Newest, bestest KALI questionnaire, annotated

Here is the annotated survey, with an attempt at dividing the questions into domains and scaling them. So, the domains so far are K=Knowledge, A=Attitude, B= Barrier, P=Practice pattern, and Y=Autonomy of the patient. If a question says “Reversed” after it, then it is phrased in the reverse or negative compared to the evidence cited.

Sorry about the messed up formatting; I swear it looks OK in Word. I will try to edit it later today when I have more time.

The KALI Project Survey

Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.

First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.

1. You are:
[1] Male [2] Female

2. Age:
[1] 20 – 29 [5] 60 – 69
[2] 30 – 39 [6] 70 – 79
[3] 40 – 49 [7] 80 – 89
[4] 50 – 59 [8] 90 or older

3. Do you have children?
[1] Yes [2] No

4. Ethnicity:
[1] Hispanic or Latino
[2] Haitian
[3] Neither Hispanic nor Haitian

5. Race (choose as many as apply):
[1] White / Caucasian [4] Native Hawaiian / Pacific Islander
[2] African American / Black [5] Native American Indian /Alaskan
[3] Asian or Asian American [6] Other:_______________________

6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] Other: ____________________________

7. Year of residency completion _____________

8. Which of the following most accurately describes your practice type?
[1] Public hospital
[2] Community health center
[3] University based practice
[4] Private practice
If private –
[a] Large partnership (four or more partners)
[b] Small partnership (two or three partners)
[c] Solo practice
[5] Military / government
[6] Other:____________________________________________

9. Do you currently practice obstetrics?
[1] Yes
If yes:
[a] Average clinical time spent with prenatal clients:______________(%)
[b] Average number of deliveries per year:________________
[2] No

10. Which of the following most accurately describes your personal practice scope?
[1] General obstetrics and gynecology
[2] General gynecology only
[3] Obstetrics only
[4] Laborist
[5] Maternal Fetal Medicine
[6] Reproductive Endocrinologist
[7] Gynecologic Oncology
[8] Urogynecology
[9] Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
[1] None / I “go bare”
[2] I pay for individual malpractice insurance
[3] My practice pays my malpractice premiums
[4] I am an employee of an institution that pays my malpractice premiums
[5] I am an employee of an organization or institution that provides legal defense but
not malpractice insurance
[6] Other: __________________________________________________

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

[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.(K)1 Reversed

2. _____Elective cesarean section should not be performed on a woman desiring several children.(K)2

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.(K)3, 4

4. _____Episiotomy should be avoided if at all possible. (K, A, P)1, 5

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery. (K)6

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries. (K)7, 8 Reversed

7. _____Insurance should not reimburse use of doulas for labor and delivery.9 (A,B)Reversed

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used. (K,P,B) 3, 10 Reversed

9. _____Fear of liability claims limit the options I present to my obstetrical patients.(B,Y,P)11, 12 Reversed

10. _____Liability insurance company policies forbid me from performing VBACs. (B,P) Reversed

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes. (K)1, 13 Reversed

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy. (K)6

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

13. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact. (A,P,K)1, 14 Reversed
14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.(Y,A,K)3 Reversed

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery. (B,P,A)15 Reversed

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.(K,A,Y)6

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.(K)2, 8

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies. (K)16, 17 Reversed
19. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.(K,Y)18

20. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.(B)6 Reversed

21. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.(K,P)1, 19Reversed

22. _____I regularly employ episiotomy to prevent pelvic floor relaxation.(K,P) 3, 5, 16, 17Reversed
23. _____Hospital policies forbid me from performing VBACs.(B)20-22Reversed

24. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.(A)7, 23, 24 Reversed
25. ¬_____I have made changes to my practice because of the risk or fear of liability claims. (B)11, 12 Reversed
26. _____Childbirth is only normal in retrospect.(A)3Reversed

27. _____Clinical guidelines are useful tools for me in daily clinical practice.(A,P)25

28. _____I regularly employ episiotomy to prevent perineal trauma.(K,P)5, 15, 17Reversed

29. _____The use of continuous EFM reduces perinatal mortality.(K)6Reversed
[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

30. _____ Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks. (K,P)18

31. _____I encourage my patients to try alternative or upright positions during the pushing stage.(A,B,P)1, 13, 26, 27

32. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care. (A,P)28 Reversed

33. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.(B,P,K)29, 30 Reversed

34. _____Women should have the right to refuse an episiotomy.(Y)12, 29, 31, 32

35. _____I recommend that most patients use a doula for their labor and delivery.(A,P,K)1, 9

36. _____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.(A)3, 28 Reversed

37. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.(K)6

38. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.(B)33 Reversed

39. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.(Y)31, 32

40. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery. (K)1, 14

41. _____If a patient asks if she could use a doula for her delivery, I would encourage her.(Y,A)1, 4
42. _____ Time and scheduling pressures affect the way I manage labor and delivery.(B) Reversed
43. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.(K)34

44. _____Episiotomies increase the risk of third and fourth degree tears.(K)5, 16, 17

45. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.(B)25 Reversed

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 sources: ______________________________________________________

Have you ever been the subject of a professional liability claim or litigation?
[1] Yes
If yes – Did the liability claim involve an obstetrical claim?
[a] Yes
[b] No
[2] No

Thank you for your time and participation!

Reference List

(1) Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
(2) ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol 2007 December;110(6):1501.
(3) Reime B, Klein MC, Kelly A et al. Do maternity care provider groups have different attitudes towards birth? BJOG 2004 December;111(12):1388-93.
(4) Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007;(3):CD003766.
(5) Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Jr., Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005 May 4;293(17):2141-8.
(6) ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstet Gynecol 9 A.D. July.
(7) Gunnervik C, Sydsjo G, Sydsjo A, Selling KE, Josefsson A. Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists. Acta Obstet Gynecol Scand 2008;87(4):438-44.
(8) NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006 March 27;23(1):1-29.
(9) Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25-8.
(10) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ 1995 September 15;153(6):769-79.
(11) Hyer R. ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates. MedScape Medical News 2009 May 9.
(12) Florida Liability Lowdown. American College of Obstetricians and Gynecologists; 2009 Aug.
(13) Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. Cochrane Database Syst Rev 2004;(1):CD002006.
(14) Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2007;(4):CD006167.
(15) Low LK, Seng JS, Murtland TL, Oakley D. Clinician-specific episiotomy rates: impact on perineal outcomes. J Midwifery Womens Health 2000 March;45(2):87-93.
(16) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006 April;107(4):957-62.
(17) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
(18) ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
(19) Wei SQ, Luo ZC, Xu H, Fraser WD. The effect of early oxytocin augmentation in labor: a meta-analysis. Obstet Gynecol 2009 September;114(3):641-9.
(20) Lyerly AD, Mitchell LM, Armstrong EM et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 2007 April;109(4):979-84.
(21) Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth 2007 December;34(4):316-22.
(22) Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. J Reprod Med 2005 April;50(4):261-6.
(23) Bettes BA, Coleman VH, Zinberg S et al. Cesarean delivery on maternal request: obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007 January;109(1):57-66.
(24) Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005 February;105(2):301-6.
(25) Vinker S, Nakar S, Rosenberg E, Bero-Aloni T, Kitai E. Attitudes of Israeli family physicians toward clinical guidelines. Arch Fam Med 2000 September;9(9):835-40.
(26) Difranco JT, Romano AM, Keen R. Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions. J Perinat Educ 2007;16(3):35-8.
(27) Gilder K, Mayberry LJ, Gennaro S, Clemmens D. Maternal positioning in labor with epidural analgesia. Results from a multi-site survey. AWHONN Lifelines 2002 February;6(1):40-5.
(28) ACOG Committee Opinion No. 395. Surgery and patient choice. Obstet Gynecol 2008 January;111(1):243-7.
(29) Fenwick J, Gamble J, Hauck Y. Reframing birth: a consequence of cesarean section. J Adv Nurs 2006 October;56(2):121-30.
(30) Goodall KE, McVittie C, Magill M. Birth choice following primary Caesarean section: mothers’ perceptions of the influence of health professionals on decision-making. Journal of Reproductive and Infant Psychology 2009 February;27(1):4-14.
(31) Simpson KR, Thorman KE. Obstetric “conveniences”: elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions. J Perinat Neonatal Nurs 2005 April;19(2):134-44.
(32) Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ 1997 March 15;156(6):811-3.
(33) Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. New York: Da Capo Press; 2007.
(34) ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004 July;104(1):203-12.


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6 responses to “Newest, bestest KALI questionnaire, annotated

  1. I was flying back from a midwifery conference last night, and was reading “Blink”. The author mentions a study where black college students were presented with twenty questions from the GRE. If in a pre-test questionnaire, the students were asked to specify their race, it HALVED the number of correct responses.

    Makes me wonder if all questionnaires that require demographic info (race, age, gender, etc) should ask those questions last?


    • MomTFH

      That’s an interesting point. I agonized over the demographics almost as much as I agonized over the rest of the survey. My IRB site administrator told me to move the question about malpractice to the end to avoid a poisoning sort of effect from it. I am not sure how the demographics questions will be received. There may be issues, especially since I decided to include “Haitian” but not other Caribbean ethnicities for a separate heading. I wrote to the admin at Anti-Racist Parent and asked their thoughts on it, but I haven’t gotten a response back.

      I am hoping that, due to the nature of the target population (practicing obstetricians) there will not be that much influence on their answers. First of all, we are asking them about their occupation – something they practice every day, so hopefully their answers will be less malleable than some other study or test situations. Also, this population is conditioned to take standardized tests – by the time you have become a practicing physician, you have taken 100s of standardized exams under more stressful conditions than this survey, so, hopefully the target population will not be as easily shaken.

      However, I am not trying to downplay the importance of demographic questions. I am struggling to find the happy medium in which the demographics are handled adequately and sensitively, and do not draw away from the original study. I wanted to originally include an expanded “gender” or “sex” question that was more inclusive to genderqueers or other non-binary gender identifying individuals, but we decided it would draw away from the main focus of my survey. (I may not 100% agree that it is still not important, but since I am in a fellowship with mentors, I tried to reach a compromise in this area).

      • I recommend reading Blink. It talks all about how hard it is so overcome our subconscious thoughts. I’m not convinced that the target population being monolithically trained will eliminate the effect. Presumably you’re asking for demographics because you want to see if there are correlations in answers? Though maybe you WANT to hone in on the thought process of someone who has been prompted by the question into “Haitian OB” mode rather than just “OB” mode?


        • MomTFH

          I may, who knows? I wanted to leave the demographics out, actually, and only ask about “gender” (not like that is any less fraught). My mentors said my survey would be considered weak if I didn’t ask about demographics. Also, many people blame the cesarean rate in Miami on the ethnicity of the mother, claiming that Hispanic women are more likely to request an elective cesarean. I am not so sure that is the case, and I think maternal request is overemphasized in general. So, ethnicity may be relevant. I am only examining the ethnicity of the providers directly.

          • I see that you acknowledge that “gender” is a very fraught question, and yet you have left no good answer for those of us for whom it is so fraught. If you absolutely must maintain the gender binary (as opposed to having a fill-in-the-blank) please consider at least rewording the question so that instead of demanding “You Are,” it says something more along the lines of “How do you identify?” Then at least we know that you’re asking for lived gender as opposed to assigned-at-birth gender.

          • MomTFH

            I actually had “How do you identify?” in that spot, and included “other:___________” and it was shot down by my mentors. I hear you.

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