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.
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. 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. Caesarean section is thus an unavoidable consequence of institutionalised childbirth, and ‘medicalisation of labour’ has been blamed for the unprecedented rise in caesarean section rates. This rise, however, cannot be explained only by known pregnancy characteristics. A significant contribution comes from changes in clinical decision-making and an increased demand for caesarean section in the absence of any medical indication. In parts of Europe, the most common indication for primary caesarean section is now ‘psychosocial’, defined as ‘maternal fear of childbirth or maternal request without any co-existing medical indication’. This could be the result of the changing attitude of women and care-providers to childbirth, a clear reflection of changing times.
The changing attitude of women to caesarean section
Women attempting a vaginal birth run the risk of requiring an instrumental vaginal delivery or an emergency caesarean section in labour, both of which are associated with significant maternal and fetal risks. A ‘planned’ caesarean section seems to ward off magically, the unpredictability and danger of birth. The perceived safety of a planned caesarean section is at least, in part, responsible for an increasing number of women requesting caesarean section. Also, women now live longer, start their families later, and have fewer children. This makes the perceived risks of vaginal birth, such as long-term urinary incontinence, higher cerebral palsy rates of 0.45–3 per 1000 births (although only 10% of these are believed to have an intrapartum origin), and higher perinatal mortality rates of 1.4 per 1000 births after 39 weeks of gestation more pertinent than the risks from multiple caesarean sections.
The changing attitude of clinicians to vaginal birth
The newest generation of obstetricians in Canada hold increasingly negative views of natural childbirth, with a predilection for caesarean section. Twenty-five per cent of obstetricians, family physicians and nurses believe that a caesarean section will prevent urinary incontinence or sexual problems despite a lack of supporting evidence. In Australia, obstetricians less than 10 years from qualification were more likely to carry out caesarean section in the absence of a medical indication, and two-thirds of current trainees expressed an intention to do so in future practice.
Socio-cultural evolution
A number of media-persons opt for caesarean section in the absence of a medical indication. Whether these ‘trend-setters’ are actually luring mothers away from vaginal births or whether they merely hold a mirror to the changing attitudes of society is debatable. Their influence on young mothers, however, cannot be underestimated. Prevalent cultural norms also play an important role in influencing women’s decisions about childbirth. In Brazil, the demand for caesarean section in both public and private sectors is about 80%. The significantly lower caesarean section rates in the public sector (25–30% v 70%), however, suggest that, in public health systems, the route of delivery is affected significantly by policies in healthcare financing.
Whatever the reason behind the request, rates of caesarean section carried out in the absence of medical indications continue to rise, and this has profound medical, monetary and ethical implications. Along with other international bodies, on the basis of current evidence, the National Institute for Health and Clinical Excellence in its recent clinical guidelines on caesarean section has suggested a systematic approach to the management of women requesting caesarean section in the absence of a medical indication.
Caesarean section on maternal request
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.
Epidemiology
Although the actual number is unknown, 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. A marked variation certainly exists in CSMR rates between and within countries. In British Columbia, Canada, where maternal choice is tracked, less than 2% of primary caesarean section are carried out because mothers request them, and most requests in other Canadian provinces come from women who have had a previous caesarean section. However, current CSMR rates are estimated at between 6 and 8% in the UK and Northern Europe, 11.2% in the USA, 17.3% in Australia, and 80% in Brazil.
Reasons for requesting caesarean section in the absence of medical indications
Decision-making surrounding ways of giving birth is influenced by previous birth experiences, fear of vaginal birth, a prior caesarean section, need for choice and control as well as social and cultural factors. The two main reasons for women requesting caesarean section are ‘tocophobia’ and the perceived safety of a planned caesarean section.
Tocophobia
Tocophobia is defined as the intense fear of vaginal childbirth, and is one of the most common reasons for requesting a caesarean section. The incidence of primary tocophobia may be as high as 6–10%. It is believed to stem from self-doubt on the ability to physically achieve a vaginal birth or unresolved issues related to the genital area, and is often associated with social factors, trauma, abuse, depression and psychodynamic causes. Secondary tocophobia on the other hand is almost always related to an adverse birthing experience.
Safety
The ‘immediate risks’ of surgical procedures, and those of planned caesarean section in particular, have significantly diminished. The safety of a procedure, however, isn’t merely restricted to the peri-operative period, and must also include delayed complications and the implications on the future reproductive life of the woman. When all these are considered, the evidence in favour of a planned caesarean section becomes less compelling.
Caesarean section on maternal request
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.
Epidemiology
Although the actual number is unknown, 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. A marked variation certainly exists in CSMR rates between and within countries. In British Columbia, Canada, where maternal choice is tracked, less than 2% of primary caesarean section are carried out because mothers request them, and most requests in other Canadian provinces come from women who have had a previous caesarean section. However, current CSMR rates are estimated at between 6 and 8% in the UK and Northern Europe, 11.2% in the USA, 17.3% in Australia, and 80% in Brazil.
Reasons for requesting caesarean section in the absence of medical indications
Decision-making surrounding ways of giving birth is influenced by previous birth experiences, fear of vaginal birth, a prior caesarean section, need for choice and control as well as social and cultural factors. The two main reasons for women requesting caesarean section are ‘tocophobia’ and the perceived safety of a planned caesarean section.
Tocophobia
Tocophobia is defined as the intense fear of vaginal childbirth, and is one of the most common reasons for requesting a caesarean section. The incidence of primary tocophobia may be as high as 6–10%. It is believed to stem from self-doubt on the ability to physically achieve a vaginal birth or unresolved issues related to the genital area, and is often associated with social factors, trauma, abuse, depression and psychodynamic causes. Secondary tocophobia on the other hand is almost always related to an adverse birthing experience.
Safety
The ‘immediate risks’ of surgical procedures, and those of planned caesarean section in particular, have significantly diminished. The safety of a procedure, however, isn’t merely restricted to the peri-operative period, and must also include delayed complications and the implications on the future reproductive life of the woman. When all these are considered, the evidence in favour of a planned caesarean section becomes less compelling.
Caesarean section on maternal request: a risk-benefit analysis
Benefits of planned caesarean section
A planned caesarean section does have a few undeniable advantages over vaginal birth, 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.
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 conducted by the World Health Organization (WHO) in 24 countries between 2004 and 2008 reported that caesarean section is associated with ‘an intrinsic risk of increased severe maternal outcomes’. The investigators concluded that caesarean section should only be carried out when a clear benefit is anticipated, a benefit that might compensate for the higher costs and additional risks associated with the operation. This study, however, like many large studies, included the risks of both emergency and planned caesarean section, a major, recurring flaw encountered in reviews and analyses. Another major flaw is that many of the earlier studies compared planned caesarean section with spontaneous (term) vaginal births, rather than with ‘planned’ vaginal births. Planned vaginal births run the risk of requiring an instrumental vaginal delivery or an emergency caesarean section in labour, both of which are associated with significantly higher complication rates (12.9% and 16.3%, respectively) compared with planned caesarean section (7%).
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Immediate risks
Good-quality evidence showing that all immediate risks are lower with any particular route of delivery is lacking; however, when it comes to early postpartum haemorrhage, obstetric shock and the need for blood transfusions, the evidence in favour of planned caesarean section is convincing ( Table 2 ). In the UK, the confidential enquiries into maternal deaths showed a dramatic drop in maternal mortality from caesarean section between the 1980s and 1990s. The analysis of 250,000 primiparous women in the Washington State Health Database carried out around the same time initially showed a significantly higher maternal mortality rate after caesarean section (10.3 out of 100,000 v 2.4 out of 100,000); however, after adjusting for maternal age and pre-eclampsia, the increase was no longer apparent. The investigators perhaps rightly concluded that caesarean section was probably a marker for pre-existing morbidity, placing women at an increased risk for mortality, rather than a risk factor for death, in and of itself. Less than 5 years later, this was confirmed by the largest dataset adjusted for pre-eclampsia and maternal age. Maternal mortality from planned caesarean section is now believed to be much lower than from a vaginal birth at one in 78,000. This reduction in operative morbidity and mortality has been attributed to the advent of safer surgical and anaesthetic techniques, the correction of pre-operative anaemia, careful peri-operative planning in cases of placenta praevia and accreta, and the widespread use of prophylactic antibiotics and postoperative thromboprophylaxis.
| May be reduced after an elective CS | May be reduced after a planned vaginal birth | No difference | Conflicting findings from studies |
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Delayed risks
Delayed risks, such as prolonged recovery, hospital readmission, incisional hernias, thromboembolic disease, and postoperative adhesions and pain, are more common with both planned and emergency caesarean section.
Risks in future pregnancies
Despite the reduction in peri-operative risks, the overall maternal mortality rates from caesarean section continue to increase, and this has been attributed to an increased incidence of uterine rupture, placenta praevia and accreta, placental abruption and ectopic pregnancies, all of which increase after a primary caesarean section. It has been rightly said that when it comes to a caesarean section, the first cut is not the deepest. The consequences of a primary caesarean section extend throughout the reproductive life of the woman and beyond, and when this is considered, the risks from a planned caesarean section clearly outweigh the benefits. The effect of a primary caesarean section on future reproductive outcome is summarised below :
Abnormal placentation
A primary caesarean section significantly increases the risk of subsequent placenta praevia and placental abruption, even after correcting for maternal age. This is probably caused by abnormal implantation and migration of the placenta secondary to uterine scarring. Placenta praevia significantly increases maternal morbidity by significantly increasing the risk of postpartum haemorrhage, blood transfusion and hysterectomy. Parity also independently increases the risk for placenta praevia; and the joint effect of parity and prior caesarean section seems greater than the effect of either factor alone. This is important because it implies that a woman requesting a primary caesarean section increases her risk of placenta praevia with each subsequent pregnancy regardless of the route of future delivery.
Uterine scar dehiscence and rupture
Uterine scar dehiscence, rupture, or both, are manifestations of poor scar integrity. The risk of symptomatic uterine rupture among women undergoing trial of labour after a prior caesarean section (vaginal birth after caesarean section [VBAC]) is 0.7%.
Peripartum hysterectomy
The incidence of peripartum hysterectomy in a subsequent pregnancy is significantly higher after a primary caesarean section. Although placenta praevia, accreta and uterine rupture after attempted VBAC are largely responsible for this, the incidence of hysterectomy is also found to be higher in those women opting for a repeat caesarean section in the absence of these conditions.
Stillbirth in subsequent pregnancies
Women who have had previous caesarean sections are at an increased risk of unexplained stillbirths at or after 34 weeks of gestation, even after adjusting for smoking, maternal age, social deprivation and birth weight. This is probably due to abnormalities in uterine blood flow, abnormal placentation and subsequent abruption.
Ectopic pregnancy
The risk ratio for an ectopic pregnancy after caesarean section is significantly high at 1.28. Ectopic pregnancies and caesarean section scar pregnancies often result in major fertility-compromising surgical interventions, maternal morbidity and mortality.
Subfertility
Women undergoing caesarean section have significantly lower rates of future childbearing. Although the cause–effect relationship between caesarean section and subfertility has not been convincingly elucidated, explanations include biological factors such as scarring, adhesions and abnormal placentation, as well as psychosocial factors that contribute towards a reluctance to get pregnant.
Miscellaneous pregnancy outcomes
A primary caesarean section is associated with an increased risk of spontaneous miscarriage, reduced fetal growth, and preterm birth in subsequent pregnancies.
Since the average woman even in the western world bears more than one child, the effects of caesarean section on future reproductive outcome must be considered at the time of a planned primary caesarean section. For reasons discussed above, it has been suggested that women desiring larger families should be dissuaded from having a primary caesarean section in the absence of a medical indication.
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. The only randomised-controlled trial that has addressed this issue found no difference in postpartum depression between women having planned vaginal births or caesarean section. Recent studies have confirmed that maternal satisfaction rates both in the immediate postpartum period and again at 3 months are at least comparable, if not higher, after planned caesarean section. The main concerns that women have during childbirth are those of extreme pain and a sense of loss of control. These issues are not influenced as much by the route of delivery as they are addressed with good communication, allowing women to feel in control and offering good pain relief.
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.
Urinary incontinence
The detrimental effect of vaginal birth and ‘protective effect’ of a caesarean section on stress urinary incontinence (SUI) is not as straightforward as once believed. A vaginal birth carries only a small risk (less than 1%) of initiating persistent SUI and, in most cases, symptoms resolve within 3 months. The Norwegian EPINCONT trial that studied the effects of nine delivery parameters on SUI found few statistically significant associations. It must be added, however, that if SUI starting in pregnancy persists at 3 months postpartum, there is a 92% risk of long-lasting SUI. On the other hand, caesarean section may reduce the incidence of SUI, but cohort studies and meta-analyses differ significantly in estimating the numbers of caesarean section needed to prevent one case of SUI. Again, the protective effect of a caesarean section decreases with age, dissipates with future vaginal births, and is abolished after three consecutive planned caesarean section or if the caesarean section is carried out after the onset of labour. In fact, in women aged 50–64 years, the prevalence of SUI was found to be high irrespective of the route of delivery (28.6% after caesarean section and 30% after vaginal births). The National Institute of Health (NIH) aptly summarised the current evidence by stating that weak-quality evidence suggested that caesarean section prevented SUI and insufficient evidence was available to recommend caesarean section for prevention.
Anal incontinence
In contrast to SUI, when it comes to anal incontinence, caesarean section is definitely protective. After vaginal births, as many as 35% primiparous women and 44% multiparous women have anal sphincter defects on endoanal ultrasound and 4% have fecal incontinence. Only 39% of anal incontinence resolves in 10 months.
Pelvic organ prolapse
The true incidence of pelvic organ prolapsed (POP) after vaginal births and caesarean section is unknown, as most studies rely on surrogate measures of POP such as symptoms or surgical treatment. A recent prospective cohort study of pelvic floor outcomes 5–10 years after childbirth showed that the odds of POP increased significantly after spontaneous vaginal births and even more after operative vaginal births, but not after planned or emergency caesarean section; however, less than 25% of these women were symptomatic. Although a vaginal birth is associated with a nine-fold higher likelihood of requiring surgery for POP compared with caesarean section, a caesarean section does not completely eliminate this risk. Again, most women having vaginal births do not require surgery for POP, and it would take 135 vaginal births to develop one surgically managed case of POP. On the basis of this evidence, caesarean section cannot be routinely advocated for the prevention of POP.
Sexual dysfunction
The only randomised-controlled trial that examined sexual function after childbirth found no difference in sexual function 6 months after a vaginal birth or a caesarean section. Other studies have confirmed no difference in sexual function even at 12–18 months, irrespective of the route of delivery.
Therefore, although weak-quality evidence suggests a protective effect of caesarean section on SUI, for other pelvic floor issues, weak-quality evidence does not favour either route of delivery. In women without previous pelvic floor dysfunction, data are currently insufficient to justify a planned caesarean section to avoid pelvic floor symptoms and, until a better understanding is reached of the issue from a societal perspective, routinely advocating caesarean section to decrease pelvic floor dysfunction is ill-advised.
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