Caesarean section on maternal request for non-medical reasons: Putting the UK National Institute of Health and Clinical Excellence guidelines in perspective

doi:10.1016/j.bpobgyn.2012.09.006

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 27, Issue 2, April 2013, Pages 165-177

https://doi.org/10.1016/j.bpobgyn.2012.09.006 Get rights and content

The past decade has seen an unprecedented rise in the demand for caesarean sections on maternal request (CSMR), in the absence of any medical or obstetric indication. Much of this rise is the result of the perceived myth of safety of caesarean sections and the changing attitudes of society and the medical profession to childbirth. The debate on the medical, ethical and cost implications of rising rates of caesarean section on maternal request have prompted the issuing of numerous guidelines over the past few years, including one by the National Institute of Health and Clinical Excellence (NICE) in the UK. All these guidelines are uniformly less critical of CSMR than guidelines issued even a decade ago, and suggest valid management strategies. In this chapter, I explore the reasons behind the increase in CSMR and review the current published research, including the risks, benefits, controversies, cost and ethics surrounding CSMR. I then discuss various guidelines, putting the NICE guidelines in perspective.

Section snippets

Childbirth in changing times

The evolutionary constraints imposed by bipedalism, encephalisation and secondary altriciality make human childbirth distinct, and significantly more difficult and dangerous than that of non-human primates.¹ The latter half of the 20th century witnessed rapid institutionalisation of childbirth in an attempt to make it safer both for mother and baby. With institutionalisation came ‘medicalisation’ and an increased use of caesarean section as the universal solution to all obstetric problems.²

Definition

Caesarean delivery on maternal request (CSMR) refers to elective delivery by caesarean section at the request of a woman with no identifiable medical or obstetric contraindications to an attempt at vaginal delivery.¹⁷

Epidemiology

Although the actual number is unknown,¹⁸ existing evidence from both retrospective and prospective studies, using different definitions of ‘maternal request’, report rates of between 1% and 48% in public sector and over 60% in the private sector healthcare systems.¹⁹ A marked

Benefits of planned caesarean section

A planned caesarean section does have a few undeniable advantages over vaginal birth,²⁶ including scheduling benefits, fewer uncertainties, a lower probability of litigation and the avoidance of difficult labour, perineal trauma and the exposure of the baby to difficult manipulations, trauma and stress. Some other presumed benefits, however, are still a matter of controversy.²⁷

Maternal risks from a planned caesarean section

Maternal risks from a planned caesarean section are presented in Table 1. A large global cross-sectional study

The psychological dimension

In the late 1990s, it was widely perceived that operative intrapartum interventions, especially primary caesarean section, carried significant maternal psychological risks, and that women having primary caesarean section were more vulnerable to grief reaction, post-traumatic distress and depression.⁶⁰ The only randomised-controlled trial that has addressed this issue⁶¹ found no difference in postpartum depression between women having planned vaginal births or caesarean section. Recent studies

The controversy surrounding caesarean section and the pelvic floor

Pelvic floor dysfunction is a broad term that includes urinary incontinence, anal incontinence, pelvic organ prolapse and sexual dysfunction. The protective effect of caesarean section on the pelvic floor has been a matter of ongoing debate, and recent evidence is summarised below.

Caesarean section and the neonate

A baby born by a planned caesarean section may have a reduced risk of perinatal mortality and morbidity from birth trauma, but may still be at risk of respiratory morbidity, inadvertent prematurity and delayed bonding. The recent evidence on the effect of primary caesarean section on neonatal wellbeing is discussed below.

The cost of caesarean section on maternal request

The cost of a caesarean section varies in different countries and healthcare systems. A number of studies carried out in North America suggest that a caesarean section is significantly more expensive than a vaginal birth.97, 98 In fact, a recent Canadian government publication suggested that a primary planned caesarean section costs at least $2265 more than a vaginal birth and reducing the caesarean section rate to the WHO-recommended 15% could save the Canadian healthcare system $25 million

The ethics of caesarean section on maternal request

The complex ethical considerations surrounding CSMR is discussed by Frank Chervenak in another chapter in this issue of Best Practice and Research Clinical Obstetrics and Gynaecology.

Caesarean section on maternal request: putting the National institute of Health and Clinical Excellence guidelines into perspective

Only a decade ago, the International Federation of Gynecology and Obstetrics in a committee report stated that carrying out caesarean section for non-medical indications was ethically unjustified.¹⁰² Canadian guidelines still suggest that a caesarean section should only be reserved for those pregnancies in which there is a threat to the health of the mother, baby, or both.¹⁰³ The past decade, however, has seen a rapid shift in the attitude of clinicians and society to vaginal birth and a

Conclusion

As the demand for CSMR continues to grow and the evidence remains conflicting, there is a pressing need for clinicians to adopt a structured approach to management based on current guidelines. Emphasis must be laid on exploring the reasons behind the request and providing unbiased information and support. All discussions should comply with the principles of medical ethics and include all benefits and risks, including the effect of the route of delivery on future reproductive outcomes. It is

References (112)

K. Rosenberg et al.
Birth, obstetrics and human evolution
BJOG
(2002)
D'Souza R & Arulkumaran S. To ‘C’ or not to ‘C’? Caesarean delivery upon maternal request: a review of facts, figures...
E.P. Stavrou et al.
Epidemiology and trends for caesarean section births in New South Wales, Australia: a population-based study
BMC Pregnancy Childbirth
(2011)
Y.V. Stjernholm et al.
Changed indications for cesarean sections
Acta Obstet Gynecol Scand
(2010)
C.L. Wendland
The vanishing mother: cesarean section and “evidence-based obstetrics”
Med Anthropol Q
(2007)
Caesarean Section: National institute of Health and Clinical Excellence Guideline; 2nd ed. London, UK: RCOG;...
E. Blair et al.
Aetiological pathways to spastic cerebral palsy
Paediatr Perinat Epidemiol
(1993)
S. Vashevnik et al.
Stillbirths and neonatal deaths in appropriate, small and large birthweight for gestational age fetuses
Aust N Z J Obstet Gynaecol
(2007)
S.P. Walker et al.
Cesarean delivery or vaginal birth: a survey of patient and clinician thresholds
Obstet Gynecol
(2007)
M.C. Klein et al.
Attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors?
Birth
(2011)

M.C. Klein et al.

The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities

J Obstet Gynaecol Can

(2009)

J.R. Wax et al.

Patient choice cesarean: an evidence-based review

Obstet Gynecol Surv

(2004)

S.J. Robson et al.

Estimating the rate of cesarean section by maternal request: anonymous survey of obstetricians in Australia

Birth

(2009)

J.E. Potter et al.

Unwanted caesarean sections among public and private patients in Brazil: prospective study

BMJ

(2001)

J.E. Potter et al.

Consumer demand for caesarean sections in Brazil. Demand should be assessed rather than inferred

BMJ

(2002)

S.F. Murray

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

BMJ

(2000)

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Caesarean delivery on maternal...

M.C. Klein

Quick fix culture: the cesarean-section-on-demand debate

Birth

(2004)

T. Lavender et al.

Caesarean section for non-medical reasons at term

Cochrane Database Syst Rev

(2012)

G.E. Hanley et al.

Regional variation in the cesarean delivery and assisted vaginal delivery rates

Obstet Gynecol

(2010)

What mothers say: The Canadian Maternity Experiences Survey. In: Canada PHAo, editor. Ottawa, Ontario: Public Health...

M.F. MacDorman et al.

Cesarean birth in the United States: epidemiology, trends, and outcomes

Clin Perinatol

(2008)

I. Wiklund et al.

Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers

Acta Obstet Gynecol Scand

(2007)

K. Hofberg et al.

Fear of childbirth, tocophobia, and mental health in mothers: the obstetric-psychiatric interface

Clin Obstet Gynecol

(2004)

A. Karlstrom et al.

Swedish caregivers' attitudes towards caesarean section on maternal request

Women Birth

(2009)

M. Wagner

Choosing caesarean section

Lancet

(2000)

H. Minkoff et al.

Elective primary cesarean delivery

N Engl J Med

(2003)

J.P. Souza et al.

Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health

BMC Med

(2010)

V.M. Allen et al.

Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term

Obstet Gynecol

(2003)

C. Holm et al.

Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study

BJOG

(2012)

D.J. Rouse et al.

Blood transfusion and cesarean delivery

Obstet Gynecol

(2006)

Why mothers die: report on confidential enquiries into maternal deaths in the UK 1994–1996

(1988)

Why mothers die 1997–99: the confidential enquiries into maternal deaths in the UK

(2001)

M. Lydon-Rochelle et al.

Cesarean delivery and postpartum mortality among primiparas in Washington State, 1987–1996(1)

Obstet Gynecol

(2001)

M. Gilliam

Cesarean delivery on request: reproductive consequences

Semin Perinatol

(2006)

D.N. Lucas et al.

Urgency of caesarean section: a new classification

J R Soc Med

(2000)

I. Yoles et al.

Increased maternal mortality in cesarean section as compared to vaginal delivery? Time for re-evaluation [abstract]

Am J Obstet Gynecol

(1998)

T. Tulandi et al.

Adhesion development and morbidity after repeat cesarean delivery

Am J Obstet Gynecol

(2009)

M. Lydon-Rochelle et al.

Association between method of delivery and maternal rehospitalization

JAMA

(2000)

E. Hemminki et al.

Long-term effects of cesarean sections: ectopic pregnancies and placental problems

Am J Obstet Gynecol

(1996)

M. Gilliam et al.

The likelihood of placenta previa with greater number of cesarean deliveries and higher parity

Obstet Gynecol

(2002)

Lancet

Caesarean section-the first cut isn't the deepest

Lancet

(2010)

P. Paul

The trouble with repeat cesareans

Time

(2009)

I. Gurol-Urganci et al.

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis

BMC Pregnancy Childbirth

(2011)

C. Onwere et al.

Maternal morbidity associated with placenta praevia among women who had elective caesarean section

Eur J Obstet Gynecol Reprod Biol

(2011)

E. Hemminki et al.

Mode of delivery and problems in subsequent births: a register-based study from Finland

Am J Obstet Gynecol

(2005)

M.B. Landon et al.

Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery

N Engl J Med

(2004)

M. Knight et al.

Cesarean delivery and peripartum hysterectomy

Obstet Gynecol

(2008)

G.A. Dildy

Postpartum hemorrhage: new management options

Clin Obstet Gynecol

(2002)

E.L. Mozurkewich et al.

Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999

Am J Obstet Gynecol

(2000)

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Tensions and interplay: A qualitative study of access to patient-centered birth counseling of maternal cesarean requests in Norway
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This study aimed to explore women's access to patient-centered counseling for concerns initiating cesarean requests in absence of obstetric indications in pregnancy, and to identify tensions, barriers and facilitators affecting such care.
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Citation Excerpt :
In a Finnish register-based retrospective cohort study25 of 110 000 births, the unadjusted risk of SAMM was greater with elective CS than vaginal birth (RR 2·5 95% CI 1·9–3·2), and with emergency intrapartum CS compared with vaginal birth (RR 4·9, 95% CI 4·2–5·8). Immediate and delayed intraoperative and postoperative risks associated with planned CS have been well documented.12,26,27 A 2017 evidence update for the UK's National Institute for Health and Care Excellence (NICE) includes nine prospective studies that compared the outcomes of planned CS with those of planned vaginal birth (for women with an uncomplicated pregnancy and no previous CS).28
A caesarean section (CS) can be a life-saving intervention when medically indicated, but this procedure can also lead to short-term and long-term health effects for women and children. Given the increasing use of CS, particularly without medical indication, an increased understanding of its health effects on women and children has become crucial, which we discuss in this Series paper. The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose–response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported. There are few studies that focus on the effects of CS on cognitive and educational outcomes. Understanding potential mechanisms that link CS with childhood outcomes, such as the role of the developing neonatal microbiome, has potential to inform novel strategies and research for optimising CS use and promote optimal physiological processes and development.
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2Caesarean section on maternal request for non-medical reasons: Putting the UK National Institute of Health and Clinical Excellence guidelines in perspective

Section snippets

Childbirth in changing times

Definition

Epidemiology

Benefits of planned caesarean section

Maternal risks from a planned caesarean section

The psychological dimension

The controversy surrounding caesarean section and the pelvic floor

Caesarean section and the neonate

The cost of caesarean section on maternal request

The ethics of caesarean section on maternal request

Caesarean section on maternal request: putting the National institute of Health and Clinical Excellence guidelines into perspective

Conclusion

Birth, obstetrics and human evolution

BJOG

Epidemiology and trends for caesarean section births in New South Wales, Australia: a population-based study

BMC Pregnancy Childbirth

Changed indications for cesarean sections

Acta Obstet Gynecol Scand

The vanishing mother: cesarean section and “evidence-based obstetrics”

Med Anthropol Q

Aetiological pathways to spastic cerebral palsy

Paediatr Perinat Epidemiol

Stillbirths and neonatal deaths in appropriate, small and large birthweight for gestational age fetuses

Aust N Z J Obstet Gynaecol

Cesarean delivery or vaginal birth: a survey of patient and clinician thresholds

Obstet Gynecol

Attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors?

Birth

The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities

J Obstet Gynaecol Can

Patient choice cesarean: an evidence-based review

Obstet Gynecol Surv

Estimating the rate of cesarean section by maternal request: anonymous survey of obstetricians in Australia

Birth

Unwanted caesarean sections among public and private patients in Brazil: prospective study

BMJ

Consumer demand for caesarean sections in Brazil. Demand should be assessed rather than inferred

BMJ

Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

BMJ

Quick fix culture: the cesarean-section-on-demand debate

Birth

Caesarean section for non-medical reasons at term

Cochrane Database Syst Rev

Regional variation in the cesarean delivery and assisted vaginal delivery rates

Obstet Gynecol

Cesarean birth in the United States: epidemiology, trends, and outcomes

Clin Perinatol

Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers

Acta Obstet Gynecol Scand

Fear of childbirth, tocophobia, and mental health in mothers: the obstetric-psychiatric interface

Clin Obstet Gynecol

Swedish caregivers' attitudes towards caesarean section on maternal request

Women Birth

Choosing caesarean section

Lancet

Elective primary cesarean delivery

N Engl J Med

Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health

BMC Med

Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term

Obstet Gynecol

Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study

BJOG

Blood transfusion and cesarean delivery

Obstet Gynecol

Why mothers die: report on confidential enquiries into maternal deaths in the UK 1994–1996

Why mothers die 1997–99: the confidential enquiries into maternal deaths in the UK

Cesarean delivery and postpartum mortality among primiparas in Washington State, 1987–1996(1)

Obstet Gynecol

Cesarean delivery on request: reproductive consequences

Semin Perinatol

Urgency of caesarean section: a new classification

J R Soc Med

Increased maternal mortality in cesarean section as compared to vaginal delivery? Time for re-evaluation [abstract]

Am J Obstet Gynecol

Adhesion development and morbidity after repeat cesarean delivery

Am J Obstet Gynecol

2
Caesarean section on maternal request for non-medical reasons: Putting the UK National Institute of Health and Clinical Excellence guidelines in perspective