Rising rates of caesarean section: an indicator of defensive medicine practiced by obstetricians

Urvashi Bhatara, Padmasri .


Background: Defensive medicine can be in the form of excessive tests, procedures, surgeries, or visits by the doctors to primarily reduce their exposure to legal liabilities. It also includes avoidance of high risk patients or procedures.  Medical profession has been included under consumer protection act which has led in developing hostile environment for medical practitioners.  This has led to increase in defensive medicine. In obstetrics and gynaecology incorporation of defensive medicine can be scrutinized by observing trends in caesarean section.

Methods: It is a retrospective study carried out for 1 year from January 2015 to December 2015. All patients in whom caesarean section was done were included in this study. Indications for which Caesarean section was done were studied and results were compared with similar studies in other hospitals.

Results: Overall rate of caesarean section observed in this study was 43.3%. Incidence of caesarean section in primigravidae was 59.5%. Only 2.1% of the patients underwent trial of scar resulting in vaginal birth. Foetal distress was one of the most common indicatorsfor caesarean section and its detection was based on foetal cardiotocograph readings. Out of all patients taken for caesarean section due to foetal distress only 28.5% of the babies required neonatal intensive care admission. Rising trend towards caesarean section on maternal request was also seen.

Conclusions: Current climate of high professional liability is detrimental to good patient care as defensive medicine provides less benefit and much harm. Practice of medicine should be safe and hassle free. For this, standard protocols should be made and followed and if practitioners are abiding with standard protocols they should be protected against litigation.


Caesarean section, Defensive medicine, Litigation, Obstetrics

Full Text:



Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005 Jun 1;293(21):2609-17.

Sekhar MS, Vyas N. Defensive medicine: a bane to healthcare. Annal Med Health Sci Res. 2013 Apr;3(2):295-6.

Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics. 2013 Dec;14(1):42.

Yeoh SB, Leong SB, Heng AS. Anaesthesia for lower-segment caesarean section: Changing perspectives. Indian J Anaesth. 2010 Sep;54(5):409.

Saleh SS. The changing trend in the rate of Caesarean section at a teaching hospital. J Obstet Gynaecol. 2003 Jan 1;23(2):146-9.

Bangal VB, Giri PA, Shinde KK, Gavhane SP. Vaginal birth after cesarean section. North Am J Med Sci. 2013 Feb;5(2):140.

Chaillet N, Dubé E, Dugas M, Francoeur D, Dubé J, Gagnon S, Poitras L, Dumont A. Identifying barriers and facilitators towards implementing guidelines to reduce caesarean section rates in Quebec. Bulletin of the World Health Organization. 2007 Oct;85(10):791-7.

Carrier ER, Reschovsky JD, Katz DA, Mello MM. High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice. Health Affairs. 2013 Aug 1;32(8):1383-91.

Baicker K, Fisher ES, Chandra A. Malpractice liability costs and the practice of medicine in the Medicare program. Health Affairs. 2007 May;26(3):841-52.

Kessler DP, McClellan M. The effects of malpractice pressure and liability reforms on physicians' perceptions of medical care. National Bureau Economic Res; 1998 Jan 1.

Patil M, Nimbargi V, Mehendale S. Trends of Cesarean Section at Tertiary care Hospital in India over 10 years. Indian J Appl Res. 2012;2(3):153-6.

Rafique S, Raana G. Changing trends in caesarean section rate and indications. Pak J Surg. 2012;28(1):60-4.

Unnikrishnan B, Rakshith Prasad B, Aishwarya Amarnath NK, Rekha T, Prasanna PM, Aishwarya A et al. Trends and indications for caesarean section in a tertiary care obstetric hospital in coastal south India. Emergency. 2010;1137:64-7.

Nahar K. Indications of Caesarean Section-Study of 100 cases in Mymensingh Medical College Hospital. J Shaheed Suhrawardy Med Coll. 2012 Oct 14;1(1):6-10.

Kaur J, Singh S, Kaur K. Current trend of caesarean sections and vaginal births. Adv Appl Sci Res. 2013;4(4):196-202.

Gupta M, Garg V. The rate and indications of caesarean section in a tertiary care hospital at Jaipur, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 2017 Apr 27; 6(5):1786-92.

Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2010 Mar.

Khawaja M, Jurdi R, Kabakian‐Khasholian T. Rising trends in cesarean section rates in Egypt. Birth. 2004 Mar;31(1):12-6.

Litorp H, Kidanto HL, Nystrom L, Darj E, Essén B. Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania. BMC Pregnancy Childbirth. 2013 Dec;13(1):107.

Aaron B Caughey. Vaginal birth after cesarean delivery. Available at accessed on 31st March 2016).

Roberts CL, Algert CS, Ford JB, Todd AL, Morris JM. Pathways to a rising caesarean section rate: a population-based cohort study. BMJ open. 2012 Jan 1;2(5):e001725.

Currie J, MacLeod WB. Doctor's Diagnostic Skill, Procedural Skill and Unnecessary C-Sections.

Gillet E, Martens E, Martens G, Cammu H. Prelabour caesarean section following IVF/ICSI in older-term nulliparous women: too precious to push?. J Pregn. 2011;2011.

Tasnim N, Mahmud G, Akram S. Predictive accuracy of intrapartum cardiotocography in terms of fetal acid base status at birth. J Coll Phys Surg Pak. 2009 Oct;19(10):632-5.

Sultana J, Chowdhury TA, Begum K, Khan MH. Comparison of normal and abnormal cardiotocography with pregnancy outcomes and early neonatal outcomes. Mymensingh medical journal: MMJ. 2009 Jan;18(1 Suppl):S103-7.

Doshi HU, Jain RK, Vazirani AA. Prognostic factors for successful vaginal birth after cesarean section: Analysis of 162 cases. J Obstet Gynecol India. 2010 Dec 1;60(6):498-502.

Gregory KD, Fridman M, Korst L. Trends and patterns of vaginal birth after cesarean availability in the United States. InSeminars Perinatol 2010 Aug;34(4):237-43.

Yang YT, Mello MM, Subramanian SV, Studdert DM. Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section. Medical care. 2009 Feb;47(2):234.

Raisanen S, Gissler M, Kramer MR, Heinonen S. Influence of delivery characteristics and socioeconomic status on giving birth by caesarean section-a cross sectional study during 2000-2010 in Finland. BMC Preg Childbirth. 2014 Mar;14(1).

Pakenham S, Chamberlain SM, Smith GN. Women’s views on elective primary caesarean section. J Obstet Gynaecol Canada. 2006 Dec;28(12):1089-94.

Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA et al. Maternal morbidity associated with multiple repeat caesarean deliveries. Obstet Gynecol. 2006 Jun 1;107(6):1226-32.