FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Abstract

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

Full text

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Int J Gynecol Obstet. 2023;163(Suppl. 2):10–20.wileyonlinelibrary.com/journal/ijgo
1 | INTRODUCTION
Cesarean delivery is a surgical procedure performed to prevent
maternal and perinatal mor tality and morbidity. As with all surgical
procedures, a cesarean is performed for medical or obstetric indica-
tions. Optimizing use of cesarean delivery is a global health priority,
given the maternal and perinat al morbidity and mortality associated
with both overuse and underuse of the procedure.1– 6 Cesarean de-
livery rates are increasing worldwide.7– 11 Published data from 154
countries covering 94.5% of the world's live births found that 21.1%
of women gave birth by cesarean globally.12 Cesarean delivery rates
varied among countries, with average rates ranging from 5% in
Sub- Saharan Africa to 42.8% in Latin America and the Caribbean.
Moreover, projections for 2030 are alarming. It is expected that
28.5% of all bir ths will be delivered by cesarean, ranging from 7.1%
in Sub- Saharan Africa to 63.4% in Eastern Asia.12
The main indications for emergency cesarean (labor dystocia,
nonreassuring fetal heart tracing, fetal malpresentation) are med-
ically reasonable; however, the biggest problems are associated
with elective cesarean. One of the key reasons for elective ce-
sarean is cesarean deliver y on maternal request (CDMR), which
continues to be a significant contributor to the unprecedented in-
crease in cesarean deliveries.13– 1 5 The percentage of CDMR varies
across the world; in most countries CDMR contributes to less than
5.0% of all deliveries.13 This article summarizes the challenges in
management of CDMR for medical professionals and for families,
DOI: 10.10 02/ ijgo .15118
SUPPLEMENT ARTICLE
FIGO good practice recommendations for cesarean delivery on
maternal request: Challenges for medical staff and families
Diana Ramasauskaite1 | Anwar Nassar2 | Akaninyene Eseme Ubom3 |
Wanda Nicholson4 | on behalf of the FIGO Childbirth and Postpartum Hemorrhage
Committee*
© 2023 Inter national Feder ation of Gynecology and Obstetr ics.
*Compl ete list of membe rs presented in A ppendix A.
1Center of Obstetrics and Gy necolo gy,
Vilnius University Medical Faculty, Vilnius,
Lithuania
2Depar tment of O bstet rics an d
Gynecol ogy, American University of
Beirut Medical Center, Beirut, Lebanon
3Depar tment of O bstet rics, Gynecol ogy
and Perinatolog y, Obafemi Awolowo
University Teaching Hospitals Complex,
Ile- Ife, Nigeria
4George Washington University Milken
Instit ute of Public Health, Washin gton,
District of Columbia, USA
Correspondence
Diana Ramasaus kaite, C enter of
Obstetrics and Gynecology, Vilnius
University Medical Faculty, M.K.
Čiurlionio str. 21/27, Vilnius LT- 03101,
Lithuania.
Email: dianaramasauskaite@gmail.com
Abstract
Elective cesarean delivery on maternal request is a challenging topic of discussion for
patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliver-
ies should include the proportion of cesarean deliveries at term that occur solely due
to maternal request rather than a maternal or fetal indication. Additionally, clinicians
should follow good clinical practice, which includes family counseling, discussions
on the benefits and potential risks of elective cesarean delivery, timing of delivery,
and ethical and legal considerations. Furthermore, there is the need for a sustained
workforce of perinatal clinicians and staff trained in the appropriate technique and
management of operative complications. This article reviews global rates of elective
cesarean on maternal request and outlines FIGO's good practice recommendations
for counseling expectant mothers and the conduct of elective cesarean versus vaginal
delivery.
KEYWORDS
cesarean delivery, elective cesarean, maternal request

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RAMASAUSKAITE et al.
and provides insight s on the strategies for decreasing rates of
CDMR.
2 | DEFINITION AND INCIDENCE
Different definitions of maternal request can be found in the medi-
cal literature. The American College of Obstetricians and Gynecolo-
gists and the Society of Obstetricians and Gynecologists of Canada
define CDMR as a primary cesarean performed in the absence of
any maternal or fetal indications.16,17 Schantz et al.18 performed a
systematic literature review and summarized published studies in-
vestigating cesarean delivery on demand. The aim of the review was
to describe the methodologies and outcomes of CDMR. The study
did not include articles with unclear definitions, especially those
with no clear distinction among elective, planned, and requested
cesarean. The study by Gossman et al.19 concluded that CDMR
might have the following t wo characteristics: (1) per formed before
the onset of labor; and (2) performed in the absence of a medical
indication. In a second systematic review, Begum et al.13 used the
definition that was approved by expert s during the State of Science
Conference in 2006.14 They defined CDMR as an elective cesarean
performed at term for a singleton pregnancy without obstetric and/
or any medical reasons. The authors also excluded data from four
studies where a previous cesarean was noted as the cause of CDMR.
Mazzoni et al.20 conducted a systematic review and meta- analysis of
observational studies on women's preferences for cesarean deliv-
ery. They included both primary and repeat cesareans. Primary and
repeat cesareans were also included in other studies.21– 24 However,
larger studies, systematic reviews, and healthcare authorities follow
the position that CDMR is a primar y cesarean. It is therefore reason-
able to add this statement to the definition of CDMR.
The incidence of CDMR and its contribution to the overall in-
crease in the cesarean delivery rate are not well known due to dif-
ferent definitions and the lack of repor ting. Begum et al.13 reported
that only 14 countries globally reported CDMR proportions. The
absolute proportion of CDMR ranged from 0.2% to 42.0%, and the
majority of studies (n = 20) reported a rate below 5.0%. Similar re-
sults were reported in a 2019 systematic review.18 The proportions
of CDMR among all deliveries ranged from 0. 2% in Ireland to 24.7%
in China. However, the proportions of women declaring that they
would prefer to give birth by cesarean delivery were higher, ranging
from 1.0% in the UK to 62.2% in Iran.18 Other studies reported a
rate below 5.0%, but the numbers are increasing. It is estimated that
2.5% of all cesarean births in the USA,16 2% in Canada,25 and 3.9% in
the Ontario province26 are a result of CDMR. In Sweden, the rate of
CDMR increased from 0.6% to 4.6% from the early 1990s to 2015.27
The rate of CDMR increased significantly from 4.5% to 9% of
all cesareans in Italy.28 The absolute proportion of CDMR was 11-
fold higher in upper middle- income countries than in high- income
countries. The Middle East had the highest CDMR rates followed
by East Asia between five geographical regions.13 Similar results
were found in the systematic review by Mazzoni et al.20 and a
higher preference for cesarean was reported in women living in a
middle- income country versus a high- income country (22.1% [95%
CI, 17.6%– 26.9%] vs. 11.8% [95% CI, 8.9%– 15.1%]). This study
also found different result s for a previous cesarean versus with-
out a previous cesarean. Higher preference for cesarean delivery
was repor ted by women with a previous cesarean (29.4% [95% CI,
24.4%– 34.8%] vs. 10.1% [95% CI, 7.5%– 13.1%]).20 The incidence of
CDMR differs in public and private hospitals, with reporting rates of
between 1% and 48% in public sector healthcare systems and 60%
in the private sector.29
3 | FIGO GOOD PRACTICE
RECOMMENDATIONS
FIGO recommends that CDMR is defined as a primary elective
cesarean deliver y performed at term in a singleton pregnancy
without any obstetric and/or medic al reasons. The appropriate
reporting of CDMR should be a key priority in maternal health
policies and prac tices to evaluate the real incidence of CDMR
and its contribution to the overall cesarean rate. Panel discussion
and recommendations on how to achieve this goal are required.
The Robson classification system30 classifies all deliveries into 10
groups based on a set of predefined obstetric parameters: parity,
previous cesarean, onset of labor, fetal presentation, number of
fetuses, and gestational age. Owing to the lack of an International
Classification of Diseases (ICD) code for CDMR, the modification
of the Robson classification system can be useful for appropriate
reporting of CDMR (subgroups in the 2 and 4 groups). FIGO's good
practice recommendations for cesarean delivery on maternal re-
quest are given in Box 1.
4 | FACTORS CONTRIBUTING TO
MATERNAL REQUEST FOR ELECTIVE
CESAREAN DELIVERY
Reasons for the choice of CDMR appear to be multifactorial.
Women's previous birth experience, fear of vaginal birth and labor
pain, and anxiety for fetal injury are the main causes for maternal
request.3 1– 3 4 The term tokophobia is mainly used in Scandinavia and
the Anglo- American countries to describe strong fear of spontane-
ous childbirth.35,36
Jenabi et al.37 summarized the data in a systematic review and
defined other reasons for CDMR: fear of urinary incontinence, pelvic
floor and vaginal trauma, doctor’s suggestion, time of birth, previous
infertility, infertility, anxiety for gynecologic examination, anxiety for
loss of control, to avoid long labor, anxiety for lack of suppor t from
the staf f, fear of feces, emotional aspects, body weight of the infant
at birth, and abnormal prenatal examination. In the same systematic
review, demographic reasons such as advanced maternal age, parity,
occupation, education, maternal obesity, family status, decreasing
level of religiosity, household income, number of living children, and
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age at marriage were identified.37 In another small study, seeking
permanent sterilization at the same time as cesarean delivery was
mentioned as the reason for the decision for CDMR.38
High cesarean delivery rates are strongly influenced by financial,
social, cultural, and legal factors. The public perception that a cesar-
ean is a very simple procedure with low risk plays a significant role
in choosing CDMR.38,39 On the other hand, attitudes of healthcare
providers have changed, particularly those of young obstetricians,
which leads to increasing numbers of CDMR.40, 41 In France, women's
requests are likely underestimated in medical files, and obstetricians
tend to report a medical indication to protect themselves legally.42
In other countries where obstetricians feel pressure to justify high
cesarean rates, providing the indication “maternal request” shifts
the responsibilit y from the obstetrician to the woman.18, 43 In some
countries the lack of assisted vaginal delivery, proper labor moni-
toring, and health system capacit y can lead to increasing rates of
CDMR.41, 44
5 | MANAGING ELECTIVE CESAREAN
DELIVERY ON MATERNAL REQUEST
Healthcare providers should not recommend cesarean delivery
without any evidence of a clinical indication or anticipated medical
benefit. When there are no evidence- based clinical indications for
cesarean, vaginal delivery should be the recommended route of de-
livery.45 Every case of CDMR should be managed properly, depend-
ing on the individual clinical situation.
6 | MATERNAL COUNSELING
All guidelines and recommendations for healthcare professionals
agree that the cornerstone of CDMR management is the proper
counseling of women requesting cesarean delivery and their fami-
lies. Understanding the reasons for CDMR in the individual situation,
providing the evidence- based information on the risks and benefit s
of elective cesarean (Table 1) without medical indications compared
with the risks and benefits of supporting an attempt at vaginal de-
livery, respect of the patient's autonomy, and other ethical princi-
ples are the key to successful counseling. When a woman request s
a cesarean deliver y, the reasons for her request must be identified,
discussed, and documented.16,17,51
Healthcare providers play an impor tant role in the decision to
undergo a CDMR.13,16– 18, 38,4 5,51,52 If a woman requests a cesarean,
the risks and benefits of the procedure compared with planned vag-
inal birth must be discussed with the patient and the substance of
what was discussed must be subsequently recorded.51 The patient
must reach an informed decision. A Cochrane systematic review
in 2012 did not identify any clinical trials comparing CDMR with
planned vaginal birth,29 and there are no current trials.52 Studies on
cesarean before the onset of labor are often used as substitutes to
determine risks and benefits.16 Available observational studies have
serious methodological issues or provide indirect evidence because
cesarean deliveries in randomized trials were performed for breech
presentation.53,54
The risks of cesarean compared with a vaginal delivery should
be clearly explained to the patient, including three times greater
risk of overall severe morbidity, any hysterectomy during labor
and postpartum, major puerperal infection, two times greater risk
of hemorrhage requiring hysterectomy, an increase in anesthetic
complications, acute renal failure, assisted ventilation or intu-
bation, puerperal venous thromboembolism, in- hospital wound
disruption, five times greater risk of cardiac arrest, and obstetric
wound hematoma. The short- and long- term risks and benefits of
planned cesarean and planned vaginal delivery are provided in
Tables 1 and 2.46– 50, 55– 60
One of the main reasons for CDMR— fear of birth and the risk of
developing depressive and post- traumatic stress disorder symptoms
with vaginal delivery— should be considered.61 Extended support
owing to fear of vaginal delivery should include repeated meetings
with a psychosocial team and objective information provided about
the benefits and risks related to different delivery modes on future
reproductive health. Fear of childbirth can be reduced by emphatic
conversation between physician or midwife and the patient, avoid-
ing criticism and helping change their attitude to birth and preg-
nancy. If a woman continues to request a cesarean after detailed
discussion and, if necessar y, support from a specialist in perinatal
BOX 1 FIGO good practice recommendations for
cesarean delivery on maternal request
1. According to the FIGO position statement, cesarean de-
livery on maternal request (CDMR) is defined as a pri-
mary elective cesarean deliver y performed at term for a
singleton pregnancy without obstetric and/or any medi-
cal reasons.
2. Healthcare providers should not recommend cesarean
deliver y without any evidence or good clinical practice-
based indication and no anticipated medical benefit.
When there are no evidence- based clinical indications
for cesarean delivery, vaginal delivery should be the rec-
ommended route of delivery.
3. Every case of CDMR should be managed properly, de-
pending on the individual clinical situation.
4. Counseling of a woman requesting cesarean delivery
and her partner is a cornerstone of managing CDMR and
reducing the rate of this procedure.
5. Health education, mandator y written informed consent,
and evidence- based intrapartum care practice are criti-
cal to promote a positive childbirth experience and pain-
less delivery.
6. The appropriate reporting of CDMR is a key strategy in
decreasing rates of CDMR.
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TABLE 1 Short- term benefit/risk evaluation for mother and newborn.
Type or cause of morbidity Reference Vaginal delivery (VD)
Cesarean delivery
(CD) Benefit/risk CD versus VD
Newborn
Neonatal respiratory
morbidity, including
transient tachypnea
Morrison 1995.46
The incidence of respiratory distress
syndrome at term was 2.2/1000
deliveries (95% CI, 1.7– 2.7)
The incidence of transient t achypnea was
5.7/1000 deliveries (95% CI, 4.9– 6.5)
The incidence of
respiratory
morbidity after
VD - 5.3/1000
The incidence of
respiratory
morbidity before
the onset of
labor 35.5/1000
and during labor
12.2/1000
The incidence of respiratory morbidity was significantly higher for the
group delivered by CD before the onset of labor compared with
CD during labor (OR 2.9; 95% CI, 1.9– 4.4; P < 0.001) and compared
with vaginal delivery (OR 6; 95% CI, 5.0– 8.9; P < 0.001)
The relative risk of neonatal respiratory morbidity for deliver y by CD
before the onset of labor during week 37+0 to 37+6 compared with
week 38+0 to 386 was 1.74 (95% CI, 1.1– 2.8; P < 0.02) and during
week 38+0 to 37+6 compared with week 39+0 to 39+6 was 2.4 (95%
CI, 1. 2– 4.8; P < 0.02)
Lacerations Gregory 201247 Not applicable 1%– 2% Fetal laceration at time of CD is probably underrepor ted. Although
most injuries are mild, affect the skin only, and heal without
significant sequela, deeper lacerations causing damage to muscle,
nerves, or bones are possible. Even superficial le sions can elongate
and cause emotional distress or require cosmetic alteration
Birth trauma
Shoulder dystocia Gregory 201247 0.2%– 2.0% Not applicable Although shoulder dystocia may be unique to vaginal delivery, “fetal
dystocia” and bir th trauma can also occur during CD
Brachial plexus injury Gregory 201247
Hankins 200648
2– 5/1000 2.1/1000 80%– 90% of brachial plexus injuries resolve without longer sequela.
Long- term permanent sequela occurs in 1– 2/10 000 births.
Specifically, brachial plexus injuries have been described in infant s
born via CD and have been repor ted to occur prior to the onset of
labor.
5000– 10 000 CDs would need to be performed to prevent 1 case of
permanent brachial plexus injury3
Fractures Gregory 201247 1%– 2 % 1%– 2%
Breastfeeding Systematic review and meta- analysis (Prior
2012; 53 studies)49
Rates of early breastfeeding (any initiation or at hospital discharge)
were lower af ter CD compared with after VD (pooled OR 0.57;
95% CI, 0.50– 0.64; P < 0.001) and lower after prelabor but not
after in- labor CD (prelabor OR 0.83; 95% CI, 0.80– 0.86; P < 0.001;
in- labor OR 1.00; 95% CI, 0.97– 1.04; P = 0.86). In mothers who
initiated breastfeeding, CD had no significant ef fect on any
breastfeeding at 6 months (OR 0.95; 95% CI, 0.89– 1.01; P = 0.08)
Mother
Overall severe morbidity Canadian national registry 1991– 200550 20 639/2 292 420;
9.0 %
1279/46 766; 27.3% An increase for short- term morbidities in the CD group. Adjus ted OR
3.1; 95% CI, 3.0– 3.3
Hemorrhage requiring
hysterec tomy
Canadian national registry 1991– 200550 254/2 292 420; 0.1% 12/46 766; 0.3% An increase in hemorrhage requiring hysterectomy in the CD group.
Adjusted OR 2.1; 95% CI, 1.2– 3.8
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Type or cause of morbidity Reference Vaginal delivery (VD)
Cesarean delivery
(CD) Benefit/risk CD versus VD
Hemorrhage requiring
transfusion
Canadian national registry 1991– 200550 1500/2 292 420; 0.7% 11/46 766; 0.2% An increase in hemorrhage requiring transfusion in the VD group.
Adjusted OR 0.4; 95% CI, 0. 2– 0.8
Any hysterectomy Canadian national registry 1991– 200550 367/2 292 420; 0.2% 27/46 766; 0.6% An increase for any hysterec tomy in the CD group. Adjusted OR 3.2;
95% CI, 2.2– 4.8
Uterine rupture Canadian national registry 1991– 200550 660/2 292 420; 0.3% 7/46 766; 0.2% An increase in uterine rupture in the VD group. Adjusted OR 0.5; 95%
CI, 0.2– 1.0
Anesthetic complications Canadian national registry 1991– 200550 4793/2 292 420; 2.1% 247/46 766; 5.3% An increase in anesthetic complic ations in the CD group. Adjusted OR
2.3; 95% CI, 2.0– 2.6
Obstetric shock Canadian national registry 1991– 200550 435/2 292 420; 0.2% 3/46 766; 0.1% An increase in obstetric shock in the VD group. Adjusted OR 0.4; 95%
CI, 0.1– 1.1
Cardiac arrest Canadian national registry 1991– 200550 887/2 292 420; 0.4% 89/46 766; 1.9% An increase in cardiac arrest in the CD group. Adjusted OR 5.1; 95%
CI , 4 .1– 6 . 3
Acute renal failure Canadian national registry 1991– 200550 45/2 292 420; 0.02% 2/46 766; 0.04% An increase in acute renal failure in the CD group. Adjusted OR 2.2;
95% CI, 0.5– 9.0
Assisted ventilation or
intubation
Canadian national registry 1991– 200550 133/2 292 420; 0.05% 6/46 766; 0.1% An increase for assisted ventilation or intubation in CD group.
Adjusted OR 2.0; 95% CI, 0.9– 4.5
Puerperal venous
thromboembolism
Canadian national registry 1991– 200550 623/2 292 420; 0.3% 28/46 766; 0.6% An increase in puerperal venous thromboembolism in the CD group.
Adjusted OR 2.2; 95% CI, 1.5– 3.2
Major puerperal infection Canadian national registry 1991– 200550 4833/2 292 420; 2.1% 281/46 766; 6.0% An increase in major puerperal infec tion in the CD group. Adjusted
OR 3.0; 95% CI, 2.7– 3.4
In- hospital wound disruption Canadian national registry 1991– 200550 1151/2 292 420; 0.5% 41/46 766; 0.9% An increase in in- hospital wound disruption in the CD group. Adjusted
OR 1.9; 95% CI, 1.4– 2.5
Obstetric wound hematoma Canadian national registry 1991– 200550 6263/2 292 420; 2.7% 607/46 766; 13% An increase in obstetric- wound hematoma in the CD group. Adjusted
OR 5.1; 95% CI, 4.6– 5.5
Hospital stay (days) Canadian national registry 1991– 200550 2.56 3 .96 An increase in hospital stay in the CD group 1.47 (1.46– 1.49)
TABLE 1 (Continued)
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RAMASAUSKAITE et al.
TABLE 2 Long- term benefit/risk evaluation for mother and newborn.
Type or cause of morbidity Reference Vaginal delivery (VD) Cesarean delivery (CD) Benefit/risk CD versus VD
Newborn
Asthma Meta- analysis (Huang
2015)55
Risk of asthma was also
higher in children
born by ins trumental
VD (OR 1.07; 95%
CI, 1.04– 1.11) but
with evidence of
heterogeneity
(I2 = 54.9%)
About 20 % increase in subsequent risk of asthma was found in children delivered by
elective and emergency CD.
Elective and emergency CD moderately increased risk of asthma (OR 1.21; 95% CI,
1.17– 1.25; I2 = 39.9%; OR 1.23; 95% CI, 1.19– 1.26)
Meta- anal ysis (Keag 2018)56 23 092/760 142 (3.0%) 4743/124 068 (3.8%) Increased odds of asthma in children aged up to 12 years delivered by CD compared
with vaginal delivery (OR 1.22; 95% CI, 1.11– 1.33, P < 0.0001; I2 = 77%)
Allergies, hypersensitivity,
dermatitis, or atopic
conditions
Meta- analysis (Keag 2018; to
enable a meta- analysis,
a single outcome from
each study was chosen)56
There was no statistically significant association between mode of delivery. There was
moderate heterogeneity betwe en the studies (I2 = 51% )
Asthma, systemic
connective tissue
disorders, juvenile
arthritis, inflammatory
bowel disease, immune
deficiencies, and
leukemia.
Danish national registries in
197 7– 2 0 1257
No associations were found between CD and type 1 diabetes, psoriasis, or celiac
disease.
Children delivered by CD had signific antly increased risk of asthma, systemic
connective tissue disorders, juvenile arthritis, inflammatory bowel disease, immune
deficiencies, and leukemia
Childhood overweight,
obesity
Meta- anal ysis (Keag 2018)56
Childhood overweight 9587/145 740 (6.6%) 3191/39 721 (8.0%) Compared with vaginal delivery, CD was associated with increased odds of childhood
overweight (OR 1.19; 95% CI, 1.04– 1.35; P = 0.01, I2 = 42%, 3 studies)
Childhood obesity at up to
5 years
5295/57 468 (9.2%) 834 /66 45 (12 .6%) Cesarean delivery was associated with increased odds of childhood obesit y at up
to 5 years when compared with vaginal delivery (OR 1.59; 95% CI, 1.33– 1.90,
P < 0.001, I2 = 68%; 6 cohorts)
Obesity at 6– 15 years 2716/29 700 (9.1%) 655/5728 (11.4%) Cesarean delivery was associate d with increased odds of childhood obesity at
6– 15 years (OR 1.45; 95% CI, 1.15– 1.83, P = 0.002, I2 = 63%; 5 cohorts)
Obesity at 20– 28 years 3105/25 342 (12.3%) 1250/ 7759 (16 .1%) Cesarean delivery was associated with increased odds of obesity at 20– 28 years
(1250/7759 CD vs. 3105/25 342 vaginal delivery; OR 1.34; 95% CI, 1.25– 1.44,
P < 0.001, I2 = 0%; 5 studies)
Inflammatory bowel
disease
Meta- anal ysis (Keag OE,
2018, 3 studies)56
7806/2 285 965 (0.34%) 878/319 164 (0.28%) Cesarean delivery was associated with reduced odds of inflammatory bowel disease
when compared with vaginal deliver y (878/319 164 CD vs. 7806/2 285 965 vaginal
delivery; OR 0.73; 95% CI, 0.69– 0.79, P < 0.001, I2 = 0%)
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Type or cause of morbidity Reference Vaginal delivery (VD) Cesarean delivery (CD) Benefit/risk CD versus VD
Mother
Stress symptoms, anxiet y,
depression
Taiwan National Health
Insurance Database,
201758
The cesarean group had a higher cumulative incidence of stress symptoms (0.7% vs.
0.5%, P < 0.05) and cumulative incidence of any of the three mental disorders
compared with the controls (2.7% vs. 2.3%, P < 0.05). The incidence rate of having
any of the three mental disorders after CD was 27.6 per 100 0 person- years, which
was signif icantly higher compared with the 23.4 per 1000 per son- years in the
vaginal birth group
Urinary incontinence Meta- analysis, 6 studies
(Keag 2018)56
7129/49 319 (14.5%) 955/6883 (13.9%) Compared to vaginal delivery, CD was associated with reduced odds of urinar y
incontinence (OR 0.59; 95% CI, 0.49– 0.70, P < 0.001; I2 = 72%)
Pelvic organ prolapse Meta- analysis, 2 studies
(Keag 2018)56
2055/34 310 (6.0%) 116/4898 (2.4%) Compared to vaginal delivery, CD was associated with reduced odds of pelvic organ
prolapse (OR 0.29; 95% CI, 0.17– 0. 51, P = 0.005, I2 = 87%)
Fecal incontinence Meta- analysis, 4 studies
(Keag 2018)56
663/36 534 (1.8%) 187/6087 (3.1%) There was no statistically significant difference in rates of fecal incontinence (OR 1.09;
95% CI, 0.71– 1.67, P = 0.69, I2 = 77%)
Dyspareunia Cohort study (McDonald
2015)59
RCT (Hannah 2004)60
When compared with vaginal deliver y, CD was associated with increased odds of
dyspareunia in one cohort study (OR 1.49; 95% CI, 1.11– 2.00), but there was
no statistically significant effec t demonstrated in the RC T (OR 0.96; 95% CI,
0.61– 1.50)
Subfertility Meta- analysis, 7 studies
(Keag 2018)56
978 990/3 075 271
(31.8%)
243 260/560 190 (43.4%) Increased odds of subfertility after CD when compared to vaginal delivery (OR 1.64;
95% CI, 1.46– 1.84, P < 0.001; I2 = 100%)
Subsequent pregnancy outcomes
Perinatal death Meta- anal ysis, 2 studies
(Keag 2018)56
385/74 170 (0.52%) 98/17 259 (0.57%) There was no st atistically significant association of mode of delivery with perinatal
mortality (OR 1.11; 95% CI, 0.89– 1.39, P = 0.22; I2 = 34%)
Placenta previa Meta- analysis, 10 studies
(Keag 2018)56
16 679/6 076 000 (0.28%) 5039/1 025 692 (0.49%) Women with previous CD had increased odds of having placenta previa compared
to women with a previous vaginal delivery (5039/1 025 692 previous CD versus
16 679/6 076 000 previous vaginal delivery; OR 1.74; 95% CI, 1.62– 1.87, P < 0.001;
I2 = 55%)
Placenta accreta Meta- anal ysis, 3 studies
(Keag 201856
188/638 867 (0.03%) 44/66 241 (0.07%) Women with previous CD had increased odds of having placent a accret a compared
to women with a previous vaginal delivery (OR 2.95; 95% CI, 1. 32– 6.60, P = 0.0 08;
I2 = 47%)
Placental abruption Meta- analysis, 6 studies
(Keag 2018)56
23 855/4 808 952 (0.5%) 6047/858 208 (0.71%) When compared with women with previous vaginal delivery, women with a previous
CD had increased odds of placental abruption (OR 1.38; 95% CI, 1.27– 1.49,
P < 0.001; I2 = 54%)
Uterine rupture Meta- analysis, 4 studies
(Keag 2018)56
56/749 372 (0.11%) 215/91 837 (0.23%) When compared with women with previous vaginal deliver y, women with a previous
CD had increased odds of uterine rupture (OR 25.81; 95% CI, 10.96– 60.76,
P < 0.001; I2 = 80%)
TABLE 2 (Continued)
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RAMASAUSKAITE et al.
psychological health with focus on tokophobia, then her request
must be granted.51
Counseling on the risks and benefits of planned cesarean should
not only be provided to the woman requesting a cesarean, but also to
her partner. Stützer et al.38 found that 50% of women who undergo
a cesarean delivery state that their partner encouraged them to use
this mode of delivery, whereas 87% of the women were supported
by their par tner in their choice for a vaginal delivery. Feelings of se-
curity and certainty are the basis for trust between medical staf f
and family. If the partner trusts the physician, it helps to strengthen
the choice of mode of delivery and a positive birth experience can
be reached.38,62,63
6.1 | Timing of maternal counseling
There are no studies that define the best time in a pregnancy to have
a discussion about the mode of bir th.51 Routes of delivery should
be discussed in the routine health screenings or pregnancy planning
visits because the majority of women have made the decision on
the route of delivery before they are pregnant. A study reported
that 61% of women choosing CDMR and 82% who opted for the
vaginal route had chosen their preferred mode of delivery before
pregnancy.38
Other studies64 suggest that the mode of birth should be dis-
cussed during the early weeks of pregnancy to identify the pro-
spective risk group of women who may need more counseling and
support around childbirth.
The importance of re- counseling must not be forgotten because
some patients change their mind and have a trial of natural delivery
with repeated counseling.
7 | FINANCIAL, ETHICAL, AND LEGAL
CONSIDERATIONS
The practices of reimbursement of CDMR are different and depend
on healthcare systems in different countries. A study suggested that
up to 78% of women would have paid for the CDMR themselves if
their insurance had denied coverage.38
CDMR also raises ethical concerns for healthcare professionals.
The principle of patient autonomy should be respected. Fur ther-
more, other ethical principles, such as beneficence, nonmaleficence,
and justice need to be taken into consideration during patient coun-
seling.17,4 5 The choice of the patient should be respected.
Ethical and juridical issues are related. Italian researchers found
that the fear of litigation binds obstetricians and gynecologist s to
perform a CDMR even if they disagree with this decision for ethical
and medical reasons.65 If a healthcare provider disagrees to perform
CDMR, the woman should be referred to another obstetrician willing
to perform a cesarean.66 It is estimated that 79% of patients would
have gone to another hospital to give birth by CDMR if the cesarean
was not offered at a par ticular hospital.38
Type or cause of morbidity Reference Vaginal delivery (VD) Cesarean delivery (CD) Benefit/risk CD versus VD
Miscarriage Met a- analysis, 4 studies
(Keag 2018)56
12 663/132 306 (9.6%) 2060/19 106 (10.8%) When compared with women with previous vaginal delivery, women with previous CD
had increased odds of miscarriage (OR 1.17; 95% CI, 1.03– 1.32, P = 0.01; I2 = 79%)
Ectopic pregnancy Meta- analysis, 3 studies
(Keag 2018)56
772/240 986 (0.32%) 223/71 040 (0.32%) When compared with women with previous vaginal delivery, women with previous CD
had increased odds of ectopic pregnancy (OR 1.21; 95% CI, 1.0 4– 1.40, P = 0.02;
I2 = 0%)
Stillbirth Meta- analysis, 8 studies
(Keag 2018)56
1905/585 370 (0.33%) 496/118 192 (0.42%) When compared with women with previous vaginal delivery, women with previous CD
had increased odds of stillbirth (OR 1.27; 95% CI, 1.15– 1.40, P < 0.001; I2 = 34%)
Hysterectomy Meta- analysis, 2 s tudies
(Keag 2018)56
31/138 048 (0.02%) 19/29 626 (0.064%) Women with previous CD had increased odds of hysterec tomy (OR 3.85; 95% CI,
1.06– 14.02, P = 0.04; I2 = 69%)
Antepartum hemorrhage Met a- analysis, 2 studies
(Keag 2018)56
1237/74 170 (1.7%) 413/17 259 (2.4%) Women with previous CD had increased odds of antepartum hemorrhage (OR 1. 22;
95% CI, 1.09– 1.36, P = 0.0007; I2 = 0%)
Postpartum hemorrhage Meta- anal ysis, 2 studies
(Keag 2018)56
7455/138 048 (5.4%) 1087/29 626 (3.7%) Women with previous CD had reduced odds of post partum hemorrhage (OR 0.72; 95%
CI, 0.55– 0.95, P = 0.02; I2 = 88%)
Preterm labor, small for
gestational age, low
birth weight (<2500 g)
or neonatal death
Meta- anal ysis (Keag 2018)56 There was no statistically significant association between previous mode of delivery
TABLE 2 (Continued)
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R AMASAUSKAITE et al.
Sorrentino et al.67 suggested that the main question in ethical
and juridical issues surrounding CDMR is counseling and encourag-
ing a woman to make an informed decision and have an overall pos-
itive birth experience.67
8 | TIMING OF DELIVERY
If a CDMR is planned in an uncomplicated pregnancy, the procedure
should be scheduled no earlier than 39 weeks of gestation to mini-
mize the risk of neonatal respiratory distress.16,17,51,56
9 | CONCLUSION
The FIGO Committee on Childbirth and Postpartum Hemorrhage
supports optimizing the rate of cesarean deliveries. Better maternal
engagement and support is required to reduce CDMR incidence and
related health and financial burdens. The routes of delivery should be
discussed during routine health screening visits or pre- conception vis-
its because the majority of women have made the decision on mode of
delivery before they are pregnant. When there are no evidence- based
clinical indications for cesarean delivery, vaginal delivery should be
recommended. Every case of CDMR should be managed properly and
depending on the individual clinical situation. Counseling of a woman
requesting cesarean delivery and her partner is a cornerstone in the
management of CDMR and reducing the rate of this operation. Guide-
lines and recommendations on the management of CDMR should be
issued in every country to ensure the highest possible standards of
health and well- being for women and also to help healthcare providers
practice safely.
AUTHOR CONTRIBUTIONS
Diana Ramasauskaite prepared the original draft. Anwar Nassar,
Akaninyene Eseme Ubom, and Wanda Nicholson contributed to re-
view and editing.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest.
DATA AVAIL ABI LIT Y STAT EME NT
Data sharing is not applicable to this article as no new data were
created or analyzed.
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18793479, 2023, S2, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.15118 by Vilnius University, Wiley Online Library on [13/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

20
|
R AMASAUSKAITE et al.
How to cite this article: Ramasauskaite D, Nassar A, Ubom
AE, Nicholson W, . FIGO good practice recommendations for
cesarean delivery on maternal request: Challenges for
medical staff and families. Int J Gynecol Obstet.
2023;163(Suppl. 2):10-20. doi:10.1002/ijgo.15118
APPENDIX A
FIGO CHILDBIRTH AND POSTPARTUM HEMORRHAGE
COMMITTEE
Wanda Nicolson (Chair), Jolly Beyeza, Anwar Nassar, Ravi Chandran,
Didier Riethmuller, Rodolfo Pacagnella, Alison Wright, Ferdousi
Begum, Sardar Muhammad Al Fareed Zafar, Diana Ramašauskaitė,
Akaninyene Ubom, Inês Nunes, Thomas Burke, Monica Oguttu,
Gerhard Theron, Gerard Visser, Eytan Barnea.
18793479, 2023, S2, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.15118 by Vilnius University, Wiley Online Library on [13/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License