“Cesarean Delivery on Maternal Request”: Was the NIH Conference Based on a Faulty Premise?

The intent of a recent National Institutes of Health State-of-the-Science Conference was to provide a “snapshot in time” of the state of knowledge about “Cesarean Delivery on Maternal Request.” Over 1,000 people registered to attend the meeting, held in Bethesda, Maryland, March 27 to 29, 2006. Anticipation and curiosity were high. Convened by the National Institute of Child Health and Human Development and the Office of Medical Applications of Research, an independent panel of 18 members had reviewed and assessed the available published evidence in advance of the conference. They considered four questions: What is the trend and incidence of cesarean delivery in the United States and other countries? What are the benefits and harms to mother and baby associated with cesarean delivery by request versus planned vaginal delivery? What factors influence benefits and harms? What future research directions should be considered with respect to cesarean delivery on request or planned vaginal delivery? The panel, mostly obstetrics specialists plus a nurse-midwife, a nurse, and a law professor, defined “cesarean delivery on maternal request” as “a cesarean delivery for a singleton pregnancy, on maternal request, at term, and in the absence of any maternal or fetal indication for cesarean,” with the focus on primary cesarean deliveries. Opportunity for public input and discussion followed presentations by “expert researchers and practitioners” over the first day and a half, and again after the panel’s state-of-the-science statement on the last day. Predictably, audience participation was passionate, challenging, and frequently confrontational, with a growing feeling of frustration as the meeting wore on. After all the study, lengthy review of the literature, and discussion, what, finally, did the panel find? The primary conclusion was that there was “insufficient evidence to fully evaluate the benefits and risks of maternal request caesarean delivery,” and that women requesting a cesarean delivery should receive “individualized counseling” on potential risks and benefits. Not answered, however, was the real question: Why was an NIH State-of-the-Science Conference on the topic of cesarean delivery on maternal request held at all? It was clear that if the organizers and others believed that “maternal request” was a driving force behind the steadily rising cesarean delivery rate, many in the audience did not. José J. Gorrín Peralta, MD, MPH, from Puerto Rico, put it bluntly: “The conceptual core of the conference was based on a false paradigm that mothers are requesting cesareans. For the panel to infer from patient charts and birth certificates of cesarean sections performed for no medical indications that it was mothers themselves who asked for the surgical procedure is unadulterated fraud. For 2 1/2 days the conference proceeded as if maternal request cesareans was a validated reality.” (J.G. Peralta, personal communication, Apr 5, 2006). Throughout the conference, presenters and panel members cited estimates of maternal request cesareans ranging from 2.5 to 18 percent—estimates that, based on lack of evidence, seemed highly unlikely. These estimates were primarily derived from vital records or hospital discharge data, and assumed that all cesareans with no documented medical indication were therefore by maternal request. Not acknowledged were just-released findings from the large and well-designed United States national study, Listening to Mothers, which reported that less than 1 percent of mothers (only 1 of 1,300 women surveyed) who had a first cesarean actually requested one (1). The survey, conducted by the Childbirth Connection (formerly the Maternity Center Association of New York City and a leading nonprofit organization that works to improve maternity care), also noted that, in contrast, nearly 10 percent of those surveyed reported feeling pressured by a health professional to have a cesarean delivery, and 42 percent believed that fear of being sued leads physicians to perform unnecessary cesareans (1). “Despite lots of talk about women’s choice and cesarean section, the Listening to Mothers survey results clarify that virtually no women are choosing to have a first, or ‘primary,’ cesarean without medical reason, and many women’s choices about how to give birth after they have had a cesarean are not being honored,” said Carol Sakala, PhD, MSPH, Director of Programs, Childbirth Connection. “Denying women the option of vaginal birth after cesarean is a major factor in our escalating national cesarean rate.” In a Boston Globe opinion that also condemned the notion of “maternal request,” Eugene Declerq, Professor in Maternal and Child Health at the Boston University School of Public Health, and Judy Norsigian, Executive Director of Our Bodies Ourselves, both members of the Birth Editorial Board, stated, “There is much we still don’t know about the impact of caesarean or vaginal birth on health outcomes. What is clear, however, is that the growth in caesareans—which includes mothers of all ages, races and across all medical conditions—is the result of a complicated shift in professional practice. It is not primarily about mothers pressuring doctors for caesareans, as contemporary media coverage would have us believe”(2). Panel members noted that the lack of consistency in terminology in studies and the absence of data on routes of planned deliveries made comparing outcomes next to impossible, since most studies reported outcomes by actual route of delivery. The panel’s failure to report any study that provided data about whether or not women are planning a primary cesarean in the absence of a medical reason forced them to use proxy studies for cesarean delivery on maternal request. In its extensive critique of the NIH Conference, the Childbirth Connection pointed out, “Deeply flawed analyses used proxy studies rated as ‘weak’ for nearly all reported outcomes. Flaws included: failure to search for and include many relevant outcomes, including numerous studies that were too small to measure specific outcomes, including numerous studies with no vaginal birth comparison groups, and including numerous studies focusing on the unique question of mode of birth for women with breech presentation”(3). Indeed, in their expert presentations, speaker after speaker cited evidence from the “Term Breech Trial”(4), a study widely described as flawed (5–7). Thus, to any observer it seemed that the panel’s conclusions were often based on evidence that was both weak and flawed—if indeed, they found any evidence at all. The panel’s primary recommendations, amid all this uncertainty, were that cesarean delivery on maternal request … should be avoided by women wanting “several children” should not be performed before the 39th week of pregnancy or without verifying fetal lung maturity has a potential benefit of decreased risk of hemorrhage for the mother and decreased risk of birth injuries for the baby has a potential risk of respiratory problems for the baby, and a longer maternal hospital stay requires individualized counseling by the practitioner of potential risks and benefits of both vaginal and cesarean delivery should not be motivated by unavailability of effective pain management In addition, the panel made various recommendations for future research, including surveys of women (before and after birth), providers, insurers, and health care facilities regarding cesarean delivery on maternal request creation of mechanisms, such as a new diagnostic code, to identify cesarean delivery on maternal request development of strategies to predict and influence the likelihood of successful vaginal birth, particularly in the first pregnancy large multicenter, multidisciplinary prospective cohort studies, enrolling women early in pregnancy with long-term follow-up, to identify benefits and risks of planned vaginal versus planned cesarean delivery exploration of the feasibility of randomized trials examination of large databases to assess incidence of various outcomes studies to determine if modifiable factors in labor management can decrease maternal and neonatal complications studies comparing cesarean delivery on maternal request and planned vaginal delivery thorough assessment of costs of cesarean delivery on maternal request The complete report from the conference is available at http://consensus.nih.gov. As pointed out by many audience members and by various groups after the conference (3,8), much important and relevant research was neither examined by the panel’s systematic review nor discussed by panelists—no studies on evidence-based optimal management for vaginal births that included “best practices,” such as low rates of medical intervention, midwifery model of care, maternal support by doulas, physiologic positions, non-forceful pushing style, restriction of unnecessary procedures, and more. Instead, planned cesareans were compared with planned hospital vaginal births, known to use excessive interventions, which carry unnecessary risks and often result in complications. As one person asked, “Why did the panel not note that a comparison with ‘best practices’ vaginal birth likely would have given very different results?” In addition, the long-standing problem of physician malpractice fear, and how defensive obstetric practice helps to drive the increase in cesarean deliveries, was not examined or addressed. In a criticism of the panel’s work, Lamaze International, a nonprofit childbirth education and advocacy group, pointed out that “their research did not consider many recognized long-term adverse outcomes associated with cesarean surgery and they did not take into account the impact that avoidable obstetric practices can cause during vaginal birth,” thereby rendering “their guidance to women and clinicians incomplete and inadequate”(8). Previously recognized international and national standards for cesarean delivery rates were considered unworthy by the NIH panel, including the World Health Organization’s (WHO) statement that a rate of more than 10 to 15 percent was not justified in any country (9). A rate of 15 percent, in fact, was later recommended (and not met) as a total cesarean delivery rate for all women in the United States 2000 Healthy People objectives (10). Currently, the revised recommended rate in the 2010 Healthy People objectives is to reduce cesarean deliveries for primary deliveries among low-risk women to 15 percent. The NIH statement, however, even disagreed with its own government objective, and advised “artificial declarations of an ideal rate should be discouraged.” In any case, clearly, the national cesarean delivery rate will soon be more than double that objective. Concerns about the excessively high cesarean delivery rate in the United States (a 40% increase since 1996) and its threat to maternal and newborn health were expressed by several experts and representatives of childbirth groups, not only at the NIH Conference but also in a media briefing before the conference, hosted by the American College of Nurse-Midwives. They stressed that many unnecessary cesareans are performed, that the risks are underreported, and benefits are often overstated (11). The briefing was part of the College’s REDUCE Campaign, recently launched “to raise public and policymaker awareness about the troubling rise in cesarean sections performed in the United States”(11). REDUCE is an acronym for “Research and Education to Decrease Unnecessary Cesarean Sections.” Several groups have joined this praiseworthy project, including the American Association of Birth Centers, Citizens for Midwifery, Coalition for Improving Maternity Services, International Cesarean Awareness Network, and Lamaze International. “Voluntary cesarean surgeries are being sold as a woman’s right to choose,” said Lamaze International President Raymond DeVries, PhD, at the media briefing. “But for a woman to choose the best option for her and her baby, she must know all the risks of surgical delivery and the comparative risks of a well-managed vaginal birth. Health care providers have the ethical and legal responsibility to provide this information to the women they care for”(11). Risks for cesareans have recently been highlighted in a major 2005 WHO survey on pregnancy outcomes after over 97,000 cesarean deliveries in 120 institutions in Latin America, which found that hospitals with the highest rates of cesareans had higher rates of maternal death and illness and higher rates of babies who died or were admitted to intensive care for 7 days or more after birth (12). The researchers noted that the findings would hold true “beyond the participating institutions.” Continuing its strong interest in the topic of cesareans, this issue of Birth offers several contributions that have relevance to issues discussed at the NIH Conference: infant and neonatal mortality for primary cesarean and vaginal births to women with “no indicated risk”; a review of nulliparous women’s views of planned cesarean birth; the upward trend in cesarean deliveries in New Jersey; alleviating women’s fears of birth that lead to requests for cesareans; lower cesarean rates for physicians and their relatives; and Part 2 of the roundtable discussion on “Why do women go along with this stuff?” At the end of the NIH Conference, most audience participants would likely agree with the Childbirth Connection’s interpretation of the event as follows: Emphasis on “maternal request” is generating confusion in the media, within the general public and among health professionals and pregnant women. The only national data collected from women themselves has found that this was a highly infrequent occurrence among women who gave birth in the U.S. in 2005. Continuing misplaced focus on so-called “maternal request” cesareans draws attention from the legal, clinical, financial and social factors that continue to drive the U.S. cesarean rate to unprecedented heights in an overwhelmingly healthy population”(3). The cesarean delivery rate continues its alarming increase in many parts of the world. Again, however, it must be emphasized that this is not women’s doing—many factors contribute, of which requests by women in the absence of medical indications comprise an extremely small number. To decrease cesarean rates in the United States, the Healthy People 2010 national objectives suggest that “use of such strategies as clearer guidelines for trials of labor and labor management, continual labor support, and focused attention on physician practice patterns” would likely improve the situation (10). Yet, these issues (and others equally important) were ignored in this NIH Conference. As many noted, it seems to have been conceived and conducted based on a faulty premise. Indeed, it was a great pity that “Research and Education to Decrease Unnecessary Cesarean Sections” (REDUCE) was not chosen as the topic for the NIH Conference instead of “Cesarean Delivery on Maternal Request.” Exploring evidence and ways to “REDUCE” the high number of cesareans is certainly a much more pressing and relevant problem for researchers, practitioners, policy makers, and the National Institutes of Health to tackle.