Examining the Evidence
Q.Is planned primary cesarean as safe as vaginal delivery for the mother?
<huc>A.</huc>Not according to this analysis of data from Massachusetts. It found that women who planned primary cesarean delivery were 2.3 times more likely to be rehospitalized within 30 days than were women who planned vaginal delivery.
Declercq and colleagues utilized a state-based data system linking birth certificates, fetal death records, and birth-related hospital discharge records from 1998 to 2003. Their study included 244,088 women (240,754 planned vaginal deliveries and 3,334 planned cesareans) with no previous cesarean and no documented prenatal risk.
Annually, about 1.2 million American women deliver by cesarean section, the most commonly performed major abdominal surgery in the nation. Yet we know surprisingly little about the phenomenon of women requesting cesareans without a medical or obstetric indication. There is no question that cesarean delivery on maternal request (CDMR) is a topic of great controversy. Despite considerable interest in the subject, there are very few data to guide practitioners.
The difficulty of comparing planned cesarean and vaginal deliveries
This study has several limitations, which are acknowledged by the authors:
- Data derived from hospital discharge records and birth certificates have limitations. The 2 groups compared in this study were reconstructed from hospital records, and the planned mode of delivery was determined retrospectively. For these reasons, the planned primary cesarean group may be an inaccurate measure and oversimplification of maternal request.
- The cesarean delivery rate in the planned vaginal birth group was low at 8.7%, compared with the overall national primary cesarean rate of 20.6% in 2004.1 This suggests that the selection of patients for inclusion in this study may have been subject to bias.
- Using an intent-to-treat analysis, the authors included women with planned vaginal birth who delivered via unplanned primary cesarean section, but failed to include the converse: women with planned cesarean delivery who presented in labor. Although mothers with labored cesareans constitute a small group, they are known to be exposed to higher complication rates than are women with unlabored cesareans.
- The primary reason for hospitalization was wound infection, and this study did not adjust for other important confounders for this complication, such as obesity.
In general, findings do not change those of the NIH panel on CDMR
This study highlights the paucity of literature on CDMR and the need for better prospective data. In a state-of-the-science conference on CDMR, sponsored by the National Institutes of Health in March 2006, a systematic review of the literature found weak evidence supporting a lower infection rate with vaginal delivery, compared with planned or unplanned cesarean.2 In our view, the study by Declercq and colleagues does not change the weak nature of evidence, but corroborates the impression of many practitioners that, in general, cesarean delivery is associated with higher rates of infectious morbidity than vaginal birth.
Although rehospitalization remains an important complication of cesarean section, the choice of delivery method is complex and involves numerous other factors such as ethics, fetal and neonatal morbidity, cultural background, professional resources, concerns about pelvic floor injury, and the risk of abnormal placentation in future pregnancies.
Bottom line: Individualize the decision
When a patient inquires about CDMR, the practitioner should carefully individualize the decision consistent with ethical principles and informed consent, while taking into account the available medical and health resources and the patient’s preferences. Unfortunately, there is little clear guidance we can offer women considering CDMR because there are major gaps in our information.
Sorely needed is a comprehensive, nationwide research effort to more precisely understand the risks and benefits—for both mother and child—of cesarean delivery on maternal request as compared with both planned vaginal delivery and medically advised cesarean section. We owe the women and children of this nation nothing less.
1. Martin JA, et al. Preliminary births for 2004: infant and maternal health. National Center for Health Statistics, Centers for Disease Control and Prevention. Available at www.cdc.gov/nchs/data/hestat/prelimbirths04health_tables.pdf. Accessed April 12, 2007.
2. National Institutes of Health State-of-the-Science Conference statement: cesarean delivery on maternal request, March 27–29, 2006. Obstet Gynecol. 2006;107:1386-1397.