gms | German Medical Science

Background: For decades, the cesarean section (CS) rate has been increasing worldwide. In Germany, the rate has increased from 15.3% (1991) to 30.9% (2021). Besides population-related factors (e.g., age increase of pregnant women), non-medically indicated factors (e.g., structural factors) are also related to the increase. One approach to limit non-medically indicated CS deliveries is to obtain a second opinion (SO).

In Germany, insured persons are entitled to an independent medical SO for selected indications according to § 27b of the German Social Code, Book V (SGB V). In 2021, the Institute for Quality and Efficiency in Health Care (IQWiG) examined whether the indication for elective CS should be included in the SO directive due to possible overuse and volume dynamics. The inclusion in the guideline was not recommended for the time being, as there were doubts about the feasibility of a structured SO procedure due to the dynamics of the indication.

Aim/research question: The aim of this study is to gain new insights into the professional view on the appropriateness and feasibility of obtaining an SO for elective CS by online surveys of obstetricians and midwives.

Methods: For both professional groups, a questionnaire was created based on the current literature and through consultation with experts and a pretest was conducted. The respective surveys were set up with LimeSurvey in January (obstetricians) and February (midwives). Obstetricians in private practices and midwives were invited to participate via different channels (e.g. e-mail distribution list, professional associations, social media). The questionnaires cover the topics of experiences with SO in the context of elective CS, assessments of feasibility, and sociodemographic characteristics. Data are currently being analyzed descriptively.

Results: There were 167 obstetricians and 297 midwives who completed the questionnaires. Of the obstetricians, 52.7% (88/167) and of the midwives, 58.2% (173/297) had already been consulted for an SO. 53.9% (90/167) of the obstetricians and 35.4% (105/297) of the midwives negated, whether something contradicts obtaining an SO, though 33% (98/297) of the answers of the midwives were invalid since both a reason against the obtaining of an SO and the answer “There is nothing against it” were indicated. 24.6% (41/167) of the obstetricians and 37.0% (110/297) of the midwives considered a structured SO procedure according to the SO directive for elective CS a useful instrument to reduce avoidable interventions. In this context, 67.7% (113/167) of the obstetricians and 81.1% (241/297) of the midwives did not consider the dynamics of the indication to be an obstacle.

Relevancy: The results show that SOs are already obtained by indications for elective CS. Overall, however, there are heterogeneous opinions among obstetricians and midwives on the subject of SOs and elective CS. It is possible that obstetricians are more familiar with the SO directive, which also concerns hysterectomy, than midwives.

Recommendations/conclusion: From providers point of view, a structured SO procedure (e.g. according to the directive) seems to be useful in general, if it should be done according to the SO guideline remains unclear.

Ethics and conflicts of interest: A vote on ethics was not necessary. The research was financed by own resources. There are no conflicts of interest.