ORIGINAL ARTICLES AND REVIEWS
Ugo IndraccoloI; Gennaro ScutieroII; Maria MatteoIII; Salvatore Renato IndraccoloIV; Pantaleo GrecoV
IUnità Operativa Complessa di Ginecologia e Ostetricia, Ospedale "Alto Tevere"di Città di Castello, ASL 1 Umbria, Città di Castello, Italy
IIUnità Operativa Complessa di Ginecologia e Ostetricia, Ospedale Civico di Codogno, Azienda Ospedaliera della provincia di Lodi, Codogno, Italy
IIIDipartimento di Scienze Cliniche e Chirurgiche, Università di Foggia, Foggia Italy
IVDipartimento di Scienze Ginecologiche, Ostetriche e Scienze Urologiche, Sapienza Università di Roma, Rome, Italy
VDipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Università degli Studi di Ferrara, Ferrara, Italy
BACKGROUND: Cesarean section on maternal request (CSMR) could represent an avoidable quota of cesareans. In Italy, this is a topical problem of health-policy, involving ethical, juridical and medical issues.
AIM AND METHODS: A 5-questions questionnaire to quantitatively assess the perspectives of medical, juridical and ethical issues of planned CSMR was administered to obstetricians and gynecologists, midwives, lawyers and pregnant women. It was assessed to what extent those issues matter on the final decision of planning a CSMR.
RESULTS: Non-homogeneous answers of stakeholders suggest different perspectives about issues on CSMR. The juridical issue seems to have the greatest impact on the final decision.
CONCLUSION: Planning a CSMR associates overall with juridical issues in each group of respondents. Therefore, an obstetrician and gynecologist is unable to counsel a patient on CSMR from a medical point of view. The most direct way for reducing cesareans in Italy could be the formal prohibition of CSMR.
Key words: cesarean section on maternal request, liability, complications
Cesarean section rate is a concern world-wide as well as in Italy, where the cesarean section rate is the highest of Europe . Like other western countries [2, 3], even in Italy cesareans section is more associated with maternal death than vaginal delivery . Additionally, some morbidity in childhood associated with cesareans seems more significant than what was believed, as reported in recent literature [5-8]. This may be due to some immunological behaviour occurring on the fetus during labour and vaginal delivery . Taken together, both maternal mortality data and neonatal morbidity associated with cesarean lead us to understand that abdominal birth is not equivalent to vaginal birth in human beings. From a medical point of view, caregivers should discourage the policy to perform cesareans. However, a pregnant women may be concerned about the harm of vaginal birth, choosing to perform a planned cesarean for preventing labour and vaginal delivery. This choice is also substantiated by literature, which does not demonstrate advantages of vaginal delivery with respect to cesarean section on maternal request (CSMR) for maternal and fetal health [10, 11]. Moreover, patients' right to chose an elective cesarean should be taken into account in the final decision of an abdominal birth independently from any medical issue.
Recently, Ecker  discussed the perspectives of physicians and patients about elective CSMR, confirming that there is no immediate expectation for CSMR to reduce the health risk for both mother and fetus. Therefore, the decision to plan a CSMR should be discussed carefully with the patient. CSMR encompasses many cultural, medical, ethical and juridical issues, leading physicians to consider it correct to perform a CSMR independently from any medical issues [13, 14] because it is the patient's own decision. This physician perspective seems to be correct under Common Law. In other law contexts, however, the behavior of physicians varies . Overall, physicians feel good about complying to patients requesting a Cesarean section, even for avoiding possible litigations.
Yet, the significantly high rate of cesarean sections, both world-wide and particularly in Italy, suggests a need to avoid cesareans in the absence of medical indications, as is the case in CSMR. In Italy, practice guidelines (www.snlg-iss.it/cms/files/LG_cesareo_comunicazione.pdf) suggest addressing the patient to another physician for obtaining a second opinion about CSMR. This recommendation aims to reduce the cesarean section rate by attenuating the birth fear of patients, providing comprehensive counseling with many caregivers about the medical issues of labour. From the point of view of Italian practice guidelines, ethical and juridical issues if the CSMR is performed and if it is not performed are not stressed. Such an aspect is likely to have raised concerns among obstetricians and gynecologists and midwives. Moreover, the cultural and juridical context in Italy cannot be generalized to other European and non-European countries, therefore information from literature about elective CSMR cannot be adapted to Italy and to Italian caregivers.
The aim of the present study is to assess the perspectives of a sample of Italian obstetricians and gynecologists (O&Gs), midwives, lawyers and patients about planned CSMR from a medical, juridical and ethical point of view.
A sample of O&Gs, midwives, lawyers and patients (in the first trimester of pregnancy) were asked to answer a brief questionnaire assessing their perspectives about planned CSMR. Respondents were sampled in North, Center and South of Italy, as following. Authors contacted personally and by e-mail known colleagues, midwives, lawyers in the North, Center and South of Italy, and asked them to answer a brief 5-question questionnaire. Patients were sampled at the Institute of Obstetrics and Gynecology (Department of Clinical and Surgical Sciences, University of Foggia), at the Complex Operative Unit of Gynecology and Obstetrics, Civic Hospital of Codogno (Azienda Ospedaliera della Provincia di Lodi) and at the Complex Operative Unit of Gynecology and Obstetrics, Hospital of Civitanova Marche (Area Vasta 3 - Marche). They were asked to answer the same 5-question questionnaire. The questionnaire was structured as follows. A brief summary-table (Table 1) of potential disadvantages and advantages of both vaginal delivery and cesarean delivery (extrapolated from Ecker  and translated into Italian). This informative table preceeded the five questions:
From a medical point of view, how proper is it to comply with the desire of a patient, who has been fully informed, yet requests a cesarean section in the absence of medical indications?
From a juridical point of view, in the absence of successive complications, how proper is it for a physician to have complied with the desire of a patient, who has been fully informed, yet has requested a cesarean section in the absence of medical indications?
From a juridical point of view, in the case of a complication due to vaginal birth, how significant is it that the physician has not complied with the request of a patient, who has been fully informed, for a cesarean section in the absence of medical indications?
From a juridical point of view, in the case of a complication due to cesarean section performed in the absence of medical indications, how significant is it that the physician has complied with the request of a patient, who has been fully informed, for a cesarean section in the absence of medical indications?
5. From an ethical point of view, how proper is it for a physician to comply with the desire of a patient, who has been fully informed, by performing a cesarean section in the absence of medical indications?
These questions investigated the perception of respondents on medical, juridical and ethical issues regarding planned CSMR. The first question assesses medical perception of CSMR (medical issue) among respondents. The second, third and fourth questions assess juridical perceptions of CSMR (juridical issue) among respondents. The fifth question assesses the ethical perception of CSMR (ethical issue) among respondents.
Respondents were invited to read the informative table before answering the five questions in a two-sheet form, sent by e-mail or given in a printed version. Answers were given following a 5-degree Likert's scale, with 1 = minimum and 5 = maximum scoring.
Answer values for the five questions given by O&Gs, midwives, lawyers and patients was compared by using the Kruskall-Wallis test, with p < 0.05 set as significant. Kyplot 2.0 was used for calculations.
36 O&Gs, 42 midwives, 22 lawyers and 25 patients provided their answers and were happy to discuss the topic. Medians of Likert' scores and absolute and percent frequencies of response categories for each group of respondents are reported in Table 2. In the last column on the right in Table 2, the significance for comparison is also reported. Indifference is considered if the higher rate of Likert' score is 3. The less close to 3 the higher rate of score is, the more relevant or less relevant the issue is.
From a medical point of view (medical issue), it seems that O&Gs and midwives agree in considering it an error to perform a planned CSMR (higher rate for score 1 on 1st question for both O&Gs and midwives). Lawyers have provided a score of 3 as higher than other scores (meaning indifference), even if a consistent fraction of them have answered with 1 and 2 (Table 2) on the 1st question, suggesting that some lawyers feel that CSMR is a medical error. On the other hand, some patients believe that planned CSMR could have a therapeutic role (same higher rates for scores 3 and 4 on 1st question), likely for avoiding complications from vaginal delivery.
Each group believes that planned CSMR has some juridical issues both in the case of no complications from the cesarean, as well as in the case of complications both from the cesarean and from vaginal delivery. However, each group considers the topic in a different way. Lawyers consider it pivotal to follow the patient's own decision (higher rate for score 5, 2nd question), independently from complications. In the case of litigation because of complications from cesarean, Italian law needs to demonstrate errors of the physician in performing the cesarean or in managing labour and delivery. Demonstrating such errors is independent from the patient's request for a cesarean and it especially matters in the case of complications from an unwanted vaginal birth (higher rate for score 5, 3rd question, and 22.7% both for scores 4 and 5 on the 4th question, with rate of the score 3: 27.3%). Therefore, in lawyers'opinions, it is pivotal to find a medical error AND to concede a planned CSMR to the patient.
Patients perspectives about juridical issues overlap with the relevance of their own decision to ask for a cesarean in the absence of medical indications. If patients ask for a cesarean, physicians should do it (higher rate for score 4 on the 2nd question). If the O&G does not perform a planned CSMR, patients feel that the physician's decision in case of a vaginal delivery complication is juridically relevant (higher rate for score 4, 3rd question), but they do not feel this decision to be juridically so relevant in case of complications due to CSMR (higher rate for scores 2 and 3 equally, on the 4th question). By speculating on these results, it appears that patients would be more likely to lodge a claim in case of complications if the O&G does not perform a CSMR. Physicians are well aware of such patient sentiments. The physicians' answers would seem to indicate that respecting patient's own decision for a planned CSMR can avoid litigations in case of complications from a cesarean (higher rate for score 1 on the 4th question and for score 4 on the 2nd question) but seem indifferent in case of complications due to vaginal delivery (score rates seem symmetrical around the value of 3 on the 3rd question, Table 2). Physicians feel that the liability for complications derives from the decision of performing a cesarean. Therefore, if they are not the ones to opt for the cesarean, they feel free from some liabilities, according to the patient's perspective. On the other hand, for Italian law, vaginal delivery complications should be attributed to medical error, but favoring a vaginal delivery rather than performing a cesarean without indications is not a medical error.
Finally, midwives oppose planned CSMR. They feel it is incorrect to perform a planned CSMR in the absence of complications (higher rate for score 1 on the 2nd question) and, therefore, they feel it juridically relevant to have performed a planned CSMR in case of cesarean complications (higher rate for score 5, 4th question). Moreover, it is indifferent to have not performed a planned CSMR in case of complications of vaginal birth (score rates seem symmetrical around the value of 3 on the 3rd question, Table 2).
Significant differences have not been found in the four groups for the 5th question assessing the ethical issue about planned CSMR. For O&Gs the issue seems irrelevant (highest rate score to 3). For midwives, performing planned CSMR does not seem ethical (highest rate score for 1). For lawyers, to comply with the desire of a patient by performing CSMR could be ethical (rate 31.8% for score 5), or indifferent (rate 27.3% for score 3), or not ethical (rate 27.3% for score 1). For patients, to comply with their own desire of planned CSMR seems ethical (higher rate for score 4). These results agree with each individual opinion about planned CSMR of each respondent group, as already reported .
Overall, assessing the distribution of the answer rates, it does not seem that respondents have a homogeneous point of view in each issue. This confirms that planned CSMR is still topical in Italy and that stakeholders approach the problem in a non-homogeneous way, both from a medical point of view and from a juridical point of view. These approaches influence the perception of the ethical issue. This kind of consideration could be generalized to the whole Italian population, complicating the general perspectives around the birth process in our country, and should be better proved with a wide population-based study.
This is the highest rate in Europe and suggests that in Italy there is a general policy to favor cesareans in absence of any indications or even without a true indication. Many cesareans are performed by O&Gs for relief of legal pressure , because there is a general consensus among many Italian people to consider a cesarean as an excellent medical treatment to avoid the pain, discomfort and potential harm of a vaginal delivery. In other words, a lot of Italian people generally consider vaginal delivery to be a primitive mode to give birth. Under those cultural perspectives and considering certain aspects and harms of vaginal delivery, it is very difficult to convince some women about the goodness of vaginal delivery with respect to a cesarean from a medical point of view. Moreover, an O&G who does not perform a CSMR is poorly valued and appears to be more susceptible to liability in the patient's opinion. Therefore, fear of litigation binds the O&Gs to perform a CSMR even if they disagree with this decision for ethical and medical reasons.
We acknowledge that the answers given in this study are from a small sample size. Therefore, results should be interpreted carefully. However, there is a need to assess the topic of planned CSMR and its multiple issues, in which the juridical one should have a pivotal role. An Italian governmental authority could be able to investigate the perspective of CSMR in a population-based study. Results would have an immediate impact on health-policy interventions in Italy.
In conclusion, in Italy, a physician is unable to counsel a patient asking for a planned CSMR from a medical point of view. Such an aspect should be taken in account in further practice guidelines concerning cesarean section. If the Italian government aims to reduce the exceptionally high cesarean section rate and homogenize the consensus about the birth process (from juridical, medical and ethical points of view), it should act in order to change patients' and other stakeholders' feelings about vaginal delivery. A formal prohibition of CSMR could be the most direct way.
We acknowledge E. Indraccolo, (Department of Economic and Statistic Sciences, University of Salerno, Italy), who was able to provide questionnaire answers from most lawyers.
1. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinatol Epidemiol 2007;21(2):98-113.
2. Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, Harper A, Hulbert D, Lucas S, Mc-Clure J, Millward-Sadler H, Neilson J, Nelson-Piercy C, Norman J, O'Herlihy C, Oates M, Shakespeare J, de Swiet M, Williamson C, Beale V, Knight M, Lennox C, Miller A, Parmar D, Rogers J, Springett A. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 (Suppl. 1):1-203.
3. Deneux-Tharaux C, Carmona E, Bouvuer-Colle M-H, Breart G. Postpartum maternal mortality and Caesarean delivery. Obstet Gynecol 2006;108(3Pt1):541-8.
4. Senatore S, Donati S, Andreozzi S (Ed.). Studio delle cause di mortalità e morbosità materna e messa a punto di modelli di sorveglianza della mortalità materna. Roma: Istituto Superiore di Sanità; 2012. (Rapporti ISTISAN, 12/6).
5. Huang L, Chen Q, Zhao Y, Wang W, Fang F, Bao Y. Is elective cesarean section associated with higher risk of asthma? A meta-analysis. J Asthma 2015;52(1):16-25.
6. Kuhle S, Tong OS, Woolcott CG. Association between caesarean section and childhood obesity: a systematic review and meta-analysis. Obes Rev 2015;16(4):295-303.
7. Adlercreutz EH, Wingren CJ, Vincente RP, Merlo J, Agardh D. Perinatal risk factors increase the risk of being affect by both type 1 diabetes and coeliac disease. Acta Paediatr 2015;104(2):178-84.
8. Kristensen K, Fisher N, Haerskjold A, Ravn H, Simões EA, Stensballe L. Caesarean section and hospitalization for respiratory syncytial virus infection: a population-based study. Pediatr Infect Dis J 2015;34(2):145-8.
9. Boutsikou T, Malamitsi-Puchner A. Cesarean section: impact on mother and child. Acta Paediatr 2011;100(12):1518-22.
10. Lee YM, D'Alton ME. Cesarean delivery on maternal request: maternal and neonatal complications. Curr Opin Obstet Gynecol 2008;20(6):597-601.
11. Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30(5):276-87.
12. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013;309(18):1930-6.
13. Minkoff H, Powderly KR, Chervenak F, McCullough LB. Ethical dimensions of elective primary cesarean delivery. Obstet Gynecol 2004;103(2):387-92.
14. Nilstun T, Habiba M, Lingman G, Saracci R, Da Frè M, Cuttini M. EUROBS study group. Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach? BMC Med Ethics 2008;9:11.
15. Vimercati A, Greco P, Kardashi A, Rossi C, Loizzi V, Scioscia M, Loverro G. Choice of cesarean section and perception of legal pressure. J Perinat Med 2000;28(2):111-7.
Received on 17 January 2015
Accepted on 28 April 2015
Conflicts of interest statement: None to declare.