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Elective C-Sections in the Spotlight

March 29, 2006 -- Women should avoid purely elective cesarean (c-section) deliveries if they are planning to have other children in the future, an expert advisory panel concluded Wednesday.

Cesarean (C-section) births raise the risk of placental complications in later pregnancies. For that reason, experts strongly recommended that women planning on becoming pregnant later avoid C-sections when doctors see no medical need to perform them.

A cesarean delivery on maternal request, or CDMR, is defined as a C-section on a mother's request of a full-term, single-child pregnancy without a medical reason for doing so.

"If a woman is planning to have several children, we clearly feel women should not opt for cesarean delivery at maternal request," says Mary E. D'Alto, MD, head of obstetrics and gynecology at Columbia University and chairwoman of the panel.

Elective cesarean should also be avoided before 39 weeks or if the baby's lung maturity cannot be verified due to risk of respiratory complications for the baby.

The recommendations came as part of a scientific review on elective cesarean birth sponsored by the National Institutes of Health.

Elective cesarean births appear to be on the rise in the U.S. despite a lack of evidence about their potential risks and benefits, the panel said.

Nearly 30% of all live births in 2004 -- around 1.2 million in total -- were by C-section. Still, there are no solid figures on how many of those C-sections are at the request of expectant mothers when no medical problem indicates surgery.

Studies estimate that up to 18% of all cesarean births may be because of CDMR, but the actual figures are not clear. There are many explanations for CDMR including mothers' concerns about complications, pain and trauma of vaginal birth, control in the ability to schedule a delivery, and avoidance of complications of a vaginal delivery due to possible weakening of pelvic muscles.

Another influence stems from the recommendation of providers and provider attitudes toward CDMR.

Insufficient Evidence of Benefits, Risks

Experts concluded that there is not enough scientific evidence available to fully evaluate the overall risks and benefits of CDMR and that more studies are needed.

"Until quality evidence becomes available, any decision to perform a CDMR should be carefully individualized and consistent with ethical principles," the panel wrote in its draft conclusions.

The advisors stressed that women considering elective C-sections have multiple discussions with their doctors over the benefits and risks of the surgery and that doctors' convenience and payment level should be left out of the equation.

"We used the word 'discussions.' We used it plurally," says Vern L. Katz, MD, a professor of obstetrics and gynecology at the Oregon Health & Science University and a member of the expert panel.

The committee wrote that women seeking elective C-sections should consider a number of important issues with their doctors. They wrote:

"For example, if the woman has a fear of the pain during labor, pain management strategies should be addressed. If her concern is about future pelvic floor disorder, her provider should discuss labor and delivery management to minimize these risks as well as well as a summary of the relevant scientific data.

"In every case, discussions should maximize her understanding of the issues and should be specific to her personal needs, such as future reproductive plans, medical risk factors, psychological needs, social and family situation, and other factors."

Experts also called for more research into the actual number of these procedures and the financial costs associated with elective C-sections.