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Am Fam Physician. 2005;72(7):1379-1380

Elective primary Cesarean delivery is highly controversial. Advocates contend that such delivery could avoid pelvic floor disorders, although opponents point out that these disorders also occur in nulliparous women and those who have delivered only by Cesarean. Opponents also draw attention to the risks of elective Cesarean delivery to the mother and fetus during the initial procedure and for later pregnancies. Physician willingness to perform elective primary Cesarean delivery is an important factor in this controversy. Surveys in several countries indicate that the majority of obstetricians would agree to a patient request for primary elective Cesarean delivery, but only 7 to 17 percent would choose this strategy for themselves or their partners. Wu and colleagues surveyed urogynecologists and subspecialists in maternal-fetal medicine in the United States about primary elective Cesarean delivery.

The researchers sent an e-mail survey to members of the American Urogynecologic Society (AUGS) and the Society for Maternal-Fetal Medicine (SMFM). Second and third surveys were sent to nonresponders. The confidential survey was obtained via a secure Web site and incorporated demographic details and practice characteristics of respondents.

Of 1,479 persons contacted, 52.9 percent responded. The average age of respondents was around 43 years; 37 percent were women, more than 80 percent were white, and less than 10 percent were unmarried. The median number of children was two, but 20 percent had none. The average respondent had been in practice for 12 to 14 years. Many respondents were in academic practice—62 percent of the AUGS members and 75 percent of the SMFM respondents. Almost all of the SMFM respondents and about one half of the AUGS participants were practicing obstetrics (95 and 45 percent, respectively).

Overall, two thirds of those who replied would agree to a request for primary Cesarean delivery, and 30 percent had already done so. This result was significantly higher for the AUGS members than the SMFM respondents (80 percent compared with 55 percent). The AUGS members also were significantly more likely to believe that women have a right to choose Cesarean delivery and were more likely to recommend this strategy for themselves or their partners. In logistic regression analysis, the most significant factors predicting support of elective Cesarean delivery were AUGS membership and male sex. The most common reasons chosen for agreeing to perform an elective Cesarean delivery were patient request (59 percent) and concern for perineal damage (39 percent). The most common reasons for not agreeing were concern for complications in future pregnancies, maternal morbidity and mortality, and doubt that surgery prevents pelvic floor problems. Cost, liability, insurance, and neonatal outcomes were given as possible reasons for both strategies, but chosen by less than 10 percent of respondents.

The authors note that their findings—about two thirds of participants would agree to primary elective Cesarean delivery, but a much lower percentage would choose this strategy for their own families—correlate with those of researchers in other countries. They draw attention to the differences between the responses from the urogynecology and maternal-fetal medicine subspecialists and speculate that this reflects the main concerns of the respective subspecialties. The authors also point out the possibility of selection bias because of the low response rate.

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