skip navigation
Vol. LVIII, No. 8
April 21, 2006

next story
With No Easy Answers, Research to Continue
Caesarean Delivery on Maternal Request: Yea or Nay?

On the front page...

An independent panel of experts assembled by NIH has determined that there is not enough quality evidence to fully evaluate the risks and benefits of caesarean delivery on maternal request (CDMR) as compared with planned vaginal delivery. More research, they said, is needed.

The panel also found that until sufficient evidence becomes available, "any decision to perform a CDMR should be carefully individualized and consistent with ethical principles."


  Panel chair Dr. Mary V. D’Alton, Columbia University’s director of obstetrics and gynecology

The State-of-the-Science conference on CDMR, convened Mar. 27-29, sparked questions from both participants and reporters covering the event.

"That's because birth is not only a physical process; it's an emotional one," said Dr. Catherine Spong, chief of NICHD's Pregnancy and Perinatology Branch and one of the conference's organizers. "Some people think no baby should ever be delivered by caesarean," she noted, "while others think all babies should be. People bring their passion to this issue."

Spong's specialty focuses on maternal health, pregnancy, fetal well-being, labor and delivery and the newborn's adjustment to life outside the womb. In collaboration with the Office of Medical Applications of Research, she and the NICHD team helped bring to NIH a panel of 18 physicians, nurse-midwives, epidemiologists, legal and patient safety experts, among others. Cosponsors included NIDDK, ORWH and NINR.

The panel's report offered several caveats.

It stressed that CDMR is not recommended for women desiring large families, since caesarean section increases the risk of placenta previa and accreta. These conditions involve abnormal implantations of the placenta, and each C-section increases risk. Complications can include catastrophic hemorrhage.

Furthermore, the panel stated that CDMR should not be performed before 39 weeks of gestation, or without having first verified fetal lung maturity.

A baby born with immature lungs is at risk for respiratory complications, which can be life-threatening.

The panel also found that "request for CDMR should not be motivated by unavailability of effective pain management, and that efforts must be made to assure its availability for all women."

Finally, the panel found that NICHD should establish and maintain a web site "to provide up-to-date information on the benefits and risks of all modes of delivery."

There are pros and cons to each mode, the panel stressed, so women and their doctors should have a series of discussions to arrive at the best choice.

What is known is that caesarean section can prevent certain birth injuries, such as asphyxia or neurological injuries, but these are rare. On the other hand, as major surgery it carries significant risks, such as infection. And the baby born surgically hasn't been exposed to the hormones in labor that help mature lung function; in addition, its chest wall hasn't been compressed during delivery. Both factors increase risk for respiratory distress as the baby tries to adapt to life outside mom.

Speaker Dr. Anthony G. Visco of the University of North Carolina at Chapel Hill presents a review of short-term maternal outcomes. Panel member Dr. Patricia J. O’Campo, University of Toronto epidemiologist, fields audience question.

Three out of 10 babies in the U.S. are delivered by caesarean section; this figure includes both elective and emergency procedures.

A caesarean is planned, or elective, when it is foreseen that vaginal birth would endanger mother, infant or both. Perhaps the mother has already had one C-section, so to forestall a uterine rupture, a repeat procedure is planned.

The unplanned procedure responds to trouble that suddenly crops up, or to deterioration in the patient's condition. Hemorrhage, disease, injury or anoxia can warrant emergency surgical intervention.

The current C-section rate, at an all-time high of 29 percent, includes CDMR. While there is some evidence that the incidence of CDMR is increasing, we don't know exactly how many of these procedures are based solely on the woman's request or on which factors: convenience, conflicts with other child care or family needs, distance from the hospital, fear of a mishap or birth injury or anxiety about pain management.

The panel report also included suggestions for future research, including:

  • Surveys of women (before and after birth), providers, insurers and health care facilities regarding CDMR;

  • Development of strategies to predict and influence the likelihood of successful vaginal birth;

  • Establishment of uniform documentation of CDMR, to accurately reflect prevalence of the procedure;

  • Examination of existing large databases to assess incidence of various complications, including rare but critical outcomes, and

  • A thorough assessment of the costs of CDMR.

"The strength of what came out of the conference," said Spong, "is that we now have available the best information on the short- and long-term risks and benefits for both the mother and baby on caesarean delivery on maternal request. This will allow a woman and her physician to have the critical discussion if she is interested in CDMR."

The full draft report is available at http://consensus. The final version will be available at the same web address soon.

back to top of page