Association Between Surgeon Gender and Maternal Morbidity After Cesarean Delivery

Abstract

Importance: The stereotype that men perform surgery better than women is ancient. Surgeons have long been mainly men, but in recent decades an inversion has begun; the number of women surgeons is increasing, especially in obstetrics and gynecology. Studies outside obstetrics suggest that postoperative morbidity and mortality may be lower after surgery by women.

Objective: To evaluate the association between surgeons' gender and the risks of maternal morbidity and postpartum hemorrhage (PPH) after cesarean deliveries.

Design, setting, and participants: This prospective cohort study was based on data from the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, a multicenter, randomized, placebo-controlled trial that took place from March 2018 through January 2020 (23 months). It aimed to investigate whether the administration of tranexamic acid plus a prophylactic uterotonic agent decreased PPH incidence after cesarean delivery compared with a uterotonic agent alone. Women having a cesarean delivery before or during labor at or after 34 weeks' gestation were recruited from 27 French maternity hospitals.

Exposures: Self-reported gender (man or woman), assessed by a questionnaire immediately after delivery.

Main outcomes and measures: The primary end point was the incidence of a composite maternal morbidity variable, and the secondary end point was the incidence of PPH (the primary outcome of the TRAAP2 trial), defined by a calculated estimated blood loss exceeding 1000 mL or transfusion by day 2.

Results: Among 4244 women included, men surgeons performed 943 cesarean deliveries (22.2%) and women surgeons performed 3301 (77.8%). The rate of attending obstetricians was higher among men (441 of 929 [47.5%]) than women (687 of 3239 [21.2%]). The risk of maternal morbidity did not differ for men and women surgeons: 119 of 837 (14.2%) vs 476 of 2928 (16.3%) (adjusted risk ratio, 0.92 [95% CI, 0.77-1.13]). Interaction between surgeon gender and level of experience on the risk of maternal morbidity was not statistically significant. Similarly, the groups did not differ for PPH risk (adjusted risk ratio, 0.98 [95% CI, 0.85-1.13]).

Conclusions and relevance: Risks of postoperative maternal morbidity and of PPH exceeding 1000 mL or requiring transfusion by day 2 did not differ by the surgeon's gender.

Figure.. Flowchart of Study Population Selection

^aThe primary end point was the incidence of a composite variable of maternal morbidity, defined by at least one of the following criteria: calculated estimated blood loss (CBL) more than 1500 mL, emergency surgery for postpartum hemorrhage or hysterectomy, uterine artery embolization, red blood cell transfusion, infection (pyelonephritis, endometritis, wound infection requiring surgery, or peritonitis), thromboembolic event (deep vein thrombosis or pulmonary embolism), transfer to intensive care unit, relaparotomy, adjacent organ injury (uterine artery, bladder or bowel injury), seizure, kidney failure requiring dialysis, or maternal death from any cause. ^bThe secondary end point was the incidence of postpartum hemorrhage defined by CBL more than 1000 mL or red blood cell transfusion by day 2 postpartum (primary outcome of the TRAAP2 trial). The blood loss was calculated as the estimated blood volume × (preoperative hematocrit − postoperative hematocrit) / preoperative hematocrit; the estimated blood volume in milliliters was calculated as the body weight in kilograms × 85.^, Preoperative hematocrit was the value most recently measured within 8 days before delivery, and postoperative hematocrit was that measured closest to day 2 after delivery (without transfusion).^,