Caesarean Section on Request: A Comparison of Obstetricians??? Attitudes in Eight European Countries

Abstract

In this cross-sectional survey, conducted in 8 European countries (Italy, Spain, France, Germany, Netherlands, Luxembourg, United Kingdom, Sweden), obstetricians who had at least 6 months of experience were surveyed regarding their attitude about performing cesarean section at the mother’s request absent of any medical indication for the procedure. Of the 149 maternity centers with neonatal intensive care units asked to participate, 105 (70%) agreed, and 1530 practitioners (77%) answered an anonymous self-administered questionnaire. The highest rate of compliance with the woman’s request because this was “her choice” (79%) was in the United Kingdom, and the lowest rate (15%) was in Spain. Being a colleague did not significantly influence a physician’s willingness to perform a cesarean, nor did fear of vaginal delivery—except in Sweden, where 49% of obstetricians would perform a cesarean because it was the patient’s choice, but 79% would perform a cesarean because of patient fear. In all countries, practitioners were more likely to accede to the woman’s request for cesarean delivery if she had a previous cesarean, traumatic vaginal delivery, intrapartum death, or a disabled first child. The reason cited most often for doing a cesarean exclusively because it was the woman’s choice was respect for the woman’s autonomy. In addition, more than half the respondents in most countries cited a wish to avoid possible legal consequences should vaginal birth be complicated. More than half of the respondents in all countries cited fear of litigation as “often” influencing their decision. Physicians from university-affiliated units were twice as likely to do a cesarean on demand. Female physicians honored the request less often than male physicians, but this was the case only for physicians who themselves had children. Factors that were not influential included the physician’s age, involvement in private practice or research, the unit’s annual delivery and cesarean rates, and whether the unit was a referral center for high-risk pregnancies. Obstetricians who are asked to perform cesarean deliveries electively must balance their respect for the woman’s autonomy and their understanding of the woman’s underlying motivations and fears against what they believe will best promote the health and well-being of both the mother and fetus.