Clinicians’ fears of litigation a factor in rising caesarean rates for first-time mothers

Experts in new Trinity College study say Irish caesarean rates are unacceptable and not in keeping with the expectations of pregnant women, after research found factors influencing decisions around the intervention to be multi-factored.

Fear of adverse outcomes including litigation was a factor, while the study found that women’s requests may not be a major factor influencing the decision-making for caesarean section for first-time mothers.

More than one third of first-time mothers are giving birth by caesarean section (CS) in the Republic of Ireland despite evidence suggesting no additional benefits to mothers and babies, the papper said. There has been a steady rise (over 30% increase), year on year, in caesarean birth rates, over the last decade.

A new study from the School of Nursing and Midwifery, Trinity College, has found that factors that influence a clinician’s decision to perform a CS on a first-time mother, are complex and multifactorial.

Researchers found that decisions are driven by a clinician’s fear of adverse outcomes and subsequent litigation, personal preference, and their threshold to intervene and the culture of practice within the system, and finally by organisational guidelines and policies.

The study is published in the current edition of the journal PLOS-One today, Wednesday.

The team conducted one-to-one interviews with 20 obstetricians and 15 midwives who were involved in the decision-making process for CS in three maternity units in the Republic of Ireland.

Three interrelated themes emerged: ‘A fear factor’, ‘clinician driven factors’ and ‘a system perspective’.

Findings suggested that decisions to perform CS are based on clinicians’ perceived fear, personal beliefs, and organisational factors. A deep insight into these factors will help clinicians identify and evaluate modifiable factors in practice to avoid excess caesarean sections. This may ultimately help develop practical approaches to reduce the number of CSs safely and effectively.

The Key findings were:  

  • Factors that influence clinicians’ decision-making are driven by their fear of adverse outcomes and subsequent litigation, personal preference, and their threshold to intervene and the culture of practice within the system, and organisational guidelines and policies.

  • Flexible criteria and ambiguity in inducing labour are major contributing factors to the rising rates of CS.

  • Women’s requests may not be major factor influencing the decision-making for CS for first-time mothers.

Looking ahead, researchers are hopeful these findings will help clinicians reflect on their decision-making practices to look for factors that can be modified to stop the rise of CSs. Furthermore, as the study outcomes are derived from the decision-makers’ perspective, researchers are optimistic that the findings will help develop practical strategies to reduce any unnecessary CSs safely.

Sunita Panda, Assistant Professor in Midwifery, School of Nursing and Midwifery, and lead author of the study said: “Becoming a mother is a unique part of a woman’s life and 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 with more than one-third of mothers giving birth to their first babies by caesarean section. 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.”

Dr Krysia Lynch, Maternity care expert and Chair AIMS Ireland added: “This is an incredibly important piece of research informing both policy makers and service users as to why our caesarean birth rates are so high and rapidly climbing. 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, this research paper has clearly shown that this is not the case. This research also highlights the lack of partnership between providers and service users and indicates 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.”

You can read the full paper: ‘Clinicians’ views of factors influencing decision-making for CS for first-time mothers—A qualitative descriptive study’ here: https://doi.org/10.1371/journal.pone.0279403

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