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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, North Carolina.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: A Web-based questionnaire was sent by e-mail to members of the American Urogynecologic Society (AUGS) and the Society for Maternal–Fetal Medicine (SMFM) who reside in the United States. The first e-mail was sent in October 2003, and 2 additional e-mails were sent to nonresponders over the next month. The survey included questions about demographics, practice patterns, and opinions about different clinical scenarios regarding elective primary cesarean delivery.
RESULTS: Of 1,479 surveys sent to functioning e-mail addresses, 782 were completed (52.9% response rate). American Urogynecologic Society and Society for Maternal–Fetal Medicine members were similar in response rate (53.0% versus 52.8%, respectively). Overall, 65.4% of physicians would perform an elective cesarean delivery, but AUGS members were significantly more likely to agree to perform an elective cesarean than SMFM members (80.4% versus 55.4%, respectively, P < .001). In a logistic regression model that included age, sex, having no children, years in practice, and subspecialty (urogynecology or maternal–fetal medicine), AUGS members were 3.4 times (95% confidence interval 2.3–4.9, P < .001) more likely to agree to perform an elective cesarean.
CONCLUSION: Among respondents, a majority of urogynecology and maternal–fetal medicine specialists surveyed would perform an elective primary cesarean delivery. Urogynecologists were significantly more likely to support elective cesareans.
LEVEL OF EVIDENCE: II-3
The potential benefits of preventing pelvic floor disorders must be weighed against the risks associated with an elective primary cesarean delivery. Maternal risks include the morbidity and mortality associated with surgery12 and possible complications in subsequent deliveries, such as uterine rupture,13 placenta previa, placenta accreta,14,15 and the risks related to repeat cesarean deliveries. An elective cesarean may also increase the fetal risks of respiratory distress syndrome,16 persistent pulmonary hypertension,17 and fetal lacerations.18
Another critical issue regarding elective primary cesarean delivery is an obstetrician–gynecologist's willingness to perform the surgery. There have been a number of questionnaire studies exploring the attitudes of obstetricians in other countries, such as England, Ireland, Israel, and Australia. In these studies, a majority of the obstetricians surveyed would agree to their patient's request for an elective cesarean delivery.20,23,24 However, only 7–17% of physicians would choose an elective cesarean delivery for themselves or their partners.19,21–24 To date, there is minimal published data on the attitudes of physicians in the United States.
The topic of elective primary cesarean delivery is frequently debated, because data comparing the short-term and long-term consequences of vaginal deliveries with those of elective cesareans is lacking. A randomized controlled trial of these 2 modes of delivery would help to settle the debate, but initiating this type of study is challenging given the controversial nature of this issue. We suspect that one of the challenges of conducting a randomized trial in an academic setting may be the differing opinions between urogynecology and maternal–fetal medicine subspecialists, because practitioners in these 2 subspecialties would likely be involved in designing such a study. Thus, we wanted to assess the attitudes of these 2 subspecialty groups in the United States regarding elective primary cesarean delivery.
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MATERIALS AND METHODS |
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The questionnaire was administered on a secure web site, and the results were kept confidential. The survey included demographic questions about age, sex, number of children, marital status, race, years in practice, principal employer (academic/teaching hospital, managed care, private practice, military, or other), area of specialty (general obstetrics and gynecology, maternal–fetal medicine, urogynecology, or other), and practicing obstetrics. Physicians were also asked about their practice patterns and their opinions about several clinical scenarios regarding elective cesarean deliveries. Physicians could respond "Definitely Yes," "Probably Yes," "Probably No," or "Definitely No" to these questions. Physicians were asked to select the reasons for agreeing or not agreeing to perform a primary elective cesarean. Many of the options were derived from articles on the risks and benefits of elective primary cesarean delivery.12,25
Statistical analysis was performed with SPSS 11.5 (SPSS Inc, Chicago, IL). All respondents were included in the analysis, including general obstetrician–gynecologists who were members of either society. For the demographic data, 
2 test was used to compare categorical variables and the Student t test was used for continuous variables. The responses of AUGS and SMFM members to questions regarding elective cesarean were analyzed by combining the affirmative answers (Definitely Yes and Probably Yes) and the negative answers (Definitely No and Probably No) and using 2. A logistic regression model was used to assess independent predictors for willingness to perform an elective cesarean while controlling for potential confounders. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated from the model. A P value less than .05 was considered statistically significant. The power calculation was based on our primary question of whether a physician would agree to perform an elective primary cesarean delivery. A sample size of 139 per group was needed to detect a difference between 40% and 60% with 90% power and an 
of 0.05.
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RESULTS |
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The demographic data of the respondents are shown in Table 1. Members of AUGS and SMFM were similar in sex, race, marital status, and percentage of physicians without children. Members of AUGS were more likely to be younger, to have been in practice for a shorter time period, to work in private practice or managed care rather than at an academic institution, and to be general obstetrician–gynecologists. In addition, 44.9% of AUGS members practice obstetrics compared with 94.7% of SMFM members.
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The attitudes of AUGS and SMFM members regarding elective primary cesarean delivery are shown in Table 2. Overall, 65.4% of responders would agree to perform an elective cesarean, and 29.6% have already performed one. A significantly higher percentage of AUGS members would agree to perform an elective cesarean than would SMFM members (80.4% versus 55.4%, respectively, P < .001). Urogynecologists were also more likely to perform an elective cesarean for an asymptomatic woman with a history of a third- or fourth-degree laceration (85.8% versus 66.8%, P < .001) and for an estimated fetal weight of 4,500 g (94.8% versus 84.0%, P < .001). Members of AUGS were more likely to believe that a woman has the right to have an elective cesarean (84.6% versus 67.6%, P < .001) and to choose/recommend an elective cesarean for themselves or their partners (45.5% versus 9.5%, P < .001). Male physicians were also more likely to believe that a woman has a right to an elective cesarean delivery (78.7% versus 66.9%, respectively, P < .001) and to have already performed one (33.3% versus 23.3%, respectively, P = .003) than female physicians.
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A logistic regression model that included subspecialty, age, sex, having no children, and years in practice was developed to determine which factors were associated with physicians agreeing to perform an elective primary cesarean delivery. In this model, AUGS members (OR 3.4, 95% CI 2.3–4.9) and male physicians (OR 1.8, 95% CI 1.2–2.6) were significantly more likely to support elective cesareans (Table 3).
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Among respondents, 9.2% consider themselves general obstetrician–gynecologists, with a higher percentage in AUGS than in SMFM. To determine whether these general obstetrician–gynecologists would influence our results, they were excluded in a subanalysis. In this subanalysis, the results remained essentially unchanged, with 83.4% of AUGS and 55.1% of SMFM members (P < .001) agreeing to perform an elective cesarean delivery. In a similar logistic regression model, AUGS members were 4.3 times more likely to support elective cesareans (95% CI 2.8 –6.6).
Physicians were asked to choose their reasons for agreeing or not agreeing to perform an elective cesarean (Table 4). The most common reason for agreeing to perform an elective cesarean was patient request, which was chosen by 59% of respondents. More than one third of total respondents chose concern for perineal damage and the long-term sequelae of urinary incontinence, fecal incontinence, and pelvic organ prolapse as additional reasons for supporting elective cesareans. The most common reasons for not agreeing to perform an elective cesarean delivery were concern for potential complications in future pregnancies, an increase in maternal morbidity and mortality, and the feeling that elective cesareans will not prevent pelvic floor disorders. Concerns regarding cost, liability, insurance, and neonatal outcomes were not frequently chosen reasons for supporting or opposing elective primary cesarean deliveries.
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DISCUSSION |
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Over half of respondents from both of the societies we surveyed would perform an elective cesarean delivery, but there were significant differences between the attitudes of AUGS and those of SMFM members. Urogynecologists were significantly more likely to support elective cesareans in all of the proposed clinical scenarios. For example, 80.4% of AUGS compared with 55.4% of SMFM members would agree to perform a truly elective delivery, and these percentages increased to 85.8% and 66.8%, respectively, if the patient had a history of a third- or fourth-degree laceration. The most striking difference between these 2 subspecialties is that 45.5% of AUGS members would choose/recommend an elective cesarean for themselves or their partners compared with 9.5% of SMFM members.
These findings are consistent with what one would think intuitively about the preferences of these subspecialists. Urogynecologists are concerned with protecting the pelvic floor, and more than 60% of AUGS members cited the importance of preventing urinary incontinence, fecal incontinence, and pelvic organ prolapse as a reason to support elective cesareans. Maternal–fetal medicine specialists may be less convinced that cesarean deliveries may help to prevent pelvic floor disorders, and they are more concerned about the potential complications for future pregnancies and the potential for increased maternal morbidity and mortality of elective cesareans. Although these 2 groups differed in their attitude about elective cesareans, both did not list either cost, liability, insurance, or effect on neonatal outcomes as major reasons to support or oppose elective cesareans.
There were also significant differences between the opinions of male and female physicians. Men were more likely to have performed an elective cesarean, to agree to perform an elective cesarean, and to believe that a woman has a right to have this elective surgery. In contrast, 15% of female obstetricians in Ireland would chose an elective cesarean compared with 4% of male obstetricians,22 and in London, 31% of female obstetricians would choose an elective delivery compared with 8% of male obstetricians.19
One of the limitations of this study is that our response rate was 52.9%, despite sending out multiple e-mails. In addition, selection bias may have occurred, because physicians who do not use e-mail would not have been contacted. Of physicians in the directories for these 2 societies, approximately 63% of AUGS and 50% of SMFM members had e-mail addresses listed. In addition, the majority of our respondents were employed at an academic institution, which also might have introduced selection bias. We were unable to compare those physicians with e-mail addresses and those without e-mail addresses to determine how representative our sample was of these societies. Given these limitations, the results of this study may not necessarily be generalizable to the overall attitudes of the membership these 2 societies.
Elective primary cesarean delivery is a controversial issue. This controversy is fueled by the lack of data regarding the short-term and long-term consequences of vaginal deliveries compared with elective cesarean deliveries. This debate will continue until a randomized controlled trial of these 2 modes of delivery is conducted. In the meantime, we believe that this study provides some insight into the attitudes of urogynecology and maternal–fetal medicine subspecialists on the issue of primary elective cesarean delivery.
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Footnotes |
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Received July 7, 2004. Received in revised form September 10, 2004. Accepted October 7, 2004.
doi:10.1097/01.AOG.0000151110.05801.c0
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REFERENCES |
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