Journal of Clinical Epidemiology 53 (2000) 10301035

Physician gender and cesarean sections

Lloyd K. Mitlera, John A. Rizzoa,b, Sarah M. Horwitza,b,c*
a

Department of Epidemiology & Public Health, Yale University School of Medicine, 60 College St., Box 208034 New Haven, CT 06520, USA
b
Institution for Social and Policy Studies, Yale University, New Haven, CT 06520, USA
c
Child Study Center, Yale University School of Medicine, New Haven, CT 06520, USA
Received 1 January 1998; received in revised form 9 January 2000; accepted 26 January 2000

Abstract
Background: Among consumers insurers, and providers there is pervasive concern regarding the high incidence of cesarean section
delivery. To date, attempts to reduce these rates have focused on the clinical behavior of providers resulting in only minimal changes.
Therefore, non-medical variables must be investigated as potential explanatory factors for the decision to perform cesarean delivery.
Methods: Data were collected on clinical and non-clinical factors for obstetrician-gynecologists delivering at Yale-New Haven Medical
Center to measure the impact of these factors on the performance of cesarean sections. Specifically, variation in patient demographic,
ante- and intra-partum risk variables, practice setting, and doctor-specific characteristics were examined. Using contingency table and logistic regression analyses the contribution of selected factors was evaluated. Results: Multivariate modeling revealed that male physicians
were significantly more likely than their female colleagues to perform cesarean section. This relationship was particularly strong in the
university practice setting. Conclusions: Efforts to reduce the incidence of cesarean section need to focus on the continuing education of
health care providers and the delineation of non-clinical factors as essential elements in the election of specific clinical therapies. 2000
Elsevier Science Inc. All rights reserved.
Keywords: Cesarean section; Physicians practice patterns; Clinical uncertainty; Physician gender

1. Introduction
In 1995 cesarean sections accounted for 21.0% of live
births in the United States [1], a rate that has nearly quadrupled over the prior two decades. While 14.5% of all deliveries are now accomplished by a primary cesarean operation,
repeat cesarean surgery accounts for 8.3% of total births [2].
Cesarean section comprises 4% of all surgical procedures in
short-term, non-federal hospitals, at a cost twice that of routine vaginal birth [3]. The greater expense of cesarean section reflects both higher hospital and physician charges, as
well as the substantial expenditures resulting from increased
maternal and neonatal morbidity [4].
Among consumers, insurers, and providers there is pervasive concern regarding the high incidence of cesarean
section delivery. To date, attempts to reduce these rates
have focused on the appropriateness of clinical indicators,
resulting in only minimal changes. Moreover, cesarean section rates have been found to vary substantially by patient
and other nonclinical factors as well [5]. Consequently, it is
important to understand any non-medical factors driving the
decision to employ the cesarean operation.
* Corresponding author. Tel.: 203-786-2854; fax: 203-785-6287.
E-mail address: patricia.krieger@yale.edu (S.M. Horwitz)

Patient, medical practice, and physician-specific factors

may each play a role in shaping the cesarean section decision. Patient demographic characteristics associated with
the incidence of cesarean surgery include advancing maternal age, white race, first pregnancy, and higher socioeconomic status [68]. Practice setting may influence the decision to perform cesarean delivery as well. For example, the
probability of cesarean section is lower for pregnant women
receiving pre-natal care in a staff model HMO compared to
women in a fee-for-service plan [9].
Additionally, provider concerns about the malpractice
environment, preferences regarding convenience and time
allocation, the quality of physicianpatient interactions,
events during medical training, and the perceived safety of
cesarean section may also contribute to the final treatment
decision. Because there are few adequate measures for such
factors, the impact of provider attitudes and beliefs has remained largely unstudied. Physician characteristics that
have been shown to affect the incidence of cesarean delivery include graduation from a foreign medical school and
board certification, possibly reflecting factors relating to
provider level of training or to patient case-mix [10].
Interestingly, previous research examining physician
gender and the cesarean decision has found little association
[5,10,11]. This is puzzling because in the context of the

0895-4356/00/$ see front matter 2000 Elsevier Science Inc. All rights reserved.
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L.K. Mitler et al. / Journal of Clinical Epidemiology 53 (2000) 10301035

birthing process, female obstetricians may on average have

better information about the costs and benefits of the alternative modes of delivery and may be more likely to communicate this knowledge to the patient [12].
Another important, though largely ignored, factor is
managed care because it may also affect the cesarean decision by limiting physician discretion. Non-clinical factors
such as the opportunity cost of time and provider preferences may have less impact on the cesarean section decision
in a managed care setting where individual decision making
is more limited [13].
The thesis of the present investigation is that non-clinical
factors such as physician gender are important in situations
involving clinical uncertainty and provider discretion. Consequently, this study evaluates the impact of such factors in
three practice settings. Specifically, the study tests for gender differences in the cesarean section decision in university
practice, private practice, and health maintenance organization (HMO) practice.
The university practice in our sample treats substantially
more complicated maternal or intrauterine fetal illnesses;
hence there is potentially more uncertainty as to the suitable
course of medical treatment. Further, clinical uncertainty
may be exacerbated by the youth and inexperience of the
house staff. At the opposite extreme, within HMOs, physicians have less latitude and fewer options in their treatment
decisions, and patients tend to be younger, at lower risk, and
thus less likely to be candidates for cesarean birth. Relative
to the university setting, clinical ambiguity should be less

1031

evident in private pay patients receiving care in the community, due to referral of the most medically ill and obstetrically complex mothers to the high-risk practices at medical
centers. We anticipate that gender-specific differences in
the cesarean section decision will be most pronounced in
the university practice setting, both because clinical uncertainty in deciding appropriate treatment course is likely to
be greatest, and because physicians have greater discretion
in choosing the appropriate treatment course than in the
HMO setting.

2. Methods
2.1. Research design
This study examines the choice of cesarean delivery or
vaginal birth at Yale-New Haven Hospital. The obstetrical
service includes a clinic linked to a faculty-supervised highrisk service, two staff model health maintenance organizations, and a large private practice service that provides a
majority of the total pregnancy-related care in the community. This data set is based on a sample frame selected from
among 4460 total deliveries including 960 cesarean sections
for the year 1990 and 3875 total deliveries including 837 cesarean sections for the year 1995.
An unmatched casecontrol study was performed by examining the first 65 available records by date of discharges
from the obstetrical service for vaginal and cesarean deliveries from among the selected months, yielding a total sam-

Table 1
Sociodemographic characteristics of mothers, neonates, and delivering physicians at Yale-New Haven Hospital in 1990 and 1995overall and by practice setting

Characteristic
MD characteristics
Male (%)
Mean physician age (years)
Teaching appointment (%)
Board certified (%)
Fetal characteristics
Abnormal fetal test (%)
Mean number other conditions
Birth weight (1000s grams)
Apgar score
Oxytocin infusion (%)
Evening delivery (%)
Delivery year 1995 (%)
Maternal characteristics
Mean maternal age (years)
Black race (%)
Nulliparity (%)
Smoker (%)
Substance abuser (%)
Toxemia (%)
Comorbid illness (%)
Infection (%)

University practice
(n 308)

Private practice
(n 546)

HMO practice
(n 146)

C-sec
(n 140)

No C-sec
(n 168)

C-sec
(n 293)

No C-sec
(n 253)

C-sec
(n 66)

No C-sec
(n 80)

C-sec
(n 499)

No C-sec
(n 501)

68.6
36.3
90.1
72.9

41.1
33.9
29.8
22.6

75.1
45.3
95.2
94.5

54.5
44.1
73.1
72.7

19.7
36.2
78.8
74.2

10.0
35.8
27.5
20.0

65.9
41.6
91.8
85.8

42.9
39.4
51.3
47.5

40.1
0.2
2.7
8.2
38.6
42.9
55.6

20.8
0.05
3.0
8.5
34.5
48.2
57.1

15.4
0.1
3.4
8.8
39.6
37.9
48.1

9.1
0.04
3.4
8.9
39.5
45.8
49.4

15.2
0.05
3.6
8.9
53.0
45.5
47.0

8.8
0.04
3.3
8.6
33.8
48.8
36.3

22.4
0.1
3.3
8.7
41.1
40.3
50.0

13.0
0.04
3.3
8.7
36.9
47.1
50.0

26.4
42.9
43.6
49.3
25.0
10.7
26.4
16.4

24.2
50.6
33.3
38.1
25.0
4.2
16.1
10.1

31.9
6.8
46.4
13.0
8.2
6.5
13.0
3.1

29.9
5.1
43.1
12.6
5.9
2.4
6.7
0.004

31.4
16.7
54.5
18.2
12.1
9.1
15.2
10.6

29.7
22.5
41.3
20.0
8.8
0.05
0.05
0.04

30.3
18.2
46.7
23.8
13.4
8.2
17.0
7.8

28.0
23.2
39.5
22.4
12.8
3.4
9.6
4.2

C-sec patient has had prior cesarean section; No C-sec patient has not had prior cesarean section.

All practices
(n 1000)

1032

L.K. Mitler et al. / Journal of Clinical Epidemiology 53 (2000) 10301035

ple of 1000 births divided evenly for the years 1990 and
1995. Charts were chosen equally from the months of February, May, August, and November to balance the effect of
house staff training, which begins each July, on the clinical
performance of the physicians who staff the university service as resident physicians or fellows. Patient sociodemographic characteristics, prominent ante-partum exposures
and intra-partum events, practice and insurance setting, and
type of delivery, were abstracted from the hospital records
by one of he authors (L.K.M.). Physician demographic data
were supplied by the Office of the Chief of the Medical
Staff. To estimate appropriate sample size, a ratio of control
to cases of 1:1, 80% power, and an alpha (Type I) error of
P 0.05 were assumed.
Clinical characteristics of pregnancies included comorbid illness, testing indicating fetal jeopardy, toxemia, multiple gestation, presence of bleeding or infection including
sexually transmitted disease, congenital anomalies of the
newborn, and the use of oxytocin infusion. Patient-specific
variables included maternal age, race, parity, marital status,
geographic residence, smoking behavior and substance
abuse profile, type of insurance, and year of birth. Physician
and practice identifiers included provider age, gender, university teaching appointment, board certification, graduation from foreign medical school, and practice setting (uni-

versity, community, or HMO). Because previous studies

have found a relationship between the time of delivery (6:00
p.m.6:00 a.m.) and the admission to delivery interval to the
performance of cesarean section, this information was collected as well [1416].
2.2. Analyses
Contingency table analysis was used to determine the association of potential explanatory factors to the outcome of
interest.
Logistic regression analysis was performed to isolate the
individual effects of the various explanatory variables. Separate models were estimated for the entire data set and for
each of the three practice settings. Due to the strong correlation between past and current cesarean sections, we elected
not to include previous cesarean section as an explanatory
variable in these models. Instead, we estimated additional
models on a subset of mothers without a previous cesarean
delivery, to see if important differences in model estimation
results emerged.
3. Results
Table 1 provides summary characteristics for the overall
sample and for each of the three practice settings. Separate

Table 2
Contingency table analysis of cesarian section controlling for practice type
Percent cesarean sectiona
Characteristics
MD characteristics
Male
Physician age 42
Teaching appointment
Board certified
Fetal characteristics
Abnormal fetal test
Number other conditions
Birth weight 4000 gm
Low apgar scorec
Oxytocin infusion
Evening delivery
Delivery year 1995
Maternal characteristics
Maternal age 35
Black race
Nulliparity
Smoker
Substance abuser
Toxemia
Comorbid illness
Infection

University practice

Private practice

HMO practice

All practices

Odds
ratiob

58.2 (96/165)
45.7 (16/35)
71.8 (127/177)
72.9 (102/140)

61.5 (220/358)
53.6 (143/267)
60.1 (279/464)
60.1 (277/461)

61.9 (13/21)
58.3 (7/12)
70.3 (52/74)
75.4 (49/65)

60.5 (329/544)
52.9 (166/314)
64.1 (458/715)
64.3 (428/666)

2.57*
1.19
10.61*
6.66*

62.0 (57/92)
79.5 (31/39)
43.7 (125/286)
57.1 (12/21)
48.2 (54/112)
42.6 (60/141)
44.8 (78/174)

66.2 (45/68)
67.7 (21/31)
52.0 (232/446)
77.8 (7/9)
53.7 (116/216)
48.9 (111/227)
53.0 (141/266)

58.8 (10/17)
50.0 (3/6)
40.8 (49/120)
0.0 (0/3)
56.5 (35/62)
43.5 (30/69)
51.7 (31/60)

63.3 (112/177)
72.4 (55/76)
47.7 (406/852)
57.6 (19/33)
52.6 (205/390)
46.0 (201/437)
50.0 (250/500)

1.94*
2.83*
0.54*
1.38
1.19
0.76*
1.00

75.0 (18/24)
41.4 (60/145)
52.1 (61/117)
51.9 (69/133)
45.5 (35/77)
68.2 (15/22)
57.8 (37/64)
57.5 (23/40)

66.0 (64/97)
60.6 (20/33)
55.5 (136/245)
54.3 (38/70)
61.5 (24/39)
76.0 (19/25)
69.1 (38/55)
90.0 (9/10)

60.0 (15/25)
37.9 (11/29)
52.2 (36/69)
42.9 (12/28)
53.3 (8/15)
60.0 (6/10)
71.4 (10/14)
70.0 (7/10)

66.4 (97/146)
44.0 (91/207)
54.1 (233/431)
51.5 (119/231)
51.2 (67/131)
70.2 (40/57)
63.9 (85/133)
65.0 (39/60)

2.37*
0.68*
1.34*
1.09
1.06
2.48*
1.94*
1.94*

a
For each practice setting, these percentages represent the fraction of all deliveries with a given characteristic that wree delivered by cesarean section. Thus,
for the characteristic delivered by a male physician, 96/165, or 58.2% of such deliveries were by cesarean section in the university practice setting, 61.5% in
the private practice setting, and so on. Figures in parentheses thus represent the numbers of deliveries with that characteristic that were delivered via cesarean
section divided by the total number of deliveries with that characteristic.
b
For each percent cesarean section characteristic, this is the odds ratio across all practices. Thus, the odds ratio that a delivery by a male physician across all
practices is via cesarean section is 2.57.
c
A low Apgar score is defined as a score below 7.
*Statistically significant at the 1% level.

L.K. Mitler et al. / Journal of Clinical Epidemiology 53 (2000) 10301035

summary statistics are provided according to whether delivery was via cesarean section or vaginal routes. For mothers
who received cesarean sections, mean age was 30.3 years
and 18.2% of these mothers were black. Nearly a quarter
(23.8%) of these mothers were smokers. Comorbid illness
was present in 17.0% and toxemia in 8.2% of all mothers
who had cesarean section. Abnormal fetal tests occurred in
22.4% of these neonates. The mean physician age for cesarean delivery was 41.6 years, and 65.9% of these attending
physicians were male. Male physicians performed 543 deliveries and female doctors 457.
For the cohort delivered vaginally, mean maternal age is
slightly lower. These mothers are slightly more likely to be
black and to have other children. The incidence of abnormal
fetal tests, toxemia, comorbid illness, and infection are all
lower among the vaginal delivery cohort. Physician characteristics differ as well. Mothers delivered vaginally are
much less likely to have had a male physician, a board certified physician, or a physician with a teaching appointment.
Table 1 also reveals dramatic differences in the characteristics of mothers and neonates across practice settings. In
the university practice, 49.3% of mothers receiving cesarean sections are smokersmore than three times the incidence of smokers in private settings, and twice the incidence in the HMO. Fetal risk is substantially higher in the
university practice setting, as indicated by the markedly
higher rates of comorbid illness and abnormal test for fetal
well-being. Relative to private practice physicians, mean
physician age is substantially lower in the university practice and HMO practice settings.
Table 2 shows the results of the contingency table analysis. A characteristic associated with a cesarean section rate
substantially above or below 50% suggests that cesarean
surgery rates differ along this feature. The cesarean section
rate is markedly higher among male doctors: regardless of
practice setting, the cesarean section rate was approximately
60% among male physicians. University teaching appointment and board certification are other physician characteristics associated with a higher incidence of cesarean section.
Fetal characteristics associated with a higher incidence
of cesarean section include: abnormal test for fetal wellbeing and other fetal comorbidities (bleeding, congenital
defect, birth injury, and multiple pregnancy). Evening deliveries were less likely to have been cesarean sections.
Older age of the mother and nulliparity are associated
with a higher incidence of cesarean section. Mothers who
are black are less likely to receive cesarean sections. Comorbid medical illness in the mother, clinically apparent
maternal infection (e.g., sexually transmitted disease), and
toxemia were all associated with a significantly greater
probability of cesarean section.
Contingency table analysis thus provides a provocative
result: physician gender appears to affect the choice of cesarean section quite strongly. Several factors, including provider age as a surrogate for practice experience, teaching
appointment, and board-certification status, are potentially

1033

Table 3
Logistic regression for the outcome of cesarian section for the entire data set
Characteristics
Physician
Male
Physician age
Teaching appointment
Board certified
Fetal
Abnormal fetal test
Number other conditions
Birth weight
Apgar score
Oxytocin infusion
Evening delivery
Delivery year 1995
Maternal
Maternal age
Black race
Nulliparity
Smoker
Substance abuser
Toxemia
Comorbid illness
Infection

Odds ratio

95% CI for odds ratio

1.38**
0.99
6.73*
1.52

1.001.88
0.971.00
3.2913.76
0.782.96

1.83*
2.27*
1.39*
1.03
0.94
0.75
0.78

1.162.88
1.224.22
1.091.79
0.891.19
0.681.31
0.561.02
0.581.06

1.07*
1.45
1.66*
1.57**
1.24
2.09**
1.61**
2.70*

1.041.10
0.952.20
1.212.29
1.062.33
0.762.03
1.024.28
1.032.54
1.395.26

*Statistically significant at the 1% level.

**Statistically significant at the 5% level.

correlated with gender and might confound any association.

Therefore, using multivariate logistic regression, the outcomes for the entire data set are provided in Table 3. Table
4 reports gender-specific effects estimated from separate
multivariate models for each of the three practice settings.
As the results in Table 3 indicate, the odds ratio for male
physician gender is 1.38 (95% CI: 1.001.88) in the full
sample. Table 4 points to substantial differences in this relationship across practice settings. In particular, the odds ratios for male physician gender is 2.82 (95% CI: 1.435.55)
for the university practice setting, and 1.65 (95% CI: 1.05
2.60) for private practice. Physician gender has no discernible effect on the performance of cesarean surgery in the
HMO setting.

Table 4
Odds ratios for the outcome of cesarian section for a male MD
Practice setting
University practice
All patients
No prior c-section
Private practice
All patients
No prior c-section
HMO practice
All patients
No prior c-section
All practice settings
All patients
No prior c-section

Odds ratio

95% CI for odds ratio

2.82*
2.75*

1.435.55
1.355.60

1.65**
1.75**

1.052.60
1.062.88

0.46
0.43

0.111.86
0.101.90

1.38**
1.31

1.001.88
0.931.83

*Statistically significant at the 1% level.

**Statistically significant at the 5% level.

1034

L.K. Mitler et al. / Journal of Clinical Epidemiology 53 (2000) 10301035

Other findings from Table 3 indicate that abnormal fetal

tests, toxemia, the presence of comorbid illness, higher birth
weight, nulliparity, increasing maternal age, and smoking are
independently associated with a greater likelihood of cesarean
delivery. Physicians who hold teaching appointments are
also significantly more likely to perform cesarean sections.
4. Discussion
This study has investigated the determinants of the cesarean section decision. While clinical differences do play an
important role in explaining outcomes, the results of this investigation suggest that non-clinical variables are important
predictors of cesarean delivery as well. It is reasonable to
assume that non-clinical factors are likely to influence the
decision-making process when there is uncertainty regarding the appropriateness of a medical judgment [17]. In such
cases, uncertainty affords the physician latitude to be more
sensitive to non-medical influences such as potential malpractice repercussions, patient satisfaction, time constraints
including coverage arrangements or office scheduling, and
physician characteristics [1821].
Other authors that have addressed the issue of gender effect and cesarean surgery [5,11,12]; ours finds an important
relationship between physician gender and the probability
of cesarean section. The precise reasons for the differences
between our findings and those of previous researchers are
unclear. One possibility is that different types of data sets
were used. Previous studies employed data that were statewide in nature but were not based on chart review; our sample was gleaned from patient medical charts at a major referral center. Each approach has advantages and limitations.
Statewide data are more generalizable, yet they often lack
the clinical information and possibly the accuracy from a
detailed chart review by an experienced clinician.
Perhaps the most important reason for the difference between our results and those of earlier research is that we
tested for differences in physician gender across practice
settings. Gender differences are greatest in the university
practice setting. As noted above, neonates in the university
practice setting are substantially sicker than in the other two
settings, and their mothers are much more likely to be smokers.
With such a high-risk patient mix, there is likely to be more
uncertainty as to the appropriate delivery mode; vaginal delivery is not a clear choice in many of these patients. When it is
less clear as to which treatment option is preferable, physicians
may rely more on their own beliefs and preferences in reaching
a decision. It is precisely under these circumstances that we
would expect gender-specific differences in treatment philosophies to be most pronounced. The gender effect is highly
significant in the private practice setting, but smaller in
magnitude, a pattern which may reflect the reduced clinical
uncertainty associated with a substantially healthier patient
population. We find no significant relationship between
gender and the cesarean section decision in the HMO setting,
where physician choice has significant boundaries. While this

finding suggests that managed care limits the importance of

non-clinical factors such as physician gender on the cesarean
section decision, the available sample of HMO patients was
relatively small so that this result should be interpreted with
caution.
These gender differences are similar to those observed in
the use of preventive services between male and female
general practitioners. Specifically, female GPs offer their
women patients more gender-specific preventive services,
such as mammograms and PAP smears, than do their male
counterparts [22,23]. Moreover, differences persist even after patient mix and practice characteristics have been controlled for [23]. Provider gender has also been shown to be
an important predictor of surgery, with female physicians
reported to perform numerically one-half the number of
hysterectomies as compared to male doctors [24,25]. Although the reasons for the gender differences need to be explained, in the final analysis, the reduction in the number of
cesarean deliveries among women physicians may occur
because they have a better innate understanding of the female body and its physical processes such as child birth, and
they also communicate and educate their patients before and
during labor more effectively than their male counterparts.
5. Conclusion
This examination of cesarean section has revealed the
important effect of physician gender on the cesarean section
decision in non-managed care settings, an effect which was
particularly large in the university practice. These findings may
reflect gender-specific differences in the perception and limits of the doctorpatient relationship, or gender differences
in treatment philosophy. Further investigation is required to
explore gender differences in terms of the structure, process,
and outcome of cesarean delivery and other medical treatments, and to better understand how and why treatment patterns may differ among male and female providers.

Acknowledgments
The authors gratefully acknowledge the cooperation of
Dr. Edwin Cadman, Chief of Medical Staff at Yale-New
Haven Hospital for his assistance in providing physician demographic data.

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