Caesarean section on request: a comparison of obstetricians' attitudes in eight European countries

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.