Choice of cesarean section and perception of legal pressure

Objective. To evaluate the perception of "Defensive Medicine" by hospital based obstetricians and the influence of this attitude on the choice of cesarean delivery. Subjects and Methods. Questionnaire sent by mail to a sample (76) of obstetricians of general district, teaching and university hospitals in a region of southern Italy (Puglia). Doctors were selected as the head, the most senior and the most junior specialist of each department. Independent variables of the study were considered as demographic data of the subjects, years of service, interest in private practice, size of the hospital, background cesarean section rate, personal and site of work exposure to legal claims. Outcome measures were experience and confidence in training for operative vaginal and breech delivery, use of the partogram in labor, opinion about a trial of labor after a previous cesarean section and about cesarean section on request, personal perception of defensive medicine. Univariate and multivariate analysis of data were performed. Results. The response rate was 83%. According to our data, seniority in service meant confidence in and request of more teaching of obstetrics manoeuvres, size of hospitals was positively related to a more rationale approach of the diagnosis of dystocia, heads of units were keener to accept the patient's wish for a cesarean section. Doctors with large private practices were less likely to be sued and the perception of legal pressure was directly related to the rate of cesarean section in each unit. Discussion. Defensive Medicine is a reality that encompasses all categories of doctors in this survey. The only differences were in the rate of perception of legal pressure. We believe that residential programs should be modified in order to improve specialists' understanding of malpractice problems and that the patient-doctor relationship should be ameliorated in public hospitals.