Decision making in medicine - Are obstetricians' physicians influenced by "non-medical" information? (original) (raw)

Competing Narratives: Examining Obstetricians' Decision-Making Regarding Indications for Cesarean Sections and Abdominal Incisions

Social Science & Medicine, 2022

This article examines the decision-making process among obstetric residents in a public maternity hospital in Mexico where the percentage of cesareans and of classical vertical incisions (rather than the more common transverse incision) were both higher than those recommended by the World Health Organization or national standards. Data were collected in 2018 through free list methodology (listing items that fall within a particular cultural domain or category) and semi-structured interviews with senior obstetric residents. Analysis revealed two competing narratives at work that influenced decision-making regarding the use of cesareans and incision type: though participants emphasized the importance of clinical indications, their reported decisions seemed to rely more heavily on subjective and non-clinical factors. Factors such as patient "type" and perceived pressure from patients influenced obstetricians' decisions to perform cesareans. Decisions about performing incision-type seemed based on a combination of clinical factors, surgical abilities, and structural pressures. The data illustrate the nuanced and contradictory elements within medical decision-making ideas and behaviors.

Explaining obstetric interventionism: Technical skills, common conceptualisations, or collective countertransference?

Women's Studies International Forum, 2008

The usual explanations for the widespread increased use of Caesarean surgery are that it is a technically straightforward and safe procedure associated with improved perinatal outcomes and that women are choosing to give birth by surgery. It is proposed in this article that obstetric clinicians share internalized beliefs which shape their interactions with childbearing women and can depersonalize maternity care and contribute to the use of operative interventions in childbirth. The origins, validity and impact on clinical practice of these assumptions are analyzed. It is suggested that the belief that birth is only normal retrospectively creates an anxiety-laden approach to care in which the prospect of catastrophes leads to avoidance and intervention; and that considering the foetus as a separate patient results in increased surveillance of women's behaviours. Physician authority reflects traditional power relations in health care and information from technology precludes other ways of knowing.

The Process of Women’s Decision Making for Selection of Cesarean Delivery

2009

Background and Aim: Although cesarean section has been considered as a way for reducing infant and mother mortality rate, it has been changed to a general dilemma, so that in Iran, cesarean rate is higher than World Health Organization standards. The aim of this study was to discover the process of decision making for selection of cesarean delivery by those whodid not have indication for cesarean. Material and Method: Twenty six pregnant women, experiencing the third trimester, were selected based on purposeful and theoretical sampling. For access to participants, the researcher referred to one teaching health care centers of Iran University of Medical Sciences and two private offices of gynecology in Tehran, Iran. The data were collected by semi-structured interviews. All data were audio taped and transcribed. Data collection and analysis was performed simultaneously. Constant comparative method was used to analyze data. Results: The main categories were "fear due to not having knowledge", "being painless, and physical and spiritual peace" and "unpleasant experience of others and their encouragement", "being worry of complications", "inappropriate communication of health care staff", and "the feeling of loneliness and death", "infant's health". Constant analysis of data revealed that women get through for creation balance in order to receipt the best result, process of to consider, making a lawful and to choice. Conclusion: Attentive to main theme that it is fear of labor and delivery is a physiology phenomenon. It is necessary to encourage methods for relieving pain and fear and for promoting self-esteem in order to make good decision by pregnant women. It is also important to encourage women for vaginal delivery.

Variation in clinical decision-making for induction of labour: a qualitative study

BMC Pregnancy and Childbirth, 2017

Background: Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals. Methods: We undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes. Results: Forty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician's perception of medical risk in the pregnancy (influenced by the obstetrician's personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a 'gatekeeper' in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates. Conclusion: Improved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.

Effect of Background Case Characteristics on Decisions in the Delivery Room

Medical Decision Making, 2010

Background. The authors investigated whether obstetricians make different decisions about a medical test case depending on the characteristics of background cases that preceded the test case. Methods. Five hypothetical cases were sent to 1247 obstetricians. The outcome of interest was the proportion of physicians who elect to perform a cesarean on a borderline test case, presented with 4 background cases. Participants were randomly assigned to 1 of 3 conditions: 1) pathological background, in which the test case was preceded by abnormal cases, typically requiring cesarean; 2) physiological background, where the test case was preceded by relatively uncomplicated cases, often suggesting a less invasive treatment; and 3) control, where the test case appeared first. Results. A significantly higher proportion of respondents chose a cesarean when the test case was preceded by physiological cases (75.4%) than when it was preceded by pathological cases (52.2%). This tendency was observed among those actively and not actively involved in obstetrics and in physicians with different levels of training. Conclusions. A patient's chances of undergoing cesarean section can be influenced by the immediately prior experience of the physician. This study with hypothetical vignettes found that background cases can influence physicians' decisions. The test case was apparently perceived as more grave when it followed uncomplicated cases as compared to when it was preceded by abnormal cases. Such inconsistencies in decision making are unlikely to be fully resolved by expertise, as suggested by the lack of differences between physicians with different training levels. An understanding of such effects may contribute to more informed consideration of unappreciated influences in making decisions.

Physician-patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: A mixed-method study

Background: Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician-patient communication leading to informed-consent for the operation. Methods: We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥80 births every month; and for physicians, was that they had performed CSs. Women aged ≥18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS we...

Physician gender and cesarean sections

Journal of Clinical Epidemiology, 2000

Background: Among consumers insurers, and providers there is pervasive concern regarding the high incidence of cesarean section delivery. To date, attempts to reduce these rates have focused on the clinical behavior of providers resulting in only minimal changes. Therefore, non-medical variables must be investigated as potential explanatory factors for the decision to perform cesarean delivery. Methods: Data were collected on clinical and non-clinical factors for obstetrician-gynecologists delivering at Yale-New Haven Medical Center to measure the impact of these factors on the performance of cesarean sections. Specifically, variation in patient demographic, ante-and intra-partum risk variables, practice setting, and doctor-specific characteristics were examined. Using contingency table and logistic regression analyses the contribution of selected factors was evaluated. Results: Multivariate modeling revealed that male physicians were significantly more likely than their female colleagues to perform cesarean section. This relationship was particularly strong in the university practice setting. Conclusions: Efforts to reduce the incidence of cesarean section need to focus on the continuing education of health care providers and the delineation of non-clinical factors as essential elements in the election of specific clinical therapies.

Involvement of first-time mothers with different levels of education in the decision-making for their delivery by a planned Caesarean section. Women’s satisfaction with information given by gynaecologists and midwives

Journal of Public Health, 2009

Aims We investigated the involvement of first-time mothers, who had a planned Caesarean section, in the decision to have a Caesarean section, taking into account their different educational levels. Subjects and methods A self-assessment questionnaire was sent in July 2005 to women who had undergone a Caesarean section in 2004. Participants were 2,685 members of a statutory health insurance fund who had given birth by Caesarean section (response rate: 48.0%). Included were primiparae with planned Caesarean section (n=352). Results The women in this cross-sectional study felt well informed about the procedure of a section but not its consequences. They used several sources of information and were most satisfied with the information provided by doctors and midwives. Of the women in this study 20% did not have a midwife. No major differences were observed between different educational levels. Conclusion Although most women were satisfied with their decision, they felt that they did not receive enough information about the consequences of a Caesarean section. This information need could be met by a further involvement of midwives in maternity care.