Cesarean delivery on maternal request in Italy

Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges

The cesarean section (CS) rate is very heterogeneous all over the world, reflecting the differences in the access to healthcare services. In higher-income countries, changes observed in the obstetrical population brought to an increased rate of cesarean section for maternal request. Besides, clinicians are facing an increasing number of induction of labor, with the consequent risk of CS if the management is inappropriate. Analyzing the rate of primary CS, the interpretation of intrapartum CTG and a tailored management of labor are also red flags that must be considered. In this optic, the implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

Diagnosis and Management of Uterine Rupture in the Third Trimester of Pregnancy: A Case Series and Literature Review

BACKGROUND

 Uterine rupture is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity requiring prompt cesarean delivery and uterine repair or hysterectomy. Previous cesarean section is the most common risk factor. The most consistent early indicator of it is the onset of prolonged and profound fetal bradycardia.

OBJECTIVE

In this study, we present six cases of uterine rupture highlighting risk factors, and challenges in diagnosis and management, along with a review of the literature.

METHOD

A retrospective case series identified eight cases during the five-year study period. All cases from January 1, 2018 to December 31, 2022 were reviewed. Cases with multiple previous cesarean sections were excluded.

RESULT

Six cases meeting the study criteria were included in our case series. Uterine rupture was a rare occurrence with a prevalence of nine in 31,315 births representing 0.03% of deliveries. No maternal mortality or need for hysterectomy occurred in our study. Fifty percent of uterine ruptures were associated with stillbirths. The most common risk factor was a previous cesarean section in 83.3%. The most common presenting sign was non-reassuring fetal status patterns in 66.6%. A single case had a silent rupture.

CONCLUSION

Signs and symptoms of uterine rupture are nonspecific making diagnosis challenging. Delay in definitive management causes significant fetal morbidity and mortality. For best outcomes, vaginal birth after a previous cesarean section needs close monitoring in appropriately prepared units with the ability to perform immediate cesarean delivery and provide advanced neonatal support.

Safety and feasibility of trial of labor in pregnant women with cesarean scar diverticulum

OBJECTIVE

Literature on trial of labor after cesarean section (TOLAC) in women with isthmoceles is scarce because of complications associated with the procedure. This study investigated TOLAC's safety and feasibility in patients with isthmoceles.

METHODS

The study group comprised 34 pregnant women with isthmoceles who vaginally delivered. The control group comprised 102 pregnant women without isthmoceles who vaginally delivered during the same period. Scar diverticula were measured using color Doppler ultrasonography; between-group delivery outcomes were compared.

RESULTS

Of the study group patients, 27/34 had isthmoceles diagnosed by ultrasound before pregnancy. Nineteen (70.37%) of these patients had mild defects and eight (29.63%) had moderate defects. The scar diverticula's mean length, depth, and width were 1.05 ± 0.62, 0.54 ± 0.28, and 1.20 ± 0.70 cm, respectively. The residual muscle layer's mean thickness was 0.27 ± 0.07 cm. The mean diverticulum depth/residual muscular thickness ratio was 2.39 ± 2.58. The duration of the first stage of labor was significantly shorter and the neonatal weight was significantly lower in the study group than control group.

CONCLUSION

Successful vaginal delivery is possible for women with mild and moderate isthmoceles. Further large-scale studies are needed to improve TOLAC's safety in pregnant women with isthmoceles.

Assessing the Factors Affecting Cesarean Section Selection in Iranian Women Using Multilevel Count Models with Excess Zeros

Background

Iran has ranked second in the frequency of cesarean delivery (CD) and this rate in 2014 has increased by 56 percent. The CD has multiple complications for the woman and newborn, and due to the women's readmission after surgery impose additional costs to the countries. Although CD has many complications and is not recommended by obstetrician and midwives; some factors affect the choice of this method of delivery.

Methods

We used data from the Iranian Institute for Health Sciences Research (IIHSR) in 2015. We studied the effects of factors such as socioeconomic and demographic factors and supplemental insurance status in the choice of CD. We used multilevel Zero-Inflated models for the modeling of data.

Results

The employed women resident in urban areas with the high-income and age greater than 34-yr old and supplemental insurance more likely chose CD. On the other hand, women with high education level, women who use at least one media (e.g. Radio, television, etc.) and women that use contraceptive methods have chosen the less CD.

Conclusion

Our findings highlighted the importance of supplemental insurance and socio-economic status in choosing a CD by women. However, in some cases especially in the rich class of society, the high cost of this type of delivery does not affect the choice decrease of it, and governments should adopt rigorous policies in using this method.

"An unnecessary cut?" multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review

BACKGROUND

Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study.

METHODS

Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance.

RESULTS

CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women's attitudes towards pregnancy and childbirth.

CONCLUSION

Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.

Caesarean Section on Maternal Request: An Italian Comparative Study on Patients' Characteristics, Pregnancy Outcomes and Guidelines Overview

In recent years, the rate of caesarean sections has risen all over the world. Accordingly, efforts are being made worldwide to understand this trend and to counteract it effectively. Several factors have been identified as contributing to the selection of caesarean section (CS), especially an obstetricians' beliefs, attitudes and clinical practices. However, relatively few studies have been conducted to understand the mechanisms involved, to explore influencing factors and to clearly define the risks associated with the caesarean section on maternal request (CSMR). This comparative study was conducted to elucidate the factors influencing the choice of CSMR, as well as to compare the associated risks of CSMR to CS for breech presentation among Italian women. From 2015 to 2018, a total of 2348 women gave birth by caesarean section, of which 8.60% (202 women) chose a CSMR. We found that high educational attainment, use of assisted reproductive technology, previous operative deliveries and miscarriages within the obstetric history could be positively correlated with the choice of CSMR in a statistically significant way. This trend was not confirmed when the population was stratified based on patients' characteristics, obstetric complications and gestational age. Finally, no major complications were found in patients that underwent CSMR. We believe that it is essential to evaluate patients on a case-by-case basis. It is essential to understand the personal experience, to explain the knowledge available on the subject and to ensure a full understanding of the risks and benefits of the medical practice to guarantee the patients not only their best scientific preparation but also human understanding.

Caesarean deliveries in China

BACKGROUND

The caesarean section rate has risen rapidly in China. The purpose of this retrospective study was to estimate caesarean section rates and indications by hospital facility level in Mainland China to investigate reasons contributing to the high rate.

METHODS

This cross-sectional hospital-based study collected data from 39 hospitals in three geographical regions in China, covering 14 different provinces, municipalities, and autonomous regions, including 20 tertiary health hospitals and 19 secondary hospitals. Data from all women who gave birth at these hospitals during 2011 were included.

RESULTS

A total of 112,138 women who gave birth after 24 weeks of gestation were surveyed. Of these pregnancies, 54.5% (61,084 cases) resulted in caesarean section, non-indicated caesarean section accounted for 38.4% of caesarean sections. Overall caesarean section rates were higher at the tertiary level hospitals (55.9%) compared to the secondary level hospitals (50.9%). The secondary level hospitals had higher rates of non-indicated caesarean section (48.9% of caesarean sections) compared to tertiary level hospitals (34.5% of caesarean sections). The rate of caesarean section on maternal request was higher in the secondary hospitals (16.6%) than in the tertiary hospitals (10%) (P < 0.001), as well as the caesarean section rate for CPD prior to labour. Operative vaginal deliveries were overall rare (1.2%) with 90.9% (1200/1320 cases) performed in the tertiary hospitals.

CONCLUSIONS

Caesarean section on maternal request accounts for a large portion of China's high caesarean section rate, especially in the secondary hospitals. The first step to reduced caesarean section rates is to decrease the number of non-indicated caesarean sections.

Do Italian women prefer cesarean section? Results from a survey on mode of delivery preferences

BACKGROUND

About 20 million cesareans occur each year in the world and rates have steadily increased in almost all middle- and high-income countries over the last decades. Maternal request is often argued as one of the key forces driving this increase. Italy has the highest cesarean rate of Europe, yet there are no national surveys on the views of Italian women about their preferences on route of delivery. This study aimed to assess Italian women's preference for mode of delivery, as well as reasons and factors associated with this preference, in a nationally representative sample of women.

METHODS

This cross sectional survey was conducted between December 2010-March 2011. An anonymous structured questionnaire asked participants what was their preferred mode of delivery and explored the reasons for this preference by assessing their agreement to a series of statements. Participants were also asked to what extent their preference was influenced by a series of possible sources. The 1st phase of the study was carried out among readers of a popular Italian women's magazine (Io Donna). In a 2nd phase, the study was complemented by a structured telephone interview.

RESULTS

A total of 1000 Italian women participated in the survey and 80% declared they would prefer to deliver vaginally if they could opt. The preference for vaginal delivery was significantly higher among older (84.7%), more educated (87.6%), multiparous women (82.3%) and especially among those without any previous cesareans (94.2%). The main reasons for preferring a vaginal delivery were not wanting to be separated from the baby during the first hours of life, a shorter hospital stay and a faster postpartum recovery. The main reasons for preferring a cesarean were fear of pain, convenience to schedule the delivery and because it was perceived as being less traumatic for the baby. The source which most influenced the preference of these Italian women was their obstetrician, followed by friends or relatives.

CONCLUSION

Four in five Italian women would prefer to deliver vaginally if they could opt. Factors associated with a higher preference for cesarean delivery were youth, nulliparity, lower education and a previous cesarean.

Cesarean section on maternal request: a societal and professional failure and symptom of a much larger problem

The scientific literature was silent about a relationship of pelvic floor, urinary, and fecal incontinence and sexual issues with mode of birth until 1993, when Sultan et al's impressive rectal ultrasound studies were published. They showed that perirectal fibers were damaged in many vaginal births, but not as a result of a cesarean section. These findings helped to pioneer a new area of research, ultimately leading to increasing support among health professionals and the public that maternal choice of cesarean delivery could be justified-even that maternal choice and autonomous decision-making trump other considerations, including evidence. A growing number of birth practitioners are choosing cesarean section for themselves-usually on the basis of concerns over pelvic floor, urinary incontinence, and sexual issues. Behind this choice is a training experience that focuses on the abnormal, interprets the literature through a pathological lens, and lacks sufficient opportunity to see normal childbirth. Cesarean section on maternal request is a complex issue based on fear and misinformation that is a symptom of a system needing reform, that is, a major change in community and professional education, governmental policy making, and creation of environments emphasizing the normal. Systemic change will require the training of obstetricians mainly as consultants and the education of a much larger cadre of midwives and family physicians who will provide care for most pregnant women in settings designed to facilitate the normal. Tinkering with the system will not work-it requires a complete refit.

Asthma and atopy in children born by caesarean section: effect modification by family history of allergies - a population based cross-sectional study

Background

Studies on the association of birth by caesarean section (C/S) and allergies have produced conflicting findings. Furthermore, evidence on whether this association may differ in those at risk of atopy is limited. This study aims to investigate the association of mode of delivery with asthma and atopic sensitization and the extent to which any effect is modified by family history of allergies.

Methods

Asthma outcomes were assessed cross-sectionally in 2216 children at age 8 on the basis of parents’ responses to the ISAAC questionnaire whilst skin prick tests to eleven aeroallergens were also performed in a subgroup of 746 children. Adjusted odds ratios of asthma and atopy by mode of delivery were estimated in multivariable logistic models while evidence of effect modification was examined by introducing interaction terms in the models.

Results

After adjusting for potential confounders, children born by C/S appeared significantly more likely than those born vaginally to report ever wheezing (OR 1.36, 95% CI 1.07-1.71), asthma diagnosis (OR 1.41, 95% CI 1.09-1.83) and be atopic (OR 1.67, 95% CI 1.08-2.60). There was modest evidence that family history of allergies may modify the effect of C/S delivery on atopy (p for effect modification=0.06) but this was not the case for the asthma outcomes. Specifically, while more than a two-fold increase in the odds of being a topic was observed in children with a family history of allergies if born by C/S (OR 2.62, 95% CI 1.38-5.00), no association was observed in children without a family history of allergies (OR 1.16, 95% CI 0.64-2.11).

Conclusions

Birth by C/S is associated with asthma and atopic sensitization in childhood. The association of C/S and atopy appears more pronounced in children with family history of allergies.

Patient-initiated elective cesarean section of nulliparous women in British Columbia, Canada

BACKGROUND

The proportion of cesarean sections is increasing in Canada overall and in British Columbia in particular. It has been suggested that this increase is partially the result of women requesting the procedure, although the prevalence of patient-initiated elective cesarean section is unclear. The objective of this study was to examine the prevalence of probable elective cesarean and physician-suggested elective cesarean section among nulliparous women who had a cesarean section in British Columbia, Canada.

METHODS

An electronic search of patient charts from seven British Columbia hospitals between June 1, 2002, and May 31, 2004, was completed and potential nulliparous women seeking elective cesarean were identified. Any women with medical factors predisposing them to a cesarean section were excluded. Identified charts were then subjected to individual chart review by two independent researchers to ensure accuracy of classification into a cohort of women with probable patient-initiated elective cesarean section.

RESULTS

For the study period, 10,546 nulliparous women gave birth at the seven study hospitals and 3,301 delivered by means of cesarean section. Of these 3,301 women, 36 were judged to have had a patient-initiated elective cesarean. These 36 women represented 0.34 percent of all nulliparous births and 1.09 percent of all nulliparous cesarean births. Those judged to have selected an elective cesarean were significantly older and had babies with a lower gestational age than women with a nonelective cesarean section. No significant differences between the two groups were found with respect to maternal weight, length of stay for the mother or baby, newborn birthweight, or special care nursery days.

CONCLUSIONS

Overall, the prevalence of nulliparous women judged to have had a patient-initiated elective cesarean was found to be low and is not likely to be substantially contributing to the rising proportion of cesarean births.

A thirty-year analysis of cesarean section rate in gestational diabetes and normal pregnant population in Tehran, Iran: a concerning trend

BACKGROUND

The aims of this study were to analyze the trend of cesarean section (CS), determining possible risk factors and also comparing the rate of CS in mothers with gestational diabetes (GDM) and normal pregnant population.

MATERIALS AND METHODS

A hospital-based midwives data collection including 37,997 pregnancies in Tehran was used for this study. The study population included all women giving birth between 1 January 1980 and 31 December 2009.

RESULTS

The global rate for CS was 37.8 and 85.9% in normal pregnant population and GDM subjects, respectively. An increase in the rate of CS was observed in normal population from 16.97% during 1980-1989 to 71.08% during 2000-2009. There was a similar upward trend for GDM subjects from 79.17 to 93.55%. The most frequent indications for CS in GDM subjects were unsuccessful induction (31%) and repeat CS (22.76%).

CONCLUSION

The rate of CS is surprisingly very high in normal pregnant population as well as subjects with GDM. This should be an alarming issue for healthcare policy-makers and a trigger for monitoring situation in the country.

Turkish obstetricians' personal preference for mode of delivery and attitude toward cesarean delivery on maternal request

OBJECTIVE(S)

(1) To investigate the cesarean rate among actively practicing obstetricians in Turkey and reasons why they choose this mode of delivery for themselves/partners. (2) To investigate the attitudes, practices, and beliefs with respect to cesarean delivery on maternal request (CDMR) among actively practicing obstetricians in Turkey.

STUDY DESIGN

This is a descriptive study performed at 7th Congress Of Turkish Society Of Gynecology and Obstetrics. A self-administered questionnaire was used for data collection. During the congress, from the obstetricians attending the congress, 500 were randomly selected; due to the room numbers, the questionnaires (total, 500) and the consent forms were distributed every fourth room. The sampled obstetricians were instructed to return the completed questionnaires and signed consent forms to the congress information desk located throughout the congress. In total, 387 (77.4%) obstetricians responded.

RESULTS

Of the respondents (if female) or their partners (if male), 239 (61.8%) respondents had undergone at least one previous cesarean section (CS), and, of these, 212 (88.7%) were primary elective cesarean deliveries. The most common reason influencing the decision of obstetricians in choosing CS for themselves/partners was reduced anorectal trauma (63.6%). In addition, 158 (40.8%) of the respondents believe that every woman has the right to request a cesarean as a mode of delivery. About half of the respondents (53.2%) said that they would perform a patient-requested CS. The most common reason why obstetricians perform CS due to maternal request was 'anxiety of patient and her partner and due to their insistence'.

CONCLUSIONS

Two-thirds of Turkish obstetricians prefer CS as mode of delivery for themselves/partners. Also half of the obstetricians in our study believe that a woman has the right to request and obtain CDMR, and half of them would agree to perform one.

Cesarean and VBAC rates among immigrant vs. native-born women: a retrospective observational study from Taiwan Cesarean delivery and VBAC among immigrant women in Taiwan

BACKGROUND

Cultural and ethnic roots impact women's fertility and delivery preferences This study investigated whether the likelihood of cesarean delivery, primary cesarean, and vaginal delivery after cesarean (VBAC) varies by maternal national origin.

METHODS

We conducted a nation-wide, population-based, observational study using secondary data from Taiwan. De-identified data were obtained on all 392,246 singleton live births (≥500 g; ≥20 weeks) born to native-born Taiwanese, Vietnamese and mainland Chinese-born mothers between January 1, 2006 and December 31, 2007 from Taiwan's nation-wide birth certificate data. Our analytic samples consisted of the following: for overall cesarean likelihood 392,246 births, primary cesarean 336,766 (excluding repeat cesarean and VBAC), and VBAC 55,480 births (excluding primary cesarean and vaginal births without previous cesarean). Our main outcome measures were the odds of cesarean delivery, primary cesarean delivery and VBAC for Vietnamese and Chinese immigrant mothers relative to Taiwanese mothers, using multiple regression analyses to adjust for maternal and neonatal characteristics, paternal age, institutional setting, and major obstetric complications.

RESULTS

Unadjusted overall cesarean, primary cesarean, and VBAC rates were 33.9%, 23.0% and 4.0% for Taiwanese, 27.6%, 20.1% and 5.0% for mainland Chinese, and 19.3%, 13.9 and 6.1% for Vietnamese respectively. Adjusted for confounders, Vietnamese mothers were less likely than native-born Taiwanese to have overall and primary cesarean delivery (OR = 0.59 and 0.58 respectively), followed by Chinese mothers (both ORs = 0.90 relative to native-born Taiwanese). Vietnamese mothers were most likely to have successful VBAC (OR = 1.58), followed by Chinese mothers (OR = 1.25).

CONCLUSION

Immigrant Vietnamese and Chinese mothers have lower odds of cesarean and higher VBAC odds than native-born Taiwanese, consistent with lower cesarean rates prevailing in their home countries (Vietnam 10.1%; mainland China 20%-50% rural and urban respectively).

Trends and determinants of caesarean sections births in Queensland, 1997-2006

BACKGROUND

The determinants of Queensland's rising caesarean section (CS) rate remain poorly understood because of the historical absence of standard classification methods.

AIMS

We applied the Robson Ten Group Classification System (RTGCS) to population-based data to identify the main contributors to Queensland's rising CS rate.

METHOD

The RTGCS was applied retrospectively to the Queensland Perinatal Data Collection. CS rates were described for all ten RTGCS groups using data from 2006. Trends were evaluated using data for the years 1997-2006. Public and private sector patients were evaluated separately.

RESULTS

In Queensland, in 2006, CS rates were 26.9 and 48.0% among public and private sector patients, respectively. Multiparous women with a previous caesarean birth (Group 5) made the greatest contribution to the CS rate in both sectors, followed by nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2) and nulliparous women in spontaneous labour (Group 1). CS rates have risen in all RTGCS groups between 1997 and 2006. The trend was pronounced among multiparous women with a previous caesarean delivery (Group 5), among women with multiple pregnancies (Group 8) and among nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2).

CONCLUSIONS

The CS rate in Queensland in 2006 was higher than in any other Australian state. The increase in Queensland's CS rates can be attributed to both the rising number of primary caesarean births and the rising number of repeat caesareans.

Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks' gestation

OBJECTIVE

To compare maternal and neonatal outcomes after elective induction of labour and elective Caesarean section with outcomes after spontaneous labour in women with low-risk, full-term pregnancies.

METHODS

We extracted birth data from 1996 to 2005 from an obstetrical database. Singleton pregnancies with vertex presentation, anatomically normal, appropriately grown fetuses, and no medical or surgical complications were included. Outcomes after elective induction of labour and elective Caesarean section were compared with the outcomes after spontaneous labour, using chi-square and Student t tests and logistic regression.

RESULTS

A total of 9686 women met the study criteria(3475 nulliparous, 6211 multiparous). The incidence of unplanned Caesarean section was higher in nulliparous women undergoing elective induction than in those with spontaneous labour (P < 0.001). Postpartum complications were more common in nulliparous and multiparous women undergoing elective induction (P < 0.001 and P < 0.01, respectively) and multiparous women undergoing elective Caesarean section, (P < 0.001). Rates of triage in NICU were higher in nulliparous women undergoing elective Caesarean section (P < 0.01), and requirements for neonatal free-flow oxygen administration were higher in nulliparous and multiparous women undergoing elective Caesarean section (P < 0.01 for each). Unplanned Caesarean section was 2.7 times more likely in nulliparous women undergoing elective induction of labour (95% CI 1.74 to 4.28, P < 0.001) and was more common among nulliparous and multiparous women undergoing induction of labour and requiring cervical ripening (P < 0. 001 and P < 0.05, respectively).

CONCLUSION

Elective induction leads to more unplanned Caesarean sections in nulliparous women and to increased postpartum complications for both nulliparous and multiparous women. Elective Caesarean section has increased maternal and neonatal risks.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Obstetricians' and midwives' attitudes toward cesarean section

BACKGROUND

The cesarean section rate has increased worldwide over the past 20 years; in Italy, it is now more than 35 percent. Although clinical factors are important, the attitudes of health practitioners toward cesarean section need further investigation to correctly identify facilitators and barriers to changes. The objective of this study was to explore the attitudes toward cesarean section of midwives and obstetricians who worked in the same geographical area.

METHODS

Face-to-face structured interviews using an adaptation of the Survey of Clinicians' Views on Caesarean Section, an anonymous questionnaire with 35 open and closed answers on practitioners' views on cesarean section, were conducted. The questionnaire was given to the entire group of midwives and obstetricians working in Modena, a northern Italian district.

RESULTS

Of 262 eligible practitioners, 248 were interviewed (response rate 94.6%). The midwives' attitudes toward cesarean section differed from those of the obstetricians. Sixty-five percent of midwives considered the rates of cesarean section in their hospitals to be too high compared with 34 percent of obstetricians (p < 0.001). Midwives were also less inclined to believe that cesarean section provides benefits to the mother (p = 0.02) or that it is indicated by previous cesarean delivery (p < 0.001). No differences were observed between male and female obstetricians.

CONCLUSIONS

In this survey, the attitudes toward cesarean section were correlated more with professional role than with gender. This information can help policy makers to shape interventions aimed at providing better care for pregnant and childbearing women.

Delivery settings and caesarean section rates in China

OBJECTIVE

To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China.

METHODS

We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables.

FINDINGS

Institutional births increased from 53.5% in 1993-1994 to 82.2% in 2001-2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4-11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001).

CONCLUSION

The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and women's demand for the procedure.

Women's views on elective primary caesarean section

OBJECTIVE

Elective primary Caesarean section (EPCS), Caesarean section performed at a woman's request in the absence of a recognized obstetrical indication, is becoming increasingly common. Recent articles and opinions in both the medical and lay press have polarized this issue. The purpose of this study was to determine the opinions and choices of nulliparous and multiparous women with respect to mode of delivery.

METHODS

All women attending antenatal clinics at Kingston General Hospital from May to August 2005 were invited to participate in a confidential survey. Basic demographic data including maternal age, level of education, parity, and previous mode of delivery were collected. Respondents who had had a previous Caesarean section were excluded from data analysis. The questionnaire provided a written statement of potential benefits and risks of an EPCS compared with vaginal delivery; no other counselling was provided. Respondents were asked if EPCS should be offered to all women and whether they would choose EPCS if given the choice. Respondents were also asked to indicate the most and least influential factors in their decision.

RESULTS

Responses were received from 107 nulliparous women and 103 multiparous women. Thirteen percent of nulliparas (14/107) stated that they would choose EPCS if given the option, compared with 5% of multiparas (5/103). Fifty-one percent of nulliparas (55/107) and 28% of multiparas (29/103) believed that EPCS should be offered to all women receiving antenatal care. The most and least important reasons, chosen from a list, for requesting or declining EPCS varied between nulliparas and multiparas. The convenience of scheduling permitted by Caesarean section was not important for either multiparas or nulliparas. The perceived risks of vaginal delivery were commonly cited by both nulliparas and multiparas as reasons for requesting EPCS, whereas the risks of Caesarean section for the baby or for future pregnancies were the most commonly cited reasons to decline EPCS in both groups. Regardless of the decision to request or decline EPCS, cost to the health care system was not an important factor for either nulliparas or multiparas.

CONCLUSION

The majority of pregnant women surveyed would not request an EPCS. However, a significant number of pregnant women, both nulliparous and multiparous, felt that women should be given the option of undergoing EPCS.

Taiwan's high rate of cesarean births: impacts of national health insurance and fetal gender preference

BACKGROUND

Taiwan has a high rate of cesarean section, approximately 33 percent in the past decade. This study investigates and discusses 2 possible factors that may encourage the practice, one of which is fetal gender difference and the other is Taiwan's recently implemented National Health Insurance (NHI).

METHODS

A logistic regression model was used with the 1989 and 1996 National Maternal and Infant Health Survey and with the 2001 to 2003 NHI Research Databases.

RESULTS

Using survey data, we found a statistically significant 0.3 percent gender difference in parental choice for cesarean section. However, no statistically significant difference was found in the rate of cesarean section before and after NHI implementation.

CONCLUSIONS

Taiwan's high cesarean section rate is not directly related to financial incentives under NHI, indicating that adjusting policy to lower financial incentives from NHI would have only limited effect. Likewise, focusing effort on the small gender difference is unlikely to have much impact. Effective campaigns by health authorities might be conducted to educate the general population about risks associated with cesarean section and the benefits of vaginal birth to the child, mother, and society.

Systematic review of nulliparous women's views of planned cesarean birth: the missing component in the debate about a term cephalic trial

BACKGROUND

The suggestion that planned cesarean birth is gaining acceptance among women has led some physicians to advocate the need for a trial of primary planned cesarean section versus planned vaginal birth in healthy women with singleton cephalic pregnancies at term. This paper reviews published studies of nulliparous women's views of mode of birth collected in the antenatal period, examining why women may express a preference for cesarean birth and exploring implications for the debate about the need for a trial.

METHODS

A systematic literature review was undertaken of Cochrane, CINAHL, EMBASE, MEDLINE, and PsycINFO using the MeSH heading "cesarean section" and four free text spellings of "cesarean," or "birth" or "delivery," near truncated synonyms of 17 words meaning expressed preference. Studies of nulliparous women with a medical indication for cesarean birth, studies where a woman's preference for mode of birth was reported in the postpartum period, surveys of midwives or obstetricians, and opinion and non-English language papers were all excluded.

RESULTS

Nine papers were included in the review, which reported rates of women expressing a preference for cesarean birth that ranged from 0 to 100 percent at recruitment. However, the papers raised specific methodological, conceptual, and cultural issues that may have influenced women's preferences for mode of birth in the populations studied. These issues included the timing and frequency of data collection, complexity of factors determining individual women's decision making, and influence of societal norms.

CONCLUSIONS

Little evidence is available that an increasing cultural acceptance of cesarean delivery will bring about support for a trial among pregnant nulliparous women. Further qualitative research investigating the influence of both obstetric and psychosocial factors on women's views of vaginal and cesarean birth is required.

Maternal request CS--role of hospital teaching status and for-profit ownership

OBJECTIVE

To examine whether hospitals' for-profit (FP) ownership and non-teaching status are associated with greater likelihood of maternal request cesarean (CS) relative to public and not-for-profit (NFP) and teaching status, respectively.

METHOD

Retrospective, cross-sectional, population-based study of Taiwan's National Health Insurance claims data, covering all 739,531 vaginal delivery-eligible singleton deliveries during 1997-2000, using multiple logistic regression analyses.

RESULTS

Adjusted for maternal age and geographic location, FP district hospitals (almost all non-teaching), followed by ob/gyn clinics were significantly more likely to perform request CS (OR=3.5-2.3) than public and NFP teaching hospitals. Among non-teaching and teaching hospitals, FPs were more likely to perform request CS than public and NFP hospitals (OR=2.3 and 2.5, respectively).

CONCLUSIONS

Our findings are consistent with greater propensity of physicians in FP institutions to accommodate patient requests involving revenue-maximizing procedures such as request CS. This effect is moderated by teaching hospitals' preference for complicated cases, consistent with their teaching mission and hi-tech infrastructure.

Maternal age and the likelihood of a maternal request for cesarean delivery: a 5-year population-based study

OBJECTIVE

The purpose of this study was to examine associations between maternal age and maternal request cesarean deliveries.

STUDY DESIGN

Five-year population-based data from Taiwan (1997-2001) that covered 904,657 singleton deliveries without a clinical indication for cesarean delivery that were judged by the attending physician were subjected to multiple logistic regression, year-wise, to examine the association of maternal age with request cesarean delivery, adjusted for health care institutional characteristics.

RESULTS

Request cesarean delivery rates steadily increased over the study period within each age group, disproportionately so among the 34+ age group. Women aged < 25 years were less likely than women aged 25 to 34 years (reference group) to request a cesarean delivery (odds ratio range, 0.67-0.88) and women aged 34+ were more likely than the reference group to have a request cesarean delivery (odds ratio range, 1.96-2.01), adjusted for health care institutional characteristics.

CONCLUSION

Population-based data confirms the expectancy that request cesarean delivery propensity increases with maternal age.