VIEWS OF OBSTETRICIANS AND PHYSIOTHERAPISTS ON ANTENATAL PREPARATION FOR CHILDBIRTH

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 ire . R e s p o n s e s o f 108 o b s te tric ia n s and 57 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 em ­ 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. OPSOMMING


INTRODUCTION
While much has been written on the historical rift that-has developed between doctors and midwives over the past century or even lon g er'' , few empirical studies appear .tohave been conducted exploring the specific param eters of these differences.. Studies -by Cogan and Hayward and Chalmers do shed some light o n 1 these issues but much still remains to be done to explore the possible differences of opinions that may exist between obstetricians and 'b th er professionals working in the area of childbirth.
: .The present study, initiated by the Obstetric Association of the South African Society of Physiotherapy, (OASASP) emerged Jas a result of perceived differences of opinions between obstetricians and physiotherapists regarding the value of ante-natal childbirth prepara tion classes.
Reports submitted 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 of both obstetricians and physiotherapists towards physiotherapist run childbirth preparation classes was undertaken to ascertain the validity and extent of 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 Dental Council register of South Africa, (Total N = 527; TVL N = 246; Cape N = 162; Natal N = 83; OFS N = 26; Namihia N = 5;) and the Southern African Independent or Self Governing States or homeland areas (N = 5; Transkei N = 2; Kwazulu N = 2; Bophuthatswana N =21).
Initially approximately 15% of obstetricians completed ques tionnaires.A second copy of the questionnaire was then sent to a random sample of 250 of the non-responding obstetricians situated in m ajor cities. Doctors residing in Namibia were 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 homeland areas as few if any physiotherapists were rejx>rted to be practicing in these areas.The second mailshot 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 Obstetric Branch of South African Physiotherapists (TV L N = 93; Cape N = 31; Natal N = 16; OFS N = 8; Namibia N = 2).A 38% response to this appeal (N = 57) was obtained.A second question naire was not sent to physiotherapists although a formal rem inder and request to participate in the study was included in the newsletter of the Association.

QUESTIONNAIRE
Two equivalent questionnaires were developed for the obstetric and physiotherapy groups.Questions were phrased in such a way as to allow doctors' views of ante natal childbirth education to be ex plored, as well as to tap physiotherapists' perceptions of obstetricians' views.Few items were open-ended: most supplied forced choice response items.
The questionnaire contained items relating to: biographical information; rates of referral to childbirth preparation classes or reasons for non-referral; existing patterns of communication between obstetricians and physiotherapists; the perceived impact of childbirth preparation classes on women's co-operation in labour; women's expectations of birth; and the perceived value and im portance of various topips that could be included in childbirth preparation cours es.
Questionnaire items were based on issues reported to the O b stetric Association as reflecting a difference of opinion between o b ste tric ia n s a n d p h y sio th e ra p ists as well as on item s included in previous studies of childbirth preparation programmes .Q uestion naires were available in both English and Afrikaans.(

Biographical Details
In all, 45.3% of the obstetricians and 49.0% of the physiother apists who completed questionnaires had been in practice for between 1 and 9 years.A further 25.9% o f the obstetricians and 26.6% o f the physiotherapists had been in practice for between 10-19 years, while th e r e m a in d e r (2 6 .8% o f th e o b s te tric ia n s a n d 17.5% o f th e physiotherapists) had been in practice for more than 20 years.Very few '(1.9% of the obstetricians and 8.8% of the physiotherapists) had practiced for less than one year.

Statistical Analyses 2
The X likelihood ratio test was used for all analyses of differen ces between obstetric and physiotherapy groups.

Response Rates
The relatively low response rate, particularly of obstetricians (20.5% ) and to a lesser extent of physiotherapists (38%), is detrim en tal to data interpretation.Findings of the study m ust therefore be v iew ed c irc u m sp ec tly .O f th o se w h o c o m p le te d q u e stio n n a ire s, 77.8% were English speaking and 22% Afrikaans.It is not possible to report accurate numbers of English o r Afrikaans speaking obstetri cians o r physiotherapists in the sample surveyed.If the language of the entry in the professional registers can be regarded as an indication of language distribution then 73% of the sample tested were English and 27% Afrikaans.
The poor response rate amongst Afrikaans speakers may be due to the poor quality of translation of the questionnaire into A frikaans that unfortunately occurred.Procedural difficulties re sulted in the questionnaires being mailed before errors of translation could be rectified.It is possible that results obtained reflect an English speaking professional view rather than being fully generalisable.
Alternatively, the paucity of Afrikaans responders may reflect som e differences of opinion regarding the issues under examination in this language group.Further research is needed to clarify the reasons underlying the unequal representation of language groups amongst responders.
T h e m ajo rity o f S o u th A frican re sp o n d e rs cam e from the Transvaal (47.2%) with 25% responding from the Cape Province, 12.9% from Natal and 6.5% from the Orange Free State.These figures represent a response rate of 46.7% from the Transvaal mail ing; 30.7% from the Cape lists; 15.7% from Natal and 4.9% from the O F ^ listings.Few respondents were obtained from Namibia (1.8%), o r (0,9% o r Namibians 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 the questionnaire explored referral rates to ante-natal education classes.Obstetricians were asked about the num ber of patients they referred to classes while physiotherapists were asked what percentage of their patients were referred to them by doctors.As can be seen from Table I obstetricians report referring both primiparous (p,001) and m ultiparous (p,001) patients for an te natal classes m ore often than physiotherapists perceive them to.(X tests were perform ed by combining frequencies "always and fre quently" and comparing these to the combined frequencies of "som e tim es", "hardly ever" and "never".(Table 1).
In general views of obstetricians and physiotherapists towards the kind of ante-natal courses patients were referred to, seemed to concur.The majority of obstetricians (68,5%) and physiotherapists (70,2% ) reported that patients were usually referred to classes of fered by physiotherapists in private practice.These courses were preferred to those offered by midwives in private practice (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% of physiotherapists (p).O f the obstetricians, 25,0% admitted to advising women not to attend classes on occasion.However, physiotherapists believed the non-referral rate of obstetricians to be in the region of 59.7%.
Both groups were asked about obstetricians' reasons for not referring women to ante-natal childbirth classes.T he most frequently reported reasons for non referral given by doctors were: that classes create unrealistic expectations o f birth (13,0% ); that classes give inappropriate or even incorrect inform ation (13,0% ) and that classes emphasize "natural birth" too much (10,2% ).Physiotherapists, how ever, believe that obstetricians do not refer their patients because they: don't know what ante natal classes offer (47,4%); do not think classes are of value for m ultiparas (36,8%); consider them to be an unnecessary financial burden for m others (26,3%); and consider that classes emphasize "natural birth" too much (21,1%).As can be seen from Table 2, doctors' and physiotherapists' reasons for non-referral do not always coincide.O b ste tric ia n s and p h y sio th e ra p ists w ere f u r th e r q u e stio n e d about one of the reasons for non-referral, viz., that women emerge from classes with expectations of a "natural" birth.Answers to the question "D o you find that m others who have attended ante-natal classes expect to have a natural/unassisted labour and birth?" re vealed some difference between obstetricians and physiotherapists.Obstetricians reported this expectation as occurring in women 81% of the time at least frequently if not m ore often, while physiotherapists believed this to be so in only 67% of cases, (p) The m ajority of physiotherapists (94.7%) also reported that they believed women to be m ore co-operative in labour if they had attended classes.Many physiotherapists (75% ) but significantly fewer obstetricians believed this to be the case (p).D octors and physiotherapists appeared to agree, however, on the value o f exercise in ante-natal preparation classes for normal pregnancies (90,7% and 94,7% respectively).
T h e issu e o f c o m m u n ic a tio n b e tw e e n o b s te tr ic ia n s a n d physiotherapists was also explored.Both doctors (75% ) and, to a significantly greater extent, physiotherapists (91,2% ) (p,05), would The idea that differences in perceived communication rates may be associated with o bstetrcians' referral to physiotherapists in general, rather than specifically for ante-natal education, was also explored.Altogether 79.6% of obstetricians reported referring p a tients to physiotherapists for reasons other than childbirth prepara tion.However only 59.7% of physiotherapists who take ante-natal classes report such referrals (p).perceived adequacy of coverage given to a variety of possible child birth education course topics and the perceived importance of these.Topics explored included physical aspects of pregnancy and birth; medical interventions commonly used; the hospital stay; psychological preparation of both m other and father, infant care and infant feeding; exercises; breathing; and other pain relieving techniques commonly used in labour.Table 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 data from respondents who completed both aspects of this question were included in data a n a lyses.Many physiotherapists responded to only one aspect of this question and these answers were, therefore, om itted from the an a lysis.
It is o f interest to note that while physiotherapists regard almost all the topics explored as necessary in childbirth education courses (range = 87.5% -100.0%;Table 3) only about half of the obstetri cians do so (range = 37.4% -82.5%;Table 3).Similarly in most instances physiotherapists perceive their current coverage o f these topics in classes to be adequate (range = 50.0%-100.0%;T able 3) while fewer obstetricians perceive this to be so (range = 19.3%-82.4%;Table 3).This trend is minimally reversed with regard to preparation for breech delivery.Some of the education topics regarded by obstetricians as less necessary are of interest.These include preparation for episiotomy (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 other hand, 82,5% of obstetricians regard preparation for early parenthood and 71.6% for life style changes resulting from parenthood to be necessary.O f note is that while obstetricians p e r ceive these topics to be poorly covered at present (19,3% and 32,8% respectively) most 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 are topics relating to the father's psychological involvement in the process o f transition to parenthood (Table 3).
As can be seen from Table 3, the most significant differences to emerge between obstetricians and physiotherapists regarding topics of importance for childbirth preparation courses related to the a n at omy and physiology of women, viz.breast care, normal labour, exer cise, diet, episiotomies, shaving and enemas, pushing, breathing and pain management techniques, infant feeding and the father's role in labour.In all instances obstetricians rated these topics as less im port ant than physiotherapists did (p).Coverage of topics as presently adequate was also perceived significantly differently by obstetricians and physiotherapists in some instances.The most significant differen ces to emerge related to the coverage of induction as well as the psychological preparation of m others for early parenthood and life style changes after birth, and for the preparation of fathers for their role as parents (p).In all instances obstetricians' ratings of the ade quacy of coverage were lower than those o f physiotherapists.

DISCUSSION
The tentative nature of any interpretations o f the findings of this study must be emphasised.The obstetricians and physiotherapists studied, do however, appear to differ with regard to many of their views on current ante-natal preparation courses.To what extent these findings may apply to the population of physiotherapists and obstetri cians in general, however, needs confirmation from future research.
, The findings of the present study suggest that physiotherapists perceive obstetricians to refer patients to childbirth classes less often than doctors report they do.Perceived reasons for non-referral also differ with obstetricians appearing to be concerned about m others developing unrealistic expectations about natural childbirth and gain ing in a c c u ra te in fo rm a tio n fro m c la sses.O n th e o t h e r h a n d , physiotherapists' primary reasons for obstetricians' non-referral ap pear to be a belief that doctors do not know what ante-natal classes actually offer.That at least one aspect of the obstetricians' fears seems to be realised, is supported by the finding that most women, as perceived by doctors ($4,5% ) and by physiotherapists (86,0% ), do show a desire for natural-childbirth following classes.W hether this is due to the content of classes themselves is open to question, as women who go to classes may be those with a higher need for natural childbirth in the first place.
Obstetricians and physiotherapists do appear to agree on the need for greater com m unication,' between them regarding patient care.It seems probable that such communication could facilitate a greater understanding between'Uhe professions regarding the place of childbirth education.The final issue explored in the present study concerned the

Percentages do not always total 100 due to one subject's incomplete responses. 6,5* 8,8 Questionnaire Analyses
to have m ore communication with each other.However, 26,9% o f o b ste tric ia n s perceive p hysiotherapists as routinely req u estin g feedback o r communication about patient referrals while 54.4% of the physiotherapists report a routine request for information.