Caesarean delivery on maternal request

Caesarean delivery on maternal request (CDMR) is a medically unnecessary caesarean section, where the conduct of a childbirth via a caesarean section (CS, or c-section) is requested by the pregnant patient.^[1] While it is a form of an elective caesarean section, the absence of a medical indication is its distinguishing mark.^[1]

Background

Over the last century, delivery by CS has become increasingly safer. The indications for delivery by CS therefore could become "softer", and the move to perform CS on request can be viewed as an extension of this development. Until recently an elective caesarean section was done on the basis of some medical grounds; the CDMR situation, however, makes the mother's preference the determining factor for the delivery mode.

An elective caesarean will be agreed in advance. An elective caesarean can be suggested by either the mother or her obstetrician, often as a result of a change in the medical status of the mother or baby. The term is used by the press and on the web in a number of different ways, but any caesarian section which is not an emergency is classified as elective. The mother in essence has agreed to it but may not have chosen it.

The popular media suggest that many women are opting for cesareans in the belief that it is a practical solution.^[2] The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth.^[3] Furthermore, with women living longer, concern about damage to the pelvic floor organs by vaginal delivery adds an additional dimension to the issue. Such damage could lead to a relaxation in the ligaments that hold the pelvic organs in place; urinary incontinence can become a consequence.

Prevalence

The movement for CDMR may have started in Brazil.^[2] It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by.^[1] The global nature of the CDMR phenomenon was underlined by a study that showed that in southeast China about 20% of women chose this mode of delivery.^[4]

Controversy

A meeting of experts sponsored by the NIH in March, 2006 attempted to address the medical issues and found "insuffient evidence to evaluate fully the benefits and risks" of CDMR versus vaginal delivery, and thus was not able to come to a consensus about the general advisability of a cesarean delivery by demand.^[1] The available evidence suggests certain differences as follows:

Proponents for CDMR will point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby.^[1] Furthermore, there is some evidence that urinary stress incontinence as a long-term result of damage to the pelvic floor is increased after vaginal birth. Opponents to CS feel that it is not natural, that the costs are higher, infection rates are higher, hospitalization longer, and rates for breastfeeding decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk.

Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is 184% higher in babies born by cesarean section.^[5] This study was harshly criticized for excluding cases where unforseen complications arose during labor from its cohort of vaginal deliveries, thereby retrospectively removing poor outcomes and artificially lowering the neonatal mortality rate in the vaginal delivery population, and for using birth certificate data instead of more reliable documentation, such as hospital discharge forms, to define cesarean sections with "no indicated risk", and thereby inappropriately including emergent cesarean sections in their "elective cesarean" cohort.^[6][7][8] In response to this criticism, the authors published a second paper analyzing the same cohort, in which they did not systematically exclude vaginal deliveries in which unexpected complications arose, and concluded that the increased risk of neonatal mortality associated with cesarean section was 69%, rather than 184%. However, they did not address the inadequacies of their data set, and did not attempt to determine the degree of error introduced when identifying elective cesarean sections by birth certificate.^[9] A study published in the February 13, 2007 issue of the Canadian Medical Association Journal found that between 1991 and 2005, women who had scheduled cesarean sections for breech birth had a 2.7% rate of severe morbidity, compared with 0.9% for women who had planned vaginal deliveries.^[10]

References

1. ^ ^{a b c d e} NIH (2006). "State-of-the-Science Conference Statement. Cesarean Delivery on Maternal Request". Obstet Gynecol 107 (6): 1386–97. doi:10.1097/00006250-200606000-00027. PMID 16738168. 
2. ^ ^{a b} Finger, C. (2003). "Caesarean section rates skyrocket in Brazil". Lancet 362 (9384): 628. doi:10.1016/S0140-6736(03)14204-3. PMID 12947949. 
3. ^ Minkoff, H.; Powderly KP, Chervenak F, McCollough LB (2004). "Ethical dimensions of elective primary cesarean delivery". Obstet Gynecol 103 (2): 387–92. doi:10.1097/01.AOG.0000107288.44622.2a. PMID 15166864. 
4. ^ Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z. (2008). "Cesarean delivery on maternal request in southeast China". Obstet Gynecol 111 (5): 1077–82. doi:10.1097/AOG.0b013e31816e349e. PMID 18448738. 
5. ^ MacDorman, MF; Declercq, E; Menacker, F; Malloy, MH (2006). "and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts". Birth 33 (3): 175–82. doi:10.1111/j.1523-536X.2006.00102.x. PMID 17324187. 
6. ^ Källén, K.; Olausson, PO (2007). "Letter: Neonatal Mortality for Low-Risk Women by Method of Delivery". Birth 34 (1): 99–100. doi:10.1111/j.1523-536X.2006.00155_1.x. PMID 16948717. 
7. ^ Pettker, C.; Funai, E (2007). "Letter: Neonatal Mortality for Low-Risk Women by Method of Delivery". Birth 34 (1): 100–101. doi:10.1111/j.1523-536X.2006.00155_2.x. PMID 17324188. 
8. ^ Roberts, C; Lain, S; Hadfield, R (2007). "Quality of Population Health Data Reporting by Mode of Delivery". Birth 34 (3): 274–275. doi:10.1111/j.1523-536X.2007.00184_2.x. PMID 17718880. 
9. ^ MacDorman, MF; Declercq, E; Menacker, F; Malloy, MH (2008). "Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an "Intention-to-Treat" Model". Birth 35 (1): 3–8. doi:10.1111/j.1523-536X.2007.00205.x. PMID 18307481. 
10. ^ Liu, Shiliange, Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term Canadian Medical Association Journal, February 13, 2007; 176 (4).

External links

• Summary of 2006 NIH Report
• NIH Cesarean Conference: Interpreting Meeting and Media Reports