Association Between Surgeon Gender and Maternal Morbidity After Cesarean Delivery

Abstract

ImportanceThe 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.ObjectiveTo evaluate the association between surgeons’ gender and the risks of maternal morbidity and postpartum hemorrhage (PPH) after cesarean deliveries.Design, Setting, and ParticipantsThis 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.ExposuresSelf-reported gender (man or woman), assessed by a questionnaire immediately after delivery.Main Outcomes and MeasuresThe 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.ResultsAmong 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 RelevanceRisks of postoperative maternal morbidity and of PPH exceeding 1000 mL or requiring transfusion by day 2 did not differ by the surgeon's gender.

Engendered Perceptions About Surgeon Gender and Patient Outcomes After Cesarean Delivery

“…Fourth, it was not stated whether the ad hoc analysis was powered to examine the effect of surgeon gender on patient outcomes; given the reported composite morbidity statistics and the imbalance in the proportion of men and women performing this surgery, it likely was not. And finally, although stated by the authors as a limitation, the binary presentation of gender is outdated and does not consider contributions of surgeons who identify as nonbinary; however, the authors performed a separate analysis of gender nonrespondents and did not observe differences in patient outcomes compared to those who selected a gender category. Ultimately, the authors found no association between surgeon gender and a composite of maternal morbidity and severe blood loss at cesarean delivery.…”

“…The mechanism and validity of this report remain unclear, and cesarean delivery—routinely performed by OB/GYN surgeons—was not included in the analysis. In the accompanying article, Bouchghoul et al investigated whether OB/GYN surgeons’ gender affects maternal outcomes after cesarean delivery. In this ad hoc analysis from the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial, the group reported no differences in composite maternal morbidity or postpartum hemorrhage based on surgeon gender, even though significantly more women than men performed the surgeries (78.8% vs 52.5%, respectively) and patients operated on by women were more likely to have gestational diabetes (which increases the risk of postoperative morbidity) .…”

“…First, the authors did not distinguish the gender of the primary supervising surgeon in each case. Rather, only gender of the surgeon performing the cesarean delivery was listed.…”

“…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 study underscores the importance of addressing erroneous assumptions and gender discrimination in medicine, even as the number of women further increase.…”

Errors in Figure and Nonauthor Collaborators Supplement

“…In the Original Investigation titled “Association Between Surgeon Gender and Maternal Morbidity After Cesarean Delivery,” published on January 25, 2023, there were errors in the Figure and the nonauthor collaborators supplement. In the Figure, the bottom 2 boxes for the primary and secondary end points are redundant information and have been removed.…”