Purpose: The worldwide increase in cesareans has raised concerns about costs as well as long term outcome for the mother. A greater demand for cesarean delivery among women contributes to the increasing rates, but changing attitudes among physicians may also play a role. Gynecologists face the risk of lawsuits or formal complaints if they choose vaginal delivery and the patient is dissatisfied with the outcome. The aim of this study was to test the hypothesis that gynecologists' choice of delivery mode (vaginal versus cesarean) is influenced by their risk attitude and their perceived risk of complaints or law suits.

Method: We mailed a seven page questionnaire to all 716 physicians working in the field of gynaecology and obstetrics in Norway, and received 507 (70.8 %) valid responses. The respondents were asked to choose between vaginal and caesarean delivery for five different pregnancy scenarios. The attitude to risk was measured by six items extracted from Jackson Personality Inventory-Revised, and MDs were accordingly classified as risk adverse, risk neutral or risk seeking. An index for “perceived risk of complaints and lawsuits” associated with making delivery decisions was constructed from six items capturing aspects of professional consequences (e.g. criticism from colleagues, negative publicity in mass media, lawsuits or formal complaints to health authorities). Respondents subsequently reported background information on medical training and socio demographic information.

Results: In one scenario 60% of the respondents preferred cesarean, while in the others the proportions were 15%, 28%, 29% and 8%, respectively. In logistic regression analysis for each of the scenarios, the odds for choosing cesarean section were greater among physicians who perceived the risk of complaints and lawsuits as high. Older age was associated with the preference for cesarean in two cases, while in one of the cases male physicians' had a stronger preference for cesarean than female. Attitude to risk, geographic region of work, field of interest (subspeciality), and being board certified versus senior resident had no association with the preference for cesarean.

Conclusions: Presented with identical clinical scenarios, the choice of delivery mode varies considerably across gynecologists. This variation may be explained by the perceived risk of complaints and lawsuits, but not by attitude to risk, age or gender.