A Review of Issues Surrounding Medically Elective Cesarean Delivery

doi:10.1111/j.1552-6909.2007.00196.x

Journal of Obstetric, Gynecologic & Neonatal Nursing

Volume 36, Issue 6, November–December 2007, Pages 605-615

https://doi.org/10.1111/j.1552-6909.2007.00196.x Get rights and content

The rate of cesarean delivery has increased dramatically over the past decade. Medically elective cesareans are a major factor contributing to this rise. This article discusses the most recent evidence on the perinatal risks of cesarean delivery versus vaginal birth, the economic impact of elective cesarean delivery, and ethical principles related to cesareans performed without medical indication. Physicians’ rationales and responses to the issues are reviewed and the recommendations and guidelines of professional organizations are summarized. Available evidence does not lend support to a current shift in clinical practice. Research is needed to adequately compare outcomes of planned cesarean delivery and planned vaginal birth. Until evidence supports medically elective cesarean as a birth option that optimizes outcomes for low‐risk mothers and their infants, obstetric care providers should continue to support evidenced‐based decision making that includes advocacy for vaginal delivery as the optimal mode of birth.

Section snippets

A review of issues surrounding medically elective cesarean delivery

The cesarean delivery rate in the United States reached an unprecedented high of 30.2% in 2005 (Hamilton et al., 2006, Martin et al., 2006) and is rising still. Cesarean delivery statistics and trends imply that indications for this major operation have changed over the past decade. Menacker (2005) reported rising rates of primary cesarean delivery in low‐risk women of all ages, races, and ethnicities. Repeated cesarean delivery rates have risen steeply since 1996, with a concordant drop to 11%

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Cited by (44)

The differences between pregnant women who request elective caesarean and those who plan for vaginal birth based on Health Belief Model
2016, Women and Birth
Citation Excerpt :
The problem is that low-risk, healthy women are choosing caesarean as a birth option despite the fact that it is fraught with possible complications, and vaginal birth is a safer birthing option. There are well-documented risks for mother and child with caesarean section, both in the current pregnancy and in subsequent pregnancies.7–9 Current literature indicates that the caesarean rate is increasing worldwide.
Although vaginal birth is the safest type of childbirth, sometimes caesarean is necessary for the safety of the mother or the infant. The problem is that low-risk, healthy women are choosing caesarean as a birth option despite the fact that it is fraught with possible complications.
To determine the differences and identify the predictors for the way women plan their childbirth based on Health Belief Model.
A cross-sectional study was conducted in Bandar abbas city, Iran, from May to October 2015. The study recruited eligible women who self identified themselves as requesting a caesarean or vaginal birth in their response to a questionnaire.
Of 470 recruited women, 183 (38.9%) planned to have a caesarean without medical indication. Maternal characteristics (age, level of education, occupational status, involvement in a medical profession, and household income) and obstetric variables (health provider type, place of prenatal care, and the number of children planned for the future) influenced the decisions made by the women. There was a significant difference between women planning a caesarean and those planning vaginal birth in terms of childbirth knowledge. Significant differences were observed regarding maternal self-efficacy, with women planning a caesarean reporting significantly lower self-efficacy than women planning a vaginal birth. Women planning a caesarean birth were also significantly less likely to perceive themselves as being at risk for caesarean-related side effects than women planning a vaginal birth.
Comprehensive childbirth knowledge can lead to positive maternal attitude towards vaginal birth and may improve birth confidence.
Cost effectiveness of using moxibustion to correct non-vertex presentation
2016, Revista Internacional de Acupuntura
Analizar el coste-efectividad de la utilización de la técnica de moxibustión para corregir la posición fetal no-cefálica y disminuir el número de cesáreas realizadas a término de embarazo.
Se elaboró un modelo determinista de análisis de decisión para analizar el coste del tratamiento de aplicación de calor mediante la combustión de Artemisia vulgaris (moxibustión) en el punto de acupuntura Vejiga 67 (V 67), en mujeres embarazadas con feto en posición no-cefálica entre las 33-35 semanas de gestación. Esta aproximación se comparó con el tratamiento convencional de recomendaciones de manejo de técnica postural genupectoral. Los costes se obtuvieron fundamentalmente de los datos suministrados por el Sistema Sanitario Público Andaluz. Los datos de efectividad parten, en el análisis basal, de un ensayo clínico realizado y publicado previamente. Para hacer los resultados generalizables a otros ámbitos de la salud, se realizó un análisis secundario basado en un metaanálisis llevado a cabo mediante análisis de efectos aleatorios de los estudios publicados en las últimas revisiones sistemáticas de moxibustión frente a tratamiento convencional. Se realizaron análisis de sensibilidad determinísticos y probabilísticos bajo diversos supuestos para evaluar la incertidumbre del resultado.
El análisis basal muestra que la aplicación de la moxibustión previene el 8,92% de los partos con presentación no-cefálica en comparación con el tratamiento convencional, con un ahorro promedio de 107,11 € por parto, principalmente por el ahorro de evitar la necesidad de realizar una cesárea. El metaanálisis reveló un riesgo relativo de la versión de la presentación no-cefálica a término de 0,34 (intervalo de confianza del 95%, 0,16-0,76). El análisis de sensibilidad demostró que la moxibustión puede evitar 0,34 cesáreas, con un coste incremental por parto que va desde 68 a –640 € para la moxibustión frente al tratamiento convencional.
El tratamiento con moxibustión aplicado en el punto de acupuntura V 67 puede evitar la necesidad de cesárea y lograr ahorro de costes para el sistema de salud en comparación con el tratamiento convencional.
To analyse the cost effectiveness of using the moxibustion technique to correct non-vertex presentation and to reduce the number of caesarean sections performed at term.
A deterministic model of decision analysis has been developed to analyse the cost of treatment in which heat is applied by moxibustion (the combustion of Artemisia vulgaris) at acupuncture point BL 67 for pregnant women with non-vertex fetal position at 33-35 weeks’ gestation. This approach was compared with conventional treatment recommendations based on the knee-chest posture technique. The costs were obtained mainly from data provided by the Andalusian Public Health System. Effectiveness data for the baseline analysis were taken from a previous clinical study. A secondary analysis was performed based on a meta-analysis conducted using random effects analysis, by reference to studies published in recent systematic reviews of moxibustion versus conventional treatment, in order to make the results generalisable to other healthcare settings. Deterministic and probabilistic sensitivity analyses were performed under diverse assumptions to assess the uncertainty of the result.
The baseline analysis shows that the application of moxibustion prevents 8.92% of deliveries with non-vertex presentation compared with conventional treatment, with an average cost saving of 107.11 € per delivery, mainly due to the cost saving from avoiding the need for caesarean section. The meta-analysis revealed a relative risk of the version of non-vertex presentation at term of 0.34 (95%CI, 0.16-0.76). The sensitivity analysis showed that moxibustion can avoid 0.34 caesarean sections, with an incremental cost per delivery ranging from 68 to –640 € for moxibustion versus conventional treatment.
Moxibustion treatment applied at acupuncture point BL 67 can avoid the need for caesarean section and achieve cost savings for the healthcare system in comparison with conventional treatment.
Cost effectiveness of using moxibustion to correct nonvertex presentation
2015, Acupuncture in Medicine
Measurement and risk adjustment of prelabor cesarean rates in a large sample of California hospitals
2014, American Journal of Obstetrics and Gynecology
Prelabor cesareans in women without a prior cesarean is an important quality measure, yet one that is seldom tracked. We estimated patient-level risks and calculated how sensitive hospital rankings on this proposed quality metric were to risk adjustment.
This retrospective cohort study linked Californian patient data from the Agency for Healthcare Research and Quality with hospital-level operational and financial data. Using the outcome of primary prelabor cesarean, we estimated patient-level logistic regressions in progressively more detailed models. We assessed incremental fit and discrimination, and aggregated the predicted patient-level event probabilities to construct hospital-level rankings.
Of 408,355 deliveries by women without prior cesareans at 254 hospitals, 11.0% were prelabor cesareans. Including age, ethnicity, race, insurance, weekend and unscheduled admission, and 12 well-known patient risk factors yielded a model c-statistic of 0.83. Further maternal comorbidities, and hospital and obstetric unit characteristics only marginally improved fit. Risk adjusting hospital rankings led to a median absolute change in rank of 44 places compared to rankings based on observed rates. Of the 48 (49) hospitals identified as in the best (worst) quintile on observed rates, only 23 (18) were so identified by the risk-adjusted model.
Models predict primary prelabor cesareans with good discrimination. Systematic hospital-level variation in patient risk factors requires risk adjustment to avoid considerably different classification of hospitals by outcome performance. An opportunity exists to define this metric and report such risk-adjusted outcomes to stakeholders.
A qualitative approach to examine women's experience of planned cesarean
2012, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
To investigate women's expectations regarding cesarean and to assess the subjective experience of birth of these women. Because the birth experience is a multidimensional phenomenon, qualitative as well as quantitative approaches were used to investigate women's expectations and experiences with cesarean.
Descriptive cohort study.
The Division of Obstetrics and Feto‐Maternal Medicine of the Department of Obstetrics and Gynecology of an Austrian medical university.
Forty‐eight women with a planned cesarean birth.
Semistructured interviews were conducted with the 48 women before (36^th week of gestation) the planned cesarean and shortly thereafter. Data were analyzed by means of a qualitative content analysis. Anxiety, depression, and psychological distress were assessed using standardized questionnaires.
More than three fourths (81.3%) of the women were satisfied with the cesarean. Nevertheless, 83.3% of the women expressed anxiety about cesarean, including fears about the health of the infant, the epidural anesthesia, and possible complications. Before the cesarean, only one half of the women (54.2%) felt that they had been sufficiently informed about the planned cesarean, and only 25% had detailed knowledge about the specific course of events of the cesarean. Quantitative assessment showed low depression levels and overall psychological distress before and after the cesarean. State anxiety levels were high before the cesarean and moderate afterwards.
Although the overall satisfaction and psychological tolerability of a planned cesarean is high, improvement is possible by providing more detailed information to the prospective mothers and by specifically addressing prevalent anxieties.
The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care
2012, Midwifery
Citation Excerpt :
Health services managers disagree contending that this discourse involves blame shifting associated with the overuse of medical intervention such as elective caesarean section birth, despite evidence of best practice (Giles, 2008). International findings indicate that maternity care professionals have a significant influence on women’s decision making (Jordan and Murphy, 2009; Michaluk, 2009) with several studies reporting almost 10% of survey respondents felt pressure from a health professional to agree to medical intervention (Young, 2006; Miesnik and Reale, 2007). That some medical professions have chosen to join the strong consumer, midwifery, health service managers alliance by advocating for women’s choice in maternity care (Rural Doctors Association of Australia, 2008) has left obstetrics isolated on this issue.
the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships.
critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services.
a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers.
maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance.
the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.

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Clinical IssuesA Review of Issues Surrounding Medically Elective Cesarean Delivery

Section snippets

A review of issues surrounding medically elective cesarean delivery

American Journal of Obstetrics and Gynecology

Obstetrics & Gynecology

Journal of Midwifery and Women’s Health

American Journal of Obstetrics and Gynecology

Journal of Obstetric, Gynecologic, and Neonatal Nursing

European Journal of Obstetrical and Gynecological Reproductive Biology

Lancet

Seminars in Perinatology

American Journal of Obstetrics & Gynecology

American Journal of Obstetrics and Gynecology

Seminars in Perinatology

Urologic Clinics of North America

Journal of Nurse Midwifery

British Journal of Obstetrics and Gynaecology

Obstetrics and Gynecology

Annals of Epidemiology

American Journal of Obstetrics and Gynecology

Lancet

Lancet

Factors related to genital tract trauma in normal spontaneous vaginal births

Birth

Fetal injury associated with cesarean delivery

Obstetrics & Gynecology

Risk of urinary incontinence after childbirth: A 10‐year prospective cohort study

Obstetrics & Gynecology

ACNM Position Statement

Elective primary cesarean section

ACOG Committee Opinion No. 289

Surgery and patient choice: The ethics of decision making

AWHONN urges more research on elective cesarean section

Lifelines

Danish obstetricians’ personal preference and general attitude to elective cesarean section on maternal request: A nation‐wide postal survey

Acta Obstetricia et Gynecologica Scandinavica

Cesarean delivery on maternal request

Obstetrics & Gynecology

Maternal morbidity associated with vaginal versus cesarean delivery

Obstetrics and Gynecology

New national survey results from mothers refute belief that women are requesting cesarean sections without medical reason

Williams Obstetrics

Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births

Obstetrics and Gynecology

Listening to mothers, II: Report of the Second National U.S. Survey of women’s childbearing experiences

Postpartum maternal mortality and cesarean delivery

Obstetrics & Gynecology

Reasons of choosing cesarean section as the delivery method by the pregnant woman referred to health‐treatment centers in Rasht

HAYAT: The Journal of Tehran Faculty of Nursing & Midwifery

International Journal of Gynaecology and Obstetrics

Two risk factors for anal sphincter tear during vaginal delivery

Obstetrics & Gynecology

Mode of delivery and severe stress incontinence. A cross‐sectional study among 2625 perimenopausal women

BJOG: An International Journal of Obstetrics and Gynaecology

Obstetrics: normal and problem pregnancies

Women’s preference for a cesarean section: Incidence and associated factors

Birth

Previous traumatic birth: An impetus for requested cesarean birth

The Journal of Perinatal Education

Previous cesarean delivery and risks of placenta previa and placental abruption

Obstetrics & Gynecology

Physician response to patient‐requested cesarean delivery

Birth

Reproductive consequences. In (Abstract, March 27‐29, 2006)

NIH State‐of‐the‐Science Conference: Cesarean Delivery on Maternal Request

Trends in maternal request cesarean delivery from 1991‐2004

Obstetrics & Gynecology

Clinical Issues
A Review of Issues Surrounding Medically Elective Cesarean Delivery