Caesarean section on request: a comparisonof obstetricians’ attitudes in eightEuropean countriesM Habiba,a M Kaminski,b M Da Fre,c K Marsal,d O Bleker,e J Librero,f H Grandjean,g

P Gratia,h S Guaschino,i W Heyl,j D Taylor,a M Cuttinik

a Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK b INSERM Unit 149,

Epidemiological Research Unit on Perinatal Health and Women’s Health, Villejuif Cedex, France c Unit of Epidemiology, Regional Health Agency of

Tuscany, Florence, Italy d Department of Obstetrics and Gynaecology, Lund University Hospital, Lund, Sweden e Department of Obstetrics and

Gynecology, Amsterdam Medical Centre, Amsterdam, The Netherlands f Fundacion Instituto de Investigacion en Servicios Salud, Valencia, Spaing INSERM Unit 558, Research Unit in Epidemiology and Public Health, Toulouse Cedex, France h Department of Gynecology and Obstetrics, Centre

Hospitalier de Luxembourg, Luxembourg i Obstetrics and Gynaecology Unit, Istituto per l’Infanzia ‘‘Burlo Garofolo’’, Trieste, Italy j Klinikum

Ludwigsburg, Frauenklinik, Ludwigsburg, Germany k Unit of Epidemiology, Ospedale Pediatrico Bambino Gesu, Rome, Italy

Correspondence: Dr M Habiba, Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester,

Robert Kilpatrick Building, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX, UK. Email mah6@le.ac.uk

Accepted 17 February 2006. Published OnlineEarly 2 May 2006.

Objective To explore the attitudes of obstetricians to performe a

caesarean section on maternal request in the absence of medical

indication.

Design Cluster sampling cross-sectional survey.

Setting Neonatal Intensive Care Unit (NICU) associated maternity

units in eight European countries.

Population Obstetricians with at least 6 months clinical

experience.

Methods NICU-associated maternity units were chosen by census

in Luxembourg, Netherlands and Sweden and by geographically

stratified random sampling in France, Germany, Italy, Spain and

UK. An anonymous, self-administered questionnaire was used for

data collection.

Main outcome measures Obstetricians’ willingness to perform

a caesarean section on maternal request.

Results One hundred and five units and 1530 obstetricians

participated in the study (response rates of 70 and 77%,

respectively). Compliance with a hypothetical woman’s request for

elective caesarean section simply because it was ‘her choice’ was

lowest in Spain (15%), France (19%) and Netherlands (22%);

highest in Germany (75%) and UK (79%) and intermediate in

the remaining countries. Using weighted multivariate logistic

regression, country of practice (P < 0.001), fear of litigation

(P = 0.004) and working in a university-affiliated hospital

(P = 0.001) were associated with physicians’ likelihood to agree

to patient’s request. The subset of female doctors with children

was less likely to agree (OR 0.29, 95% CI 0.20–0.42).

Conclusions The differences in obstetricians’ attitudes are not

founded on concrete medical evidence. Cultural factors, legal

liability and variables linked to the specific perinatal care

organisation of the various countries play a role. Greater emphasis

should be placed on understanding the motivation, values and

fears underlying a woman’s request for elective caesarean delivery.

Keywords Caesarean, maternal request, obstetricians’ attitude.

Please cite this paper as: Habiba M, Kaminski M, Da Fre M, Marsal K, Bleker O, Librero J, Grandjean H, Gratia P, Guaschino S, Heyl W, Taylor D, Cuttini M.

Caesarean section on request: a comparison of obstetricians’ attitudes in eight European countries. BJOG 2006; 113:647–656.

Introduction

Caesarean section performed at patients’ request in the

absence of a medical indication is a focus of considerable

attention both for clinical and ethical reasons.1–5 The reported

rates range from 2.6% in Flanders6 to 26.8% in Western

Australia.7 Different sampling frameworks and the inconsist-

ent use of the term ‘on demand’ may, at least partially, explain

such wide variation.8,9 Nevertheless, there are indications that

maternal request is becoming increasingly relevant in situa-

tions where medical justification may not—in itself—be suf-

ficient to recommend a caesarean delivery.10–12 The caesarean

section rate is rising in most developed countries, and evi-

dence from North Carolina suggests that the rising primary

DOI: 10.1111/j.1471-0528.2006.00933.x

www.blackwellpublishing.com/bjogIntrapartum care

ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 647

caesarean section rate is not explained by changes in patients’

characteristics.13 A growing awareness of consumer preferen-

ces is said to play a major role.14 However, physicians’ atti-

tudes can significantly influence or motivate patients’ choice,15,16

a point which acquires prominence in the light of the evidence

that a significant proportion of obstetricians in the USA (46%)

and of female obstetricians in London (31%) would favour

a caesarean section for themselves or for their partners in an

uncomplicated pregnancy.17,18 Yet, this view was shared by

only 16% of Scottish female obstetricians,19 15% of female UK

trainees,20 7% of obstetricians in the Republic of Ireland,21 2% of

Norwegian22 and Flemish6 obstetricians and by only 1.4% of

those in the Netherlands.23

That a proportion of obstetricians would prefer a caesarean

section for themselves or for their partner may reflect their

perception of its overall safety or other advantages compared

with vaginal delivery.24 There is also an evidence of an

increased willingness of obstetricians to accept their patients’

request for a caesarean delivery in the absence of ‘mitigating’

circumstances. When surveyed, 69% of consultant obstet-

ricians in England and Wales indicated that they would per-

form an elective caesarean birth on maternal request due to

fear of litigation and pressure from the patients,25 and

approximately 50% of obstetricians in Israel were willing to

perform a caesarean section on request in support of patient’s

autonomy.26 That this be the case despite the generalised

concerns about the rising caesarean section rates represents

a significant shift from the position held by most obstetricians

two decades ago.27 The exact reasons for this change remain

to be explored.

Data that allow direct comparison between countries and

provide insight about the factors influencing clinical decision

making are scarce. A European multicenter study project

(EUROBS) on ethical issues in pre- and perinatal care offered

the opportunity to describe the attitudes of a large represen-

tative sample of obstetricians in eight European countries

towards a request for caesarean delivery in the absence of

compelling medical reasons and to explore the possible

underlying factors.

Methods

SampleEight European countries took part in the EUROBS project

(Developments of Perinatal Technology and Ethical Decision-

Making during Pregnancy and Birth: the Obstetricians’ Per-

spective): France, Germany, Italy, Luxembourg, Netherlands,

Spain, Sweden and UK. In every country, only maternity units

associated with a third-level Neonatal Intensive Care Unit

(NICU) were sampled. The cluster sampling strategy mir-

rored the one adopted in a previous European study on

ethical issues in neonatal medicine (EURONIC).28,29 In Lux-

embourg, The Netherlands and Sweden, all the existing

NICU-associated maternity units were recruited (census sam-

pling); whereas in France, Germany, Italy, Spain and UK,

random samples stratified by geographical area were selected.

In every recruited unit, all physicians with at least 6 months

experience in obstetrics were invited to participate in the

study.

Data collectionData collection took place in 2001–02. Structured question-

naires were used to record information on unit organisation

and policies and to survey the obstetricians’ practices and

attitudes in six major areas: prenatal ultrasound examination,

late termination of pregnancy, management of severe prema-

turity, situations of conflicting opinions between staff and the

women, legal concerns in obstetric practice and maternal

request for caesarean section. The head or the clinical director

of each unit was contacted inviting the unit to participate and,

in case of agreement, to identify a local study coordinator. The

local study coordinator undertook the distribution of the staff

questionnaires to eligible obstetricians. Completed question-

naires were returned in sealed envelopes to the coordinating

centre in Italy either directly or via the local coordinator.

The staff questionnaire was anonymous and self-administered

to protect confidentiality. Thus, nonresponders were not

identified and no reminders were sent. It was developed in

English and translated into national languages; a back-

translation into English was performed to check the accuracy

of the translation and ensure identical semantic content. A

pilot study was carried out to assess the questionnaires’ read-

ability and suitability to the different national contexts.

This study explores obstetricians’ attitudes to a woman’s

request for caesarean delivery in case of uncomplicated term

pregnancy as an area of potential conflict between staff and

women. Respondents were asked to consider whether or not

they would perform a caesarean section on a 25-year-old

woman, with a singleton uncomplicated pregnancy in cephalic

presentation at 39 weeks of gestation, who requests cae-

sarean section despite the obstetrician’s recommendations

for vaginal delivery and despite her being informed of the

higher morbidity and mortality associated with surgical birth.

Respondents were also asked to consider their response in

case the patient’s preference was based on one of the following

distinct scenarios: a) her personal choice, b) fear of vaginal

delivery, c) previous caesarean section, d) previous traumatic

vaginal delivery, e) previous intrapartum fetal death, f) that

her first child was disabled and g) the patient were a colleague.

Respondents who indicated compliance with maternal

request based on any of these reasons were then asked to

clarify their rationale by selecting one or more of the follow-

ing nonexclusive options: a) out of respect for the woman’s

autonomy, b) to avoid possible problems with noncompli-

ance during delivery and c) to avoid possible legal consequen-

ces in case something goes wrong. Space was allowed to write

Habiba et al.

648 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

in additional answers beyond the preset ones. Different sec-

tions of the questionnaire addressed doctors’ demographic

and professional characteristics and their perception of the

effect of litigation on their practice. The latter question aimed

at establishing the number of obstetricians who felt that their

personal medical practice was influenced ‘often’, ‘occasionally’

or ‘not at all’ by fear of litigation.

Statistical analysisQuestionnaire coding and data entry were performed at the

coordinating centre in Italy. Statistical analysis was carried

out with the STATA statistical package (version 8.0).30

Weights, computed as the inverse of the probability for a given

maternity unit to be selected within a certain country and

geographical stratum, were applied to take into account the

different sampling fractions adopted in the participating

countries.28,29,31 Standard errors were adjusted for intracluster

correlation, that is the nonindependence of observations

within the same maternity unit.31

Unless stated otherwise, results are presented as weighted

proportions and 95% CI. Multivariate logistic regression

analysis was used to explore factors associated with an obstet-

rician’s agreement with the request for caesarean delivery

solely because it was the woman’s personal choice. The doctor-

related variables considered as predictive factors included age,

sex, having had children, current religion and religiousness,

length of experience in obstetrics, involvement in private

practice, involvement in research and self-reported feelings

that fear of litigation influences one’s clinical practice. The

unit-related variables included number of deliveries per year,

number of obstetric beds, unit proportion of caesarean deliv-

eries, whether or not the hospital and/or the unit was univer-

sity affiliated and whether or not the unit was a referral centre

for high-risk pregnancies. The final model retained the vari-

ables significantly associated with the outcome of interest at

the 0.05 level. A statistically significant interaction (P = 0.01)

was found between the obstetricians’ gender and having had

children; therefore, the odds ratios for women versus men

were reported separately according to whether or not they

had children.

Results

One hundred and forty-nine units were invited to participate

in the study and 105 agreed, corresponding to a unit response

rate of 70% (Table 1). Completed questionnaires were

returned from 1530 obstetricians, with an overall staff

response rate of 77% (ranging from 63% in Germany to

93% in France). The number and main socio-demographic

and professional characteristics of the participating doctors

are shown in Table 2. In every country except Italy, France

and Luxembourg, about half of the respondents were women.

In Italy and Sweden, 40% of respondents were aged 50 years

or more, compared with only 7% in the UK. In all countries

except Luxembourg, most physicians were working full time

in the hospital; in Italy, Spain and Luxembourg, a large pro-

portion of respondents also had a private practice either

within the same hospital or outside it.

Table 3 shows the proportion of obstetricians who, in each

country, would perform a caesarean section at term for a

25-year-old healthy woman in the absence of strict medical

indications. Compliance with this hypothetical woman’s

request simply because this was ‘her choice’ was lowest in

Spain (15%), France (19%) and The Netherlands (22%);

highest in Germany (75%) and UK (79%) and intermediate

in the remaining countries. Being a colleague did not signifi-

cantly alter physicians’ willingness to perform a caesarean

section; the same holds for fear of vaginal delivery, with the

exception of Sweden where the proportion of respondents

accepting the woman’s request raised from 49 to 79%. In

every country, doctors said that they were more likely to

comply with the woman’s request in case of a previous cae-

sarean section, traumatic vaginal delivery, intrapartum death

or if the first child was disabled. Although a shift in opinion in

favour of caesarean delivery was observed in all countries

given these mitigations, the differences between countries

remained. Only in Spain and France, a sizeable proportion

of physicians (33 and 16%, respectively) would in any case

reject the woman’s request for a caesarean delivery.

Respect for the woman’s autonomy was the most fre-

quently quoted reason for performing a caesarean section

simply because it was the patient’s choice (Table 4). However,

prevention of possible legal consequences linked to compli-

cations of vaginal birth was also mentioned by more than 50%

of respondents in every country except The Netherlands and

Sweden.

Obstetricians were asked in a different section of the

questionnaire whether they felt that their personal medical

practice was influenced by fear of litigation, and their answers

Table 1. Sample size and response rate

Country Obstetric units Physicians

Number

recruited

Response

rate (%)

Number

responding

Response

rate (%)

Italy 28 85 383 90

Spain 15 75 328 80

France 10 53 100 93

Germany 13 41 139 63

Netherlands 10 100 126 74

Luxembourg 1 100 15 79

UK 11 65 163 65

Sweden 17 100 276 74

Total 105 70 1530 77

Obstetricians’ attitudes to request for caesarean

ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 649

are shown in Figure 1. In every country, more than 50% of

respondents answered that ‘occasionally’ this was the case.

Fear of litigation was quoted as ‘often’ influencing decision

making more frequently in Italy and Spain, while the opposite

was true in Sweden and The Netherlands.

Table 5 shows the results of the multivariate logistic analy-

sis exploring the factors associated with obstetricians’ likeli-

hood to comply with the woman’s request for a caesarean

section purely because it was her choice. Differences between

countries remained statistically significant after potential

Table 2. Socio-demographic and professional characteristics of responding obstetricians (unweighted proportions)*

Italy,

n (%)

Spain,

n (%)

France,

n (%)

Germany,

n (%)

Netherlands,

n (%)

Luxembourg,

n (%)

UK,

n (%)

Sweden,

n (%)

Sex

Male 241 (64) 169 (52) 63 (63) 71 (51) 64 (51) 10 (67) 84 (52) 127 (46)

Female 133 (36) 155 (48) 37 (37) 68 (49) 61 (49) 5 (33) 76 (47) 147 (54)

Age (years)

Younger than 30 35 (9) 68 (21) 17 (17) 24 (17) 10 (8) 2 (13) 18 (11) 3 (1)

30–39 67 (18) 103 (32) 46 (46) 73 (53) 65 (52) 5 (33) 85 (53) 60 (22)

40–49 124 (33) 78 (24) 22 (22) 23 (17) 27 (22) 6 (40) 45 (28) 102 (37)

50 and more 149 (40) 75 (23) 15 (15) 19 (14) 23 (18) 2 (13) 12 (7) 109 (40)

Having had children

Yes 264 (70) 195 (60) 71 (71) 58 (42) 80 (64) 9 (60) 102 (64) 249 (91)

No 111 (30) 128 (40) 29 (29) 81 (58) 45 (36) 6 (40) 58 (36) 25 (9)

Length of experience in obstetrics (in years)

Less than 1 0 16 (5) 5 (5) 5 (4) 0 1 (7) 3 (2) 4 (1)

1–5 59 (15) 89 (27) 21 (21) 68 (49) 38 (30) 2 (13) 39 (24) 51 (19)

More than 5 322 (85) 222 (68) 74 (74) 65 (47) 87 (70) 12 (80) 120 (74) 219 (80)

Full-time work in the hospital

Yes 329 (86) 288 (88) 97 (97) 130 (94) 109 (87) 6 (40) 149 (92) 246 (89)

No 52 (14) 40 (12) 3 (3) 8 (6) 17 (13) 9 (60) 13 (8) 29 (11)

Private practice activity

Yes 298 (78) 134 (41) 26 (26) 11 (8) 1 (0.8) 8 (57) 22 (14) 19 (7)

No 84 (22) 193 (59) 74 (74) 128 (92) 125 (99) 6 (43) 139 (86) 256 (93)

*Within countries, discrepancies between totals and number of responding obstetricians as presented in Table 1 are due to missing values.

Table 3. Respondents’ attitudes towards a request for caesarean delivery for an uncomplicated term pregnancy (weighted proportions)*

Italy, %

(95% CI)

Spain, %

(95% CI)

France, %

(95% CI)

Germany, %

(95% CI)

Netherlands, %

(95% CI)

Luxembourg, %

(95% CI)

UK, %

(95% CI)

Sweden, %

(95% CI)

Proportion of physicians who would comply with this woman’s request for a caesarean delivery for each of the following reasons

1. This is her choice 55 (46–64) 15 (9–23) 19 (14–26) 75 (57–87) 22 (17–29) 57 (33–78) 79 (72–85) 49 (42–57)

2. Fear of vaginal delivery 46 (38–54) 10 (6–16) 14 (8–24) 85 (72–92) 30 (24–37) 50 (24–76) 76 (69–82) 79 (71–85)

3. Previous caesarean

section

93 (90–95) 38 (30–48) 49 (38–60) 92 (83–97) 62 (48–75) 86 (76–92) 98 (93–99) 73 (67–77)

4. Previous traumatic

vaginal delivery

78 (70–84) 38 (30–47) 77 (61–88) 97 (89–99) 81 (76–86) 86 (76–92) 99 (96–100) 94 (91–96)

5. Previous intrapartum

death

81 (76–85) 60 (50–70) 67 (54–78) 94 (88–97) 90 (86–93) 93 (88–96) 98 (95–99) 90 (86–93)

6. Her first child is disabled 80 (73–85) 54 (45–63) 55 (43–67) 96 (89–99) 76 (67–83) 86 (76–92) 94 (89–97) 86 (80–90)

7. This patient is a colleague 47 (40–55) 21 (16–28) 26 (18–36) 78 (67–86) 27 (21–34) 57 (33–78) 76 (68–82) 58 (51–64)

Proportion of physicians who would in any case refuse to comply with this woman’s request for a caesarean delivery

2 (0.8–5) 33 (25–43) 16 (9–27) 2 (0.5–10) 6 (3–12) 7 (4–12) 0 6 (3–9)

*A 25-year-old pregnant woman starts labour at 39 completed weeks. The fetus was apparently normally formed, healthy and in cephalic

presentation. Despite being informed that a vaginal delivery is indicated, and of the higher morbidity and mortality associated with caesarean

delivery, the woman insists on a caesarean section.

Habiba et al.

650 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

confounders were controlled for. Caesarean section on

demand appeared more likely to be accommodated in the

UK and Germany and less likely in Spain, France and The

Netherlands. Physicians from university-affiliated units were

twice as likely to perform a caesarean section on demand. In

contrast, being a female doctor decreased the probability of

accepting a patient’s request for a caesarean section, but the

effect was statistically significant only among physicians who

had children themselves (OR 0.29, 95% CI 0.20–0.42). A con-

sistent, statistically significant trend emerged between obstet-

ricians’ self-reported feeling that their clinical practice was

influenced, occasionally or often, by fear of litigation and

the willingness to perform a caesarean delivery at the patient’s

request. Factors not associated with the likelihood of agreeing

to a woman’s request for a caesarean section were the doctor’s

age, current religion and religiousness, length of experience in

obstetrics, involvement in private practice or research, the

unit’s annual delivery rate, the number of obstetric beds,

the unit’s caesarean rates and whether the unit was a referral

centre for high-risk pregnancies (data not shown).

Discussion

This study presents the findings of a large representative sam-

ple of obstetricians from NICU-associated maternity units in

eight European countries. The census or the random sam-

pling strategy that was adopted and the overall high physi-

cians’ response rate within the recruited units (77%) support

the validity of our data, although in some countries, a lower

unit recruitment fraction might have impaired the represen-

tativeness of the results at national level.

When confronted with a woman’s request for a caesarean

delivery in the absence of clinical indication, the attitude of

European obstetricians varied within as well as between coun-

tries. Obstetricians from Spain, France and The Netherlands

were the least likely and those from UK and Germany the

Table 4. Reasons for supporting this woman’s choice for a caesarean delivery independently from other medical or nonmedical indications

(weighted proportions)

Italy, %

(95% CI)

Spain, %

(95% CI)

France, %

(95% CI)

Germany, %

(95% CI)

Netherlands, %

(95% CI)

Luxembourg, %

(95% CI)

UK, %

(95% CI)

Sweden, %

(95% CI)

Proportions of physicians indicating the following reasons*

Out of respect for the

woman’s autonomy

93 (87–97) 83 (61–94) 79 (62–90) 95 (80–99) 96 (78–99) 100 97 (92–99) 97 (93–99)

To avoid possible problems

of noncompliance during

delivery

45 (33–58) 40 (30–51) 53 (33–72) 49 (41–58) 37 (22–55) 62 (50–74) 33 (29–37) 52 (39–64)

To avoid possible legal

consequences if

something goes wrong

63 (54–71) 81 (70–89) 89 (50–99) 69 (59–77) 30 (13–53) 87 (69–96) 52 (40–63) 31 (25–37)

*Proportions computed on physicians who would perform a caesarean section simply because it was the woman’s choice. Answers were

not mutually exclusive.

0

10

20

30

40

50

60

70

80

90

100

Italy Spain France Germany Netherlands Luxembourg UK SwedenNo Yes, occasionally Yes, often

Figure 1. Proportion of physicians feeling that their personal medical practice is influenced ’occasionally’ or ’often’ by fear of litigation.

Columns indicate weighted proportion; vertical bars indicate 95% CI.

Obstetricians’ attitudes to request for caesarean

ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 651

most likely to accept a request for a caesarean section based

exclusively on patient’s choice. International variability was

not explained by differences in physicians’ demographic and

professional characteristics or by characteristics of the units.

Thus, it is likely that cultural factors, as well as elements

related to the national organisation of perinatal care, play

a role. Differences in physicians’ attitudes across countries

have been reported also by other studies. Doctors from

Greece, Spain and Italy appeared less likely and those from

the Netherlands most likely to give complete information in

relation to intensive care interventions.32 Neonatologists were

less likely to involve parents in decisions concerning their

preterm babies in the NICUs of France, Italy and Spain, com-

pared with the northern countries such as Sweden and UK.28

Medical paternalism is said to be a more dominant tradition

in France, while in the Anglo-Saxon cultures, patient’s con-

sent is given more prominence.33 These patterns may partially

explain our findings in Spain and France on the one hand and

the UK on the other hand. In the Netherlands, a very low

national caesarean section rate34 is coupled with a policy of

prenatal care delivered, in case of low-risk pregnancy, by GPs

and midwives rather by obstetricians:23: a pattern consistent

with the lower agreement with caesarean on demand docu-

mented in our study as well as in others.23,35

Obstetricians’ attitudes, however, are also dependent on

the clinical question asked. According to our data, in most

countries, a maternal request for a caesarean delivery

appeared more likely to be accepted when backed up by

a medical or quasi-medical justification, even when question-

able from an evidence-based perspective (e.g. previous cae-

sarean section, traumatic delivery, intrapartum death or

disabled child). Physicians’ acceptance of such reasoning

seemed to be high in every country except Spain. In the Neth-

erlands, the resulting change in attitudes was quite remark-

able, suggesting that a shift from the ‘normal pregnancy’

paradigm moved the woman’s request to a different level of

consideration. In Spain, however, despite the overall high

caesarean section rate,34 none of the mitigating quasi-medical

indications was sufficient to persuade a significant proportion

of doctors to accept a caesarean delivery on request. The

marked contrast between Spain and other countries such as

UK and Germany is unlikely to be explained by differences in

the interpretation of medical evidence; rather, it seems to

emphasise the value attributed to patient’s choice.

Although ‘country’ is an important explanatory variable for

doctors’ attitudes towards maternal choice, responses within

countries were not uniform, pointing to the role of unit policies

or even practitioners as individuals. Physicians’ age as well as

other personal and professional characteristics such as religion,

length of clinical experience, private practice and involvement in

research were not significant explanatory variables. Female gen-

der was only associated with a lower likelihood of accepting the

woman’s request for a caesarean delivery among female doctors

who themselves had children: a finding which might explain the

inconsistencies that emerged in previous studies between the

obstetrician’s gender and the preferences for caesarean delivery

for themselves or for their partners.18,20,21

In this study, personal financial incentives did not seem to

influence doctors’ decision with regards to caesarean section

on demand. Obstetricians from the three countries with the

highest percentage of respondents engaged in private practice

(Italy, Luxembourg and Spain) had an average or low accep-

tance for caesarean section on request, whereas in countries

with the highest acceptance rate for caesarean on demand,

a smaller percentage of obstetricians engaged in private prac-

tice. Also, in multivariate analysis, private practice was not

a significant predictive variable.

In contrast, a physician’s self-reported feeling that ‘fear of

litigation influences his/her clinical practice’ emerged as the

variable more strongly and consistently associated with will-

ingness to perform a caesarean delivery on maternal request,

with odds ratios raising from 1.84 for those reporting ‘occa-

sional’ influence to 3.01 if it was ‘often’. Although respect for

patient’s autonomy was the most widely quoted reason by

physicians’ willing to accept the woman’s request, a relevant

proportion (from about 30% in the Netherlands and Sweden

to more than 80% in Spain, Luxembourg and France) also

mentioned the wish to avoid legal consequences in case of

complications during vaginal birth. Taken together, these

Table 5. Predictors of obstetricians’ reported decision to perform

caesarean section because it is the woman’s choice

OR (95% CI)* P value**

Country

Italy 1 ,0.001

Spain 0.11 (0.06–0.20)

France 0.14 (0.07–0.25)

Germany 2.59 (1.15–5.84)

Netherlands 0.21 (0.11–0.38)

Luxembourg 1.55 (0.54–4.49)

UK 2.75 (1.52–4.99)

Sweden 1.19 (0.68–2.10)

Sex No children Having children

Male 1 1

Female 0.85 (0.51–1.40) 0.29 (0.20–0.42)

Feeling that fear of litigation influences one’s clinical practice

No 1 0.004

Occasionally 1.84 (1.16–2.91)

Often 3.01 (1.60–5.65)

University-affiliated unit

No 1 0.001

Yes 2.05 (1.35–3.09)

*Odds ratio are adjusted for all the variables listed herein.

**P values refer to the overall statistical significance of the association

between the explanatory variable and the outcome.

Habiba et al.

652 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

findings indicate that the issue of respect for autonomy may

be compounded by the practice of defensive medicine, which

has been linked to higher caesarean section rates in some

countries,36–38 although supportive evidence remain contro-

versial.36,39,40

Fear of litigation appeared less relevant to physicians’ deci-

sion making in Sweden and The Netherlands, a finding con-

sistent with the low medico-legal burden in these countries.

Yet, there was an important difference between the two coun-

tries with regards to accepting the patient’s ‘choice’ of a cae-

sarean section. Clearly, several factors interact to determine

obstetricians’ attitudes towards caesarean section on demand

in various countries; the relative weight of these factors seems

to be modulated by the specific national or regional character-

istics of medical practice and perinatal care organisation.

A study published in 1986 found that only 2% of US obstet-

ricians would agree to carry out a caesarean section on a pri-

migravid woman at term with no other medical problems and

that a higher risk of litigation swayed 3% towards performing

a caesarean section.27 A later study conducted in 2000

reported that most practitioners in the Portland, Oregon met-

ropolitan area, would not perform a caesarean section based

on patients’ request or in the absence of clear medical indi-

cation.41 In the study by Ghetti et al.,41 only 9% of female

responders and 29.2% of male responders said that they

would consider a caesarean section for fear of urinary incon-

tinence after vaginal delivery. This, however, contrasts with

the higher acceptance of maternal request reported by Kenton

et al.,42 where 67% of recently trained obstetricians and

gynaecologist were willing to perform a primary caesarean

section specifically to prevent pelvic floor disorders. The US

findings that age, years in practice and practice type were not

associated with willingness to perform caesarean section on

request41,42 are in agreement with the findings in our study.

Many publications have mentioned about the risk of fur-

ther increase in caesarean section rate should caesarean sec-

tion on demand become widespread. So far, however, the

relationship between obstetricians’ willingness to perform

a caesarean section based on patient’s request and caesarean

section rates in the respective countries has been inconsistent.

Spain, where our study has shown a low acceptance of mater-

nal request, has the second highest caesarean section rate after

Italy.34 The UK, which has the highest level of acceptance for

maternal request, ranks fourth with regards to its caesarean

section rate.34 On the other hand, The Netherlands features

both a low caesarean section rate and a low acceptance of

maternal request.4 Up to now, the proportion of pregnant

women who actively ask for and are granted an elective cae-

sarean section has probably been quite limited in Europe.16

Should such demand increase, it is hard to believe that we

would not witness a rise of caesarean section rates. In that

situation, issues of costs and resource allocation should also

be considered.43

Traditionally, caesarean delivery has been associated with

a higher maternal mortality and morbidity, both short and

long term, and with neonatal respiratory distress.2,5,44 How-

ever, most of the published literature is based on women who

required a caesarean section because of medical reasons,45 and

it is difficult to disentangle the adverse effects of surgery from

those of its underlying indications. Advances of medical care

have certainly rendered caesarean delivery safer.37 At the same

time, medicalisation of vaginal birth has been linked to

adverse effects such as pelvic floor injury and its sequelae,

which are now quoted as major reasons in favour of caesarean

delivery.46 Reliable data allowing an unbiased comparison of

maternal and fetal benefits and risks, both short and long

term, of planned caesarean versus vaginal delivery are

scarce.5,45,46 Thus, the elements for evidence-based decision

making about the most appropriate way of delivery for the

individual, healthy woman who request an elective caesarean

section are lacking.

In principle, the existence of clinical uncertainty about

alternative treatment strategies makes a good case for allow-

ing the patient’s preferences to prevail.39 However, compli-

ance with patients’ request for caesarean delivery has been

criticised as the easy short cut, which exempts physicians from

dealing with the anxiety associated with childbirth and pro-

viding proper counselling and support.47 Ultimately, the

‘choice’ in favour of caesarean section might be disempower-

ing to women.48 Against this background, it is interesting that

in both our study and that by Ghetti et al.,41 female obstet-

ricians were less likely to agree with the woman’s request,

particularly when they had children themselves.

Apart from financial incentives, obstetricians may see other

advantages in elective caesarean section, such as better control

of the birth process and timing of delivery.15,49 The relation-

ship between the physicians’ attitudes towards caesarean on

demand and the fear of litigation, highlighted in ours as well

as in previous studies,25,35 represents an additional warning.

So far, litigation has largely centred on fetal damage and on

withholding rather than performing medical procedures.47–49

Thus, elective caesarean birth seems less risky than labour

from a liability standpoint.49

One potential criticism of our study is the choice of the

cutoff point for inclusion, which allowed the inclusion of

obstetricians who may not themselves be finally responsible

for making such controversial decisions. However, as the

questions posed addressed values and beliefs, we were inter-

ested in the views of all respondents (of whom only 71 had

between 6 and 12 months of experience in obstetrics). The

choice of 12 months experience as a cutoff point did not alter

the overall results, and furthermore, neither the obstetricians’

age nor the length of experience were significant predictors in

the multivariate analysis.

Despite the appeal of autonomy and ‘consumer’s ethics’,14

women are still highly dependent on the information provided

Obstetricians’ attitudes to request for caesarean

ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 653

by their physician. Rather than expressing a free, informed

choice for caesarean delivery, they may become trapped

between the obstetricians’ attitudes,15 lack of opportunities

for nonmedicalised vaginal birth16 and media-publicised fash-

ionable trends featuring vaginal delivery as unsafe, archaic,

disfiguring and ultimately socially unacceptable.48 The cur-

rent controversy surrounding this topic suggests the need

for further research to better characterise the cost-benefit bal-

ance and risks of caesarean section in uncomplicated preg-

nancies compared with truly nonmedicalised spontaneous

vaginal birth. Both short- and long-term outcomes should

be considered.

Until better evidence becomes available, individual obstet-

ricians faced with a request for elective caesarean delivery are

charged with the delicate task of fostering their patient’s

autonomy and freedom of choice by exploring the motivation

and fears underlying such request5,45,46 and ultimately act

according to what they believe to better promote the health

and welfare of mother and fetus.50

Acknowledgements

We acknowledge the contribution of Michael Hills as stati-

stical advisor and of the IRTEF Institute in data management.

We are very grateful to our colleagues who answered our

questionnaire.

Conflict of interest

None.

Funding

The results presented in this study are part of the European

Concerted Action project EUROBS on ‘Developments of

perinatal technology and ethical decision-making during

pregnancy and birth: the obstetricians’ perspective’, funded

by the European Commission (Contract no. BMH4-CT98-

3376, Project coordinator: Marina Cuttini, IRCCS Burlo Gar-

ofolo, Trieste). The views expressed are those of the authors

and the sponsor has played no part in study design, execution,

analysis, preparing or reviewing the manuscript. The decision

to submit for publication it that of the authors and the cor-

responding author. Dr M.C acts as custodian for the data.

Other members of the EUROBS studygroup

C Arnaud and M Garel (France); P Benciolini, C Viafora and

R Saracci (Italy), Manuel Marın Gomez (Spain), G Lingman

and T Nilstun (Sweden), I de Beaufort (Netherlands).

List of participating obstetrics units

• France

Hopital Maison Blanche, Reims (R Gabriel, C Quereux); Centre

Hospitalier Universitaire, Amiens (J Gondry, JC Boulanger); Cen-

tre Hospitalier Universitaire Jean Bernard, Poitiers (G Magnin);

Centre Hospitalier, Saint Brieuc (B Cloup, A Renaud-Giono); Cen-

tre Hospitalier Universitaire, Caen (M Dreyfus, M Herlicoviez);

Centre Hospitalier Universitaire, Rouen (L Marpeau); Hopital

Antoine Beclere, Clamart (F Audibert, R Frydman); Hopital Robert

Debre, Paris (P Blot); Hopital Nord, Saint Etienne (MN Varlet, P

Seffert); Hopital Francxois Mitterand, Pau (C Belcikowski, M Che-

valier); Hopital Bretonneau, Tours (J Lansac); Maternite Port-

Royal, Paris (D Cabrol); Hopital Jeanne de Flandre, Lille (F Puech).

• Germany

Marienkrankenhaus, Hamburg (U Blasshof, P Scheidel); Stadt.

Krankenhaus, Luneburg (E Walbrodt, J Gille); Stadt. Kranken-

haus Koln-Holweide, Koln (U Schellenberger, F Wolff); Klinikum

Frauenklinik, Bamberg (J Peisl, R v Hugo); Universitatsklinik,

Gottingen (W Heyl, G Emons); Universitatsklinikum Virchow

Klinikum, Berlin (U Buscher, JW Dudenhausen); Universitatskli-

nikum, Dresden (A Riehn, W Distler); Universitatsklinikum,

Leipzig (B Viehweg, M Hockel); Universitats-Frauenklinik, Mun-

ster (W Klockenbusch, L Kießl); Frauenklinik der Universitat,

Gießen (M Zygmunt, W Kunzel); Frauenklinik der Universitat,

Mainz (P Brockerhoff, PG Knapstein); Frauenklinik der Univer-

sitat, Munchen (F Kainer, G Kindermann); Universitatsklinikum,

Tubingen (B Schauff, D Wallwiener); Stadt. Krankenhaus Mun-

chen-Schwabing, Munchen (EM Grischke); Stadt. Krankenanstal-

ten, Krefeld (W Poleska, J Baltzer).

• Italy

Ospedale Santa Croce, Moncalieri To (ME Renzetti, R Monti);

Ospedale Niguarda Ca’ Granda, Milano (A Ragusa, S Garsia);

Ospedale di Circolo e Fondazione Macchi, Varese (P Clerici, G

Maffioli, D Balestreri, PF Bolis); Azienda Ospedaliera S Anna, Como

(G Bonifacino, F Colombo); Ospedale Bolognini, Seriate Bg (G

Palmerio, LD Moretti); Ospedale Policlinico G B Rossi, Verona

(E Zardini, D Pecorari, V Silvestre, L Fedele); Universita degli

Studi di Padova, Padova (DM Paternoster, A Ambrosiani, F

Lauri, S Mazzer, M Rondinelli, P Grella); Istituto per l’Infanzia

Burlo Garofolo, Trieste (S Guaschino); Policlinico Universitario

di Udine, Udine (F Petraglia); Presidio Ospedaliero di Gorizia,

Gorizia (C Gigli); Policlinico S Orsola-Malpighi, Bologna

(LF Orsini, D De Aloysio); Ospedale Maggiore, Bologna (M

Lenzi, C Melega); Ospedale S Maria Annunziata, Firenze (C

Campatelli, Gaggi); Ospedale Civile Spirito Santo, Pescara (V

Palladoro, R Lotti); Presidio Ospedaliero di Belcolle, Viterbo

(G Palla); Policlinico Umberto I, Roma (M Anceschi, EV Cosmi);

Ospedale SS Annunziata, Napoli (C Picardi, R Arienzo); Azienda

Ospedaliera S Giovanni di Dio e Ruggi d’Aragona, Salerno (C

Lomiento, A Fasolino, De Angelis, R Quirino); Ospedale A Per-

rino, Brindisi (S Burlizzi, ER Poddi); Azienda Ospedaliera Vito

Fazzi, Lecce (F Totaro Aprile, A Perrone, FG Tinelli); Ospedali

Riuniti di Foggia, Foggia (Maruotti, F Pietropaolo, G Arciuolo,

P Lauriola, C Napolitano, CM Troysi); Ospedali Riuniti Bianchi

Melacrino Morelli, Reggio Calabria (N Bitto, PF Tropea);

Habiba et al.

654 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

Presidio Ospedale Civico e Benfratelli, Palermo (P Bellipanni, C

Giannola, C Vicari, V Giambanco); Universita degli Studi di

Cagliari, Ospedale San Giovanni di Dio, Cagliari (S Ajossa, GB

Melis).

• Luxembourg

Luxembourg Hospital Centre (P Gratia).

• Spain

Hospital Clınico Universitario de Santiago, Santiago de Campos-

tela (R Ucieda Somoza, M Iglesias Dıaz); Hospital Central de

Asturias, Oviedo (A Escudero Gomis, S Villaverde Fernandez);

Hospital de Basurto, Bilbao (T Martinez-Astorquiza, JM Usandizaga

Pombo); Hospital Ntra. Sra. de Aranzazu, San Sebastian (JJ

Urtiaga Unda, JJ Larraz Soravilla); Hospital Infantil Miguel Servet,

Zaragoza (JJ Tobajas Homs, C Gonzalez Batres); Casa de Mater-

nitat, Barcelona (E Barrau Vernia, V Caradach); Hospital Ntr Sra

de Candelaria, Tenerife (JA Cortell Olcina, F Martin Casanas);

Hospital Universitario Virgen de la Arrixaca, Murcia (JL Delgado

Martın, JJ Parrilla); Hospital Universitario de Canarias, Tenerife

(J Parache); Hospital Son Dureta, Palma de Mallorca (A Marques

Bravo, M Usandizaga Calparsoro); Hospital Clınico S Carlos,

Madrid (MA Herraiz, M Escudero Fernandez); Hospital

Universitario Santa Cristina, Madrid (E Soto Sanchez,

F Izquierdo Gonzalez); Hospital Materno-Infantil de Malaga Car-

los Haya, Malaga (J Carrera Rodriguez, M Abehsera Bensabat);

Hospital San Pedro de Alcantara, Caceres (JI Morinigo Yague, C

Alcon Alcon); Hospital Clınico San Cecilio de Granada, Granada

(A Cano Aguilar, M Dolz Romero); Hospital General Universi-

tario de Alicante, Alicante (JC Martınez Escoriza).

• Sweden

Centrallasarettet, Falun (I Westman, A-C Cachrimanidou); Cen-

tralsjukhuset, Karlstad (J Hareide, G Wadsten); Sundsvalls Sju-

khus, Sundsvall (L Berglund); Centralsjukhuset, Kristianstad (H

Strom, G Helm); Universitetssjukhuset MAS, Malmo (S Montan);

Malarsjukhuset, Eskilstuna (B Moller, M Rom); Karnsjukhuset,

Skovde (J Leyon, G Wallstersson); Centrallasarettet, Vasteras

(LOW Svensson); Lanssjukhuset Ryhov, Jonkoping (R Boij, R

Lenrick); Centrallasarettet, Boras (T Solum); Sahlgrenska Univer-

sitetssjukhuset/Ostra, Goteborg (U-B Wennerholm, M Wennerg-

ren); Akademiska Sjukhuset, Uppsala (U Hansson); Norrlands

Universitetssjukhus, Umea (P-A Holmgren, I Sjoberg); Region-

ssjukhuset i Orebro, Orebro (G Falk, M Lood); Regionssjukhuset i

Linkoping, Linkoping (A Jeppsson, G Berg, S Kjellberg); Univer-

sitetssjukhuset i Lund, Lund (G Lingman, K Marsal); Karolinska

Sjukhuset, Stockholm (O Bakos, V Odlind).

• The Netherlands

Maxima Medical Center, Veldhoven (MY Bongers); Isala Clinics,

Zwolle (J van Eyck); Academic Medical Centre at the University of

Amsterdam, Amsterdam (M Pel, OP Bleker); Free University Med-

ical Centre, Amsterdam (JIP de Vries, HP van Geijn); Academic

Hospital Groningen, Groningen (MP Heringa, JP Holm); Leiden

Academic Medical Centre, Leiden (J van Roosmalen, HHH Kan-

hai); Academic Hospital Maastricht, Maastricht (LLH Peeters, JG

Nijhuis); Academic Medical Centre St Radboud, Nijmegen (PP Van

den Berg, DDM Braat); Academic Medical Centre Utrecht, Utrecht

(HW Bruinse, G Visser); Erasmus Medical Centre, Rotterdam (EAP

Steegers, JW Wladimiroff).

• The UK

Derriford Hospital, Plymouth (I Montague, AD Falconer); Leices-

ter Royal Infirmary, Leicester (A Akkad, C Stewart); King’s Col-

lege Hospital, London (M Marsh); Southmead Hospital, Bristol

(D Bisson); Nottingham City Hospital, Nottingham (H Hamoda,

DT Liu); Birmingham Womens Hospital, Birmingham (MJ Whit-

tle); St James University Hospital, Leeds (G Mason); Rosie Hos-

pital, Cambridge (P Plumpton, C Lees); North Staffordshire

Maternity Hospital, Stoke on Trent (GV Sunanda, G Masson);

Royal Gwent Hospital, Newport (R Gonsalves); University Hos-

pital of Wales, Cardiff (K Sidhu, N Amso). j

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