European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 95–98
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Personal birth preferences and actual mode of delivery outcomes of obstetricians and gynaecologists in South West England; with comparison to regional and national birth statistics Katie Lightly a,1,*, Elisabeth Shaw d,1, Narges Dailami b,1, Dina Bisson c,1 a
Speciality Trainee in Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, United Kingdom University of West of England. Coldharbour Lane, Bristol, BS16 1QY, United Kingdom Consultant Obstetrician and Gynaecologist, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, United Kingdom d Consultant Obstetrician and Gynaecologist. Arrowe Park Hospital, Wirral, Merseyside, CH49 5PE b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 February 2014 Received in revised form 1 July 2014 Accepted 20 July 2014
Objective: To determine personal birth preferences of obstetricians in various clinical scenarios, in particular elective caesarean section for maternal request. To determine actual rates of modes of deliveries amongst the same group. To compare the obstetrician’s mode of delivery rates, to the general population. Study design: Following ethical approval, a piloted online survey link was sent via email to 242 current obstetricians and gynaecologists, (consultants and trainees) in South West England. Mode of delivery results were compared to regional and national population data, using Hospital Episode Statistics and subjected to statistical analysis. Results: The response rate was 68%. 90% would hypothetically plan a vaginal delivery, 10% would consider a caesarean section in an otherwise uncomplicated primiparous pregnancy. Of the 94/165 (60%) respondents with children (201 children), mode of delivery for the first born child; normal vaginal delivery 48%, caesarean section 26.5% (elective 8.5%, emergency 18%), instrumental 24.5% and vaginal breech 1%. Only one chose an elective caesarean for maternal request. During 2006–2011 obstetricians have the same overall actual modes of birth as the population (p = 0.9). Conclusions: Ten percent of obstetricians report they would consider requesting caesarean section for themselves/their partner, which is the lowest rate reported within UK studies. However only 1% actually had a caesarean solely for maternal choice. When compared to regional/national statistics obstetricians currently have modes of delivery that are not significantly different than the population and suggests that they choose non interventional delivery if possible. ß 2014 Published by Elsevier Ireland Ltd.
Keywords: Mode of delivery Obstetricians Birth preferences
Introduction Publication of the NICE caesarean section guideline [1] has reestablished debate in the media and scientific literature [2,3] about caesarean section for maternal request. Obstetricians have previously been reported to have interventional attitudes and high preference rates for elective caesarean section for themselves, even in an uncomplicated primiparous pregnancy [4,5]. This perceived interventional attitude may have implications on how the patients we look after perceive us as obstetricians. It may also
* Corresponding author. Tel.: +44 07875642837. E-mail addresses: [email protected], [email protected] (K. Lightly). 1 North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB. http://dx.doi.org/10.1016/j.ejogrb.2014.07.005 0301-2115/ß 2014 Published by Elsevier Ireland Ltd.
be relevant for some to know the birth choices we make for ourselves/our partners. In 1996, 17% of London based obstetricians (female obstetricians 31%) said they would have an elective caesarean section in the absence of any clinical indication [4,5]. This original research was repeated in 2002, including 313 London obstetricians and 279 obstetricians working elsewhere in the UK. Similar attitudes were shown with 17% of London obstetricians (female obstetricians 21%) choosing elective caesarean section versus 13% outside London [6]. Subsequent studies showed a more balanced attitude amongst national UK trainees in 2001 (76% response rate) with 16% of male trainees and 15% of female trainees opting for a caesarean section [7]. Internationally rates vary [8]; with only 1.1% Danish [9], 2% Belgian [10], 7% Irish [11], 11% Australian/New Zealand [12] and 21% up to 46% of American obstetricians [13] stating that they would
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K. Lightly et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 95–98
choose an elective caesarean in an uncomplicated primiparous pregnancy. Only one previous small UK study in 2002 has determined how obstetricians actually deliver [14]. This Scottish study included 42 female obstetricians (47%) with children. 67% had a vaginal delivery and 3 (7%) had an elective caesarean section (no data was given about the indication for elective caesarean section). In Norway obstetricians had a higher caesarean section rate than the general public [15] (27% compared to 12%) and also a higher rate when compared to general physicians (27% compared to 19%) [15]. 5.3% of the general population in the UK National Sentinal Caesarean section audit [16] reported a preference for a caesarean birth in 2001. This was mainly attributable to a higher preference for caesarean birth among patients with previous caesarean. 3.3% primigravida would prefer a caesarean section. The rates of caesareans actually performed for maternal request are not well documented due heterogenicity of definition, coding, recall bias and different inclusion criteria in studies and vary hugely internationally. The incidence in UK is quoted at 6–8% [1]. No previous study has determined both how obstetricians in the UK deliver and compared these to regional/national averages; nor surveyed the same group of obstetricians to find their theoretical mode of delivery preferences and compared these to their actual modes of delivery. Objectives This study aimed to determine personal preferences of obstetricians on mode of delivery for themselves or their partners in various clinical scenarios and to determine actual rates of modes of deliveries amongst obstetricians and gynaecologists in the South West of England. Materials and methods Following ethical approval, an online survey was developed by the investigators utilising information from previously published similar studies and other ideas; this was piloted by 10 obstetricians and gynaecologists across all grades in the host organisation and amended. The survey link was sent to all current obstetricians and gynaecologists (consultants and trainees ST1-7) in SW England (Severn and Penninsula Deanery Schools region) via email and reminder emails, using a robust database, in October 2011. The databases were validated by contacting each trust and deanery School in the region. The questionnaire included questions regarding preferred mode of delivery for themselves/their partners in various theoretical clinical scenarios and actual mode of delivery if they had children, including indication if the mode of delivery was elective caesarean section. The local region was surveyed, rather than a national survey, in order to improve response rates and because a reliable database exists of these email addresses. The survey sample is representative of SW obstetricians. The mode of delivery data was compared to national data and regional population data for 2006–2011, as individual trust Hospital Episode Statistics (HES) are available from 2006. All births within the study group were compared with the national HES data from 1986 to 2011. Statistical analysis was performed using SPSS Version 18. Methods used were Kruksal Wallis test, both t-test and Mann– Whitney U (to look at non parametric and parametric comparison) and Chi-squared tests. Results The response rate was 165/242 (68%). Basic demographics of respondents; 35% male and 65% female. 48% consultants and 52%
trainees. Of the consultants; 56% male and 44% female. 11% of consultants were not currently practicing obstetrics, however it is assumed the majority did at the time of the childbirth. When asked about preferences for mode of delivery for themselves/their partners, 90% would plan a vaginal delivery, and 10% would consider an elective caesarean section in an otherwise uncomplicated primiparous pregnancy. Men were more likely to opt for a caesarean (13%) than women (9%). When faced with other clinical scenarios higher numbers would consider elective caesarean; notably if they had estimated fetal weight >4.5 kg (58%), estimated fetal weight 4–4.5 kg (20%) and term + 12 with an unfavorable cervix (30%). There is no statistically significant association between stated mode of delivery preference compared to grade of doctor, gender or whether individuals have their own children. 94/165 (60%) respondents had their own children. The actual mode of delivery for first born child was analyzed. This group was chosen because it is directly relevant to the study question, i.e. choice for primiparous uncomplicated pregnancy, and the first delivery often defines the future obstetric outcomes. Obstetricians and gynaecologists first child deliveries were: normal vaginal 48%, caesarean section 26.5% (elective 8.5%, emergency 18%), instrumental 24.5% and vaginal breech 1%. Elective caesarean was performed in 8.5%; reasons were given in 87% of these. Only one chose an elective caesarean for maternal request (1%). The other reasons given were breech presentation (3%) and intrauterine growth restriction (3%). The subgroup of births in 2006–2011 was analyzed because: this group is the most relevant to current obstetric practice; the HES data collection method changed in 2006 to using operational procedure codes (OPCS), allowing comparison with both regional and national data; over 50% of the obstetricians gave birth during this time period; this cohort includes both primiparous and multiparous, therefore can be reliably compared with the regional and national data. When comparing obstetrician and gynaecologists overall mode of delivery (MOD) for births in 2006–2011, vaginal vs. caesarean section, there is no statistically significant difference between the three groups, Kruskal–Wallis test p = 0.9 (see Fig. 1). Kruskal–Wallis test is a suitable method of analysis when comparing more than two groups when the data is non parametric, this analysis eliminates type one errors. When comparing the individual modes of delivery, there was a statistical difference (Kruksal–Wallis test p < 0.001) with elective caesarean section having the largest error (see Fig. 2).
Fig. 1. Overall mode of delivery (total vaginal and total caesarean section) for births in 2006–2011; South West obstetricians and gynaecologists compared with South West regional and national population data, taken from Hospital Episode Statistics (financial years 2006–2011).
K. Lightly et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 95–98
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Fig. 3. South West England obstetricians and gynaecologists mode of delivery for all births from 1986 to 2011, compared with national population data taken from Hospital Episode Statistics. Fig. 2. South West England obstetrician and gynaecologists mode of delivery for births in 2006–2011, compared with population data from South West region and nationally, taken from Hospital Episode Statistics (financial years 2006–2011).
All clinicians’ deliveries within the study, including all primiparous and multiparous, are compared with national HES population data 1986–2011 (see Fig. 3). This data shows no significant difference between obstetricians and the normal population, t-test p = 0.9 (or Mann–Whitney U, p = 0.9). The lack of any statistical difference occurred even though proportionally more obstetricians gave birth in the latter cohorts, when there is an overall trend toward more caesarean births. There is a statistically significant difference in mode of delivery over the last 20 years in the study group, with a trend toward decreasing normal vaginal delivery rates and increasing caesarean section. Chi-squared test to compare whether the groups changed over time shows statistical difference (Chi-sq = 37.7 with df = 20, p-value < 0.01). This reflects the national trend (see Fig. 4).
Comments This study reports one of the lowest rates of UK obstetricians and gynaecologists stating they would request an elective caesarean section for themselves/their partner in an uncomplicated pregnancy,
10%. It is more in keeping with other surveys obstetricians outside of London. In addition, this study has shown the actual rate of caesarean section for maternal choice as 1%, which is lower than either the UK rate of 7% reported in the National Sentinel Audit (2001) [16] or more recent international data from Australia of 3% caesarean section for maternal request [17]. Rates of overall mode of delivery for SW obstetricians are the same as the regional and national population, using HES over the last 20 years. This research helps address a question specifically posed in the debate about whether women should be able to request a caesarean section which asked ‘‘whether obstetricians are also afraid of natural birth’’ [3]. Our results show that in the SW region obstetricians and gynaecologists do not make birth choices that are significantly different from the women that they care for, are homogenous to the regional population and support normal birth. This should improve the confidence of patients and colleagues in obstetricians. The actual mode of birth amongst obstetricians reflects the national trend of increasing caesarean sections. This is contrary to the perception that was previously suggested [4] in 1996 that obstetricians often prefer to choose an elective caesarean for uncomplicated pregnancies. Interestingly within the corresponding quinquennia 1996–2000, there was an apparent increase in elective caesareans amongst obstetricians compared with the
Fig. 4. South West England obstetricians and gynaecologists mode of delivery, grouped in five year intervals.
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normal population. However this was not sustained in subsequent years. The quality of the maternity HES used to provide comparison with population data must be considered. Prior to 2006 data was completed in 73–75% of maternity HES. It relied upon data entered into more extensive birth data fields. The method of HES data collection changed in 2006 and coding was according to operational procedure codes. This reliability has previously been discussed [18] and is comprehensive. Data is absent in the main procedure code for method of delivery in just 0.6%, therefore this population data can be reliably used to compare with the cohort of obstetricians. This survey had an acceptable response rate (68%) which was improved through being carried out regionally, a national survey would have been more representative of the UK obstetricians, but at the cost of a lower response rate. These results may not be generalisable for the whole UK. Other limitations include not including speciality doctors (unless they were considered as consultants) as they were not included in the email database and that the survey was not assessed for reliability and validity prior to use. Conclusions Although 10% of SW obstetricians and gynaecologists report they would request caesarean section for themselves/their partner,
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Personal birth preferences and actual mode of delivery outcomes of obstetricians and gynaecologists in South West England; with comparison to regional and national birth statistics Katie Lightly a,1,*, Elisabeth Shaw d,1, Narges Dailami b,1, Dina Bisson c,1 a
Speciality Trainee in Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, United Kingdom University of West of England. Coldharbour Lane, Bristol, BS16 1QY, United Kingdom Consultant Obstetrician and Gynaecologist, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, United Kingdom d Consultant Obstetrician and Gynaecologist. Arrowe Park Hospital, Wirral, Merseyside, CH49 5PE b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 February 2014 Received in revised form 1 July 2014 Accepted 20 July 2014
Objective: To determine personal birth preferences of obstetricians in various clinical scenarios, in particular elective caesarean section for maternal request. To determine actual rates of modes of deliveries amongst the same group. To compare the obstetrician’s mode of delivery rates, to the general population. Study design: Following ethical approval, a piloted online survey link was sent via email to 242 current obstetricians and gynaecologists, (consultants and trainees) in South West England. Mode of delivery results were compared to regional and national population data, using Hospital Episode Statistics and subjected to statistical analysis. Results: The response rate was 68%. 90% would hypothetically plan a vaginal delivery, 10% would consider a caesarean section in an otherwise uncomplicated primiparous pregnancy. Of the 94/165 (60%) respondents with children (201 children), mode of delivery for the first born child; normal vaginal delivery 48%, caesarean section 26.5% (elective 8.5%, emergency 18%), instrumental 24.5% and vaginal breech 1%. Only one chose an elective caesarean for maternal request. During 2006–2011 obstetricians have the same overall actual modes of birth as the population (p = 0.9). Conclusions: Ten percent of obstetricians report they would consider requesting caesarean section for themselves/their partner, which is the lowest rate reported within UK studies. However only 1% actually had a caesarean solely for maternal choice. When compared to regional/national statistics obstetricians currently have modes of delivery that are not significantly different than the population and suggests that they choose non interventional delivery if possible. ß 2014 Published by Elsevier Ireland Ltd.
Keywords: Mode of delivery Obstetricians Birth preferences
Introduction Publication of the NICE caesarean section guideline [1] has reestablished debate in the media and scientific literature [2,3] about caesarean section for maternal request. Obstetricians have previously been reported to have interventional attitudes and high preference rates for elective caesarean section for themselves, even in an uncomplicated primiparous pregnancy [4,5]. This perceived interventional attitude may have implications on how the patients we look after perceive us as obstetricians. It may also
* Corresponding author. Tel.: +44 07875642837. E-mail addresses: [email protected], [email protected] (K. Lightly). 1 North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB. http://dx.doi.org/10.1016/j.ejogrb.2014.07.005 0301-2115/ß 2014 Published by Elsevier Ireland Ltd.
be relevant for some to know the birth choices we make for ourselves/our partners. In 1996, 17% of London based obstetricians (female obstetricians 31%) said they would have an elective caesarean section in the absence of any clinical indication [4,5]. This original research was repeated in 2002, including 313 London obstetricians and 279 obstetricians working elsewhere in the UK. Similar attitudes were shown with 17% of London obstetricians (female obstetricians 21%) choosing elective caesarean section versus 13% outside London [6]. Subsequent studies showed a more balanced attitude amongst national UK trainees in 2001 (76% response rate) with 16% of male trainees and 15% of female trainees opting for a caesarean section [7]. Internationally rates vary [8]; with only 1.1% Danish [9], 2% Belgian [10], 7% Irish [11], 11% Australian/New Zealand [12] and 21% up to 46% of American obstetricians [13] stating that they would
96
K. Lightly et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 95–98
choose an elective caesarean in an uncomplicated primiparous pregnancy. Only one previous small UK study in 2002 has determined how obstetricians actually deliver [14]. This Scottish study included 42 female obstetricians (47%) with children. 67% had a vaginal delivery and 3 (7%) had an elective caesarean section (no data was given about the indication for elective caesarean section). In Norway obstetricians had a higher caesarean section rate than the general public [15] (27% compared to 12%) and also a higher rate when compared to general physicians (27% compared to 19%) [15]. 5.3% of the general population in the UK National Sentinal Caesarean section audit [16] reported a preference for a caesarean birth in 2001. This was mainly attributable to a higher preference for caesarean birth among patients with previous caesarean. 3.3% primigravida would prefer a caesarean section. The rates of caesareans actually performed for maternal request are not well documented due heterogenicity of definition, coding, recall bias and different inclusion criteria in studies and vary hugely internationally. The incidence in UK is quoted at 6–8% [1]. No previous study has determined both how obstetricians in the UK deliver and compared these to regional/national averages; nor surveyed the same group of obstetricians to find their theoretical mode of delivery preferences and compared these to their actual modes of delivery. Objectives This study aimed to determine personal preferences of obstetricians on mode of delivery for themselves or their partners in various clinical scenarios and to determine actual rates of modes of deliveries amongst obstetricians and gynaecologists in the South West of England. Materials and methods Following ethical approval, an online survey was developed by the investigators utilising information from previously published similar studies and other ideas; this was piloted by 10 obstetricians and gynaecologists across all grades in the host organisation and amended. The survey link was sent to all current obstetricians and gynaecologists (consultants and trainees ST1-7) in SW England (Severn and Penninsula Deanery Schools region) via email and reminder emails, using a robust database, in October 2011. The databases were validated by contacting each trust and deanery School in the region. The questionnaire included questions regarding preferred mode of delivery for themselves/their partners in various theoretical clinical scenarios and actual mode of delivery if they had children, including indication if the mode of delivery was elective caesarean section. The local region was surveyed, rather than a national survey, in order to improve response rates and because a reliable database exists of these email addresses. The survey sample is representative of SW obstetricians. The mode of delivery data was compared to national data and regional population data for 2006–2011, as individual trust Hospital Episode Statistics (HES) are available from 2006. All births within the study group were compared with the national HES data from 1986 to 2011. Statistical analysis was performed using SPSS Version 18. Methods used were Kruksal Wallis test, both t-test and Mann– Whitney U (to look at non parametric and parametric comparison) and Chi-squared tests. Results The response rate was 165/242 (68%). Basic demographics of respondents; 35% male and 65% female. 48% consultants and 52%
trainees. Of the consultants; 56% male and 44% female. 11% of consultants were not currently practicing obstetrics, however it is assumed the majority did at the time of the childbirth. When asked about preferences for mode of delivery for themselves/their partners, 90% would plan a vaginal delivery, and 10% would consider an elective caesarean section in an otherwise uncomplicated primiparous pregnancy. Men were more likely to opt for a caesarean (13%) than women (9%). When faced with other clinical scenarios higher numbers would consider elective caesarean; notably if they had estimated fetal weight >4.5 kg (58%), estimated fetal weight 4–4.5 kg (20%) and term + 12 with an unfavorable cervix (30%). There is no statistically significant association between stated mode of delivery preference compared to grade of doctor, gender or whether individuals have their own children. 94/165 (60%) respondents had their own children. The actual mode of delivery for first born child was analyzed. This group was chosen because it is directly relevant to the study question, i.e. choice for primiparous uncomplicated pregnancy, and the first delivery often defines the future obstetric outcomes. Obstetricians and gynaecologists first child deliveries were: normal vaginal 48%, caesarean section 26.5% (elective 8.5%, emergency 18%), instrumental 24.5% and vaginal breech 1%. Elective caesarean was performed in 8.5%; reasons were given in 87% of these. Only one chose an elective caesarean for maternal request (1%). The other reasons given were breech presentation (3%) and intrauterine growth restriction (3%). The subgroup of births in 2006–2011 was analyzed because: this group is the most relevant to current obstetric practice; the HES data collection method changed in 2006 to using operational procedure codes (OPCS), allowing comparison with both regional and national data; over 50% of the obstetricians gave birth during this time period; this cohort includes both primiparous and multiparous, therefore can be reliably compared with the regional and national data. When comparing obstetrician and gynaecologists overall mode of delivery (MOD) for births in 2006–2011, vaginal vs. caesarean section, there is no statistically significant difference between the three groups, Kruskal–Wallis test p = 0.9 (see Fig. 1). Kruskal–Wallis test is a suitable method of analysis when comparing more than two groups when the data is non parametric, this analysis eliminates type one errors. When comparing the individual modes of delivery, there was a statistical difference (Kruksal–Wallis test p < 0.001) with elective caesarean section having the largest error (see Fig. 2).
Fig. 1. Overall mode of delivery (total vaginal and total caesarean section) for births in 2006–2011; South West obstetricians and gynaecologists compared with South West regional and national population data, taken from Hospital Episode Statistics (financial years 2006–2011).
K. Lightly et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 95–98
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Fig. 3. South West England obstetricians and gynaecologists mode of delivery for all births from 1986 to 2011, compared with national population data taken from Hospital Episode Statistics. Fig. 2. South West England obstetrician and gynaecologists mode of delivery for births in 2006–2011, compared with population data from South West region and nationally, taken from Hospital Episode Statistics (financial years 2006–2011).
All clinicians’ deliveries within the study, including all primiparous and multiparous, are compared with national HES population data 1986–2011 (see Fig. 3). This data shows no significant difference between obstetricians and the normal population, t-test p = 0.9 (or Mann–Whitney U, p = 0.9). The lack of any statistical difference occurred even though proportionally more obstetricians gave birth in the latter cohorts, when there is an overall trend toward more caesarean births. There is a statistically significant difference in mode of delivery over the last 20 years in the study group, with a trend toward decreasing normal vaginal delivery rates and increasing caesarean section. Chi-squared test to compare whether the groups changed over time shows statistical difference (Chi-sq = 37.7 with df = 20, p-value < 0.01). This reflects the national trend (see Fig. 4).
Comments This study reports one of the lowest rates of UK obstetricians and gynaecologists stating they would request an elective caesarean section for themselves/their partner in an uncomplicated pregnancy,
10%. It is more in keeping with other surveys obstetricians outside of London. In addition, this study has shown the actual rate of caesarean section for maternal choice as 1%, which is lower than either the UK rate of 7% reported in the National Sentinel Audit (2001) [16] or more recent international data from Australia of 3% caesarean section for maternal request [17]. Rates of overall mode of delivery for SW obstetricians are the same as the regional and national population, using HES over the last 20 years. This research helps address a question specifically posed in the debate about whether women should be able to request a caesarean section which asked ‘‘whether obstetricians are also afraid of natural birth’’ [3]. Our results show that in the SW region obstetricians and gynaecologists do not make birth choices that are significantly different from the women that they care for, are homogenous to the regional population and support normal birth. This should improve the confidence of patients and colleagues in obstetricians. The actual mode of birth amongst obstetricians reflects the national trend of increasing caesarean sections. This is contrary to the perception that was previously suggested [4] in 1996 that obstetricians often prefer to choose an elective caesarean for uncomplicated pregnancies. Interestingly within the corresponding quinquennia 1996–2000, there was an apparent increase in elective caesareans amongst obstetricians compared with the
Fig. 4. South West England obstetricians and gynaecologists mode of delivery, grouped in five year intervals.
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normal population. However this was not sustained in subsequent years. The quality of the maternity HES used to provide comparison with population data must be considered. Prior to 2006 data was completed in 73–75% of maternity HES. It relied upon data entered into more extensive birth data fields. The method of HES data collection changed in 2006 and coding was according to operational procedure codes. This reliability has previously been discussed [18] and is comprehensive. Data is absent in the main procedure code for method of delivery in just 0.6%, therefore this population data can be reliably used to compare with the cohort of obstetricians. This survey had an acceptable response rate (68%) which was improved through being carried out regionally, a national survey would have been more representative of the UK obstetricians, but at the cost of a lower response rate. These results may not be generalisable for the whole UK. Other limitations include not including speciality doctors (unless they were considered as consultants) as they were not included in the email database and that the survey was not assessed for reliability and validity prior to use. Conclusions Although 10% of SW obstetricians and gynaecologists report they would request caesarean section for themselves/their partner,
