|Panel Finds Insufficient Evidence to Recommend For or Against
Maternal-Request Caesarean Delivery
Women requesting a Caesarean delivery should be thoroughly counseled on potential
risks and benefits
An independent panel convened by the National Institutes of Health announced
today that the available information comparing the risks and benefits of Caesarean
delivery on maternal request (CDMR) versus planned vaginal birth do not provide
the basis for a recommendation in either direction.
The panel defined CDMR as a Caesarean delivery for a pregnancy with a single
baby at the mother’s request when she has no established medical indication for
the procedure. CDMR is a subset of elective Caesarean delivery, and distinct
from both emergency Caesarean delivery and Caesarean performed following attempted
Potential benefits of CDMR as compared with planned vaginal delivery include
a decreased risk of hemorrhaging for the mother, and a reduced risk of certain
birth injuries for the baby. Potential risks of CDMR include an increased risk
of respiratory problems for the baby and a longer maternal hospital stay.
The panel added that each woman requesting CDMR deserves individualized counseling
regarding the potential risks and benefits of both vaginal and Caesarean delivery.
When counseling patients, providers should also consider such factors as societal
and cultural conventions, ethical issues, available resources, and other factors
pertaining to the individual patient.
Panel members did find evidence to suggest caution in certain situations. They
concluded that CDMR should be avoided for women desiring large families. This
is because the risk of serious complications for subsequent pregnancies increases
with each additional Caesarean delivery.
The panel further stressed that CDMR should not be performed before the 39th
week of pregnancy or without verification that the fetus’ lungs have matured
sufficiently to avoid newborn respiratory complications.
In its report, the panel also expressed concern that a woman might choose a
Caesarean delivery because effective pain management would not be available at
the facility in which she would give birth.
“CDMR should not be motivated by unavailability of effective pain management,” the
panel wrote. “Efforts must be made to assure availability of pain management
services for all women.”
To address the weaknesses they identified in the available scientific literature,
the panel made a variety of recommendations for future research, including:
- Surveys of women (before and after birth), providers, insurers, and health
care facilities regarding CDMR,
- Development of strategies to predict and influence the likelihood of successful
- Establishment of uniform documentation of CDMR, to accurately reflect prevalence
of the procedure,
- Examination of existing large databases to assess incidence of various complications,
including rare but critical outcomes, and
- A thorough assessment of the costs of CDMR.
The panel released its findings this morning, following two days of expert presentations
and panel deliberations. Full text of the panel’s draft state-of-the-science
statement will be available late today at http://consensus.nih.gov. The final
version will be available at the same Web address in three to four weeks. Statements
from past conferences and additional information about the NIH Consensus Development
Program are also available at the Web site, or by calling 1-888-644-2667.
The 18 members of this State-of-the-Science panel were nominated for selection
by peers who were confident that these individuals’ areas of expertise would
significantly contribute to the process of critically examining scientific evidence
on Caesarean section on maternal request. The panel included educators, researchers,
statisticians, and practitioners in obstetrics and gynecology, preventive medicine
and biometrics, family planning and reproductive physiology, nurse midwifery,
anesthesiology, patient safety, epidemiology, pediatrics, perinatal medicine,
urology, urogynecology, general nursing, inner city public health sciences, law,
psychiatry, and health services research. The panel was chaired by Mary D’Alton,
M.D., chair of the Department of Obstetrics and Gynecology at Columbia University
Medical Center and Chief of Obstetrics and Gynecology at the New York-Presbyterian
In addition to the material presented at the conference by speakers and the
comments and concerns of conference participants presented during discussion
periods, the panel considered pertinent research from the published literature
and the results of a systematic review of the literature commissioned by the
NIH Office of Medical Applications of Research (OMAR). The systematic review
was prepared through the Agency for Healthcare Research and Quality (AHRQ) Evidence-based
Practice Center (EPC) program, at the RTI International-University of North Carolina
Evidence-based Practice Center. The EPCs develop evidence reports and technology
assessments based on rigorous, comprehensive syntheses and analyses of the scientific
literature, emphasizing explicit and detailed documentation of methods, rationale,
The panel’s statement is an independent report and is not a policy statement
of the NIH or the federal government. The NIH Consensus Development Program,
of which this conference is a part, was established in 1977 as a mechanism to
judge controversial topics in medicine and public health in an unbiased, impartial
manner. NIH has conducted 118 consensus development conferences, and 26 state-of-the-science
(formerly “technology assessment”) conferences, addressing a wide range of issues.
A backgrounder on the NIH Consensus Development Program process is available
The conference was sponsored by the Office of Medical Applications of Research
(OMAR) and the National Institute of Child Health and Human Development (NICHD).
Cosponsors included the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), the Office of Research on Women’s Health (ORWH), and the National
Institute of Nursing Research (NINR).
Note to Radio Editors: An audio report of the conference results will be available
after 5:00 p.m. today from the NIH Radio News Service by calling 1-800-MED-DIAL
(1-800-633-3425) or visiting http://www.nih.gov/news/radio/index.htm.
The Office of the Director, the central office at NIH, is responsible for
setting policy for NIH, which includes 27 Institutes and Centers. This involves
planning, managing, and coordinating the programs and activities of all NIH
components. The Office of the Director also includes program offices which
are responsible for stimulating specific areas of research throughout NIH.
Additional information is available at http://www.nih.gov/icd/od/.
The National Institutes of Health (NIH) — The Nation's Medical Research
Agency — includes 27 Institutes and Centers and is a component of
the U.S. Department of Health and Human Services. It is the primary federal
agency for conducting and supporting basic, clinical and translational medical
research, and it investigates the causes, treatments, and cures for both common
and rare diseases. For more information about NIH and its programs, visit http://www.nih.gov.