To ‘C’ or not to ‘C’?/Caesarean delivery upon maternal request: a review of facts, figures and guidelines

Abstract

The last few decades have seen an unrelenting rise in caesarean section (CS) rates. In addition to an increase in numbers of CS performed worldwide, there has also been a change in the indications for CS, a reflection of changing times. A new dilemma facing obstetricians is the increasing demand for CS in the absence of any medical indication (caesarean delivery on maternal request - CDMR). The paucity of evidence either in favour or against, the poor understanding of long-term health and financial implications and the complex ethical issues surrounding CDMR make counselling extremely challenging. Needless to say, CDMR has generated enormous interest both in the media and among health-care providers, and many national and international bodies have now issued guidelines on the topic. In this editorial, we have aimed to explore the factors responsible for the increase in CDMR rates, assess the safety and cost implications of CS and review the recent guidelines and recommendations on CDMR.

Cesarean section on demand: a population-based study in Southern Brazil

“…In the United Kingdom and in the North of Europe the prevalence varies from 6% to 8%, in the United States 11.2%, while in Australia 17.2%. 1 In Rio Grande, only the cesarean sections performed on demand would represent at least one third of the rate recommended by the World Health Organization (WHO). This reinforces, once again, the urgent need to implement policies that are more compelling to combat the abusive practice of cesarean sections in Brazil.…”

“…This meant that the cesarean section, taken initially as a universal solution to obstetric problems, became one of the procedures most commonly performed. 1 In Brazil, in addition to occupy a world leadership in the occurrence of cesarean section, this method became the most common method for babies to be born. 2 The indiscriminate use of cesarean sections has very little to do with clinical needs for pregnant woman and/or the newborn, but it has to do with the will of the mother, the physician and the socioeconomic level of the family.…”

“…6 The main reason why they claim for this is to avoid pain, laceration or tokophobia, which refers to the irrational fear of vaginal delivery. 1 The occurrence of this type of cesarean section without medical indication has been increasing throughout the world, and this violates the principles of good medical practice, submitting the patient to unnecessary risks and increasing the expense in the health sector. 7 Between 6% and 17% of cesarean sections in different countries occur by maternal demand.…”

“…7 Between 6% and 17% of cesarean sections in different countries occur by maternal demand. 1 In Brazil, the cesarean section on demand has been little studied. There is no population-based study found which addresses this issue.…”

Incongruence between the Preferred Mode of Delivery and Risk of Childbirth Complications among Antepartum Women in Mulago Hospital, Uganda

“…Furthermore, there is associated risk of long-term complications such as adhesion formation, incision hernia, uterine scar dehiscence (in future pregnancies), adherent placenta and placenta previa [1]- [5]. Caesarean delivery may be associated (in subsequent pregnancies) with delayed conception, increased risk of ectopic pregnancy, preterm birth and uterine scar dehiscence or rupture [20].…”