Caesarean delivery on maternal request

The concept of "caesarean delivery on maternal request" is not well-recognized in health care, and consequently, when it occurs there are not mechanisms in place for reporting it for research or distinguishing it in medical billing.[2]

Over the last century, delivery by CS has become increasingly safer. The medical reasons for selecting CS instead of a vaginal birth 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 caesarean 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 caesareans in the belief that it is a practical solution.[3] 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.[4]

The movement for CDMR may have started in Brazil.[3] 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.[5]

Increasingly, caesarean sections are performed in the absence of obstetrical or medical necessity at the patient's request, and the term Caesarean delivery on maternal request has been used.[1] Another term that has been used is "planned elective cesarean section".[6] As of 2006, there is no ICD code, thus the extent of the use of this indication is difficult to determine. The mother is the only party who may request such an intervention without indication.

Caesarean sections are in some cases performed for reasons other than medical necessity. These can vary, with a key distinction being between hospital- or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick Caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined.[7] It is through these lenses that CDMR can sometimes be viewed as an example of unnecessary health care.

Requirements for a second opinion from an additional doctor before giving a caesarean section has a small effect on reducing the rate of unnecessary caesarean sections.[17] Communities of health care providers who peer review each other and come to agreement about the necessity of caesarean sections tend to use them less frequently.[17] When medical guidelines are shared by local community leaders which mothers trust, then those mothers are more likely to have vaginal delivery after having had a previous caesarean delivery.[17] When mothers have access to childbirth classes and relaxation classes mothers are more likely to use vaginal delivery when the pregnancy is otherwise low risk.[17]

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.[18] This study was harshly criticized for excluding cases where unforeseen 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.[19][20][21] 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.[22] 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.[23]

• Summary of 2006 NIH Report
• Mothers Report Cesarean Views and Experiences:National Listening to Mothers Survey Results