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Obstetrics & Gynecology 2006;108:1121-1129
© 2006 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Patient Refusal of Emergency Cesarean Delivery

A Study of Obstetricians’ Attitudes in Europe

Marina Cuttini, MD, MPH1, Marwan Habiba, MD, PhD2, Tore Nilstun, PhD3, Silvia Donfrancesco, MSc1, Micheline Garel, MSc4, Catherine Arnaud, MD5, Otto Bleker, MD, PhD6, Monica Da Frè, MSc7, Manuel Marin Gomez, MD8, Wolfgang Heyl, MD, PhD9, Karel Marsal, MD, PhD10, Rodolfo Saracci, MD11 for the European Obstetricians (EUROBS) Study Group*

From the 1Unit of Epidemiology, Ospedale Pediatrico Bambino Gesù, Roma, Italy; 2Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, United Kingdom; 3Department of Medical Ethics, University of Lund, Lund, Sweden; INSERM 4Epidemiological Research Unit on Perinatal and Women’s Health, Villejuif Cedex, France; Université Pierre et Marie Curie-Paris 6, Paris, France, INSERM Research Unit in Epidemiology and Public Health, Toulouse Cedex, France; 6Department of Obstetrics and Gynecology, Amsterdam Medical Centre, Amsterdam, the Netherlands; 7Unit of Epidemiology, Regional Health Agency of Tuscany, Florence, Italy; 8Valencian School of Health Studies, Valencia, Spain; 9Klinikum Ludwigsburg, Frauenklinik, Ludwigsburg, Germany; 10Department of Obstetrics and Gynaecology, Lund University Hospital, Lund, Sweden; and 11Division of Epidemiology, IFC-National Research Council, Pisa, Italy.

OBJECTIVE: To compare the attitudes of a large sample of obstetricians from eight European countries toward a competent woman’s refusal to consent to an emergency cesarean delivery for acute fetal distress.

METHODS: Obstetricians’ attitudes in response to a hypothetical clinical case were surveyed through an anonymous, self-administered questionnaire. The sample included 1,530 obstetricians (response rate 77%) from 105 maternity units (response rate 70%) in eight countries: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden and the United Kingdom.

RESULTS: In every country, the majority of obstetricians would keep trying to persuade the woman, telling her that failure to perform cesarean delivery might result in the fetus surviving with disability, or even that her own life might be endangered. In Spain, France, Italy, and, to a lesser extent, Germany and Luxembourg, a consistent proportion of physicians would seek a court order to protect fetal welfare or avoid possible legal liability or both. In the United Kingdom, Sweden, and Netherlands, several respondents (59%, 41%, and 37%, respectively) would accept the woman’s decision and assist vaginal delivery. Only a small minority (from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without a court order.

CONCLUSION: Case law arising from a few countries (United States, Canada, and the United Kingdom) and professional guidelines favoring women’s autonomy have not solved the underlying ethical conflict, and in Europe acceptance of a woman’s right to refuse cesarean delivery, at least in emergency situations, is not uniform. Differing attitudes between obstetricians from the eight countries may reflect diverse legal and ethical environments.

LEVEL OF EVIDENCE: III






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