Fear of litigation influences decisions around caesareans

One of the main factors that influences a clinician’s decision to perform a caesarean section on a first-time mother in Irish maternity hospitals is a fear of litigation, a new study has found.

Caesarean birth rates in Ireland have been increasing year-on-year over the last decade and currently, more than one-third of first-time mothers give birth in this way.

Researchers at the School of Nursing and Midwifery in Trinity College Dublin (TCD) set out to explore the views of obstetricians and midwives when it came to the factors influencing their decision-making around first-time mothers.

As part of the study, 20 senior obstetricians and 15 midwives from three maternity hospitals were interviewed. The majority of participants had over five years experience working in this area at the time of their interview.

Three main themes were reported; a fear of adverse outcomes and subsequent litigation; personal preferences and the culture of practice within the system.

The researchers found that a perceived fear of adverse outcomes and/or legal implications, which were influenced by a clinician’s past experience, society and media, were a major influencing factor when it came to decision-making around caesarean sections.

One midwife commented that the fear of litigation is so big, “you have to practise defensively sometimes”.

“It’s better to do a caesarean that’s not necessary than…you end up with cerebral palsy or something awful like that,” the midwife said.

One senior obstetric registrar commented that “nobody wants to stand in court and defend themselves, so definitely one of the reasons what the rate of caesarean section is going overboard is the fear of litigation”.

The researchers also noted that a clinician’s past experience of an adverse outcome remained with them forever and often influenced their decision-making for the rest of their professional lives.

The second theme found in the study – personal preferences – referred to the clinicians’ personal beliefs and interpretations of clinical situations. These included a clinician’s level of tolerance and threshold to wait for the natural progression of labour or intervene early in cases involving suspected foetal distress.

The researchers noted that a clinician’s confidence and skills had a big influence on the overall decision-making process, with one midwife suggesting that if the obstetrician does not feel confident “they might say that it’s not suitable for vaginal delivery and then proceed to section”.

The final theme was the culture of practice. This included possible differences in care for women who use the public or private system and organisational factors, such as hospital guidelines around induction of labour.

Most of the participants perceived rates of induction in their place of work as very high, particularly among first-time mothers. One consultant obstetrician pointed to the challenge of the “significant section rate in primigravids (first-time mothers) who have their labour induced”.

“So, a really important factor is evaluating if the induction fails, does this women really warrant a caesarean section?” the obstetrician asked.

Infrastructural limitations also influenced decisions, such as labour ward capacity and staffing shortages.

“For right or wrong, you do make decisions based on the other external influences which are…too many patients and…too few staff,” a consultant obstetrician commented.

According to the study’s lead author, Sunita Panda, assistant professor in midwifery in TCD’s School of Nursing and Midwifery, “most women wish for a natural birth with a sense of achievement, however, the steady rising rates of caesarean section has become a growing concern”.

“It is crucial and timely to understand the factors that influence the decision-making and take action to stop the rising rates of caesarean sections safely and effectively,” she said.

According to Prof Maeve Eogan, a consultant obstetrician and gynaecologist, at the Rotunda Hospital in Dublin, these findings contribute to knowledge around decision-making in obstetrics and midwifery.

“As other papers have identified, many variables, including important human factors, influence these decisions and it is important to integrate these findings in obstetric, midwifery and service user education, as well as in-service development,” she noted.

Meanwhile, the study was described as “an incredibly important piece of research” by Dr Krysia Lynch, a maternity care expert and chairperson of AIMS Ireland, which is the Association for Improvements in Maternity Services.

“The most recent maternity safety statements available for 2022 show five of our units with a first-time mother caesarean birth rate of over 50%, with another three having a rate of over 40%. These rates are perhaps partially informed by our equally high induction of labour rates. 

“Service users expect that our high caesarean rates reflect evidence-based practice and absolute need, however, this research paper has clearly shown that this is not the case,” she commented.

She said that the findings also highlight a “lack of partnership between providers and service users and indicate that the pregnant person is not at the centre of their care”.

“AIMS Ireland would urge policy makers and those involved in implementing the National Maternity Strategy to take immediate action to curb our ever-increasing caesarean birth rate before it accelerates out of all control,” Dr Lynch added.

The study is published in the journal, PLOS-One, and can be viewed here.