Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section

Abstract

BackgroundUnexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AimTo map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. MethodsA custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 “evidence-based” statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FindingsTotal 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications “valid” compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DiscussionBoth inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. ConclusionGreater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.