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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.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX
 REFERENCES
 
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

Between the 1980s and 1990s, cases of cesarean delivery performed by court order in the absence of the woman’s consent raised considerable attention in the media and resulted in a long-running debate in the professional literature. Most cases were from the United States and Canada, and a disproportionate number of the patients involved were poor, black, or non–English-speaking women.1,8 In the United States, the first publicized case of a court decision for cesarean delivery dates from 1981.10 Since then, landmark judgments from appeals courts, together with position statements from the American College of Obstetricians and Gynecologists (ACOG) and other professional organizations, have consistently affirmed the right of a competent and informed pregnant woman to make her own health care choices, apparently settling the issue once and for all. But is it really so? When the life of a pregnant woman or of a viable fetus is at stake, decision making remains highly problematic, and as recently as 2004 the state of Utah charged Melissa Rowland with the murder of her stillborn fetus because of a delay in accepting a physician’s advice for a cesarean delivery.18 At the same time, the extent to which professional organizations’ statements represent a consensus view is not known, as data on physicians’ opinions and attitudes regarding forced cesarean delivery are scarce. A multinational European study (EUROBS) on ethical issues in pre- and perinatal care provided an opportunity to describe the attitudes of a large, representative sample of obstetricians in eight countries toward a woman’s refusal to consent to an emergency cesarean delivery for acute fetal distress, as well as an opportunity to explore possible predictive factors.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 APPENDIX
 REFERENCES
 
Eight European countries took part in the EUROBS project: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden, and the United Kingdom. In every country, only maternity units associated with a neonatal intensive care unit (NICU) were sampled. The sampling strategy mirrored that adopted in a previous European study on ethical issues in neonatal medicine.19,20 In Luxembourg, the Netherlands, and Sweden, all existing NICU-associated maternity units were asked to participate, whereas in the other countries (France, Germany, Italy, Spain, and the United Kingdom), random samples stratified by geographical area were selected. In every participating unit, all physicians with at least 6 months’ experience in obstetrics were recruited for the study.

Out of 149 invited maternity units, 105 agreed to take part, corresponding to an overall unit response rate of 70% (100% in the Netherlands, Sweden, and Luxembourg; 85% in Italy; 75% in Spain; 65% in the United Kingdom; 53% in France; and 41% in Germany). Completed questionnaires were returned from 1,530 obstetricians, a staff response rate of 77%. National response rates are presented in Table 1.


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  		Table 1. Sociodemographic and Professional Characteristics of Responding Obstetricians (Unweighted Proportions)

 

Data collection took place in 2001–2002. A structured questionnaire was used to survey the obstetricians’ self-reported practices and attitudes in five major areas: prenatal ultrasound examination, late termination of pregnancy, management of severe prematurity, situations of conflicting opinions between staff and the women, and legal concerns in obstetric practice. The questionnaire was anonymous and self-administered to protect confidentiality. It was developed in English and translated into national languages. A back-translation into English was done to check the accuracy of the translation and ensure identical semantic content.

This paper explores the obstetricians’ attitudes toward a woman’s refusal of cesarean delivery that was deemed medically necessary because of acute fetal distress. Respondents were presented with a detailed description of a fictitious but paradigmatic case (Table 2) and were asked whether they would a) accept the woman’s decision and assist vaginal delivery; b) seek an emergency court order to override the woman’s refusal; or c) proceed with cesarean delivery without such order. The type of information provided to the woman and the obstetrician’s motives for seeking a court order were explored as well. Respondents were asked to report their selected actions according to a three-point scale (yes, maybe, or no); only the proportion of "yes" answers is reported in the tables.


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  		Table 2. Respondents’ Attitudes Towards a Woman’s Refusal of Emergency Cesarean Delivery for Acute Fetal Distress (Weighted Proportions)

 

Statistical analysis was carried out with the STATA 8.0 (Stata Corporation, College Station, TX). Weights, computed as the inverse of the probability for a given maternity unit to be selected within a certain country and geographical stratum, were applied to take into account the different sampling fractions adopted in the participating countries.21,22 Standard errors were adjusted for intracluster correlation, that is, the nonindependence of observations within the same maternity unit.22

Unless stated otherwise, results are presented as weighted proportions and 95% confidence intervals. Multivariable logistic regression analysis was used to explore factors associated with an obstetrician’s self-reported choice to accept the woman’s decision and assist vaginal delivery (yes versus maybe or no). Together with country, the following variables were considered for inclusion in the multivariable model: physicians’ sociodemographic and personal characteristics (age, sex, having children, being married or living with a partner, religious affiliation, and the importance attributed to religion in one’s life); professional variables (position, length of experience in obstetrics and in delivery room assistance, full-time versus part-time hospital appointment, and private practice involvement); and variables related to the unit (university affiliation, being a referral center for high-risk pregnancies, unit cesarean delivery rates). Forward and backward selection procedures were implemented, retaining in the final model the variable of sex, along with those variables consistently showing a statistical significance (P≤.05) in both procedures.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 APPENDIX
 REFERENCES
 
The numbers and proportions of responding physicians per country and their sociodemographic and professional characteristics are presented in Table 1. In every country except Italy, France, and Luxembourg, about half the respondents were female. In Italy and Sweden, 40% of respondents were aged 50 years or more, compared with only 7% of those in the United Kingdom. In all countries except Luxembourg, most physicians were working full-time in the hospital. In Italy, Spain, and Luxembourg, a relevant proportion of respondents also had a private practice, either within the same hospital or outside it.

Most respondents in Italy, Spain, and Luxembourg were Roman Catholic, whereas in Germany and Sweden the majority were Protestant. A small minority of respondents in Italy, Spain, and Germany reported that they considered religion not at all important in their lives, whereas in the other countries this view was expressed by an appreciably higher proportion, ranging from one fourth to over one third of respondents.

Table 2 shows the obstetricians’ attitudes toward a woman’s refusal of a cesarean delivery that was deemed necessary because of acute fetal distress. In every country, the vast majority of obstetricians stated that they would keep trying to persuade the woman to consent to cesarean delivery, telling her that failure to do so might result in the fetus surviving with a disability or even, in Germany and France especially, that her own life might be in danger. In Spain, France, Italy, and to a lesser extent, Germany and Luxembourg, a considerable proportion of physicians would seek a court order, either to safeguard fetal welfare or to avoid possible legal liability or both. In contrast, most respondents in the United Kingdom (59%), Sweden (41%), and Netherlands (37%) would accept the woman’s decision and assist vaginal delivery. In every country, only a small minority (ranging from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without seeking a court order.

Table 3 shows the results of the multivariable logistic model exploring the factors associated with the obstetricians’ answer that they would accept the woman’s decision and assist vaginal delivery—a variable which was chosen as a model outcome among the other possible responses (Table 2) because it indicates a clear-cut acceptance of the woman’s choice. Odds ratios (OR) greater than 1 indicate an increased willingness, and those less than 1 indicate a decreased willingness to comply with the woman’s choice compared with the reference category.


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  		Table 3. Predictors of Obstetricians’ Reported Answer That They Would Accept the Woman’s Decision and Assist Vaginal Delivery: Results of a Multivariable Logistic Model

 

Being married or living with a partner, considering religion as "not at all" important in one’s life, and working in a university-affiliated unit increased the likelihood of an obstetrician’s reporting compliance with the woman’s will. In contrast, age over 30, being the head, deputy, or adjunct head of the unit, recent routine delivery room practice for at least 1 year, and working part-time in the hospital all decreased such a likelihood. Differences between countries remained statistically significant, with respondents in the United Kingdom being largely the most likely and those in Spain, France, and Italy the least likely to accept the woman’s decision.


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
APPENDIX
 REFERENCES
 
When confronted with a competent, informed woman’s refusal to consent to a cesarean delivery deemed necessary to protect the life and health of a term fetus, the obstetricians’ attitudes in the various European countries differ. To some extent, differences in attitudes occur along a north-south divide, with respondents from northern European countries (Sweden, United Kingdom, and the Netherlands) being more willing and those from countries in southern Europe (Italy, Spain, and France) being less willing to comply with the woman’s autonomous decision. Within countries, personal and professional characteristics of the individual physician appeared to play a role. Being the chief, deputy, or adjunct chief of the unit, a position linked to greater accountability, and possibly, legal liability, significantly decreased the likelihood of accepting the woman’s decision. In contrast, demographic variables such as younger age and being married or living with a partner, as well as personal values such as attributing little importance to religion in one’s life, were associated with greater willingness to do so. No statistically significant difference appeared according to the obstetrician’s gender.

To our knowledge, this is the only international study providing comparable data on physicians’ attitudes toward coerced cesarean delivery. The overall high physician response rate within the recruited units (77%) supports the validity of our findings, although the lower unit recruitment fraction of some countries, mainly due to organizational reasons, may have impaired representativeness at the national level.

The kind of north-south divide found in this study has been reported in other areas of clinical medicine, such as patients’ information provision and forgoing life support in adult intensive care,23,24 parents’ visiting policies in the neonatal nursery, and involvement in decisions.21 A previous study from this same EUROBS project confirms the influence of nationality on obstetricians’ acceptance of women choices.25 Different legislation may have an influence. In the United Kingdom, a fetus has no legal status.16 The legal position was further clarified when a court of appeals pronounced that a competent woman could choose not to have medical intervention, even if the consequence might be the death or serious handicap of the child she bore or her own death.12,26 Similarly, in Sweden the fetus does not have any legal rights until it is born and shows signs of life. The constitutional law about health care guarantees the woman respect for her right to self-determination and integrity, including the right to refuse any medical investigation and treatment.

Also in Italy the Constitution supports the right of a competent adult to reject medical treatment.27 However, Italian law is strongly protective of human life, particularly when children and neonates are involved; immediately before being born, a fetus is assumed to have the same rights as a neonate. Thus, although no cases of court-enforced cesarean deliveries have been reported in Italy, physicians may view a court opinion as a safeguard against claims of negligence, particularly in a situation of emergency that could later give rise to doubts about the appropriateness of the information provided or the accuracy of ascertainment of patient’s competence.

In France, the findings of a qualitative study carried out, within this same EUROBS project, through in-depth personal interviews with a small sample of obstetricians and midwives28 may shed light on the reasons underlying the French position. Most respondents stated that situations of maternal-fetal conflict are extremely rare, almost always concerning women from other countries (mainly African) and cultures. They indicated that cesarean deliveries would always be carried out eventually, either by the woman finally accepting medical advice or, more rarely, through a court order. Less often they would tell the woman that without surgery the baby would die. One obstetrician mentioned the possibility of using sedatives to overcome the woman’s opposition (M. Garel, unpublished findings, 2000), a finding that may shed light on the lack of women’s resistance, which is sometimes reported in instances of coerced cesarean delivery.5 Overall, the ethical values emerging from these interviews seem consistent with the emphasis on beneficence, rather than on patients’ autonomy, which is said to prevail in France.29 They are probably common in other European countries as well, as indicated by our finding that a nonnegligible proportion of respondents would stretch the arguments to persuade the woman by telling her that her own life might be in danger, despite there being no hint of this risk contained in the case description.

In the last decades, the progress of medical technology has rendered the fetus more "visible" within the mother’s womb30 and increasingly accessible to medical intervention. Consequently, the idea of "the fetus as a patient" has gradually emerged, and the old notion of "maternal-fetal dyad" has been replaced by the "two-persons" model.

Yet, all preventive, diagnostic, and therapeutic interventions must still be carried out through the woman’s body. When for any reason the woman refuses to comply, a situation of maternal-fetal conflict is said to arise: a term that has been criticized on the grounds that it would wrongly place the site of disagreement between the mother and her fetus, rather than between the mother and health care providers who have their own (perhaps incorrect) views of the best course of action.7

The issue of coerced cesarean delivery for acute fetal distress is minor in terms of occurrence frequency, but it is important as a clear-cut example of such a conflict of values. That the adoption of the two-persons model of obstetric care may have radicalized the conflict is shown in the writings of Chervenak et al,5 who suggested that beneficence-based obligations toward the term fetal patient provide a sufficient ethical justification for emergency coerced cesarean delivery, even in the absence of court order—a view that is shared also by the authors of a much more recent paper.9

In contrast, Mattingly32 follows a different line of reasoning to show that the two-persons model does not, in her opinion, grant the fetus any greater protection. Mattingly agrees that, because of parental responsibility and because she has made the decision to carry on with the pregnancy in the first place, a woman has a positive duty of beneficence, and a negative one of nonmaleficence, toward her term or near-term fetus. Failure to honor such duties by a competent, informed woman may well disqualify her as natural proxy decision maker for the fetus. Nevertheless, any different decision reached by an alternative proxy, whether it be the father, the physician, or even the court, will always require the woman’s consent to be implemented through her own body.32 This reasoning provides the ethical basis for the pronouncements of professional organizations and appellate courts, which, without denying the beneficence obligations toward the fetus, have nevertheless reaffirmed the right of a competent woman to her bodily integrity. In fact, the courts of every country have so far been reluctant to order other competent adults to undergo medical or surgical procedures for the benefit of another person, even when refusal entails the death of such person.6 It is argued that making pregnancy an exception would open also for such cases, as well as possibly discouraging some women most at risk from seeking appropriate prenatal care (Beech BA. Court ordered caesarean sections are discouraging women from seeking obstetric care [letter]. BMJ 1997;314:1908.). Yet, such a conclusion may be extremely hard for the clinician to accept, as our findings clearly show, particularly in countries where the concept of patients’ autonomy is less strongly valued.

When coercion by means of a court order is no longer an option, what are the alternatives for the obstetrician who, in his or her best judgement, aims at preventing damage to the fetus? In their discussion of the ethics of informed consent, Beauchamp and Childress33 differentiate between persuasion, ie, influence by appeal to reason, and the various forms of manipulation, including deception. While the first is definitely part of a clinician’s duty, manipulation may represent a violation of patient’s autonomy. In our study, the possible use of sedation suggested by the qualitative interviews carried out in France and the agreement with the argument of danger to the woman’s health reported by some respondents in various countries suggest that sometimes the line between persuasion and manipulation might become blurred.

With the exception of clear-cut cases of a patient’s incompetence, persuasion remains the main noncontroversial option. It requires both the existence of a firm patient-physician trust relationship and the exploration of a woman’s preferences and values since early gestation. The physician should adopt, as suggested by Harris,34 a broader perspective, taking into account socioeconomic, cultural, and racial inequalities, to achieve fetal well-being through promotion of maternal well-being. In contrast with the traditional "conflict of rights" framework, this "care-based" approach would maximize the chances for "prevention, rather than criminalization, of prenatal harm."34


   APPENDIX
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX
REFERENCES
 
Other members of the European Obstetricians (EUROBS) Study Group are as follows: H. Grandjean, M. Kaminski (France); P. Benciolini, S. Guaschino, and C. Viafora (Italy); P. Gratia (Luxembourg); I. de Beaufort (Netherlands); J. Librero (Spain); G. Lingman (Sweden); and D. Taylor (UK).

List of Participating Obstetrics Units

France: Hôpital Maison Blanche, Reims (R. Gabriel, C. Quereux); Centre Hospitalier Universitaire, Amiens (J. Gondry, J. C. Boulanger); Centre Hospitalier Universitaire Jean Bernard, Poitiers (G. Magnin); Centre Hospitalier, Saint Brieuc (B. Cloup, A. Renaud-Giono); Centre Hospitalier Universitaire, Caen (M. Dreyfus, M. Herlicoviez); Centre Hospitalier Universitaire, Rouen (L. Marpeau); Hôpital Antoine Béclère, Clamart (F. Audibert, R. Frydman); Hôpital Robert Debré, Paris (P. Blot); Hôpital Nord, Saint Etienne (M. N. Varlet, P. Seffert); Hôpital François Mitterand, Pau (C. Belcikowski, M. Chevalier); Hôpital Bretonneau, Tours (J. Lansac); Maternité Port-Royal, Paris (D. Cabrol); Hôpital Jeanne de Flandre, Lille (F. Puech).
Germany: Marienkrankenhaus, Hamburg (U. Blasshof, P. Scheidel); Städt. Krankenhaus, Lüneburg (E. Walbrodt, J. Gille); Städt. Krankenhaus Köln-Holweide, Köln (U. Schellenberger, F. Wolff); Klinikum Frauenklinik, Bamberg (J. Peisl, R. v. Hugo); Universitätsklinik, Göttingen (W. Heyl, G. Emons); Universitätsklinikum Virchow Klinikum, Berlin (U. Büscher, J. W. Dudenhausen); Universitätsklinikum, Dresden (A. Riehn, W. Distler); Universitätsklinikum, Leipzig (B. Viehweg, M. Höckel); Universitäts-Frauenklinik, Münster (W. Klockenbusch, L. Kießl); Frauenklinik der Universität, Gießen (M. Zygmunt, W. Künzel); Frauenklinik der Universität, Mainz (P. Brockerhoff, P. G. Knapstein); Frauenklinik der Universität, München (F. Kainer, G. Kindermann); Universitätsklinikum, Tübingen (B. Schauff, D. Wallwiener); Städt. Krankenhaus München-Schwabing, München (E. M. Grischke); Städt. Krankenanstalten, Krefeld (W. Poleska, J. Baltzer).
Italy: Ospedale Santa Croce, Moncalieri To (M. E. Renzetti, R. Monti); Ospedale Niguarda Ca’ Granda, Milano (A. Ragusa, S. Garsia); Ospedale di Circolo e Fondazione Macchi, Varese (P. Clerici, G. Maffioli, D. Balestreri, P. F. Bolis); Azienda Ospedaliera S Anna, Como (G. Bonifacino, F. Colombo); Ospedale Bolognini, Seriate Bg (G. Palmerio, L. D. Moretti); Ospedale Policlinico G B Rossi, Verona (E. Zardini, D. Pecorari, V. Silvestre, L. Fedele); Università degli Studi di Padova, Padova (D. M. Paternoster, A. Ambrosiani, F. Lauri, S. Mazzer, M. Rondinelli, P. Grella); Istituto per l’Infanzia Burlo Garofolo, Trieste (S. Guaschino); Policlinico Universitario di Udine, Udine (F. Petraglia); Presidio Ospedaliero di Gorizia, Gorizia (C. Gigli); Policlinico S Orsola-Malpighi, Bologna (L. F. Orsini, D. De Aloysio); Ospedale Maggiore, Bologna (M. Lenzi, C. Melega); Ospedale S Maria Annunziata, Firenze (C. Campatelli, Gaggi); Ospedale Civile Spirito Santo, Pescara (V. Palladoro, R. Lotti); Presidio Ospedaliero di Belcolle, Viterbo (G. Palla); Policlinico Umberto I, Roma (M. Anceschi, E. V. Cosmi); Ospedale SS Annunziata, Napoli (C. Picardi, R. Arienzo); Azienda Ospedaliera S Giovanni di Dio e Ruggi d’Aragona, Salerno (C. Lomiento, A. Fasolino, De Angelis, R. Quirino); Ospedale A Perrino, Brindisi (S. Burlizzi, E. R. Poddi); Azienda Ospedaliera Vito Fazzi, Lecce (F. Totaro Aprile, A. Perrone, F. G. Tinelli); Ospedali Riuniti di Foggia, Foggia (Maruotti, F. Pietropaolo, G. Arciuolo, P. Lauriola, C. Napolitano, C. M. Troysi); Ospedali Riuniti Bianchi Melacrino Morelli, Reggio Calabria (N. Bitto, P. F. Tropea); Presidio Ospedale Civico e Benfratelli, Palermo (P. Bellipanni, C. Giannola, C. Vicari, V. Giambanco); Università degli Studi di Cagliari, Ospedale San Giovanni di Dio, Cagliari (S. Ajossa, G. B. Melis).
Luxembourg: Luxembourg Hospital Centre (P. Gratia).
Spain: Hospital Clínico Universitario de Santiago, Santiago de Campostela (R. Ucieda Somoza, M. Iglesias Díaz); Hospital Central de Asturias, Oviedo (A. Escudero Gómis, S. Villaverde Fernandez); Hospital de Basurto, Bilbao (T. Martinez-Astorquiza, J. M. Usandizaga Pombo); Hospital Ntra. Sra. de Aránzazu, San Sebastián (J. J. Urtiaga Unda, J. J. Larraz Soravilla); Hospital Infantil Miguel Servet, Zaragoza (J. J. Tobajas Homs, C. González Batres); Casa de Maternitat, Barcelona (E. Barrau Vernia, V. Caradach); Hospital Ntr Sra de Candelaria, Tenerife (J. A. Cortell Olcina, F. Martin Casañas); Hospital Universitario Virgen de la Arrixaca, Murcia (J. L. Delgado Martín, J. J. Parrilla); Hospital Universitario de Canarias, Tenerife (J. Parache); Hospital Son Dureta, Palma de Mallorca (A. Marqués Bravo, M. Usandizaga Calparsoro); Hospital Clínico S Carlos, Madrid (M. A. Herráiz, M. Escudero Fernandez); Hospital Universitario Santa Cristina, Madrid (E. Soto Sanchez, F. Izquierdo Gonzalez); Hospital Materno-Infantil de Málaga Carlos Haya, Málaga (J. Carrera Rodriguez, M. Abehsera Bensabat); Hospital San Pedro de Alcántara, Cáceres (J. I. Moriñigo Yague, C. Alcón Alcón); Hospital Clínico San Cecilio de Granada, Granada (A. Caño Aguilar, M. Dolz Romero); Hospital General Universitario de Alicante, Alicante (J. C. Martínez Escoriza).
Sweden: Centrallasarettet, Falun (I. Westman, A.-C. Cachrimanidou); Centralsjukhuset, Karlstad (J. Hareide, G. Wadsten); Sundsvalls Sjukhus, Sundsvall (L. Berglund); Centralsjukhuset, Kristianstad (H. Ström, G. Helm); Universitetssjukhuset MAS, Malmö (S. Montan); Mälarsjukhuset, Eskilstuna (B. Möller, M. Rom); Kärnsjukhuset, Skövde (J. Leyon, G. Wallstersson); Centrallasarettet, Västerås (L. O. W. Svensson); Länssjukhuset Ryhov, Jönköping (R. Boij, R. Lenrick); Centrallasarettet, Borås (T. Solum); Sahlgrenska Universitetssjukhuset/Östra, Göteborg (U.-B. Wennerholm, M. Wennergren); Akademiska Sjukhuset, Uppsala (U. Hansson); Norrlands Universitetssjukhus, Umeå (P.-Å. Holmgren, I. Sjöberg); Regionssjukhuset i Örebro, Örebro (G. Falk, M. Lood); Regionssjukhuset i Linköping, Linköping (A. Jeppsson, G. Berg, S. Kjellberg); Universitetssjukhuset i Lund, Lund (G. Lingman, K. Marsal); Karolinska Sjukhuset, Stockholm (O. Bakos, V. Odlind).
The Netherlands: Maxima Medical Center, Veldhoven (M. Y. Bongers); Isala Clinics, Zwolle (J. van Eyck); Academic Medical Centre at the University of Amsterdam, Amsterdam (M Pel, O. P. Bleker); Free University Medical Centre, Amsterdam (J. I. P. de Vries, H. P. van Geijn); Academic Hospital Groningen, Groningen (M. P. Heringa, J. P. Holm); Leiden Academic Medical Centre, Leiden (J. van Roosmalen, H. H. H. Kanhai); Academic Hospital Maastricht, Maastricht (L. L. H. Peeters, J. G. Nijhuis); Academic Medical Centre St. Radboud, Nijmegen (P. P. Van den Berg, D. D. M. Braat); Academic Medical Centre Utrecht, Utrecht (H. W. Bruinse, G. H. A. Visser); Erasmus Medical Centre, Rotterdam (E. A. P. Steegers, J. W. Wladimiroff).
The United Kingdom: Derriford Hospital, Plymouth (I. Montague, A. D. Falconer); Leicester Royal Infirmary, Leicester (A. Akkad, C. Stewart); King’s College Hospital, London (M. Marsh); Southmead Hospital, Bristol (D. Bisson); Nottingham City Hospital, Nottingham (H. Hamoda, D. T. Liu); Birmingham Womens Hospital, Birmingham (M. J. Whittle); St James University Hospital, Leeds (G. Mason); Rosie Hospital, Cambridge (P. Plumpton, C. Lees); North Staffordshire Maternity Hospital, Stoke on Trent (G. V. Sunanda, G. Masson); Royal Gwent Hospital, Newport (R. Gonsalves); University Hospital of Wales, Cardiff (K. Sidhu, N. Amso).


   Footnotes
 
* For members of the European Obstetricians (EUROBS) Study Group and a list of participating obstetrics units, see the Appendix.

The results presented in this paper are part of the European Concerted Action project EUROBS on "Developments of perinatal technology and ethical decision-making during pregnancy and birth: the obstetricians’ perspective" funded by the European Commission (contract no. BMH4-CT98–3376; project coordinator, Marina Cuttini, IRCCS Burlo Garofolo, Trieste).

The authors thank Michael Hills for acting as statistical advisor and the IRTEF Institute for data management.

Corresponding author: Marina Cuttini, MD, MPH, PhD, Unit of Epidemiology, Ospedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4, 00165 Roma, Italy; e-mail: cuttini{at}opbg.net. Back

doi:10.1097/01.AOG.0000239123.10646.4c


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX
 REFERENCES
 
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