["Defensive medicine" in the choice of cesarean section]

To evaluate the perception of "Defensive Medicine" by hospital obstetricians and the influence of this attitude on the choice of cesarean delivery.

Questionnaire sent by mail to a sample of obstetricians of general district, teaching and university hospitals in a region of southern Italy (Puglia). Doctors were selected as the head, the senior and the junior specialist of each department. Independent variables of the study were considered as demographic data of the subjects, seniority, interest in private practice, size of the hospital, background cesarean section rate, personal and site of work exposure to legal claims. Outcome measures were experience and confidence in training for operative vaginal and breech delivery, use of the partogram in labour, opinion about a trial of labour after a previous cesarean section and about section on request, personal perception of Defensive Medicine. Univariate and multivariate analysis of data were performed.

The response rate was 83%. According to our data, seniority in service meant confidence in obstetrics manoeuvres and more will to teach them; size of hospitals was positively related to a more rationale approach of the diagnosis of dystocia; heads of units were more prone to accept the patient's wish for a cesarean section. Doctors with large private practices were less likely to be sued and the perception of legal pressure was directly related to the rate of cesarean section in each unit.

Defensive Medicine is a reality that encompasses all categories of doctor in this survey. The only differences were in the rate of perception of legal pressure. We believe that residential programs should be modified in order to improve specialists' understanding of malpractice problems and that the patient-doctor relationship should be ameliorated in public hospitals.