Caesarean delivery on maternal request

Caesarean delivery on maternal request (CDMR) is a caesarean section birth requested by the pregnant woman without a medical reason.[1]

Caesarean delivery on maternal request
Specialtyobstetrics

Background

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] 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.[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]

Maternal request

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.

Routine hospital practices

Non-medically indicated scheduling of childbirth before 39 weeks gestation brings "significant risks for the baby with no known benefit to the mother." Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%.[8] The researchers found many benefits but “no adverse effects” in the health of the mothers and babies at those hospitals.[8][9]

In this context, it is worth remembering many studies have shown operations performed out-of-hours tend to have more complications (both surgical and anaesthetic).[10] For this reason, if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery.

Doctor fear of lawsuits

Another contributing factor for doctor-ordered procedures may be fear of medical malpractice lawsuits. Italian gynaecologyst Enrico Zupi, whose clinic in Rome, Mater Dei, was under media attention for carrying a record of Caesarian sections (90% over total birth), explained: “We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to defensive medicine. We will keep acting this way as long as medical mistakes are not depenalized. We are not martyrs. So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section"[11]

Mother fear of vaginal birth

Studies of United States women have indicated married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women, although they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone.[12] In contrast, a recent study in the British Medical Journal retrospectively analysed a large number of Caesarean sections in England and stratified them by social class. Their finding was Caesarean sections are not more likely in women of higher social class than in women in other classes.[13] Some have suggested, due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, women should be discouraged or forbidden from choosing it.[14]

Some 42% of obstetricians believe the media and women are responsible for the rising Caesarean section rates.[15] A study conducted in Sweden, however, concludes that relatively few women wish to be delivered by Caesarean section.[16]

Reducing unnecessary caesarean sections

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]

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.[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]

References
  1. 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. American College of Obstetricians and Gynecologists (April 2013). "Cesarean delivery on maternal request". 121 (Committee Opinion No. 559): 904–7. Cite journal requires |journal= (help)
  3. Finger, C. (2003). "Caesarean section rates skyrocket in Brazil". Lancet. 362 (9384): 628. doi:10.1016/S0140-6736(03)14204-3. PMID 12947949. S2CID 54353381.
  4. 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 14754712. S2CID 21783487.
  5. 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. S2CID 5914048.
  6. Hannah, Mary E. (2 March 2004). "Planned elective cesarean section: A reasonable choice for some women?". Retrieved 11 December 2018.
  7. MacKenzie IZ, Cooke I, Annan B (2003). "Indications for Caesarean section in a consultant obstetric unit over three decades". J Obstet Gynaecol. 23 (3): 233–8. doi:10.1080/0144361031000098316. PMID 12850849. S2CID 25452611.
  8. "Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age" (PDF). Archived from the original (PDF) on 2012-11-20. Retrieved 2012-07-13.
  9. "Term Pregnancy: A Period of Heterogeneous Risk for Infant Mo... : Obstetrics & Gynecology". Retrieved 2012-07-12.
  10. Cullinane M, Gray A, Hargraves C, Lansdown M, Martin I, Schubert M. "Who operates when? – The 2003 Report of the Confidential Enquiry into Perioperative Deaths" (PDF). Archived from the original (PDF) on 2012-02-20. Retrieved 2009-07-30. Cite journal requires |journal= (help)
  11. "La clinica dei record: 9 neonati su 10 nati con il parto cesareo". Corriere della Sera. 14 January 2009. Archived from the original on July 24, 2009. Retrieved 2009-02-05.
  12. Wagner, Marsden (November 2006). Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First. p. 42. ISBN 978-0-520-24596-9.
  13. Barley K, Aylin P, Bottle A, Jarman B (2004). "Social class and elective Caesareans in the English NHS". BMJ. 328 (7453): 1399. doi:10.1136/bmj.328.7453.1399. PMC 421774. PMID 15191977.
  14. Bewley S, Cockburn J (2002). "The unfacts of 'request' Caesarean section". BJOG. 109 (6): 597–605. doi:10.1111/j.1471-0528.2002.07106.x. PMID 12118634. S2CID 9702229.
  15. Usha Kiran TS, Jayawickrama NS (2002). "Who is responsible for the rising Caesarean section rate?". J Obstet Gynaecol. 22 (4): 363–5. doi:10.1080/01443610220141263. PMID 12521454.
  16. Hildingsson I, Rådestad I, Rubertsson C, Waldenström U (2002). "Few women wish to be delivered by Caesarean section". BJOG. 109 (6): 618–23. doi:10.1111/j.1471-0528.2002.01393.x. PMID 12118637. S2CID 24902574.
  17. Khunpradit, Suthit; Tavender, Emma; Lumbiganon, Pisake; Laopaiboon, Malinee; Wasiak, Jason; Gruen, Russell L; Khunpradit, Suthit (2011). "Non-clinical interventions for reducing unnecessary caesarean section". Cochrane Database of Systematic Reviews (6): CD005528. doi:10.1002/14651858.CD005528.pub2. PMID 21678348.
  18. MacDorman, MF; Declercq, E; Menacker, F; Malloy, MH (2006). "Infant 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. CiteSeerX 10.1.1.513.7283. doi:10.1111/j.1523-536X.2006.00102.x. PMID 16948717.
  19. 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 17324187.
  20. 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.
  21. 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.
  22. 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.
  23. 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).
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