w ere not followed up as their num bers were few. In addition second questionnaires were not sent to obstetricians in Independent States, Self-governing States, rural o r hom eland areas as few if any physiotherapists w ere rejx>rted to be practicing in these areas. T he second m ailshot resulted in a total response rate from obstetricians of 20.5% (N = 108). In addition 150 questionnaires were sent to all physiotherapists belonging to the O bstetric Branch o f South African Physiotherapists (T V L N = 93; Cape N = 31; Natal N = 16; O FS N = 8; N am ibia N = 2). A 38% response to this appeal (N = 57) was obtained. A second q u e stio n ­ naire was not sent to physiotherapists although a formal rem inder and request to participate in the study was included in the new sletter of the Association. QUESTIONNAIRE Two equivalent questionnaires w ere developed for the ob ste tric and physiotherapy groups. Q uestions were phrased in such a way as to allow do cto rs’ views o f a nte natal childbirth education to be ex ­ plored, as well as to tap physiotherapists' perceptions o f ob ste tric ia n s’ views. Few items were open-ended: m ost supplied forced choice response items. T he questionnaire contained items relating to: biographical information; rates of referral to childbirth preparation classes or reasons for non-referral; existing p attern s of com m unication betw een obstetricians and physiotherapists; the perceived impact of childbirth preparation classes on wom en's co-operation in labour; w om en's expectations of birth; and the perceived value and im portance of various topips that could be included in childbirth p reparation c o u rs­ es. Q uestionnaire items w ere based on issues re ported to the O b ­ stetric Association as reflecting a difference of opinion betw een o b ­ s te tr i c ia n s a n d p h y s io th e r a p is ts a s w ell a s on ite m s in c lu d e d in previous studies o f childbirth preparation program m es . Q u e stio n ­ naires were available in both English and Afrikaans. (C opies o f the questionnaires a re available from the authors.) * Ms B Fish, BSc (Physiotherapy). A nte-N atal Educator, P O Box 735, R a ndpark Ridge 2156. P ro f B Chalmers* PhD. School of Psychology, University o f the W itw atersrand, Johannesburg. D r D Meyer PhD. D epartm ent o f Statistics, University o f the W itw atersrand, Johannesburg. •A ddress reprint requests to P rof B Chalm ers, School of Psychology, University o f the W itw atersrand, P O W its 2050 South Africa. Physiotherapy, May 1991, vol 41 no 2 Page 37 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Biographical Details In all, 45.3% of the obstetricians and 49.0% of the physiother­ apists w ho com pleted questionnaires had been in practice for between 1 and 9 years. A fu rth er 25.9% o f the obstetricians and 26.6% o f the physiotherapists had been in practice fo r betw een 10-19 years, while th e r e m a i n d e r ( 2 6 .8 % o f th e o b s t e t r i c ia n s a n d 1 7 .5 % o f th e physiotherapists) had been in practice for m ore than 20 years. Very fe w '(1 .9 % o f the obstetricians and 8.8% of the physiotherapists) had practiced for less than one year. Statistical Analyses 2 T he X likelihood ratio test was used fo r all analyses of differen­ ces betw een obstetric and physiotherapy groups. RESULTS Response Rates T he relatively low response rate, particularly o f obstetricians (20.5% ) and to a lesser extent o f physiotherapists (38% ), is de trim en ­ tal to d ata interpretation. Findings o f the study m ust therefore be v ie w e d c irc u m s p e c tly . O f th o s e w h o c o m p le te d q u e s tio n n a ir e s , 77.8% w ere English speaking and 22% Afrikaans. It is not possible to re p o rt accurate num bers of English o r A frikaans speaking o b ste tri­ cians o r physiotherapists in the sam ple surveyed. If the language of th e e ntry in the professional registers can be regarded as an indication of language distribution then 73% of the sam ple tested were English and 27% Afrikaans. T he p oor response rate am ongst A frikaans speakers may be due to th e p o o r quality o f translation of the questionnaire into A frikaans that unfortunately occurred. Procedural difficulties r e ­ sulted in the questionnaires being mailed before e rro rs of translation could be rectified. It is possible that results obtained reflect an English speaking professional view ra th e r than being fully generalisable. Alternatively, the paucity of A frikaans responders may reflect som e differences of opinion regarding the issues u nder examination in this language group. F u rth e r research is needed to clarify the reasons underlying the unequal representation of language groups am ongst responders. T h e m a jo rity o f S o u th A fric a n r e s p o n d e r s c a m e fro m th e Transvaal (47.2% ) with 25% responding from the Cape Province, 12.9% from N atal and 6.5% from the O range F ree State. T hese figures represent a response rate of 46.7% from the Transvaal m ail­ ing; 30.7% from the C ape lists; 15.7% from Natal and 4.9% from the O F ^ listings. Few respondents w ere obtained from N am ibia (1.8% ), o r (0,9% o r N am ibians surveyed) o r from Kwazulu (0.9% ), (0.4% Kwazulu response rate. N o area of origin was given by 4.3% of the sample. O ne section of th e questionnaire explored referral rates to ante-natal education classes. O bstetricians were asked a bout the n u m b er o f patients they referred to classes while physiotherapists w ere asked w hat percentage o f th eir patients were referred to them by doctors. A s can be seen from T able I obstetricians re p o rt referring both prim iparous (p,001) and m ultiparous (p,001) patients for a n te ­ natal classes m ore often than physiotherapists perceive them to. (X tests w ere perform ed by combining frequencies “always and fre ­ quently” and com paring these to the com bined frequencies o f “so m e ­ tim es”, “hardly ev er” and “n ever”. (T able 1). In general views o f o bstetricians and physiotherapists tow ards the kind of ante-natal courses patients w ere re fe rre d to, seem ed to concur. T he m ajority of obstetricians (68,5% ) and physiotherapists (70,2% ) re p o rte d that patients w ere usually referred to classes o f­ fered by physiotherapists in private practice. T hese courses w ere preferred to those offered by midwives in private p ractice (37,0% of obstetricians and 33,3% of physiotherapists). However, obstetricians do favour hospital based courses m ore than physiotherapists realised (33,7% of obstetricians and 12,3% o f physiotherapists (p). O f the obstetricians, 25,0% adm itted to advising w om en not to a tte n d classes on occasion. However, physiotherapists believed the n on-referral ra te of obstetricians to be in the region o f 59.7%. Both groups w ere asked a b o u t o b stetricians’ reasons fo r not referring women to ante-natal childbirth classes. T h e m ost frequently re p o rte d reasons fo r non referral given by do cto rs were: th at classes crea te unrealistic expectations o f birth (13,0% ); that classes give in appropriate o r even incorrect inform ation (13,0% ) and th at classes emphasize “natural b irth ” too much (10,2% ). Physiotherapists, how ­ ever, believe that obstetricians do n ot re fe r th eir p atien ts because they: d o n ’t know what a n te natal classes offer (47,4% ); do n ot think classes are of value for m ultiparas (36,8% ); consider them to be an unnecessary financial burden for m others (26,3% ); and c onsider th at classes em phasize “natural birth " too much (21,1% ). As can b e seen from T able 2, d o c to rs’ and physiotherapists’ reasons fo r n on-referral do not always coincide. TABLE 2: Reasons for non -referral to ante-natal classes. As perceived by : (%) Reason for non-referral Obstetricians Physiotherapists Classes create unrealistic ' expectations of birth 13.0 19.3 Classes give inappropriate or incorrect information 13.0 17.5 Classes emphasise "natural birth” too much 10.2 21.1 Doctors do not know what classes offer 1.9 47.4 Classes not relevant for multiparas 6.5 36.8 Classes are an unnecessary financial burden 5.6 26.3 Classes are medically inadvisable 3.7 19.3 Classes create unrealistic expectations of Doctor's role 6.5 5.8 O b s te t r ic ia n s a n d p h y s io th e r a p is ts w e re f u r t h e r q u e s t io n e d about one of the reasons for non-referral, viz., that w om en em erge from classes with expectations of a “n a tu ra l” birth. Answers to the question “D o you find that m others who have atte n d ed ante-natal classes expect to have a natural/unassisted labour and b irth ? ” r e ­ vealed som e difference betw een obstetricians and physiotherapists. O bstetricians re ported this expectation as occurring in w om en 81% of the tim e at least frequently if n ot m ore often, while physiotherapists believed this to be so in only 67% o f cases, (p) T he m ajority of physiotherapists (94.7% ) also re ported that they believed w om en to be m ore co-operative in labour if they had atten d ed classes. Many physiotherapists (75% ) but significantly fewer obstetricians believed this to be the case (p). D octors and physiotherapists a p p ea red to agree, however, on the value o f exercise in a nte-natal pre p ara tio n classes for norm al pregnancies (90,7% and 94,7% respectively). T h e is s u e o f c o m m u n i c a t i o n b e t w e e n o b s t e t r i c i a n s a n d physiotherapists was also explored. Both d o c to rs (75% ) and, to a significantly g re a te r extent, physiotherapists (91,2% ) (p,05), would TABLE 1 : Perceptions o f obstetricians and of physiotherapists o f referral rates Perceived Frequency of Referral (%) referral rates Always Frequently Sometimes Hardly ever Never of Primiparas by Obstetricians 41,7 Physiotherapists 0,0 36,1 29,8 12,0 49,1 3 7 21,1 6.5 0,0 of Multiparas by Obstetricians 13,9 35,2 35,2 8,3 Physiotherapists 0,0 5,3 42,1 43,9 ‘ Percentages do not always total 100 due to one subject's incomplete responses. 6,5* 8,8 Questionnaire Analyses Bladsy 38 Fisioterapie, Mei 1991, dee! 47 no 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) like to have m ore com m unication with each other. However, 26,9% o f o b s te tric ia n s p e rc e iv e p h y s io th e ra p is ts a s ro u tin e ly re q u e s tin g feedback o r comm unication about patient referrals while 54.4% of the physiotherapists rep o rt a routine request fo r information. T he idea that differences in perceived com m unication rates may be associated with o b s te trc ia n s ’ referral to physiotherapists in general, ra th e r than specifically for ante-natal education, was also explored. A ltogether 79.6% o f obstetricians re ported referring p a ­ tients to physiotherapists fo r reasons o th e r than childbirth p re p ara ­ tion. How ever only 59.7% o f physiotherapists who take ante-natal classes report such referrals (p). perceived adequacy of coverage given to a variety of possible c hild­ birth education course topics and the perceived im portance of these. T opics explored included physical aspects of pregnancy and birth; medical interventions commonly used; the hospital stay; psychological preparation o f both m other and father, infant care and infant feeding; exercises; breathing; and o th e r pain relieving techniques commonly used in labour. T able 3 reports the percentage of obstetricians and physiotherapists reporting that these topics are necessary in childbirth preparation courses, and the percentage reporting that they are being adequately covered at present. Only the d ata from respondents who com pleted both aspects o f this question w ere included in d ata a n a ­ lyses. Many physiotherapists responded to only one aspect of this question and these answers were, therefore, om itted from the a n a ­ lysis. It is o f interest to note that while physiotherapists regard alm ost all the topics explored as necessary in childbirth education courses (range = 87.5% - 100.0%; T able 3) only about h alf o f the o b ste tri­ cians do so (range = 37.4% - 82.5%; T able 3). Similarly in most instances physiotherapists perceive th eir c urrent coverage o f these topics in classes to be a d equate (range = 50.0% - 100.0%; T able 3) while fewer obstetricians perceive this to be so (range = 19.3% - 82.4%; T able 3). This trend is minimally reversed with regard to preparation for breech delivery. Some o f the education topics regarded by obstetricians as less necessary are o f interest. T hese include prep aratio n for episiotom y (41,5% ), shaving and enem as (41,0% ), exercise (42,7% ), breast care (39,0% ), breast feeding (39,0% ) and bottle feeding (38,3% ). On the o th e r hand, 82,5% o f obstetricians regard pre p ara tio n fo r early p a renthood and 71.6% fo r life style changes resulting from p a renthood to be necessary. O f n ote is that while o bstetricians p e r ­ ceive these topics to be poorly covered at present (19,3% and 32,8% respectively) m ost physiotherapists perceive them to be well taught (82,4% and 76,5%, respectively). Acknowledged by both groups as being fairly im portant and not well enough covered at present a re topics relating to the fa th e r’s psychological involvement in the process o f transition to pa ren th o o d (Table 3). As can be seen from T able 3, the m ost significant differences to em erge betw een obstetricians and physiotherapists regarding topics o f im portance fo r childbirth preparation courses related to the a n a t­ omy and physiology o f women, viz. b reast care, norm al labour, ex er­ cise, diet, episiotom ies, shaving and enem as, pushing, breathing and pain m anagem ent techniques, infant feeding and the fa th e r’s role in labour. In all instances obstetricians rated these topics as less im p o rt­ ant than physiotherapists did (p). C overage o f topics as presently a d equate was also perceived significantly differently by o bstetricians and physiotherapists in som e instances. T he most significant d iffere n ­ ces to em erge related to the coverage o f induction as well as the psychological preparation o f m others fo r early parenthood and life style changes a fte r birth, and for the p reparation of fathers fo r th eir role as parents (p). In all instances obstetricians’ ratings o f the a d e ­ quacy o f coverage w ere lower than those o f physiotherapists. DISCUSSION T he tentative n a tu re of any in te rp reta tio n s o f the findings o f this study must be emphasised. T he obstetricians and physiotherapists studied, do however, a p p ea r to differ with regard to m any o f th eir views on current ante-natal preparation courses. T o what extent these findings may apply to the population of physiotherapists and o b ste tri­ cians in general, however, needs confirm ation from future research. , T he findings of the present study suggest that physiotherapists perceive obstetricians to re fe r patients to childbirth classes less often than doctors rep o rt they do. Perceived reasons fo r non-referral also differ with obstetricians appearing to be concerned a bout m others developing unrealistic expectations a b o u t natural childbirth a nd g ain­ ing i n a c c u r a t e i n f o r m a t i o n f r o m c la s s e s . O n t h e o t h e r h a n d , physiotherapists’ prim ary reasons fo r obstetricians’ non-referral a p ­ p e ar to be a belief that doctors do not know w hat ante-natal classes actually offer. T hat at least o ne aspect of the obstetricians’ fears seems to be realised, is supported by the finding that most wom en, as perceived by doctors ($4,5% ) and by physiotherapists (86,0% ), do show a desire for n a tural-childbirth following classes. W h eth er this is d ue to the content of classes them selves is open to question, as women w ho go to classes may be those with a higher need fo r natural childbirth in the first place. O bstetricians and physiotherapists do a p p ea r to agree on the need for g re ater com m unication,' betw een them regarding patient care. It seem s probable th at such com m unication could facilitate a g re ater understanding betw een'Uhe professions regarding the place of childbirth education. TABLE 3: Perceived importance and adequacy of cover­ age of topics included in childbirth preparation courses. Topics % reporting % regardinge N responding topic as coverage as to each item necessary adequate Obstet Physio Obstet Physio Obstet Physio rnysicai aspects: Anat/physiol of female 47.4*100.0 64.1“ 100.0 78 17 Anat/physiol of male 59.3 100.0 40.7 50.0 27 8 Breast care 39.0* 94.1 7 2 .7 *" 100.0 77 17 Normal labour 42.2*100.0 7 4 .7 *" 100.0 90 17 Breech delivery 51.9**&2.3 55.6 53.9 27 13 Pregnancy care: Exercise 42.7 100.0 72.0 100.0 82 17 Diet Medical Interventions: 45.8* 94.1 50.0 64.7 72 17 Caesarean section 50.0*tb0.0 66.7*** 94.1 78 17 Forceps 57.8*f00.0 53.1*** 88.2 64 17 Induction 59.7*ft)0.0 49.3* 100.0 67 17 Epidural/analgesia 57.0*f00.0 57.0*** 94.1 79 17 Episiotomy 41.5*100.0 70.7*** 100.0 82 17 Shaving & enemas 41.0*100.0 72.3*** 100.0 83 17 Labour: Pushing techniques 43.5100.0 76.1*** 100.0 92 17 Breathing techniques 37.4*100.0 82.4 100.0 91 17 Pain 43.3*100.0 74.4*** 100.0 90 17 Post Partum: In hospital stay 54.4 100.0 58.8 88.2 68 17 Going home 63.8**§4.1 44.8*** 82.4 58 17 Baby care 60.0 87.5 47.7 75.0 65 16 Infant Feeding: Breast feeding 39.0 100.0 68.8 100.0 77 • 17 Bottle feeding Fathers’ role: 38.3*100.0 68.3 73.3 60 15 Role in labour 50.7*100.0 61.6 94.1 73 . 17 Psychological aspects 75.0*tb0.0 26.9* 53.3 52 15 Psychological experiences of labour 68.31 0 0 .0 Psychological preparation: 41.7 86.7 60 15 For early parenthood 82.5 94.1 19.3* 82.4 57 17 For life style changes 71.6 94.1 32.8 * Significant difference with a P-value .001 ** Significant difference with a P-value .01 *** Significant difference with a P-value .05 76.5 67 17 T he final issue explored in the present study concerned the Physiotherapy, May 1991, vol 41 no 2 Page 39 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) T here also appears to be agreem ent on the type o f ante-natal preparation class to which obstetricians re fe r m ost often: in this case, physiotherapist run courses. W hile obstetricians do a p p ea r to support physiotherapist run childbirth preparation classes, they do have som e very specific, c lear criticism s o f the services offered by them. B y f a r t h e g r e a t e s t c o n t r a s t b e tw e e n o b s t e t r i c i a n s ’ a n d physiotherapists’ views appeared to o ccur with regard to the necessity and adequacy o f coverage' o f various topics usually included in child­ birth preparation classes. F a r fewer obstetricians than physiothera­ pists see the necessity for the m ajority o f topics covered in classes. In addition fewer obstetricians see these topics as being adequately covered by existing preparation courses anyway. This underestim a­ tion o f the value of topics on the part o f obstetricians extends even to such topics as prep aratio n for breast and bottle feeding as well as for alm ost routine but frequently disliked procedures6 associated with lab o u r such as episiotom ies, shaving and enemas. While obstetricians a p p ea r to underestim ate the need fo r p re p ­ aratio n on a num ber o f topics, physiotherapists appear to perceive th eir coverage o f m ost topics as alm ost totally adequate. The main area to be acknowledged by both groups as reasonably im portant and not adequately covered in c u rre n t classes a re those relating to psycho­ logical preparation fo r parenthood and in particular to the fath er’s involvement throughout his transition to parenthood. T he existence of such institutes as the International C hildbirth E ducation A ssociation based in the USA and the National Childbirth T rust based in the UK, suggests a need, at least on the p art of m others, for childbirth preparation courses. O pen to question and currently receiving m uch attention, is the question o f how best to approach the c ontent and m ethods to be utilized in courses 7-21. T he efficiency of childbirth education courses, like many o th e r aspects of 22.23medical and particularly obstetric care, is being questioned today F u rth e r research is still needed to clarify what should be offered to parents-to-be, how it should be done and why. T hese questions C o n tro l Physio­ therapist Addington Hospital, Durban Commencing salary R38 697 per annum plus a 10% non-pensionable allowance. R e q u ire m e n ts: • Registration as a Physiotherapist w ith the SAMDC PLUS • A t least seven years' appropriate experience. N o te : • A p p lic a tio n s must be subm itted on form Z.83, obtainable from any Public Service departm ent, and should be accompanied by certified copies o f qualifications. A p p lic a tio n s , stating reference num ber 36067/326, to the D irector General, Provincial A d m inistration o f N atal, Private Bag X9037, Pieterm aritzburg 3200. E n q u irie s : M r G. M innie, tel. (031) 32-2111 ext 660. Clo sing date: 30 M ay 199.1. THE PUBLIC SERVICE where quality counts assum e even g re a te r p roportions when placed in a cross cultural Southern A frican context. T h ere is an urgent need to question the applicability as well as efficiency o f c u rre n t approaches to childbirth education in the South A frican community. REFERENCES 1. W agner M. W hose baby is it anyway? Paediatric Perinatal Epidemiology. 1988; 2:118-123. 2. W H O , R e p o rt. Having a Baby in E urope: R e p o rt on a Study, C openhagen, W H O Regional Office for E urope, Public H ealth in E urope. 1985: 26. 3. Cogan R . T he delivery o f childbirth reports: An analysis o f sam ple bias in questionnaire returns. Journal o f Psychosomatic Research. 1975; 19: 39- 42. 4. Hayward J, C halm ers B. O b stetricians’ and m others’ perceptions of o b ste ­ tric events. P a p e r p resented to the 9th Congress of the International Society o f Psychosom atic O bstetrics and Gynaecology, A m sterdam , May 1989. 5. C halm ers B, M eyer D, W ern e r S. 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