The KALI questionnaire

This is the survey on labor interventions that will be my research project for my fellowship. Many of these are taken from other studies, position statements, practice bulletins, and meta-analysis conclusions. There is also a demographics and practice description portion of the questionnaire, which I did not include in this post. The target population will be practicing ob/gyns in a certain geographical area. Please let me know what you think.

Keep in mind that the question are supposed to be mixed to prevent bias based on how they ordered are in conjunction with other questions on the same topic, and they are mixed in positive and negative phrasing, and mixed in whether they are talking about practice, knowledge, attitudes or future intentions.

Here it is:

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you to choose to most appropriate response:

1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly disagree

1. Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.

2. Elective cesarean section should not be performed on a woman desiring several children.

3. Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.

4. Episiotomy should be avoided if at all possible.

5. The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.

6. In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.

7. Insurance should not reimburse use of doulas for labor and delivery.

8. I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used.

9. Fear of liability claims limit the options I present to my obstetrical patients.

10. Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.

11. The use of continuous EFM does not result in a reduction of cerebral palsy.

12. All women in labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

13. Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.

14. I regularly employ episiotomy to shorten the second stage of labor and delivery.

15. Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.

16. Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.

17. The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.

18. Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.

19. I regularly employ episiotomy to prevent pelvic floor relaxation.

20. If you or your partner were pregnant for the first time, would you choose / recommend an elective cesarean delivery for yourself or your partner in the absence of any medical or obstetrical indication?

21. I have made changes to my practice because of the risk or fear of liability claims.

22. Childbirth is only normal in retrospect.

23. I regularly employ episiotomy to prevent perineal trauma.

24. The use of continuous EFM reduces perinatal mortality.

25. I encourage my patients to try alternative or upright positions during the pushing stage.

26. Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.

27. I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.

28. Women should have the right to refuse an episiotomy.

29. I encourage patients to use a doula for their labor and delivery.

30. I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.

31. There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.

32. Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.

33. I discuss the risks and benefits of episiotomies with my patients prior to delivery.

34. Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.

35. Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.

36. Episiotomies increase the risk of third and fourth degree tears.

37. Clinical guidelines are useful tools for me in daily clinical practice.

38. Clinical guidelines are overly rigid and difficult to adapt to individual patients.

How often do you consult the following sources regarding obstetrical practice?

1= Never 2= Rarely 3 = Sometimes 4 = Often 5 = Always

1. ACOG Practice Bulletins
2. ACOG Committee Opinions
3. Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. Cochrane Database
5. Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. Books and/or textbooks
7. Professional conferences
8. Physicians in my practice
9. Physicians in my local community
10. Physicians I trained with in residency
11. Physicians I consider experts in the field
12. Other ____________________________

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11 responses to “The KALI questionnaire

  1. I realize I’m outing myself as an über-nerd by replying to this post on a Saturday night! I haven’t done this sort of research in over 20 years, though, so take me with a grain of salt. We historians would love to be able to survey dead people, but haven’t figured out how to do it yet.

    I think overall you’ve done an outstanding job with this questionnaire. Here are a few minor, minor suggestions.

    While the prompts are very balanced and mixed (as you wrote in your post), I wonder if there could be another statement on episiotomy to balance the one asserting that it prevents pelvic floor relaxation. Something like: “An episiotomy is unlikely to prevent future prolapse and may even increase its odds.”

    #20 is phrased as a question rather than a statement, and it uses the second-person “you” form instead of “I,” as the other items do.

    You’ve got just three statements that refer to doulas. Might you want to beef that up a bit? If I recall correctly, the use of a doula is one of the areas you’re investigating.

    I wonder if it would be fruitful to pose a statement such as: “I would like to offer my patients the option of VBAC, but my hospital and/or insurer prevent me from doing so.” I’m always interested in the question of how basically well-intentioned people can be thwarted by institutional constraints, and I think this is an area where it would be worth assessing how professional ethics and judgment collide with institutional barriers.

    Might you want to have a flip-side to your Pitocin question – something like “I regard Pitocin as helpful in augmenting certain complicated labors, but I consider its use inappropriate in routine situations.”

    Obviously you know doctor-talk far better than I, and obviously you should take anything you find useful and discard the rest.

    I think this is a really cool project and I’m enjoying your updates on it. To me, it looks as though you’ve laid an excellent foundation for it.

  2. Reading your survey reminds me I need to get going on some of my own survey work for this semester!

    One question about this item:
    12. All women in labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

    I wonder if you will get some variability in that question based on dilation/progression of labor. You could get some people who do AROM on every woman when she walks in the door, whether she’s 1 cm or 9 cm, but you could also get some head-scratching with your respondents thinking “Well, I *almost* always do it but not if…” So maybe a clarification there?

    At my school there’s an institute that will specifically go over survey questions with you and critique them. I don’t suppose you have anything like that? They have been amazing for helping with projects I’ve worked on. One recommendation of theirs that was great was to go through the survey with some intended subjects and have them think out loud as they answered. We did this for a physician-targeted survey with one of our classmates who’s in family practice, and she brought up topics we never even thought of and helped us refine the questions a lot.

    Good luck! I second that it is fascinating to get these updates, and really interested to see how this progresses.

    • MomTFH

      Yeah, we struggled with that AROM question. I originally had the term “early labor” in there, and was thinking that “present” meant at admission, and most women are admitted in early labor. They do have a Likert scale to work with, so they can agree but not strongly agree with the pitocin question and the AROM question if they have qualifications.

      I have been working with mentors at my school. I was planning on running by some of the physicians here, too.

  3. doctorjen

    I was going to suggest having a questiong like a previous commenter suggested – something about the provider wishing to offer VBAC but not being able to due to hospital or insurer policies. As I read through your questions I think you were trying to see if providers do not offer VBAC despite the evidence – but you might want to be able to separate agreeing with the evidence and institutional issues. Speaking from personal experience, I feel strongly that offering VBAC is evidenced based, but I am no longer allowed to attend VBACs due to hospital policy that a surgeon must remain in house with a laboring VBAC and no surgeon will back me up for my own VBAC clients.

    Overall, I thought your questions were a good mix of positive and negative about each issue. If it would be helpful, I’d be happy to answer your survey with a comment about what I’m thinking with each answer as a pre-test subject for you. (I’m a family doc, not an OB, but still a physician who attends births) This way, you might find out if any of the questions mean something different to a practicing physician than they do to you.

    • MomTFH

      Thanks for your suggestions. I actually wanted more questions about barriers but they are hard to write. If I say “I would offer VBACs but my hospital or insurance won’t let me” and they answer disagree or strongly disagree, I don’t know if they are saying no, they would never offer VBACs or no, their hospital and insurance allow them. I suppose the other questions on VBAC may help me tease that out, but I want to write good questions with clear answers. You are right though, I should work on one that is more specific to that kind of barrier.

      I was aiming for this when I wrote the statement “Hospital standards of care or policies sometimes get in the way of optimal management of individual patients” but it is so general, it doesn’t specify what policies get int he way of what kind of management.

  4. doctorjen

    Can I email the survey to you somewhere, or do you want me to post it here?

  5. I swear that I commented on some of your questions…must have got lost in the internet ether! Anyway I had some suggestions for re-writing the AROM question among other things.

    • MomTFH

      Thanks! I did rewrite it. I added the words “in early active labor” after “presents”. We had struggled with that question already. I had a different wording originally that included the early labor part, but the question was awkwardly worded. My mentor rewrote it without the early labor part. I am a over processor, so I thought the revised wording was OK, because I would read it and think, well, most women present in early labor, so we are talking about most women presenting, so we are talking about early labor. But, it is better to be explicit than implicit.

      I will post the new survey soon. I have yet one more tweak first.

  6. Pingback: Reply turned post, participatory medical education style « Mom’s Tinfoil Hat

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