Introduction

The number of cesarean deliveries in the United States has hovered around 32% in the past decade.  Cesarean birth is easily documented and the numbers are a benchmark for birth outcomes and best practice.  Cesarean delivery by maternal request (CDMR), on the other hand, is very hard to quantify.   It is hard to capture exactly how many cesareans are performed at the request of the pregnant parent.  Difficulties in estimating the prevalence of CDMR has been attributed to the lack of an International Classification of Diseases (ICD) code for CDMR and to documentation inconsistencies that are recorded.

Cesarean Delivery on Maternal Request in the United States from 1999 to 2015 (Trahan, Czuzoj-Shulman, & Abenhaim, 2021) aimed to document the rate of CDMR and identify the characteristics of parents who are electively choosing to give birth by planned cesarean.

The American College of Obstetricians and Gynecologists has the following recommendations for cesarean delivery on maternal requests (ACOG Committee Opinion No. 761, 2019):

• If a patient's main motivation to elect a cesarean delivery is a fear of pain in childbirth, obstetrician–gynecologists and other obstetric care providers should discuss and offer the patient analgesia for labor, as well as prenatal childbirth education and emotional support in labor.
• In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended.
• After exploring the reasons behind the patient’s request and discussing the risks and benefits, if a patient decides to pursue cesarean delivery on maternal request, the following is recommended:
• In the absence of other indications for early delivery, cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks.
• Given the high repeat cesarean delivery rate, patients should be informed that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each subsequent cesarean delivery.

How was the study conducted

ICD-9 diagnosis and procedure codes were used to identify people who had an elective primary cesarean delivery in the United States from 1999 through 2015.  If there was a maternal or fetal indication for a primary cesarean delivery, it was determined that it was not a cesarean delivery by maternal request.  The prevalence of CDMR over time was observed.  Maternal demographics collected include race, age, geographic region, nulliparity, hospital and insurance type.

What were the results

During the time period examined there were 13,698,835 births. After analysis, it was determined that 228,586 births were cesarean delivery by maternal request.  This was 1.67% of all the births during that period. CDMR represented 5.5% of all cesarean deliveries. The rate of CDMR increased during the study period from 1.03% to 1.62%.

The people who chose CDMR were more likely to be over age 35, high income and be covered by private insurance.

Despite the rate of adverse outcomes being low overall, people who delivered by CDMR were a greater risk of complications including venous thromboembolism, myocardial infection, sepsis, disseminated intravascular coagulation, a greater need for blood transfusions, a prolonged hospital stay and an increase in deaths.  People who had a CDMR were less likely to experience a postpartum, hemorrhage.

Discussion and Conclusions

Cesarean deliveries by maternal request represent a small number of all live births and all cesarean deliveries.  The number of CDMR births increased from 1999 to 2015.  People over 35 who were in a higher income bracket, with private insurance, were more likely to chose a CDMR.  Those who chose a CDMR were more likely to experience an adverse outcome but the overall risks of adverse outcomes is low.  The researchers did not believe that the increasing rate of CDMR births was a main contributor to the rising cesarean rate in the USA.  The number of people who elect a cesarean delivery upon request represent a minority.

One concern that arose during the evaluation of the data is that people who give birth by CDMR are coded as a cesarean delivery for macrosomia, while not meeting the ACOG recommendations for elective cesarean birth due to a large baby, which is currently 5 kg for non-diabetic people and 4.5 kg diabetic parents.  This misrepresentation may mean that the rate of CDMR is underestimated.

The reasons that a person may chose a CDMR are not well understood. Previous traumatic experiences, anxiety, tocophobia, and prior poor obstetrical outcomes.

While the number of CDMR births is small overall, the lack of opportunities to have a vaginal birth after cesarean may have a large impact on the increasing cesarean rate in the USA if and when those CDMR parents go on to birth again.  (National Center for Health Statistics, 2020) Questions on equitable practices need to be raised when the income status, race and insurance status of those people undergoing a CDMR are examined.

References

Cesarean delivery on maternal request. ACOG Committee Opinion No. 761. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e73–7.

National Center for Health Statistics. “Recent Trends in Vaginal Birth After Cesarean Delivery: United States, 2016-2018.” Center for Disease Control and Prevention. Updated March 5, 2020.

Trahan, M. J., Czuzoj-Shulman, N., & Abenhaim, H. A. (2021). Cesarean Delivery on Maternal Request in the United States from 1999 to 2015. American Journal of Obstetrics and Gynecology.

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