Risk of Maternal Morbidity After C-Section No Different Based on Surgeon Gender

Risk of maternal morbidity, including postpartum hemorrhage, after cesarean deliveries did not differ by surgeon gender, according to a prospective cohort study from France.

Among over 4,000 women, maternal morbidity was 14.2% with male surgeons versus 16.3% with female surgeons (adjusted risk ratio [RR] 0.92, 95% CI 0.74-1.13, P=0.46), reported Loïc Sentilhes, MD, PhD, of Bordeaux University Hospital, and colleagues.

The incidence of postpartum hemorrhage, defined as a calculated estimated blood loss >1,000 mL or red blood cell transfusion by postpartum day 2, was also no different, with rates of 28% with male surgeons and 29.7% with female surgeons (adjusted RR 0.98, 95% CI 0.85-1.13, P=0.73), they detailed in JAMA Surgery.

“Our findings are significant in that they add substantially to the string of studies contradicting the age-old dogma that men are better surgeons than women,” Sentilhes and team wrote. However, “our results contrast with recent data showing that surgeon gender is associated with increased morbidity in patients of the opposite sex, with worse outcomes among female patients treated by male surgeons.”

This is the first study to examine an association between surgeon gender and maternal morbidity, and Sentilhes told MedPage Today that “the findings were not a surprise: there is no rationale to believe that men are better surgeons than women.”

However, he noted that prejudice in obstetrics and gynecology is still “insidious.” According to one study, women ob/gyns in France had lower expectations of an academic career than men because of a lack of mentors, lack of identification with a same-sex role model, and doubts about their abilities.

In an accompanying commentary, Amanda N. Fader, MD, of the Johns Hopkins School of Medicine in Baltimore, and colleagues pointed out that “the necessity of such a study in 2022 is discouraging, yet appraising surgical outcomes based on gender may be an essential step toward reducing implicit bias and dispelling engendered perceptions regarding gender and technical proficiency.”

“The urgency to confront discriminatory perceptions and experiences concerning gender, race and ethnicity, sexual orientation, and economic class cannot be understated,” they wrote.

The researchers also noted that although there was a significant difference between the number of male attending obstetricians and female attending obstetricians (47.5% vs 21.2%, P<0.001), “interaction between surgeon gender and level of experience on the risk of maternal morbidity did not differ statistically significantly, nor did the interactions between gender and either the type of cesarean delivery (before labor/during labor without oxytocin/during labor with oxytocin) or the type of anesthesia (epidural or spinal/general).”

“Our findings have important implications for the promotion of gender equality among surgeons, in particular obstetricians but also among medical doctors,” said Sentilhes. “Policymakers need to combat prejudice against women in surgical careers, so that women no longer experience conscious or unconscious barriers or difficulties in their professional choices, training, and relationships with colleagues or patients.”

Of note, Sentilhes and colleagues did find that other factors were associated with higher risk of maternal morbidity and postpartum hemorrhage after C-section, including prepregnancy BMI, multiple pregnancy, gestational age at delivery, type of cesarean delivery, and general anesthesia.

This secondary analysis was based on data from the randomized, placebo-controlled Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, which took place from March 2018 through January 2020 at 27 French maternity hospitals.

Sentilhes and team included 4,244 women, with 943 male surgeons and 3,301 female surgeons performing cesarean deliveries.

Maternal morbidity was defined as a calculated estimated blood loss >1,500 mL, emergency surgery for postpartum hemorrhage or hysterectomy, uterine artery embolization, red blood cell transfusion, infection (pyelonephritis, endometritis, wound infection requiring surgery, peritonitis), a thromboembolic event (deep vein thrombosis or pulmonary embolism), transfer to the intensive care unit, re-laparotomy, adjacent organ injury (uterine artery, bladder or bowel injury), seizure, kidney failure requiring dialysis, or maternal death from any cause.

The authors noted that surgeons included in this study were aware of the TRAAP2 objectives, which may have led to performance bias and to more equivalent outcomes across genders and experience levels. Furthermore, the trial may be underpowered to detect differences between male and female surgeons for rare but severe adverse events.

In addition, the commentators noted that “the complex intersection of surgeon volume, experience, gender, clinical decision-making skills, and patient-level and clinical factors affecting patient outcomes may not be truly accounted for in [the study’s] methodology.”