Arguments in favor of cesarean section at the mother's request

• There is the perception of maternal and fetal benefits, such as convenience and social planning - since most women are planning to have only 2 children - and the convenience of scheduling the day of delivery. Peer pressure is also mentioned, because cesarean section is widely used by celebrities and there is talk of vaginal birth being 'archaic'. Even the term 'tokophobia' is mentioned, which is defined as the fear of childbirth or pregnancy usually due to a history of sexual abuse, traumatic childbirth.

• Fetal benefits include avoiding risks such as stillbirth, prematurity, cerebral palsy and fetal trauma; and maternal benefits include avoiding risks, since the risk-benefit ratio associated with surgical intervention has evolved along with improved techniques for surgical intervention, anesthesia, infection control and blood banks, as well as avoiding emergency cesarean sections during labor, which are associated with increased morbidity and mortality.

• Avoidance of pain during labor has also been cited as a potential maternal benefit of planned cesarean delivery, and is antecedent to previous experience of traumatic delivery, pelvic floor problems, genital prolapse, urinary incontinence, instrumental delivery, and fecal incontinence.

• Respect for the choice of the pregnant woman or the autonomy of the woman's decision is probably one of the most important factors. And it is more frequent in highly interventional settings where the use of artificial oxytocin, electronic fetal monitoring, epidural analgesia, artificial rupture of membranes and instrumented deliveries are common, where adverse outcomes may be greater.

• The ability to schedule cesarean sections allows physicians to plan staffing on an as-needed basis, perform the intervention during daytime hours, and likely reduce the incidence of litigation associated with vaginal delivery or emergency cesarean sections. It would also help avoid criticism from colleagues of alleged medical malpractice, little time for guidance/counseling, time for surgery, and financial gain³.

Arguments against a cesarean section at the mother's request

• Mainly there is the increased risk of maternal mortality, which some studies report to be 3.8 times higher in a cesarean section than in a vaginal delivery. The mortality rate of planned cesarean section in the United Kingdom from 1994 to 1996 has been calculated and was estimated to be almost three times higher than that of vaginal deliveries.

• There is also increased morbidity due to increased blood loss, increased risk of transfusion, postoperative infection, thromboembolism and pulmonary embolism. The case fatality rate for all cesarean sections is six times higher than for vaginal delivery; the rate is almost three times higher even for elective cesarean section. These differences are highly significant. In the absence of other evidence (e.g., from randomized controlled trials of different modes of delivery), it is not appropriate to be dogmatic about best practice, but all involved should take very seriously any decision to perform major surgery with an associated mortality¹⁵.

• Although cesarean section is considered a simple and safe procedure, the intervention has its risks. A study of 221 consecutive cesarean sections at a large London teaching hospital has shown that maternal morbidity is common after cesarean section. Problems with anesthesia, hemorrhage, paralytic ileus, wound problems, and infectious complications were common, and the complications were often unrelated to the condition that led to the indication for cesarean section. Postpartum hospital stay was greatly increased by cesarean section and further prolonged by postoperative complications. Fortunately, in modern obstetric practice maternal mortality is rare and therefore it is important to assess morbidity to measure the success of this procedure. This study shows that there is significant morbidity associated with cesarean section¹⁶.

• Cesarean section has social inconveniences, such as longer hospitalization time and greater restriction in daily activities. Difficulties in breastfeeding are also mentioned^17,18.

• There are several studies that mention that after cesarean section there is a greater frequency of problems in the following pregnancy, such as hemorrhages in the second half of pregnancy due to placenta previa, placental accretism, uterine rupture, adhesions, and decreased fertility¹⁹. Other long-term risks are ectopic pregnancy, hemorrhage and hysterectomy after uterine evacuation, implantation endometriosis, adenomyosis and increased hospital readmission^20,21.

• Cesarean section has also been associated with emotional difficulties, such as postpartum depression and negative feelings about the birth experience, not specifically among women who choose to deliver by cesarean section^22,23.

• Among the fetal and neonatal risks, studies mention an increased likelihood of neonatal respiratory distress syndrome, transient tachypnea of the newborn, fetal laceration, and increased likelihood of decreased breastfeeding³.

• It has been suggested that neonatal risks that increase with cesarean delivery include increased admission to neonatal units/separation of the mother from the newborn, iatrogenic prematurity, tearing, increased neonatal respiratory problems, and stillbirths in the subsequent pregnancy^24-27.

• From an economic point of view, the costs of cesarean section are twice that of a vaginal delivery. An economic model developed to determine the cost to the National Health Service of scheduled cesarean section in the absence of medical indication estimated this to be between £10.9-£14.8 million per year; the average cost saving of performing a scheduled vaginal delivery instead of a scheduled cesarean section was £1,257 per birth²⁸.

• However, in the U.S., the costs of increased intervention in vaginal deliveries, especially the addition of oxytocin, appear to override the cost differences between the two modes of delivery. According to one study, if epidural anesthesia is also used, total costs exceed the cost of scheduled cesarean delivery by almost 10%²⁹.

Physicians' attitudes toward requesting cesarean delivery for an uncomplicated term pregnancy

There are differences among physicians on the non-medical reasons for a cesarean section. In the United Kingdom and Germany, a high percentage of physicians indicate that the main reason is the woman's right to choose the type of delivery (79% and 75%, respectively) and having a previous cesarean section (98% and 92%), as well as a history of a previous traumatic vaginal delivery (99% and 97%), fetal death in childbirth (98% and 94%) and disabled first child (94% and 96%). In Spain, France and the Netherlands, the right to choose (15%, 19% and 22%, respectively), as well as fear of childbirth (10%, 14%, 30%) are much lower. It seems that previous cesarean section and previous traumatic vaginal delivery is an accepted reason between 38%-86% for Italy, Spain, France, Holland, Luxembourg and Sweden. When it comes to a colleague requesting cesarean section, physicians in these countries accept the request for cesarean delivery between 21%-78%³⁰.

The main reasons for physicians to support the woman's choice for cesarean delivery, regardless of other medical or non-medical indications, are respect for the woman's autonomy, avoidance of possible problems during delivery and avoidance of possible legal consequences³⁰.

According to the International Federation of Gynecology and Obstetrics (FIGO), there is ethical concern throughout the medical profession about the increasing rate of cesarean deliveries. Cesarean section is more expensive than a normal delivery and as a surgical intervention has more potential dangers for mother and baby. Physicians have a professional duty to do no harm to their patients, which includes a moral obligation to take care to use health care resources appropriately. Physicians are not obligated to perform a procedure for which there is no certain medical benefit. There is currently no conclusive evidence on the risks and benefits of cesarean section for nonmedical reasons compared with vaginal delivery at term³¹.

The available evidence suggests, as described above, that vaginal delivery is safer in the short and long term for both mother and child. Physicians have a duty to inform and counsel women on these issues.

There may be four possible positions when considering a request for an elective cesarean section in a pregnancy without other complications. The first is for the physician to recommend elective cesarean section to the woman during vaginal delivery with the available evidence to support this position, i.e., a medically indicated cesarean section. Or it may be the case that the physician recommends vaginal delivery with the available evidence to support this position, i.e., the physician refuses to perform a cesarean section for non-medical indications. A third position is that the physician considers vaginal delivery and elective cesarean section to be equivalent, with evidence to support this position, allowing the woman's choice. And a final position would be for the physician to consider the available evidence to be uncertain as it does not support any particular type of delivery, so the woman's choice may be allowed³.

In conclusion, cesarean delivery at the mother's request compared to planned vaginal delivery is a multifaceted and complex issue; published data are minimal; they are mostly based on indirect comparisons and their implications for women of childbearing age, health professionals and society are unknown.

Most indirect outcome studies do not adequately adjust for confounding factors and, therefore, should be interpreted with caution.

In the absence of trial data, there is an urgent need for systematic review of observational studies and synthesis of qualitative data to better assess the short- and long-term effects of cesarean and vaginal delivery.

In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended.

After exploring the reasons behind the patient's request and discussing the risks and benefits, if the expectant mother decides to request a cesarean - a subjective and very personal decision - the following is recommended: in the absence of other indications for early delivery, a cesarean delivery should not be performed at maternal request before 39 weeks gestational age. And, given the high rate of repeat cesarean deliveries, patients should be informed that the risks of placenta previa, placenta accreta spectrum and gravid hysterectomy increase with each subsequent cesarean delivery. For physicians, performing a cesarean section for non-medical reasons is a professional decision, the ethics of which are being debated without sufficient evidence on the risks and benefits.