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

BJOG. 2006 Jun;113(6):647-56. doi: 10.1111/j.1471-0528.2006.00933.x.


Objective: To explore the attitudes of obstetricians to perform 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 1,530 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.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Attitude of Health Personnel*
  • Attitude to Health*
  • Cesarean Section / psychology*
  • Cross-Sectional Studies
  • Elective Surgical Procedures / psychology*
  • Europe
  • Female
  • Humans
  • Male
  • Middle Aged
  • Obstetrics*
  • Patient Advocacy
  • Pregnancy