Attitudes Drive Everything: With providers and women fearful of birth and operating in an evidence vacuum, the results are not wonderful

Research by our UBC affiliated Child and Family Research Institute has revealed that the increase in Caesarean section rates across Canada may be largely due to the attitudes and beliefs of the obstetricians and other providers towards birth technology and Caesarean sections. 81 per cent of obstetricians 40 years or younger were women versus 40 per cent over 40 years of age. The attitudes and beliefs vary by age of practitioner. In contrast to their older counterparts, younger obstetricians were significantly more likely to favour a hospital based medically managed birth and the routine use of epidural analgesia in normal births. They were less likely to support vaginal birth after Caesarean section or to appreciate the importance of mothers’ role in their own birth. They also appeared to be more “fearful” of the consequences of vaginal birth, particularly in relation to urinary incontinence and sexual problems and more likely to select Caesarean section for their own births. Older obstetricians, the majority of which are male, were more supportive of a woman-centered model of care, more positive about birth plans, and were more likely to see vaginal birth as more empowering to the mother than Caesarean section. (1) The finding that younger obstetricians, who are mostly women, appeared to have less appreciation of the role of a woman in her own birth than older usually male obstetricians is counterintuitive and requires further study. These attitudes appear related to experiences in training rather than to gender, as younger male obstetricians have attitudes similar to their female counterparts. Without addressing the educational system, attitudes will be difficult to change.

Another study by our group (2) found that clients of midwives, were more supportive of women’s roles in their own deliveries and less likely to support the use of technology, compared to physicians’ patients. It should be noted that regardless of the type of care provider, many women reported inadequate knowledge of common procedures. Women’s lack of knowledge about procedures such as epidural analgesia, Caesarean section and episiotomy, raise concerns about prenatal education and prenatal care. Attendance at prenatal education classes is decreasing in all regions of Canada and most pregnant women indicated they use health care providers, books and the internet as their main sources of prenatal information. (2) When combined with evidence on the nature of obstetrical power and control, and research showing that many providers are not evidence-based in their views, (3) this suggests that even a woman with strong values and beliefs could find it challenging to assert her choices in the professionally controlled process of birth. Women, especially first time mothers, who do not have evidence-based knowledge, are likely to be particularly sensitive to negative attitudes toward birth procedures and processes, from providers and other sources.

A third study from our group found that family doctors who do not provide intrapartum care have more negative attitudes toward birth and are less evidence-based about what is going on in the delivery suite. (4) Since this group provides more than 50% of the antenatal care in Canada, efforts to keep them up to date need to be implemented, lest they transmit their negative attitudes to women before transfer for birth care to other providers.

Finally as Caesarean section rates are steeply rising, with BC having the highest rates in Canada, and for the first time, maternal mortality and morbidity rates are increasing in the US and Canada due to overuse of Caesarean sections, (2)it is time for the public to realize that Caesarean section, while life-saving when needed, is not as safe a vaginal birth (5-7), and it is not just another way to have a baby.

And lest you think that this is a Canadian problem, the educational and training systems for medical students and obstetrical and family practice residents is the same both sides of the border. Educational, rather than health care models, trumps evidence. We are teaching directly and indirectly that childbirth is just an opportunity for things to go wrong. Medical students, obstetrical and family practice residents rarely see normal birth, and they are not exposed to midwives in hospital or at home births. It is going to take a revolution driven by women to change this, as practitioners are not going to change very soon. To the barricades!

Posted by:  Michael Klein, MD

[Editor's note:  As an example of the debate Dr. Klein introduces here, proposing that Caesarean birth is "not just another way to have a baby," check out this article in today's edition of The Sun, questioning whether or not Caesarean birth is "normal."]




1.         Klein M, Liston R, Fraser W, Baradaran N, Hearps S, Tomkinson J, et al. The attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors. Birth. 2011.

2.         Klein M, Kaczorowsk J, Hearps S, Tomkinson J, Baradaran N, Hall W, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. JOGC. 2011(June):598-608.

3.         Klein M, Kaczorowski J, Hall W, Fraser W, Liston R, Eftekhary S, et al. The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences But Important Similarities. Journal of Obstetrics & Gynaecology Canada: JOGC. 2009;31(9 ):827-40.

4.         Klein M, Kaczorowski J, Tomkinson J, Hearps S, Baradaran N, Brant R. Family physicians who provide intrapartum care and those that do not: very different ways of viewing childbirth. Can Fam Phys. 2011 57(4):e139-e47.

5.         SOGC. Joint Policy Statement on Normal Childbirth. JOGC. 2008;221(December):1163-5.

6.         SOGC. C-sections on demand—: SOGC’s position. [Press Release].  Society of Obstetricians and GynecologistsMar 10, 2004.

7.         Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Cmaj. 2007 February 13, 2007;176(4):455-60.


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  1. June 22nd, 2011 at 22:39 | #1

    Dr. Klein,
    Thank you and your colleagues for your work. I would add that childbirth organizations, and certifying doula organizations should use your work to do some education/attitude self-reflection as well. For our paradigm teaches that birth is the center of a woman’s reproductive universe. We too need to open our curriculum to the full continuum of the life course: preconception’ interconception, and reproductive life planning. Againg, thank you for your contributions.

  2. June 23rd, 2011 at 17:49 | #2

    Great, succinct presentation of the facts. So, how do we start a revolution? I would like all the organizations supporting natural/vaginal births to put a very strong focus on becoming very visible in the educational institutions. We are spinning our wheels, trying to affect the consumer and the already practicing healthcare providers. Grass roots, get them while they are still in school!!

  3. June 25th, 2011 at 11:08 | #3

    As a nurse I have worked in home birth settings with practitioners that support the natural progression of labor– and I have worked in hospital settings with lots of interventions taking place. I agree with the observations presented in this article.

  1. June 30th, 2011 at 01:01 | #1
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  3. December 20th, 2012 at 01:33 | #3