Fear of litigation is a key factor in decision to perform C-sections

The rising rate of caesarean sections (CS) worldwide, despite the considerable evidence that vaginal birth is safer and associated with fewer complications, is a growing concern among women and healthcare professionals.

In a systematic review of 34 international studies conducted in 20 different countries, Trinity researchers have found that 'clinicians' beliefs' are the main factor influencing obstetricians' and midwives' decisions to perform CS. These beliefs were mostly related to clinicians' personal preferences, an over-estimation of the degree of risk associated with vaginal birth or vaginal birth after caesarean section (VBAC), and caesarean sections being seen as a safe and convenient option.

Fear of litigation and professional agreements and disagreements were identified as key factors in the decision-making process, according to the study, published recently in the journal, PLOS ONE. Insufficient human and physical resources, lack of unified guidelines, financial benefits to the hospital, and private versus public health care facilities were also influencing factors, ultimately contributing to the rise in rate of CS, according to the authors.

The systematic review, part of a Health Research Board-funded study, describes the views of 9,008 midwives and obstetricians obtained from research conducted over the 24-year period from 1992 to 2016. It provides in-depth understanding of clinicians' views of the factors that influence the decision to perform a CS and so will be of significant benefit to policy-makers seeking to improve and promote normal births and reduce CS rates.

Lead author, Sunita Panda, PhD candidate and Health Research Board Research Fellow at the School of Nursing and Midwifery, Trinity commented: "Caesarean section rates are increasing worldwide, particularly among first-time mothers, with limited explanation of the factors that influence the rising trend. This is a big concern for health care professionals because vaginal birth is safer and associated with fewer complications. Our research is the first systematic review of international research on the topic and it gives important insight into the 'why' behind the rising rate of CS. Our study identified the significant influence of 'fear of litigation' on clinicians' decision to perform CS, irrespective of hospital setting, age, gender, professional experience, resources and culture within the health care system."

Professor Cecily Begley, Chair of Nursing and Midwifery in Trinity College Dublin, and co-author of the paper, commented: "This research generates strong evidence to influence clinical practice. Clinicians often have multiple reasons for deciding to perform a CS; however, the key issue is the justification of these reasons and the impact of the decision on the mother and baby. This study will be of significant benefit to policy-makers seeking to improve and promote normal births and reduce CS rates."

Key findings:

• Fear of legal consequences and litigation was a major and significant influence on the decision to perform CS. Most of the perceived fear related to legal consequences arising from complications associated with vaginal birth compared with birth by CS, despite the fact that CS causes more maternal mortality and morbidity.
• Decision-making was further influenced by clinicians' perception of the small degree of risk involved in performing a CS and their belief in CS being a 'safe' procedure compared to vaginal birth.
• Personal convenience for obstetricians also influenced the decision to perform CS rather than aim for vaginal birth, and related to perceptions of CS being an organised, orderly, convenient and controlled birthing option compared to attempts at vaginal birth and having to be available throughout labour, day and night.
• Midwives' perspectives differed, and they viewed 'convenience' as a cause of unnecessary CS.
• Inter-professional conflict, differences in attitudes, and lack of cooperation among midwives and obstetricians, and obstetricians with different levels of experience, are some other reported factors that influenced the decision to perform a CS, or a repeat CS instead of aiming for vaginal birth after caesarean section (VBAC).
• The influence of private health care systems was mentioned frequently by clinicians, sometimes in association with financial payments, or benefits to the hospital.
• Lack of hospital guidelines or clinicians' unawareness of the existing guidelines and protocols were other factors that influenced the decision-making process.
• Clinicians viewed maternal request as one of the factors, which was mostly influenced by women's socio-cultural perspective, their preferences, demands and obstetricians' perception of women's anxiety and fear. The study findings suggested that obstetricians more so than midwives were inclined to support women's request to perform a CS.

Professor Michael Turner, a collaborator on this research study, and UCD Professor for Human Reproduction at the Coombe Women and Infants University Hospital, added: "This innovative research is important because the evidence is that caesarean section rates are continuing to escalate and have not yet plateaued. About one in three births in Ireland is now by either elective or emergency section. If we are to reverse this trend nationally, we need to better understand the complexity of the decisions made by women and their obstetricians."

Assistant Professor Dr Deirdre Daly, the supervisor of the PhD work, added: "It is really important to understand these factors because they influence individual clinicians' attitudes towards the natural progress of labour and spontaneous birth, even when the woman and baby are well and have no risk factors. This then leads to the decision to intervene prematurely, often without medically justifiable reasons."