Soon-to-be mothers and their clinicians need to thoughtfully consider the positive and negative outcomes, for both mothers and babies, of cesarean delivery on maternal request, according to a new report by researchers at the RTI International-University of North Carolina at Chapel Hill (RTI-UNC) Evidence-based Practice Center. Cesarean delivery on maternal request is a procedure done when no factors, for either the mother or the infant, make it medically necessary, and the number of such procedures, like cesarean deliveries generally, appears to be increasing.

The report finds no major differences in results between a first-time cesarean delivery at the mother’s request and a planned vaginal delivery. The authors caution, however, that the evidence is too weak to warrant a firm conclusion that absolutely no differences exist between the cesarean and the vaginal options. For example, available data often does not distinguish between cesarean deliveries done at the request of the mother and other planned cesareans performed for factors such as breech presentation.

The report, funded by the Agency for Healthcare Research and Quality (AHRQ), provides for the first time a comprehensive framework through which health-care professionals and their patients can better understand the tradeoffs in potential benefits and risks between planned cesarean delivery and planned vaginal delivery. Key maternal outcomes studied include bleeding, infection, surgical complications, urinary incontinence and length of hospital stay. Important neonatal outcomes include breathing problems and birth trauma.

The authors note that, if a woman chooses to have a cesarean for her first delivery, she is more likely to have her subsequent deliveries by cesarean. They point out, as well, that risks are likely to increase with the number of repeat cesareans.

Dr. Anthony G. Visco, the clinical director of the review and associate professor in the UNC School of Medicine’s department of obstetrics and gynecology, said, “Doctors and researchers need to take many factors into account to accurately assess the benefits and harms of planned cesarean compared with those associated with planned vaginal deliveries.” He adds that “we really have no simple answers about a woman’s choice to request a cesarean delivery. Making this choice involves many questions unique to her, including her plans for future childbearing. Such decisions should always be made in consultation with a medical professional.”

A major limitation of the available literature is that studies typically combine outcomes from emergency cesareans and planned cesarean deliveries. In addition, the evidence base does not distinguish between planned cesarean deliveries performed at the request of the mother and other planned cesareans performed for factors such as breech presentation. These shortcomings likely create an incomplete picture of the positive and negative outcomes of the procedure for both mothers and babies.

“Although these findings seem to indicate no significant difference in outcomes between planned cesarean and planned vaginal deliveries for either mothers or their new babies, the data mask the fact that an unknown number of planned vaginal deliveries end with emergency cesarean deliveries,” said Dr. Meera Viswanathan, director of the project and a senior research analyst at RTI International. “We have every reason to believe that planned cesarean deliveries on maternal request without medical complications may be safer for both mother and child than emergency cesareans resulting from a planned vaginal delivery. Still, even a planned cesarean delivery is major surgery and has associated risks.”

Based on their review of 69 publications selected from among more than 1,400 abstracts on this topic, the authors recommended developing a consensus-based set of terms to distinguish delivery routes accurately, creating a minimum data set of information about planned cesarean deliveries based on maternal request, and developing better measures to assess both short- and long-term outcomes for mothers and their babies.

Results from this systematic review were among several studies that formed the basis for the National Institutes of Health State-of-the-Science Conference earlier this week in Bethesda, Md. The complete evidence report is available on the AHRQ Web site at
http://www.ahrq.gov/

The evidence review was conducted by AHRQ’s RTI-UNC Evidence-based Practice Center -  a collaboration between RTI and the five health professions schools and the Cecil G. Sheps Center for Health Services Research at UNC. Funding for this specific project was provided by the National Institutes of Health.