Increased rate of C-section in women with rheumatic diseases—indications under the magnifying glass: a retrospective cohort study

Introduction Women with systemic lupus erythematosus (SLE) and inflammatory joint diseases (IJD) show higher obstetric risk and cesarean delivery (CD) rates than healthy women. CD is associated with increased maternal and neonatal morbidity and healthcare costs; however, data on indications for CD in women with rheumatic diseases are limited. This study aimed to investigate the reasons for increased CD rates in women with SLE and IJD using the Robson classification and a detailed analysis of CD indications. Materials and methods In this retrospective single-center cohort study, CD rates and indications in women with SLE and IJD were compared with healthy controls (HC) as part of the RhePro Study, which prospectively collected data from patients with rheumatic diseases before, during, and after pregnancy to investigate reproductive health in this specific cohort. The study population was classified according to the Robson system, the mode of delivery was assessed, and CD indications were categorized as absolute obstetric, relative composite, or rheumatic disease-related. Results A total of 185 women were included (119 HC, 40 SLE, 26 IJD). Women with IJD had significantly fewer vaginal deliveries (23.1% vs. 54.6% in HC, p = 0.009) and higher CD rates (65.4% vs. 37.8% in HC, p = 0.038) compared with healthy controls. CD and vaginal delivery rates did not differ significantly between IJD and SLE. SLE patients had the highest proportion of absolute obstetric CD indications (78.95%), compared with HC (55.56%) and IJD (23.53%). In contrast, 64.7% of CDs in IJD patients were performed for composite indications. The most common indication for CD was one previous CD (25.93%). Conclusion High CD rates in IJD patients, despite few absolute obstetric indications, suggest potentially modifiable clinical decision-making. In IJD, CDs were largely driven by composite indications. Neither SLE nor IJD alone necessitate cesarean delivery, and cesarean deliveries should be reduced in rheumatic patients without absolute indications, in line with WHO recommendations.