Gonen, R. MD; Tamir, A. DSc; Degani, S. MD
The controversy surrounding patient choice cesarean delivery is not new. This controversy encompasses medical, legal, and ethical issues. The legal and ethical aspects include women's right to choose the mode of delivery, what is a real informed consent, and should doctors perform surgery in the absence of medical indication. Moreover, in countries where deliveries are conducted by doctors (rather than by midwives), who may find elective cesarean delivery more convenient and perhaps economically more profitable, it may be difficult sometimes to separate patient choice cesarean delivery from doctor's choice cesarean delivery. 1 The lack of reliable data comparing short‐ and long‐term consequences of planned elective cesarean delivery compared with that of planned vaginal delivery is central to this debate.
In 1993, the British government's document “Changing Childbirth” placed increased emphasis on informed patient choice in relation to antenatal care and delivery. 2 In a survey of London obstetricians conducted in 1997, 17% overall and 31% of the female obstetricians stated that if they or their partners had an uncomplicated singleton pregnancy at term, they would choose cesarean delivery. 3 In 1999, the Committee for the Ethical Aspects of Human Reproduction and Women's Health of the International Federation of Gynecologists and Obstetricians (FIGO) stated in a report: “Performing cesarean section for non‐medical reasons is ethically not justified.” 4 Despite this report, a year later, Dr. Harer, president of the ACOG, suggested in an editorial that elective cesarean and vaginal birth are equally safe, and therefore either option should be made available to women, underscoring women's right to choose. 5 On the other hand, the UK Confidential Enquiries Into Maternal Deaths 6 and numerous other studies have shown that cesarean deliveries carry a higher risk for maternal morbidity and mortality compared with vaginal deliveries. 7,8
We sought to survey the attitude of Israeli obstetricians regarding their position on patient choice cesarean delivery. In Israel, medical care is based on the National Health Insurance Act, which provides health care to all citizens free of charge. Only a minority of medical services is based on private medicine. The national cesarean delivery rate in 1999 was 16%. The vast majority of deliveries are attended by midwives, under the supervision of residents and specialists who are on staff in the hospitals. In such circumstances, it seems most unlikely that “doctor's choice,” motivated by convenience or reimbursement, would influence “patient's choice.” Therefore, surveying Israeli obstetricians' opinions regarding patient choice cesarean delivery is likely to reflect a true and unbiased professional view of what is best for the patient rather than what is best for the doctor.
MATERIALS AND METHODS
The survey was strictly anonymous. A questionnaire was sent by mail to 650 Israeli obstetricians (approximately 60% of the obstetricians in Israel) who were on a mailing list as participants in national monthly meetings of obstetricians. A total of 270 questionnaires were answered. No follow‐up questionnaires were sent to obstetricians who did not return the questionnaire, and their demographic data were not investigated. However, the demographic profile of the respondents, as presented in Table 1, was similar to that of the general population of obstetricians in Israel, except a somewhat lower representation of residents among participants in the survey.
The single‐page questionnaire included the following demographic details: gender, age group (less than 35, 35–50, greater than 50 years), principal employer (hospital, managed care organizations, private), professional status (resident in training or specialist), and level of academic teaching degree. This was followed by three short case presentations: each involved an otherwise healthy woman with an uncomplicated cephalic term gestation, who requested an elective cesarean delivery; the respondents were asked if they would consent to the patient's request. Female doctors were then asked if they would choose elective cesarean delivery for themselves; similarly, male doctors were asked about their preference for their partners. This was followed by a question regarding the respondent's attitude towards women's right to choose cesarean delivery in the absence of medical indication (yes, no, undetermined). The final question was directed to those who gave a positive answer to the previous question. They were asked if they thought obstetricians should inform their patients of their right to choose cesarean delivery.
Data were analyzed using SPSS 9.0 (SPSS Inc., Chicago, IL). χ2 test was used for categoric variables. Logistic regression was performed to determine which of the variables was associated with the dichotomous dependent variable. Odds ratios and 95% confidence intervals (CI) were calculated for the significant variables.
The demographic data of the 257 respondents is shown in Table 1. The number and percentage of obstetricians who consented to perform cesarean in the three cases presented in the questionnaire are shown in Table 2. The respondents' consent rate ranged from 40% to 79% according to the clinical situation. Eighty‐eight respondents (34%, 95% CI 28, 40) agreed to perform cesarean in all three clinical situations, 121 (47%, 95% CI 41, 53) consented in one or two clinical situations, and 48 (19%, 95% CI 14, 23) refused to perform cesarean in all three clinical situations. Agreement or refusal to perform cesarean was not influenced by gender, principal employer, professional status, or the presence of an academic teaching degree. However, obstetricians with a high‐ranking academic teaching degree were significantly more prone to consent to perform cesarean than obstetricians with a low‐ranking degree or without an academic teaching degree, 49% versus 31% (χ2 = 5.63, P < .02).
With regard to their attitude towards women's right to choose cesarean without a medical indication, 116 (45%, 95% CI 39, 51) were in favor, 122 (48%, 95% CI 41, 54) opposed, and 19 (7%) were undetermined (Figure 1A). Respondents' attitude towards women's right to choose cesarean was not influenced by gender, age, principal employer, professional status, or academic degree. However, respondents with a high‐ranking teaching academic degree were significantly more prone to support patient choice cesarean than respondents with either a low‐ranking or no academic degree (64%, 95% CI 50, 78 versus 41%, 95% CI 34, 48) (χ2 = 8.17, P <.001).
When the 116 respondents who supported women's right to choose cesarean were asked if they thought obstetricians should inform their patients about this right, 62 (53%, 95% CI 44, 63) responded yes, 45 (39%, 95% CI 30, 48) responded no, and nine (8%) did not respond to the question. Respondents' attitude towards the obligation to inform their patients of this right was not influenced by gender, age, principal employer, professional status, or academic degree.
When asked about their personal preference for the mode of delivery, 19 of the 206 (9%) obstetricians who responded to this question chose cesarean delivery for themselves (if female) or their partners (Figure 1B). There was no significant difference between the preferences of female obstetricians (three of 53, 6%, 95% CI 0, 12) and those of male obstetricians (16 of 153, 10%, 95% CI 6, 15). Obstetricians' preference for cesarean delivery was not influenced by gender, age, principal employer, professional status, or a teaching academic degree. Respondents who preferred cesarean delivery for themselves or their partners were more likely to consent to perform cesarean in all three clinical situations and to support patients' autonomy to choose cesarean delivery than respondents who did not choose cesarean delivery for themselves, 63% (95% CI 41, 85) and 89% (95% CI 76, 100) versus 30% (95% CI 24, 37) and 40% (95% CI 33, 47), respectively (χ2 = 8.27 and 17.42, respectively, P < .005). Of the 187 respondents who did not choose cesarean delivery for themselves or their partners, 39 (21%) also refused to perform cesarean delivery in all three clinical situations. However, 57 (30%) consented to perform cesarean in all three clinical situations, and 74 (40%) said they supported women's right to choose cesarean delivery.
We then sought to define variables that may help to distinguish between “supporters” and “opponents” of patient choice cesarean. For this purpose, we constructed two logistic regression models to determine which of the variables were associated with either “supporters” or “opponents” of patient choice cesarean. For the purpose of this model, we defined “supporters” as respondents who consented to perform cesarean in all three clinical situations and supported patients' right to choose cesarean. Similarly, we defined opponents as those who opposed cesarean in all three clinical situations and opposed patients' right to choose cesarean. Only the personal preference for cesarean of the respondents (P = .001, odds ratio 5.5, 95% CI 2.0, 15.2) and the status of a specialist (P = .05, odds ratio 2.7, 95% CI 1.04, 7.3) were significantly correlated with being a “supporter.” None of the variables examined were found to be significantly correlated with being an opponent of patient choice cesarean delivery.
Approximately half of the respondents to this survey—of whom 81% were certified obstetricians, 73% working in hospitals and 26% with a teaching academic degree—consented to patient choice cesarean. The rate of consent ranged from 80% in the case of a 40‐year‐old primigravida to 41% in the case of a primigravida with no known risk factors. Almost half of the respondents supported the principle that women should have the right to choose cesarean as the mode of delivery if they wish so. Moreover, half of the obstetricians who supported patients' right to choose cesarean stated that doctors should inform their patients of this right. We were surprised to find that only a minority (9%) of the Israeli obstetricians stated that for themselves or their partners they would prefer cesarean without a medical indication. This is in contrast to the results of a survey of 206 London obstetricians, of whom 17% opted for cesarean. 2 Moreover, in that survey, 31% of the female obstetricians preferred cesarean compared with 6% in the present study. Our results are closer to a Dutch study in which only 1.4% of female obstetricians opted for cesarean. 9
Consent or refusal to patient request for elective cesarean delivery, as well as the support of women's autonomy in the choice of the mode of delivery, was not significantly influenced by various demographic variables. However, obstetricians with a senior academic teaching degree were more inclined to consent to patient choice cesarean delivery than obstetricians with a low‐ranking academic teaching degree or those without an academic teaching degree. The only significant distinguishing variables among obstetricians who consistently supported patient choice cesarean delivery were their own preference for cesarean delivery and being a specialist rather than a resident.
Two inherent limitations of this study should be noted. The questionnaires were not randomly distributed among all of the obstetricians in the country, and the response rate was only 39%. However, because the demographic profile of respondents, as presented in Table 1, reflected that of the general population of obstetricians in Israel (except a smaller proportion of residents who were surveyed), we believe that chances for bias are minimal, and our results are a valid presentation of the opinions of Israeli obstetricians.
It can thus be concluded that the vast majority (91%) of Israeli obstetricians believe that vaginal delivery is preferable to cesarean; yet almost half of them support women's autonomy to choose cesarean delivery. Consequently, approximately half of the respondents were willing to perform cesarean on request because of their support of women's autonomy, despite the fact that they personally thought vaginal delivery to be a better option.