This study suggests that patient perceptions towards forceps are generally negative. Patients of all demographics were more likely to believe that forceps should not be used because they are unsafe for mom and baby. In addition, many patients did not believe forceps could lower the cesarean delivery rate. Consistent with the overall perception, about half of patients believed that training physicians could be allowed to learn to place forceps on a live volunteer. The subgroup analysis of demographic variables showed that White ethnicity and higher education levels tended to have more favorable attitudes, while extremes of age or government insurance status tended to produce unfavorable attitudes.
We felt that these attitudes were not that surprising and could be explained by several possibilities. One simple reason is that patients are simply reflecting the same ambivalences apparent within obstetrical providers in current practice. When used incorrectly, forceps can clearly lead to neonatal trauma. As documented elsewhere, the rates of forceps deliveries have decreased compared to vacuum deliveries.1,2 Concern about litigation has been documented, but the decreased use also appears to be partly due to practitioner’s preference.6 Sometimes this preference reflects decreased training opportunities. For example, some residency programs only choose to teach vacuum deliveries rather than forceps. In other instances, providers may have trained in residency but have since abandoned the practice.
Another reason for the unfavorable attitude towards forceps could be a recognized trend in patients and providers increasingly favorable attitudes for Cesarean delivery overall.7 While most women aim for spontaneous vaginal delivery, there is a clear minority of women who would choose elective Cesarean outright.8,9 In general, Cesarean deliveries appear to be desired by both patients and providers rather than engage in a difficult operative vaginal delivery, whether vacuum or forcep. There are even current reports which wonder if training for vacuum operative vaginal deliveries will also become scarce.10 Both of these trends may mean that most women feel that operative vaginal deliveries are the lesser option compared to a Cesarean delivery. Unfortunately, this survey did not compare those two options directly, but it would be an interesting follow up study.
A minority ethnicity did show less favorable attitudes towards forceps, and these are worth exploring briefly. African Americans consistently show poorer outcomes in pregnancy compared to their white counterparts.11,12,13 They also experience bias and prejudice in the medical system.14,15 Historical cases such as the Tuskegee syphilis experiment have created reasons for distrust of medical professionals within the African American community.16 These reasons may all be working to create even more unfavorable impressions towards the obstetric forceps, a tool which already comes with significant debate about its use.
Hispanics and Other ethnicity may have shown unfavorable attitudes due to larger representation of immigrants within those ethnic groups. For example, immigrants in the Netherlands reported issues of communication, autonomy, and respect.17 An Australian sponsored study looked at 5 host countries with significant immigrant populations and also found issues with communication and discrimination.18 In the United States, cases of anti-immigrant bias are no less common and can be seen in Hispanic, Asian, and other ethnicity groups.19 These examples of problematic communication likely contribute to distrust of medical professionals or the health care system by these ethnicity groups.16,20
Our analysis of educational background suggested that only the least educated group, those without a high school diploma, were especially skeptical of forceps. This is likely due to lower health literacy. Lower levels of education are highly predictive of low health literacy.21 In turn, prior studies have shown that lower health literacy is linked to lower levels of trust in physicians.22,23
The subgroup analysis of insurance status showed expected and unexpected findings. Prior studies show that patients with Medicare or Medicaid have lower health literacy than patients with private insurance.24,25 Similarly, studies of self-insured patients have also shown lower health literacy,25 and that they tend to avoid participating in clinical trials or research studies due to safety concerns.26,27 However, in this study, self-insured patients had favorable views of forceps (Q1, 58% favorable) while government-insured patients had unfavorable views of forceps (Q1, 31% favorable). Demographically, both subgroups had similar ethnicity and education levels. Lower levels of health literacy about forceps would explain why government-insured patients had unfavorable attitudes, but it would not explain our self-insured patients’ attitudes. This subgroup may require further study as our sample size of self-insured patients was small.
Age surprisingly did not produce expected statistical differences. Teenagers would be expected to have the lowest health literacy, and they did show the least favorable attitudes towards forceps. However, the low numbers of teenagers likely played a role in the absence of a statistical finding. We did find a statistically lower number of age 30–39 patients who believed that forceps delivery could reduce the Cesarean delivery rate (Q4, OR 0.62 [0.4,0.9]), but this was isolated and the other age categories did not support a trend. It is worth noting that age > 39 produced an unfavorable attitude similarly as teenagers towards trainees practicing on live-models in our study. Many women who are advanced maternal age consider themselves “high risk” and may seek to reduce any risk to their pregnancy outcomes.28 This could easily include allowing trainees to participate in their care or delivery. More study is likely needed on the effect of age on attitudes towards medical trainees’ education.
There are several strengths to this study. To our knowledge, there have been no studies conducted that document patient perception towards forceps. The demographic population of the patients who completed the survey is applicable to university settings. There were enough respondents to confidently determine if a difference existed. Additionally, the survey layout was simple and easy to understand, therefore most surveys had answers to every question. This study is subject to several limitations. We did not include parity or prior operative delivery in our survey, and both of these may impact patient perspective of forcep use. Our results might not be generalizable outside of a University setting. Community training programs may have a different set of assumptions governing clinical care and training protocols. Additionally, survey data is subject to a responder’s bias, which may skew results.