Caesarean section should be available on request: AGAINST: Caesarean delivery on maternal request is a bad idea

There are many reasons for women to choose cesarean on maternal request (CDMR), including the perceived safety of the procedure, potential benefits for the pelvic floor and for the infant, fear of pain with vaginal birth (VB), and convenience. Also, patient autonomy is often cited as a major reason for supporting the right of women to choose CDMR. However, there are considerable medical and ethical reasons for not performing CDMR. Caesarean delivery (CD) is associated with an increase in short-term maternal morbidity and mortality. Numerous ‘intention to treat’ cohorts demonstrate increased morbidity with intended CD. For example, a Canadian cohort showed an increased risk for cardiac arrest, anesthetic complications, venous thromboembolism, infection and hysterectomy with intended CD (Liu et al., CMAJ 2007;176:455). Similarly, another Canadian study of women with prior CD noted an increased risk of maternal death in women with scheduled repeat CD (RR 5.25, 95% CI, 1.58, 17.49) compared with those intending VB (Wen et al., Am J Obstet Gynecol 2004;191:1263). The absolute risks of serious morbidity and mortality associated with CD are low, but if enough CDs are performed, there will be an increase in both morbidity and mortality. In addition to short-term morbidity, there is an increased risk of long-term morbidity associated with CD. The most serious risk is an increase in the risk of placenta accreta spectrum. The risk for accreta increases with increasing numbers of CDs and it is one of the most morbid complications facing obstetricians today. The incidence has dramatically increased in concert with increasing rates of CD. As current rates of VB after CD are low, the initial CDMR will almost always lead to repeat CD. Moreover, CD in the first pregnancy ultimately limits family size, with subsequent implications for demographics and social welfare systems. Also, the benefits to the fetus from CDMR are based on delivery at 39 weeks of gestation. This would likely lead to decreased stillbirths, neonatal deaths and serious neonatal morbidity. However, the same benefits could be obtained from inducing labour at 39 weeks of gestation, rather than performing CDMR. Indeed, the main reason that pregnancies are not routinely induced at 39 weeks is fear of needlessly increasing the CD rate. There are also important short- and long-term adverse fetal consequences of CD, especially in unlaboured cases (Steer and Modi, Lancet 2009;374:675). Another problem is that many of the theoretical benefits from CDMR are uncertain and may be incorrect. Injury to the anal sphincter is avoided by CDMR but such complications are rare. The effect of CDMR on urinary incontinence and pelvic organ prolapse is much less certain as both of these conditions may occur in women who do not undergo VD (Lavender et al., Cochrane Database Syst Rev 2012;(3):CD004660). Finally, the notion of maternal autonomy must be balanced against the autonomy of physicians, who have a strong desire not to cause harm to their patients. Few if any physicians would consider performing an unnecessary cholecystectomy just because a patient requested it. Undeniably, such practice would be considered malpractice! The popularity of cosmetic surgery is often used as justification for CDMR. However, in those cases there is a clear perceived benefit. The information used to justify CDMR is fallible, much like the misconceptions prompting patients to refuse vaccinations. Considering the clear harms and unproven benefits, CDMR cannot be justified. Nothing to disclose.

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