Birth outcomes following cesarean delivery on maternal request: a population-based cohort study

Caesarean delivery on maternal request: the perspective of the postpartum women

BACKGROUND

Caesarean delivery on maternal request (CDMR) is an increasing delivery option among women. As such, we aimed to understand the reasons that led pregnant women to request a caesarean delivery.

METHODS

A phenomenological study was conducted with semi-structured interviews, in a convenience sample, for women who had undergone a CDMR between March and June 2023, in a public reference university hospital in Campinas, Brazil. The interviews were recorded, transcribed and subjected to thematic analysis, supported by Nvivo®, and Reshape®.

RESULTS

We interviewed eighteen women between 21 and 43 years of age. The reasons for C-section as their choice were: 1) fear of labour pain, 2) fear for safety due to maternal or fetal risks, 3) traumatic previous birth experiences of the patient, family or friends 4) sense of control, and 5) lack of knowledge about the risks and benefits of C-section.

CONCLUSIONS

The perception of C-section as the painless and safest way to give birth, the movement of giving voice and respecting the autonomy of pregnant women, as well as the national regulation, contribute to the increased rates of surgical abdominal delivery under request. Cultural change concerning childbirth and better counseling could support a more adequate informed decision-making about delivery mode.

Infant Infections Following Cesarean Delivery on Maternal Request: A Population-Based Cohort Study

OBJECTIVES

Investigations about cesarean delivery (CD) on maternal request (CDMR) and infant infection risk frequently rely on administrative data with poorly defined indications for CD. We sought to determine the association between CDMR and infant infection using an intent-to-treat approach.

METHODS

This was a population-based cohort study of low-risk singleton pregnancies with a term live birth in Ontario, Canada between April 2012 and March 2018. Subjects with prior CD were excluded. Outcomes included upper and lower respiratory tract infections, gastrointestinal infections, otitis media, and a composite of these 4. Relative risk and 95% CI were calculated for component and composite outcomes up to 1 year following planned CDMR versus planned vaginal deliveries (VDs). Subgroup and sensitivity analyses included age at infection (≤28 vs. >28 days), type of care (ambulatory vs. hospitalisation), restricting the cohort to nulliparous pregnancies, and including individuals with previous CD. Last, we re-examined outcome risk on an as-treated basis (actual CD vs. actual VD).

RESULTS

Of 422 134 pregnancies, 0.4% (1827) resulted in a planned CDMR. After adjusting for covariates, planned CDMR was not associated with a risk of composite infant infections (adjusted relative risk 1.02; 95% CI 0.92-1.11). Findings for component infection outcomes, subgroup, and sensitivity analyses were similar. However, the as-treated analysis of the role of delivery mode on infant risk for infection demonstrated that actual CD (planned and unplanned) was associated with an increased risk for infant infections compared to actual VD.

CONCLUSIONS

Planned CDMR is not associated with increased risk for neonatal or infant infections compared with planned VD. Study design must be carefully considered when investigating the impact of CDMR on infant infection outcomes.

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.

Bleeding disorders and postpartum hemorrhage by mode of delivery: a retrospective cohort study

Background

Pregnant persons with bleeding disorders and their potentially affected newborns are at a higher risk of peripartum bleeding complications. The safest mode of delivery for persons with bleeding disorders remains debated, leading to uncertainties in decision-making between the patient and her multidisciplinary team.

Objectives

This study aimed to describe maternal outcomes for pregnant persons with bleeding disorders by mode of delivery and to examine whether postpartum hemorrhage (PPH) and neonatal hemorrhagic manifestations are associated with the mode of delivery.

Methods

We collected retrospective data on pregnant persons with bleeding disorders who delivered at a single center from 2010 to 2021. Descriptive statistics, Fisher exact test, and odds ratios were used for analysis.

Results

A total of 82 pregnancies in 56 subjects were included. Hemophilia A and von Willebrand disease represented the largest cohort, at 30% (17/56) each. Overall rates of primary and secondary PPH were 7.3% (6/82) and 17.4% (12/69), respectively. We did not find a statistically significant difference between mode of delivery and PPH. Upon comparing vaginal and cesarian deliveries, we found an odds ratio of 0.7 (95% CI, 0.1-3.4) for primary PPH and 2.6 (95% CI, 0.4-16.4) for secondary PPH. One male newborn with severe hemophilia A was treated for a suspected intracranial hemorrhage.

Conclusion

In our cohort, high rates of PPH remained an important complication for pregnant persons with bleeding disorders. There was no significant difference in PPH based on modes of delivery. The small sample size likely limited the power of our study, and consequently, future larger studies are needed.

Epidemiology of Caesarean section on maternal request in Australia: A population-based study

OBJECTIVE

To explore the trends, determinants, and short-term maternal and neonatal health outcomes of Caesarean section on maternal request (CSMR).

DESIGN

Population-based record linkage study.

SETTING

Birth registry data for all births in Queensland, Australia, from 2008 to 2017.

PARTICIPANTS

Pregnancies resulting in live or intrapartum stillbirth with >=20 gestational weeks and/or >=400 gm birth weight were the study population. The analytic sample was restricted to low-risk pregnancies by excluding preterm, non-cephalic pregnancies with medical risk factors.

MEASUREMENTS

CSMR was defined as a first-time C-section in singleton, term pregnancies with an ICD-10-AM code of O-82/O-47. CSMR trend was reported in age-standardised rate using a join-point regression model. The determinants and perinatal outcomes of CSMR were tested against Spontaneous vaginal births (VBs) and planned VBs including assisted VBs and emergency C-sections in this group. The generalised estimating equation technique was used for regression analysis and reported in the odds ratio (OR) at a 95% Confidence Interval (CI).

FINDINGS

Of total C-sections (n = 204,863), the average annual change in CSMR rate was 4.4% (95% CI: 2.1-6.7%, p<0.01) for the total pregnancies (N=613,375) Of the analytic sample (N=365568), nulliparous women with age ≥35 years (OR: 2.32,95% CI: 2.09-2.57), delivered at private hospitals (OR:4.90; 95% CI: 4.65-5.18); with mood disorders (OR: 2.15; 95% CI: 1.88-2.43) were positive and midwives birth attendant (OR 0.28; 95% CI: 0.26 to 0.30) was negative influencing factors for CSMR. In a propensity score matched sample; CSMR observed an increasedrisk of anaesthetic complications (OR: 8.00; 95% CI:1.95-32.82) and slightly reduced odds of birth asphyxia (OR:0.20;95%CI:0.06-0.60)against planned VBs while the overall incidence of birth-asphyxia was low (1.29%) However, neonatal morbidities (OR:1.61; 95% CI:1-2.59) and special care admission (OR:2.15; 95% CI:1.03-4.5) were higher after CSMR in comparison to SVBs CONCLUSION: Despite being linked with adverse perinatal health outcomes, the incidence of CSMR increased 1.75-fold during the past 10 years. Maternal educational interventions to provide adequate information, including the long-term risks and benefits of C-sections, can help reduce the growing rates of CSMR.

Factors Influencing Polish Women's Preference for the Mode of Delivery and Shared-Decision Making: Has Anything Changed over the Last Decade?

Background and Objectives: Shared-decision making has become an important trend in the problem of women’s preference for the way of delivery. There are different factors influencing women, including obstetric history, culture, religion, family and social influences. Materials and Methods: The study was designed as an online survey with the aim of acquiring information about women’s knowledge, opinions and preferences about the mode of delivery and the decision-making process. Data were collected from 1175 women in 2010 and 1033 in 2020. Results: A significant increase in the proportion of women who prefer vaginal delivery (VD) was found to be present with an increasing level of education, with the lowest rate in the group with primary education (66.0% in 2010 and 33.3% in 2020) and highest with medical education—86.3% in 2010 and 69.3% in 2020 (p < 0.05). This trend existed both in 2010 and 2020; however, the proportion of women who preferred VD has decreased over the last decade in all groups, and even two-fold in the primary education group. No significant correlation was found between a history of previous delivery and the preference of the way of delivery, decision-making or paid cesarean delivery on maternal request (CDMR). A history of VD significantly reduced the preference for having a cesarean delivery, with only 6.9% of women in 2010 with a history of VD, and 8.9% in 2020 having preferred a cesarean delivery. In 2010, 34.9% of women with a history of cesarean section (CS) only, compared to 6.9% of women with a history VD only, had preference for CS with, respectively, 36.4% vs. 5.8% in 2020. Conclusions: As the proportion of women who prefer cesarean delivery has significantly increased over the last decade, we should emphasize the importance of educating women about the advantages and disadvantages of vaginal and cesarean delivery. The patient’s preference should always be discussed with the obstetrician and the medical indications explained.

A Decade of Wishes-Changes in Maternal Preference of the Mode of Delivery among Polish Women over the Last Decade

Background and Objectives: The maternal preference of mode of delivery is an important problem in respect of patient's autonomy and shared decision-making. The objective of the study was to obtain information about women's preferences of the mode of delivery and knowledge about the cesarean section and its' consequences. Materials and Methods: The study was based on a survey filled in by 1175 women in 2010 and 1033 women in 2020. Respondents were asked about their preference of mode of delivery, possible factors influencing their decision and their knowledge about risks and benefits of cesarean section. Results: There was a significant increase in the rate of women who declared cesarean section as their preferred mode of delivery, from 43.97% in 2010 to 56.03% in 2020 (p < 0.05). In 2010 26.51% of women thought that choice of mode of delivery should be their autonomic decision, 46.36% preferred decision-sharing with their obstetrician, 25.64% thought that cesarean section should be performed for medical indications only (respectively 34.86%, 44.45% and 19.38% in 2020). Conclusions: There has been a significant increase in the rate of Polish women who prefer cesarean delivery over the last decade, as well as in the rate of women who consider the mode of delivery as their autonomic decision.