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Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion
European Journal of Obstetrics & Gynecology and Reproductive Biology 97 (2001) 15±16
Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion Christina S. Cotzias, Sara Paterson-Brown*, Nicholas M. Fisk Institute of Obstetrics and Gynaecology, Imperial College School of Medicine, Queen Charlotte's and Chelsea Hospital, Goldhawk Road, London W6 0XG, UK Received 8 August 1999; accepted 5 April 2000
Abstract Aim: To determine what proportion of obstetricians would agree to elective pre-labour CS for `maternal request'. Methods: Every ®fth consultant on an alphabetical list of obstetricians in England and Wales obtained from the RCOG (243) was surveyed by post and asked (a) ``Would you agree to perform an elective CS on a woman with an uncomplicated singleton cephalic pregnancy at term for `maternal request?''' and (b) if yes, in relation to this `Has your practice changed over recent years?'' Results: 155 questionnaires were returned (63% response rate Ð four unanswered, leaving 151 for analysis). One hundred and four (69%) consultants said they would agree to `maternal request' for CS. Of the `yes' respondents, 62 (60%) claimed their practice had changed recently. Conclusion: This survey demonstrates that a majority of obstetricians are now prepared to agree to maternal request for CS in the absence of obstetric indications. # 2001 Elsevier Science Ireland Ltd. All rights reserved.
1. Introduction
2. Materials and methods
The changing childbirth [1] policy in the UK recommends increasing maternal choice in obstetric decision making. It had been assumed that with increasing maternal input obstetric intervention rates would decline. In contrast, caesarean section (CS) rates are increasing with mothers increasingly involved in deciding on a CS [2]. Ten years ago, obstetricians were asked how they would respond to `maternal request' for CS in an uncomplicated pregnancy; the majority refused, a stance supported by the study authors [3] and a subsequent editorial [4]. More recently, when one consultant announced on television that he was prepared to provide CS on demand, the media and an editorial [5] quoted colleagues strongly opposed to this. Although, some have even claimed it would be medicolegally negligent to agree to such a request, the opinion of the wider obstetric body is not known. We determined what proportion of obstetricians would agree to elective prelabour CS for `maternal request'.
In May 1998, every ®fth consultant on an alphabetical list of obstetricians in England and Wales obtained from the Royal College of Obstetricians & Gynaecologists was surveyed by post. Two hundred and forty-three were asked (a) ``Would you agree to perform an elective CS on a woman with an uncomplicated singleton cephalic pregnancy at term for `maternal request?''' and (b) if yes, in relation to this ``Has your practice changed over recent years?'' Obstetricians were asked to circle a yes/no response and add further comments. All responses were anonymous and no reminders were sent.
* Corresponding author. Tel.: 44-0181-383-3586; fax: 44-0181-383-3419. E-mail address: [email protected] (S. Paterson-Brown).
3. Results and discussion One hundred and ®fty-®ve questionnaires were returned (63% response rate), of which four were unanswered, leaving 151 for analysis. Of the 104 (69%) consultants who circled `yes' in response to the `maternal request' question, 28 (27%) commented that they would only agree reluctantly and 62 (60%) commented that they would ®rst fully counsel the patient as to the risks of CS. Responses were not signi®cantly in¯uenced by age, sex, year of appointment or type of hospital (Table 1).Of the `yes' respondents 62 (60%) agreed that their practice had changed over recent
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 0 ) 0 0 3 6 0 - 2
16
C.S. Cotzias et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 97 (2001) 15±16
Table 1 Responses to the `maternal request' questionnairea Yes group (n104)
No group (n47)
Age (years) median; and range Female sex Year appointed consultant; median and range Teaching hospital appointment No. whose practice has changed in recent years (%)
44; 32±64 27 (26%) 1989; 69±97 32 (31%) 62 (60%)
47; 34±65 13 (28%) 1992; 68±98 12 (25%)
Factors influencing change commented on Litigation Patient pressure Evidence-based medicine
22/62 (35%) 55/62 (89%) 19/62 (32%)
a
None significant.
years. The most common reasons offered for this were patient pressure (89%), litigation (35%), and the practice of evidence-based medicine (32%); more than one reason was often cited. This survey demonstrates that a majority of obstetricians are now prepared to agree to maternal request for CS in the absence of obstetric indications. Accordingly, such agreement or at least acquiescence, cannot be considered medicolegally negligent. Instead, the risk-bene®t ratio is changing; research and audit increasingly document the sequelae of labour and vaginal delivery to both the baby and the mother's pelvic ¯oor, and the safety of elective pre-labour CS has improved under regional analgesia with thromboprophylaxis and antibiotic cover. If a well-informed woman decides she wants to accept the extra risks of CS for the sake of her baby and pelvic ¯oor, our study shows that almost 70% of consultants in England and Wales would go along with her choice.
Contributors Christina S Cotzias had the original idea for the study, collected and analysed the data and drafted the paper. Sara Paterson-Brown and Nicholas M Fisk contributed to the study design, drafting and revising the paper. References [1] Cumberledge J. Changing Childbirth. London: HMSO, 1993. [2] Mould TA, Chong S, Spencer JA, Gallivan S. Women's involvement with the decision preceding their caesarean section and their degree of satisfaction. Br J Obstet Gynaecol 1996;103:1074±7. [3] Johnson SR, Elkins TE, Strong C, Phelan JP. Obstetric decision making: responses to patients who request caesarean delivery. Obstet Gynecol 1986;67:847±50. [4] Hall M. When a woman asks for a caesarean section. BMJ 1987;294:201. [5] Editorial. What is the right number of caesarean sections? Lancet 1997; 349:815.
Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion Christina S. Cotzias, Sara Paterson-Brown*, Nicholas M. Fisk Institute of Obstetrics and Gynaecology, Imperial College School of Medicine, Queen Charlotte's and Chelsea Hospital, Goldhawk Road, London W6 0XG, UK Received 8 August 1999; accepted 5 April 2000
Abstract Aim: To determine what proportion of obstetricians would agree to elective pre-labour CS for `maternal request'. Methods: Every ®fth consultant on an alphabetical list of obstetricians in England and Wales obtained from the RCOG (243) was surveyed by post and asked (a) ``Would you agree to perform an elective CS on a woman with an uncomplicated singleton cephalic pregnancy at term for `maternal request?''' and (b) if yes, in relation to this `Has your practice changed over recent years?'' Results: 155 questionnaires were returned (63% response rate Ð four unanswered, leaving 151 for analysis). One hundred and four (69%) consultants said they would agree to `maternal request' for CS. Of the `yes' respondents, 62 (60%) claimed their practice had changed recently. Conclusion: This survey demonstrates that a majority of obstetricians are now prepared to agree to maternal request for CS in the absence of obstetric indications. # 2001 Elsevier Science Ireland Ltd. All rights reserved.
1. Introduction
2. Materials and methods
The changing childbirth [1] policy in the UK recommends increasing maternal choice in obstetric decision making. It had been assumed that with increasing maternal input obstetric intervention rates would decline. In contrast, caesarean section (CS) rates are increasing with mothers increasingly involved in deciding on a CS [2]. Ten years ago, obstetricians were asked how they would respond to `maternal request' for CS in an uncomplicated pregnancy; the majority refused, a stance supported by the study authors [3] and a subsequent editorial [4]. More recently, when one consultant announced on television that he was prepared to provide CS on demand, the media and an editorial [5] quoted colleagues strongly opposed to this. Although, some have even claimed it would be medicolegally negligent to agree to such a request, the opinion of the wider obstetric body is not known. We determined what proportion of obstetricians would agree to elective prelabour CS for `maternal request'.
In May 1998, every ®fth consultant on an alphabetical list of obstetricians in England and Wales obtained from the Royal College of Obstetricians & Gynaecologists was surveyed by post. Two hundred and forty-three were asked (a) ``Would you agree to perform an elective CS on a woman with an uncomplicated singleton cephalic pregnancy at term for `maternal request?''' and (b) if yes, in relation to this ``Has your practice changed over recent years?'' Obstetricians were asked to circle a yes/no response and add further comments. All responses were anonymous and no reminders were sent.
* Corresponding author. Tel.: 44-0181-383-3586; fax: 44-0181-383-3419. E-mail address: [email protected] (S. Paterson-Brown).
3. Results and discussion One hundred and ®fty-®ve questionnaires were returned (63% response rate), of which four were unanswered, leaving 151 for analysis. Of the 104 (69%) consultants who circled `yes' in response to the `maternal request' question, 28 (27%) commented that they would only agree reluctantly and 62 (60%) commented that they would ®rst fully counsel the patient as to the risks of CS. Responses were not signi®cantly in¯uenced by age, sex, year of appointment or type of hospital (Table 1).Of the `yes' respondents 62 (60%) agreed that their practice had changed over recent
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 0 ) 0 0 3 6 0 - 2
16
C.S. Cotzias et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 97 (2001) 15±16
Table 1 Responses to the `maternal request' questionnairea Yes group (n104)
No group (n47)
Age (years) median; and range Female sex Year appointed consultant; median and range Teaching hospital appointment No. whose practice has changed in recent years (%)
44; 32±64 27 (26%) 1989; 69±97 32 (31%) 62 (60%)
47; 34±65 13 (28%) 1992; 68±98 12 (25%)
Factors influencing change commented on Litigation Patient pressure Evidence-based medicine
22/62 (35%) 55/62 (89%) 19/62 (32%)
a
None significant.
years. The most common reasons offered for this were patient pressure (89%), litigation (35%), and the practice of evidence-based medicine (32%); more than one reason was often cited. This survey demonstrates that a majority of obstetricians are now prepared to agree to maternal request for CS in the absence of obstetric indications. Accordingly, such agreement or at least acquiescence, cannot be considered medicolegally negligent. Instead, the risk-bene®t ratio is changing; research and audit increasingly document the sequelae of labour and vaginal delivery to both the baby and the mother's pelvic ¯oor, and the safety of elective pre-labour CS has improved under regional analgesia with thromboprophylaxis and antibiotic cover. If a well-informed woman decides she wants to accept the extra risks of CS for the sake of her baby and pelvic ¯oor, our study shows that almost 70% of consultants in England and Wales would go along with her choice.
Contributors Christina S Cotzias had the original idea for the study, collected and analysed the data and drafted the paper. Sara Paterson-Brown and Nicholas M Fisk contributed to the study design, drafting and revising the paper. References [1] Cumberledge J. Changing Childbirth. London: HMSO, 1993. [2] Mould TA, Chong S, Spencer JA, Gallivan S. Women's involvement with the decision preceding their caesarean section and their degree of satisfaction. Br J Obstet Gynaecol 1996;103:1074±7. [3] Johnson SR, Elkins TE, Strong C, Phelan JP. Obstetric decision making: responses to patients who request caesarean delivery. Obstet Gynecol 1986;67:847±50. [4] Hall M. When a woman asks for a caesarean section. BMJ 1987;294:201. [5] Editorial. What is the right number of caesarean sections? Lancet 1997; 349:815.