The Politics of Women's Health

Maternal Request for Cesarean Delivery: Myth or Reality?

The rate of cesarean deliveries in the United States has skyrocketed in recent years; in  2004 nearly 30 percent of women who gave birth had cesarean section deliveries. Many factors contribute to this rise, from the failure of hospitals to support normal physiologic labor to providers’ fear of malpractice suits (for an excellent analysis, see “Why Does the National U.S. Cesarean Section Rate Keep Going Up?") Another factor often cited as contributing to the rise is maternal request for cesareans. But is it true that increasing numbers of women are themselves choosing to have cesarean sections for non-medical reasons?

In March 2006 the National Institutes of Health invited health care providers and maternity care experts to a state-of-the-science conference entitled "Cesarean Delivery on Maternal Request." The conference was designed to examine the evidence related to the following questions:

• What are trends in the use of cesarean section, including the extent to which women in the U.S. are themselves initiating and planning primary (initial) cesareans while understanding that there is no medical need?
  
  
• What are short- and long-term benefits and harms to mothers and babies of "cesarean delivery on maternal request" when compared with planned vaginal birth?
  
  
• What factors influence benefits and harms of planned cesarean and planned vaginal birth?
  
  
• What future research is needed to help make appropriate decisions about planned cesarean section by choice with no medical reason versus planned vaginal birth?

At the end of the conference, a multi-disciplinary panel issued a statement, "Cesarean Delivery on Maternal Request."  The panel could not agree on whether physicians should do a caesarean delivery when there is no clear medical indication, just because a woman requests one.  While acknowledging that  "the available evidence and data comparing risks and benefits of planned vaginal delivery and Caesarean delivery on maternal request are sparse and provide few clear conclusions,” the panel nonetheless felt that they could conclude that “there appear to be relatively similar degrees of risk from both pathways in women intending to limit their childbearing to one or two children."

Many childbirth advocates and practitioners are extremely critical of the statement. They point to scientific evidence that vaginal births without the inappropriate use of instruments and procedures such as routine episiotomy are safer and have fewer adverse outcomes for both mothers and babies. They also say the panel overestimated the number of women truly requesting cesareans, included flawed research and analyses, and failed to give adequate attention to long term negative effects of cesarean births.

The panel did reach one conclusion that has met with widespread agreement: If a woman is planning to have more than one child, vaginal birth is clearly the preferred mode for the safety of both the baby and the mother. 

To find out more, see the following:

• NIH Cesarean Conference: Interpreting Meeting and Media Reports
  An excellent critique from Childbirth Connection, a nonprofit organization that uses research, education and advocacy to improve maternity care.
  
  
• Cesarean Section When It’s Not Medically Necessary: Safe Practice or Risky Decision?
  Advice from the National Women's Health Network.
  
  
• "Mothers Aren't Behind A Vogue for Caesareans" 
  A Boston Globe editorial on the myth of maternal request for cesareans, written by Our Bodies Ourselves Executive Director Judy Norsigian and professor of maternal and child health at Boston University School of Public Health Gene Declercq.
  
  
• Don't Blame Mothers for C-Section Vogue 
  An expanded commentary by Judy Norsigian and Gene Declerq.
  
  
• ICAN Responds to Maternal Request Cesarean Statement by NIH (.pdf)
  A response from the International Cesarean Awareness Network, whose mission is to improve maternal-child health by preventing unnecessary cesareans.
  
  
• Comments on the NIH State of the Science conference "Cesarean Section by Maternal Request”
  Comments from conference participant and Citizens for Midwifery president Susan Hodges.
  
  
• Patient-Choice Vaginal Delivery? 
  This essay from the American Annals of Family Medicine examines why the language of choice is used to justify elective cesareans, but not to allow women the option of vaginal birth after cesarean or vaginal breech birth.

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