Why women and people with breasts are less likely to receive CPR, and what training can do about it

When someone collapses in cardiac arrest, the first few minutes are critical. Early cardiopulmonary resuscitation (CPR) and early defibrillation are among the strongest predictors of survival. Despite this, a substantial body of research consistently shows that women and people with breasts are less likely to receive bystander CPR, particularly in public settings (European Heart Journal, 2019).

This is not a marginal issue. It has direct implications for survival, neurological outcome, and equity in emergency care. For workplaces, community groups, and training providers across Milton Keynes and the surrounding counties, this evidence presents both a challenge and a clear opportunity to improve readiness and outcomes.

At DTMK Training Services, we believe this disparity can be reduced through evidence informed training, honest discussion of real-world barriers, and the use of realistic training equipment that reflects real people rather than idealised models.

What the research tells us about CPR disparities

Large observational studies across Europe and North America have repeatedly identified a disparity in bystander CPR rates between men and women. A landmark study published in the European Heart Journal found that women experiencing out of hospital cardiac arrest were significantly less likely to receive bystander CPR than men (European Heart Journal, 2019).

Within professional discussion, a figure of around 28 percent lower likelihood of women receiving bystander CPR is often quoted. While the exact percentage varies depending on methodology and population, the consistent finding across the literature is that women are less likely to receive early resuscitation attempts (American Heart Association, 2024).

Resuscitation Council UK has publicly acknowledged this disparity, stating that women are less likely to receive timely CPR and that survival rates are lower at successive stages of care. They have called for action to address this inequality (Resuscitation Council UK, 2023).

What this means for survival outcomes

Bystander CPR is a critical link in the chain of survival. Early chest compressions maintain cerebral and coronary perfusion and increase the likelihood of successful defibrillation.

Evidence summarised by the US National Institutes of Health shows that although bystander CPR improves survival overall, the survival benefit appears smaller for women than for men. This suggests that differences in early response, recognition, and treatment pathways may contribute to poorer outcomes (National Institutes of Health, 2023).

Resuscitation Council UK has also highlighted lower survival rates for women at multiple stages of care, from recognition and early response through to later phases of treatment (Resuscitation Council UK, 2024). Delays or absence of early CPR have measurable consequences.

Why people hesitate: understanding the barriers to CPR on women

The disparity in bystander CPR does not arise from a single cause. It reflects several overlapping and interacting barriers that influence behaviour at the point of collapse.

Fear of inappropriate contact or accusations

Fear of inappropriate contact, particularly involving breasts or chest exposure, is a commonly reported barrier. Evidence reviewed by the International Liaison Committee on Resuscitation identifies discomfort around chest exposure and anxiety about accusations as genuine contributors to hesitation, particularly during defibrillation and pad placement (ILCOR, 2023).

Public judgement and the digital age

This concern is amplified by the modern context. Traumatic public incidents are now frequently recorded, photographed, or live streamed. For some would be rescuers, the fear is not only of doing the wrong thing, but of having a life-saving intervention taken out of context and publicly scrutinised.

While resuscitation guidance is clear that life-saving actions must take priority, these social pressures are real and should be openly addressed within training rather than ignored.

Reduced recognition of cardiac arrest in women

Evidence suggests that bystanders may be slower to recognise cardiac arrest in women, particularly in public settings. This can delay emergency calls and the initiation of CPR (Resuscitation Council UK, 2023; ScienceDirect, 2024).

Training that does not reflect real life

Many people first learn CPR using flat chested, unclothed manikins. While CPR technique does not change, encountering a real person with breasts, clothing, or different body shapes can create hesitation.

Research suggests that a lack of representative training equipment may reduce confidence and willingness to act (Health Promotion International, 2024).

Uncertainty around defibrillator pad placement and bras

Defibrillator pad placement is a common source of hesitation, particularly when the person in cardiac arrest has larger breasts. The core principle is unchanged. Pads must be placed in the correct positions with good contact on bare skin to allow effective defibrillation (Resuscitation Council UK, 2025).

Historically, training often implied that a bare chest was always required. Current guidance is more nuanced. Both Resuscitation Council UK and ILCOR acknowledge that routine bra removal is not always necessary, provided correct pad placement and skin contact can be achieved without delay (ILCOR, 2023).

In practice, this distinction matters. While a completely bare chest may feel simpler in some situations, there are circumstances where leaving a bra in place can actively help. For people with larger breasts, a bra may support and lift breast tissue away from the pad placement areas, making anatomical landmarks easier to identify and allowing more accurate pad positioning in a high stress situation.

If a bra does not interfere with pad positioning or adhesive contact, adjusting or working around it may enable faster action and greater confidence. If it interferes with correct pad placement, contains metal beneath the pad position, or causes delay, it should be removed immediately (Resuscitation Council UK, 2025; ILCOR, 2023).

The guiding principle is speed and effectiveness, not rigid adherence to a single approach.

What resuscitation guidance says

Resuscitation Council UK states that if a person is unconscious and not breathing normally, CPR should be started immediately regardless of gender (Resuscitation Council UK, 2024).

ILCOR, whose consensus informs guidance from bodies including the European Resuscitation Council, emphasises immediate chest compressions and early defibrillation as good practice statements (ILCOR, 2025).

The practical reality of CPR on people with breasts

CPR on a person with breasts is still CPR. Chest compressions are delivered to the centre of the chest, on the lower half of the breastbone. Breast tissue does not change hand position, compression depth, or rate.

For defibrillation, the priority is correct pad placement with good skin contact. Clothing should be managed in whatever way allows this to be achieved quickly and effectively.

How DTMK Training Services addresses the fact people with breasts are less likely to receive CPR

Real time feedback manikins

We use standard Laerdal QCPR manikins that provide real time feedback on compression depth, rate, recoil, and hands off time. This helps learners trust their technique and reduces hesitation caused by self-doubt.

Realistic and representative manikins

Alongside our standard Laerdal QCPR manikins, we also use additional manikins designed to reflect the diversity of real patients. This includes manikins with female chest anatomy, allowing learners to practise CPR and defibrillation on people with breasts rather than only flat chested models (Health Promotion International, 2024).

Demonstration of CPR using a modern manikin with breasts

We also use manikins representing older and obese adults, including male manikins with a larger chest contour and increased soft tissue across the chest. While this tissue is not breast tissue, the external appearance and feel can be similar in terms of hand positioning, pad placement, and visual presentation.

This reflects real cardiac arrest scenarios, where chest size and shape vary widely regardless of gender. Training that does not reflect this reality leaves learners unprepared.

Demonstration of CPR using an obese training manikin

Training for dignity and urgency

Learners are taught to manage clothing quickly and respectfully while reinforcing that delays increase the risk of death, in line with ILCOR guidance (ILCOR, 2023).

Open discussion of fears

Concerns about accusations, embarrassment, and public scrutiny are discussed openly and addressed with practical communication strategies.

Realistic scenarios

Clothing, accessories, and varied body types are deliberately used to mirror real world emergencies rather than idealised classroom scenarios.

Why this matters locally

Across Milton Keynes, Buckinghamshire, Bedfordshire, Oxfordshire, and Northamptonshire, cardiac arrest can happen anywhere. The willingness of bystanders to act decisively will shape outcomes.

If training fails to address known barriers, inequality persists. The evidence shows the gap is real. The solution is practical.

A clear message to finish

If someone is unconscious, call 999 and start CPR if they are not breathing normally. Use a defibrillator if one is available. Gender, anatomy, clothing, or fear of judgement must never delay life-saving action.

Training exists to make that response automatic.

References

American Heart Association (2024) Disparities in survival benefits among people receiving bystander CPR following out of hospital cardiac arrest. Journal of the American Heart Association. Available at: https://www.ahajournals.org/doi/10.1161/JAHA.124.035794 (Accessed: 31 January 2026).

European Heart Journal (2019) Sex differences in bystander cardiopulmonary resuscitation and survival following out of hospital cardiac arrest. European Heart Journal, 40(47), pp. 3824–3834. Available at: https://academic.oup.com/eurheartj/article/40/47/3824/5492041 (Accessed: 31 January 2026).

Health Promotion International (2024) Representation, confidence, and CPR: the impact of manikin design on bystander willingness. Health Promotion International, 39(6). Available at: https://academic.oup.com/heapro/article/39/6/daae156/7906013 (Accessed: 31 January 2026).

International Liaison Committee on Resuscitation (ILCOR) (2023) Removal of bra for pad placement and defibrillation: Task Force synthesis and evidence to decision framework. Available at: https://costr.ilcor.org (Accessed: 31 January 2026).

International Liaison Committee on Resuscitation (ILCOR) (2025) International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: Basic Life Support. Available at: https://ilcor.org/uploads/BLS-2025-COSTR-Full-Chapter.pdf (Accessed: 31 January 2026).

National Institutes of Health (2023) Disparities found in survival benefits for people receiving bystander CPR after cardiac arrest. Available at: https://www.nih.gov/news-events/news-releases/disparities-found-survival-benefits-people-receiving-bystander-cpr-cardiac-arrest (Accessed: 31 January 2026).

Resuscitation Council UK (2023) RCUK response to research stating women are less likely than men to be resuscitated. Available at: https://www.resus.org.uk/about-us/news-and-events/rcuks-response-research-stating-women-are-less-likely-men-be-resuscitated (Accessed: 31 January 2026).

Resuscitation Council UK (2024) Every Second Counts campaign. Available at: https://www.resus.org.uk/every-second-counts (Accessed: 31 January 2026).

Resuscitation Council UK (2025) Adult basic life support guidelines. Available at: https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/adult-basic-life-support-guidelines (Accessed: 31 January 2026).

ScienceDirect (2024) Sex differences in recognition and bystander response to out of hospital cardiac arrest. Resuscitation Plus. Available at: https://www.sciencedirect.com/science/article/pii/S0300957224001175 (Accessed: 31 January 2026).