Defensive medicine and cesarean sections in Brazil

Abstract

Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians’ fear of litigation as possible influencing factors, cannot be overlooked. This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS. In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits. The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed. The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.

How defensive medicine is defined in European medical literature: a systematic review

“…(6) The study includes data from Europe. *USA,11 12 14 76–145 New Zealand,74 75 146 147 China,148–150 Japan,151 152 Iran,153 Israel,154–160 Sudan,161 Canada,162 163 Australia,164 165 South Africa,166 Singapore,167 India,168 Hong Kong,169 Brazil170 and one study from both USA, Canada and South Africa 73…”

Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees

“…The road to sort out litigation in healthcare is complex compared with the experience of high-income countries but needs to be addressed if CS use is to be reduced in a sustainable manner. 42–44 The disagreement regarding the association between financial incentives and surgical deliveries is not surprising. This association is relevant for physicians paid in a fee-for-practice model.…”

“…The fear of litigation was deeply rooted among experienced obstetricians in public hospitals as they feel they work in an environment with minimum support. The road to sort out litigation in healthcare is complex compared with the experience of high-income countries but needs to be addressed if CS use is to be reduced in a sustainable manner 42–44. The disagreement regarding the association between financial incentives and surgical deliveries is not surprising.…”

Cesarean sections and social inequalities in 305 cities of Latin America

“…Decisions made by healthcare workers are also strongly affected by concerns of possible legal consequences. Obstetricians and gynecologists are among the medical professionals with highest litigation risk ( Rudey et al, 2021 ), which makes medical decisions, such as indicating a CS, as a defensive method to avoid potential litigation. It has been reported that vaginal births are associated with a higher risk of lawsuits when complications do occur than CS ( Wagner, 2000 ; Rudey et al, 2021 ; Shwayder, 2007 ; Kravitz et al, 1991 ).…”

“…Obstetricians and gynecologists are among the medical professionals with highest litigation risk ( Rudey et al, 2021 ), which makes medical decisions, such as indicating a CS, as a defensive method to avoid potential litigation. It has been reported that vaginal births are associated with a higher risk of lawsuits when complications do occur than CS ( Wagner, 2000 ; Rudey et al, 2021 ; Shwayder, 2007 ; Kravitz et al, 1991 ). In addition, based on the belief that CS makes deliveries more predictable, controllable, and more easily monitored ( Cartwright, 2016 ), a scheduled cesarean delivery is a potential time-management solution ( Lin & Xirasagar, 2004 ; Rebelo et al, 2010 ).…”