Key result
Higher cardiac disease severity in pregnancy linked to ~19-point higher cesarean delivery rate.
Why the study?
Delivery planning in pregnancies complicated by cardiac disease lacks comprehensive evaluation of delivery mode selection stratified by disease severity using the mWHO staging system.
Meta-Analysis (n=89,333)
Yes
There is a concerning overuse of cesarean deliveries in pregnancies complicated by cardiac disease across all severity stages, highlighting a substantial gap between current clinical practice and guidelines that recommend vaginal delivery as standard practice.
CS rates rise progressively with mWHO severity, reaching 68% in class IV; challenges guideline preference for vaginal delivery and supports adherence audits.
INTRODUCTION: Cardiovascular conditions represent a leading cause of indirect maternal morbidity, making delivery planning a critical component of care in affected pregnancies. To evaluate the delivery mode selection in pregnancies complicated by cardiac disease, stratified by disease severity according to the modified World Health Organization (mWHO) staging system. METHODS: We conducted comprehensive searches in four major electronic databases (PubMed, Web of Science, Scopus, and Embase) for literature published through July 11, 2025. The electronic search was supplemented by manual screening of reference lists from included studies. We included peer-reviewed English full-text studies with ≥ 15 participants that reported delivery modes in pregnant women with cardiac disease, categorized by mWHO stages (I-IV). Both observational and interventional study designs were eligible. Our primary outcome was the rate of cesarean delivery (CS), with assisted vaginal delivery (AVD) rates analyzed as a secondary outcome. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. We performed random-effects meta-analyses to pool delivery method prevalence estimates. Subgroup analyses stratified studies by country income level (World Bank gross national income per capita categories) to examine socioeconomic influences on delivery choice. RESULTS: From 26 eligible cohort studies (n = 89,333 pregnancies with cardiac disease), 24 met quality criteria for meta-analysis. Pooled CS rates increased progressively with mWHO severity: Stage I (40.6% [95% CI: 28.8%-52.4%]), Stage II (43.4% [95% CI: 31.5%-55.4%]), Stage II/III (50.0% [95% CI: 36.5%-63.5%]), Stage III (56.0% [95% CI: 42.0%-70.0%]), and Stage IV (67.8% [95% CI: 50.4%-85.2%]). For combined risk categories, low-risk (mWHO I-II) pregnancies showed lower intervention rates (CS: 39.2% [95% CI: 32.8%-45.7%]; AVD: 13.9% [95% CI: 7.0%-20.8%]) compared to high-risk (mWHO III-IV) pregnancies (CS: 57.7% [95% CI: 49.1%-66.2%]; AVD: 16.6% [95% CI: 8.6%-24.7%]). Notably, higher-income countries demonstrated significantly lower CS rates in both low- and high-risk groups (p < 0.05), suggesting socioeconomic influences on delivery decisions. CONCLUSION: This study documents concerning CS overuse in cardiac pregnancies with disease severities. Current guidelines recommend vaginal delivery as standard practice, reserving surgical intervention for specific obstetric or critical cardiac conditions. However, our findings suggest a substantial gap between clinical practice and current guideline recommendations in this regard, requiring extensive attention. PROSPERO REGISTRATION: The review protocol was registered on 11/10/2024 under reference number CRD42024608358.
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Parsaei et al. (2026) conducted a meta-analysis in Pregnancies complicated by cardiac disease (n=89,333). High-risk cardiac disease (mWHO III-IV) vs. Low-risk cardiac disease (mWHO I-II) was evaluated on Rate of cesarean delivery (CS). Higher cardiac disease severity (mWHO III-IV) during pregnancy was associated with a higher rate of cesarean delivery compared to low-risk (mWHO I-II) pregnancies (57.7% vs 39.2%).
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