Grand Rounds: When mom requests a cesarean

The rate of cesarean delivery (CD) in the United States skyrocketed to 29.1% in 2004¹ -an increase of 40% since 1996. Cesarean rates continue to increase not only in this country, but worldwide: 55% in Brazilian women of higher economic status,² with rates approaching 80% to 90% in private Brazilian hospitals,³ Italian rates at 33.2% in 2000,⁴ and similarly 32% in Taiwan.⁵

It's interesting to note that both primary and repeat cesareans in the US are rising at similar rates; primary CD probably reflects changes in physicians' practice patterns, the medical-legal climate, and the recent trend in maternal request, while repeat CD may reflect less enthusiasm for vaginal birth after cesarean (VBAC), much of it due to physician fear, with national rates now less than 10%.

The modern concept of primary elective cesarean upon maternal request (CDMR) is a hotly debated issue in obstetrics, first proposed by Feldman in 1985 in response to the medical-legal environment.⁶ Women keen on this idea often dread labor, fear the pain, along with the risk of death and fetal injury; many are also concerned about damage to their pelvic floor. Because the contemporary woman lives longer, bears fewer children, and is more focused on quality of life, concern for pelvic floor problems seems to be more significant. Finally, the convenience of planning, timing, and maintaining control of one's life also holds appeal for a number of women.

It has been estimated that 4% to 18% of all cesareans worldwide are performed upon maternal request.⁷ In Italy, where one region has even mandated this option by law, 9% of cesareans are CDMR.⁸ In the US the percentage of CDMR is unclear, as there is no coding for this category, and birth certificate data do not capture this information. Elective primary CD accounts for approximately 8% of all deliveries in this country, and 28% of all CDs, but includes such indications as breech and previa.⁹ Still, as extracted from birth certificate data, it has been reported that 5.5% of all live births are primary cesareans with "no indicated risk,"¹⁰ but others have estimated that 2.6% of all deliveries in 2003 are a result of CDMR¹¹ ; both figures remain unconfirmed.

What do your colleagues think?

Surveys from the United Kingdom, New Zealand, Ireland, Canada, and Israel indicate that 7% to 30% of obstetricians and 4% of midwives prefer CD for themselves or their spouses, and 62% to 81% of obstetricians would offer and perform a CD on request for their patients.^12-18 A British survey of clinicians found that almost half of obstetricians thought that women should be offered their choice of delivery method, with more male than female providers taking this position, and 33% of midwives agreed; moreover, 33% of obstetricians considered undergoing elective CD for themselves or their spouses, again more male than female, but only 9% of the midwives agreed.¹⁹

During a review course, a questionnaire administered to US obstetrician-gynecologists trained in the last 5 years revealed that 59% would perform elective primary CD, and 67% would do so specifically to prevent injuries to the pelvic floor; many offer VBAC, but in counseling and consenting patients, fewer than one third included risks of pelvic floor injuries.²⁰ In 2005, 80% of American Urogynecologic Society members said they would perform elective primary CD; so too would 55% of Society for Maternal-Fetal Medicine members agree to this request.²¹