Danish obstetricians' personal preference and general attitude to elective cesarean section on maternal request: A nation-wide postal survey
Abstract
Objective. To assess Danish obstetricians' and gynecologists' personal preference and general attitude towards elective cesarean section on maternal request in uncomplicated single cephalic pregnancies at term.
Design. Nation-wide anonymous postal questionnaire.
Population. Four hundred and fifty-five obstetricians and gynecologists identified in the records of the Danish Society of Obstetrics and Gynecology from January 2000.
Main outcome measures. Personal preference on the mode of delivery and general attitude towards elective cesarean section on maternal request in an uncomplicated single cephalic pregnancies at term.
Results. Of Danish specialists in obstetrics and gynecology, 1.1% would prefer an elective cesarean section in an uncomplicated pregnancy at 37 weeks of gestation with fetal weight estimation of 3.0 kg. This rose to 22.5% when the fetal weight estimation was 4.5 kg at 37 weeks. The main reasons given for preferring abdominal deliveries was the risk to the fetus, risks of perineal injury, and urinary and anal incontinence.
Of Danish specialists in obstetrics and gynecology, 37.6% agreed with a woman's right to have an elective cesarean section on maternal request without any medical indication. Obstetricians and gynecologists who had experienced a noninstrumental vaginal delivery themselves or practiced as a private gynecologist only, were less likely to agree with the woman's right to elective cesarean section on maternal request.
Conclusion. The vast majority of Danish obstetricians and gynecologists would personally prefer vaginal delivery in uncomplicated pregnancies, but nearly 40% agree with the woman's right to request a cesarean section.
Throughout the late 1990s the use of an invasive procedure in pregnancy, labor and delivery has increased in the industrialized world. This increase is partly the result of medical indications based on best evidence and the personal experience of the obstetrician. But it is now more and more influenced by the wishes and choices of the well-informed mother and her family. When originally introduced, cesarean section was only performed when medical or obstetric complications occurred. Throughout the last decade, the numbers of indications have gradually increased. Maternal request for elective cesarean section in situations without any medical or obstetric indication has been added to the list of indications. It has been presented in the public and medical literature as a basic maternal right, as long as the women has been fully informed about the risk (1). This viewpoint has been supported by the decreasing risks related to cesarean section, together with the possibility of stillbirth from 37 weeks of gestation (2). Elective cesarean section has been proposed as the answer to the rising diversity of the pelvis and the size of the fetal brain and skull in the human birth process caused by evolution (3).
In England official reports have suggested that women should have a central role in their obstetric care, place of delivery and the degree of intervention (4), and that maternity services should be more women-centred (5). A questionnaire study from London found that 31% of female obstetricians would personally prefer elective cesarean section in an uncomplicated pregnancy (6). In Denmark official law proclaims the dignity, integrity and self-determination as fundamental to the legal position of the patient, and the Guidelines for Antenatal Care from the National Board of Health emphasizes the central role of every woman's needs, experience, integrity and the possibility of choice (7). Whether this supports the woman's right to an elective cesarean section in uncomplicated pregnancies is not clear. The debate of the availability of cesarean section on maternal request will without doubt intensify in the years to come. Because of this, we thought it important to evaluate the personal preference of delivery mode among Danish specialists in obstetrics and gynecology, and their general attitude towards elective cesarean section on maternal request.
Materials and methods
In January 2000, 455 specialist obstetricians and gynecologists were identified from the records of the Danish Society of Obstetrics and Gynecology. In January 2001, all were sent a postal questionnaire, and 2 months later the nonresponders were sent a reminder. Data were handled anonymously. The first part of the questionnaire included questions about their age and gender, how many years they had practiced as specialists, and the type of hospital and region in which they were practicing. Furthermore they were asked how many children they had, if they as parents had experienced elective or emergency cesarean section, or if they had had any experience of forceps or ventouse deliveries. The second part included questions to female specialists about their personal preference and male specialists concerning their recommendation to their partners. They were asked about their personal preference of delivery mode if they or their partner was a nulliparous woman in an uncomplicated pregnancy with a singleton in cephalic presentation at 37 full weeks, with ultrasonically estimated fetal weights of 3.0, 4.0 and 4.5 kg. If they opted for cesarean section, they were then asked on what basis their preference was made. Furthermore they were asked about their attitude to elective cesarean section on maternal request without any medical indication. A total of 401 (88,1%) returned the questionnaires of whom 17 did not want to participate, and another 20 did not respond to all the questions. Three-hundred-and-sixty-four (80.0%) responders were left for the final analysis. Statistical analysis was performed using SAS for Windows, Release 6.12 (SAS Institute Inc., Cary, NC, USA). In the multiple logistic regression analysis, the odds ratios and their corresponding 95% confidence intervals were calculated, and if the value 1.0 was not included in the confidence interval, the test result was considered statistical significant (p-value < 0.05).
Results
As seen in Table I, 98.9% of the Danish obstetric and gynecology specialist responders would prefer to await the onset of spontaneous labor in an uncomplicated pregnancy with a single cephalic presentation at term with an ultrasonically estimated fetal weight of 3.0 kg at 37 weeks; 1.1% would prefer an elective cesarean section. With an increasing weight estimation of the fetus, the preference for elective cesarean section and induction increased to 22.5% and 33.8%, respectively. The reasons among the participants for preferring cesarean section are seen in Table II. The risks of perineal injury, and anal and urinary incontinence increases with the increase in estimated fetal weight from 50 to 76% and 25 to 84% respectively. Risk of sexual dysfunction was the reason for elective cesarean section in 25–33.3% of the cases.
| Estimated fetal weight | 3.0 kg | 4.0 kg | 4.5 kg |
|---|---|---|---|
| Elective cesarean section | 1.1% | 3.3% | 22.5% |
| Induction | 0.0% | 8.8% | 33.8% |
| Await spontaneous labor | 98.9% | 87.9% | 42.3% |
| In doubt | 0.0% | 0.0% | 1.4% |
| Estimated fetal weight | 3.0 kg | 4.0 kg | 4.5 kg |
|---|---|---|---|
| Risk of perineal injury | 50.0% | 66.6% | 76.8% |
| Risk of anal and urinary incontinence | 25.0% | 58.3% | 84.1% |
| Risk of sexual dysfunction | 25.0% | 33.3% | 30.5% |
| Risk of injury to the child | 75.0% | 83.3% | 80.5% |
| Risk of pain in labor | 0.0% | 0.0% | 4.9% |
| Wish to control time of delivery | 0.0% | 8.3% | 1.2% |
Concerning the women's right to choose an elective cesarean section on request without any medical indication, 56.6% (n = 206) said no, 37.6% (n = 137) said yes, and 5.8% (n = 21) were in doubt. Of the 206 who responded ‘no’, 20 (5.5%) responders added, in free text, that they would to some extent accept a maternal request after careful discussion of the risks and consequences. Table III presents the multiple logistic regression model exploring risk indicators for elective cesarean section on maternal request. A history of a noninstrumental vaginal delivery [OR = 0.49, 95% CI (0.27–0,90)], and that being a private gynecologic specialist [OR = 0.36, 95%CI (0.17–0.78)] significantly reduced the acceptance of elective cesarean section. No other types of previous delivery method, age or gender revealed any important or significant relations in the regression model.
| Variables | Number | % | ORcrude | ORadj | 95% CI |
|---|---|---|---|---|---|
| Non-instrumental vaginal delivery | |||||
| No | 75 | 20.6 | 1.00 | 1.00 | |
| Yes | 289 | 79.4 | 0.58 | 0.49 | (0.27–0.90) |
| Instrumental vaginal delivery | |||||
| No | 296 | 81.3 | 1.00 | 1.00 | |
| Yes | 68 | 18.7 | 1.11 | 0.91 | (0.50–1.66) |
| Elective cesarean section | |||||
| No | 318 | 87.1 | 1.00 | 1.00 | |
| Yes | 46 | 12.9 | 0.84 | 0.65 | (0.32–1.36) |
| Emergency cesarean section | |||||
| No | 317 | 87.4 | 1.00 | 1.00 | |
| Yes | 47 | 12.6 | 1.40 | 1.10 | (0.52–2.25) |
| Gender | |||||
| Male | 220 | 60.4 | 1.00 | 1.00 | |
| Female | 144 | 39.6 | 0.85 | 0.82 | (0.50–1.34) |
| Age, years | |||||
| < 45 | 69 | 19.0 | 1.69 | 1.67 | (0.82–3.39) |
| 45–49 | 90 | 24.7 | 1.43 | 1.26 | (0.67–2.40) |
| 50–54 | 81 | 22.3 | 0.87 | 0.74 | (0.39–1.40) |
| > 54 | 124 | 34.0 | 1.00 | 1.00 | |
| Employment | |||||
| Consultant | 202 | 55.5 | 1.00 | 1.00 | |
| Senior House Registrar | 93 | 25.5 | 1.01 | 0.87 | (0.47–1.61) |
| Private Specialist | 54 | 14.8 | 0.37 | 0.36 | (0.17–0.78) |
| Others | 15 | 4.1 | 0.36 | 0.36 | (0.09–1.43) |
- Adjusted Odds Ratio's and 95% Confidence Intervals are mutually adjusted for all variables in the table.
Discussion
In their original paper, Al-Mufti et al. found that 17% of the 206 responding obstetricians working within London's M25 region would prefer an elective cesarean section if they or their partner were pregnant for the first time with a single cephalic presentation in an uncomplicated pregnancy at term (6). The preference increased to 39 and 68% if the fetal weight was estimated to be between 4.0 and 4.5 kg or more than 4.5 kg. In their analysis they found a significantly higher preference for elective cesarean section among female compared with male obstetricians. The authors asked to what extent personal attitudes and preferences in health care professionals might influence the counselling process of patients, and whether elective cesarean section should be offered to all women, as the option seems available to obstetricians. Gabbe and Holzman surveyed 117 North American obstetricians attending a meeting arranged by the American College of Obstetricians and Gynecologists in August 2000. They found that 46.2% would personally prefer to be delivered by cesarean section (8). If fetal weight was estimated in the two categories as in the paper by Al-Mufti et al., the preference for abdominal delivery would increase to 70 and 88% respectively. Both studies report a high preference for elective cesarean section, which contrasts significantly to the 1.1% found in our study and in an anonymous nation-wide postal survey among obstetricians in the Netherlands (9). We found a similar, but less dramatic, increasing preference for elective cesarean section with increasing birth-weight estimations. As the main reasons for elective cesarean section in our study were risk to the fetus, perineal injury, and anal and urinary incontinence, this trend is probably the result of the increasing risks of difficult vaginal deliveries with increasing birth weight (10–12). The study from London covers a specific region that, according to the authors, has a socially and ethnically diverse population and is very heterogeneous in terms of medical practice. This does not necessarily imply that the participants in the survey reflect the surrounding community, and one should be careful not to generalize such results. The American study covers two districts of the American College of Obstetricians and Gynecologists, and the participants were asked about their personal preference for mode of delivery during a panel discussion. As the proportion of obstetricians attending the meeting was unclear, it is difficult to know if we can generalize the result to the population of North American obstetricians. Our study and the Dutch study are nation-wide, with acceptable high response rates. Even if these studies do not represent the real attitude among obstetricians in England and North America, the tendency of a higher preference towards cesarean section on maternal request could contribute to the higher cesarean section rates in these countries compared with those seen in Denmark and the Netherlands (9,13).
Our study supports that obstetricians in Denmark, in general, do not prefer cesarean section in uncomplicated pregnancies, and they are divided in opinion about whether a woman should be able to choose an elective cesarean section without any medical or obstetric indication. It seems that personal experience of delivery is important regarding the question about cesarean section on maternal request. Obstetricians and gynecologists who had had a personal experience of a noninstrumental vaginal delivery were less likely to agree with a request for cesarean section, but personal experience of either a previous operative vaginal delivery, an elective or emergency cesarean section did not affect their agreement with a request for cesarean section. The other influential factor in our study of agreement with cesarean section on maternal request was the low acceptance among gynecologic private specialists. In Denmark, private specialists in gynecology and obstetrics do not practice obstetrics. Their low acceptance of cesarean section on maternal request could be because of the fact that they had had no experience of this new phenomenon in obstetrics in their earlier practice as obstetricians.
As seen in the study by Al-Mufti et al., we expected gender to have a significant impact on the attitude of cesarean section on maternal request. This was not seen in the crude or adjusted estimates in the regression analysis, indicating no confounding age and other variables in the study. Our study shows that Danish obstetricians and gynecologists themselves generally prefer vaginal deliveries in uncomplicated pregnancies. On the other hand, a large proportion of Danish obstetricians and gynecologists accept the woman's right to request an elective cesarean section if no medical or obstetric indications are present. As a consequence, obstetricians and midwives should be encouraged to ensure the safety of both vaginal and abdominal births, as well as making birth a satisfying experience for the mother, baby and their family.
Graham et al. found that almost one-third of 166 women undergoing emergency cesarean section expressed negative feelings towards their delivery, compared with 13% among those choosing an elective section. In this study, the proportion of women in which maternal preference was a direct factor in the decision for cesarean section was 1.8% (14). In an Australian study, 6.4% of the women requested an cesarean section, and of those most had a current obstetric complication or had experienced a previous complicated delivery (15). Health care systems are concentrating more on the individual's rights and influence on intervention, and cesarean section on maternal request will undoubtedly be part of obstetric management in the future.
We should try to clarify what proportion of pregnant women prefer this mode of delivery, and the motive behind their wish. This should be carried out by prospective data collection, focusing on this phenomenon in institutions that prefer cesarean section on maternal request. In addition, institutions that do not accept cesarean section on maternal request should collect data concerning women that initially want an abdominal delivery and either end up in a trial of labor or change the place of birth. This would give us valid information about the size and nature of this obstetric dilemma, and whether or not we should try to convince these women about having a trial of labor. We believe that, together with the physical outcomes of the mother and fetus, maternal satisfaction is also an important outcome measure. The mother's involvement in and influence on the mode of delivery might affect her satisfaction (16,17).
As professional caregivers, we should inform our patients about the means and consequences, and also what we think is most appropriate for them. But the integrity of the woman is fundamental and her own wishes and experience might differ from ours. If we disagree with her preference of delivery mode, we must remember that she will live with the consequences of her delivery, and we should respect her choice (18). In future, we need an open concept of the good, as suggested by Wackerhausen. From his philosophical perspective, it is not the professionals, but the informed and autonomous individual, who should decide what is good and what is bad (19).
