Clinicians’ views of factors influencing CS decision-making

By Sunita Panda on 23 November 2018 Research Midwives Magazine Caesarean Section

There is limited explanation for the increasing rates of CS globally. Despite having evidence that vaginal birth is safer for most women, and associated with fewer complications compared to CS, many countries continue to have a rising trend in CS rates. Understanding the reasons from the decision-makers’ perspective is vital to reduce unnecessary CS.

This article summarises the findings from a systematic review and metasynthesis of clinicians’ views of factors that influence clinicians’ decision to perform a CS. Findings were obtained from 34 studies that included 9008 midwives and obstetricians, and were conducted in 20 countries over the 24-year period from 1992 and 2016.

While the factors that influenced clinicians’ decision-making for CS were complex, clinicians’ personal attitude and beliefs about CS being a ‘safe’ option and a generalised fear of litigation and perceived safety concerns were key influencing factors. A difference in views among midwives and obstetricians, and among obstetricians with different levels of experience, was another factor that further influenced their decision-making.

Clinicians also viewed women’s requests for CS as an influencing factor, however, other literature suggests that this has a minimal influence on overall CS rates. In general, the lack of unified hospital guidelines or a lack of awareness of existing guidelines, especially on women’s requests for CS or when deciding to aim for vaginal birth after CS, along with obstetricians’ personal convenience were key factors in the decision-making process.

Similarities and differences in the views of clinicians practising in Organisation for Economic Co-operation and Development (OECD) and non-OECD countries emerged, both in an institutional and a cultural context. While a fear factor was evident across all countries, clinicians in OECD countries were more fearful about an adverse outcome and subsequent legal consequences, whereas social stigma associated with litigation was the prime concern among clinicians practising in non-OECD countries. Staffing and infrastructural resources, along with financial benefits associated with performing CS and privatisation of care, were additional influencing factors.

Although these findings are limited to the views of midwives and obstetricians whose decision to perform a CS may have been influenced by their healthcare system and local management policies, this metasynthesis deepens our overall understanding of factors influencing the decision to perform a CS. These findings give insight into the ‘why’ behind the influencing factors, pave the way for future discussions on ‘next step’ actions and will contribute to future intervention studies that focus on modifiable factors aimed at reducing unnecessary CS. 

Sunita Panda is a doctoral research fellow at Trinity College Dublin


Panda S, Begley C, Daly D. (2018) Clinicians’ views of factors influencing decision-making for caesarean section: a systematic review and metasynthesis of qualitative, quantitative and mixed methods studies. PLOS ONE 13(8): e0202688.

Top