This powerpoint is a literature review on Cesarean Delivery by Maternal Request (CDMR). It introduces various birthing methods including cesareans and reports on the recent trends of cesarean delivery in the U.S. It then explores CDMR and the trends, issues, and concerns that surround it.

1. Babies on Demand
Cesarean Delivery on Maternal Request

2. Babies on Demand
• What is a Cesarean?
– What are the trends?
• What is Cesarean
Delivery on Maternal
Request (CDMR)?
– What are the trends?
– What are the concerns?
– What are the reasons
women are requesting
cesareans?
© Anne Geddes • What next?

3. Birthing
• Vaginal Birth
– Planned Vaginal Birth: includes vaginal births that
require emergency cesareans.
© 2009 Nucleus Medical Media, Inc
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.

4. Birthing Interventions
• Assisted Vaginal Births (e.g. amniotomy, forceps,
vacuum extraction, epidural anesthesia).
• Induction: procedure used to stimulate uterine
contractions during pregnancy before labor begins
spontaneously.
– Elective: elective inductions are those that are
undertaken without definite medical indications
© Robin Elise Weiss
© iStockPhoto © Robin Elise Weiss
© Robin Elise Weiss © iStockPhoto
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.

5. Birthing Interventions
• Cesarean Section: Extraction of the infant,
placenta, and membranes through an incision in the
maternal abdominal and uterine walls.
© 2009 Nucleus Medical Media, Inc
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.

6. Types of Cesareans
• Emergency: procedures initiated after labor has
begun due to complications with vaginal delivery
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.

7. Types of Cesareans
• Elective: planned
cesarean delivery for a
wide range of maternal
and fetal indications.
• Medically necessary factors
• Physician-driven factors
• Maternally-driven factors
© Nursing for Women’s Health
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.

8. Recent Trends of
Cesarean Delivery in the
U.S. 1996-2007
• Dramatic increases in cesareans, rising 53%
• Increases across all demographics race,
ethnicity, age, and socioeconomic status
• Increases for infants of all gestational ages with
preterm infants increasing the greatest
• Increases in all 50 states with rates rising over
70% in six U.S. states
Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.

9. Recent Trends of
Cesarean Delivery in the
U.S. 2007

10. Recent Trends in Cesarean
Delivery in the U.S.
35
Cesareans per 100 live births
30
25
20
15
1991 1995 1999 2003 2007
Year
Figure 1. Cesarean delivery rates in the United States, 1991-2007. Source: CDC/NCHS. National Vital
Statistics System.
Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.

11. Birthing Methods In
the U.S.
Primary Elective Pre-Labor Cesarean Delivery as a
percentage of all Cesarean Deliveries in the US in 2001
28%
Cesarean Births
"Primary Elective" Pre-Labor
Cesearean Births
72%
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

12. Why the Rise?
• Multiparious Women
– More repeat cesarean
– Less VBAC procedures
• Advancement in Technology
– More multiple Births due to fertility treatment
– More older women giving birth
– More inductions
• Physician Driven Factors
– Physician Practice Patterns
– Physician Convenience
– Legal Pressures
• Maternally Driven Factors
– Cesarean Delivery on Maternal Request (CDMR)
Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.

13. Should Rising Cesarean
Rates Be a Concern?
• In 2007, 1.4 million women had cesarean birth
– Number of cesarean births has increased 71% since 1996
• Cesarean Sections are major abdominal surgery
– Associated with higher rates of
• Surgical complications
• Maternal re-hospitalization
• Complications requiring neonatal ICU admission
– Associated with higher costs
• Nearly double that of vaginal birth
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88. Menacker, F.,
Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.

14. Projected Trends in
Cesarean Delivery in the
U.S.
40
Cesareans per 100 live births
R² = 0.74127
35
30
25
20
15
1991 1995 1999 2003 2007 2011 2015
Year
Figure 1. Cesarean delivery rates in the United States, 1991-2007. Source: CDC/NCHS. National Vital
Statistics System.
Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.

15. What is Cesarean Delivery
on Maternal Request
(CDMR)?
• CDMR: a cesarean delivery for a singleton pregnancy on
maternal request at term in the absence of any medical or
obstetric indications.
• Why is CDMR difficult to define?
– Not easily identifiable
• What descriptions are included in CDMR?
– Cesarean delivery with no labor or medical indication
– Cesarean delivery with “no indicated risk”
– Cesarean section by choice (CSBS).
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.
Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.

16. Recent Trends of Cesarean
Delivery on Maternal
Request (CDMR) in the U.S.
• 2006 estimates of CDMR are between 4% and 18% of all
cesareans but the validity of these estimates are questionable.
© Anne Geddes
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

17. Birthing Methods in
the U.S.
Birthing Method Prevalence Per 100 Live Births in U.S.
2001
5% 2%
Non-Cesarean Births
17%
Cesarean Births
Cesarean with "no indicated
risk"
Cesarean with no labor or 76%
medical indication
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

18. Should Cesarean Delivery
on Maternal request (CDMR)
Be a Concern?
Significant Maternal Outcomes
• Maternal length of hospital stay
• Hemorrhage
© East arolina University
© VCU Medical Center
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

19. Should Cesarean Delivery
on Maternal request (CDMR)
Be a Concern?
Significant Neonatal Outcomes
• Respiratory morbidity
© www.childrens.com
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

20. Projected Trends in
Cesarean Delivery in the
U.S.
Projected Trends of Cesarean Section with "No
Indicated Risk" and "No Labor or Medical Indication"
10
9 R² = 1
8
7
6
5.5 Linear(No Indicated Risk)
5 R² = 0.78593
4 Linear(No labor or
3 3.3 Linear(No Labor or Medical
2
2.6 Indication)Indication)
Medical
1.9
1
0
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
2017
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

21. World Health Organization
(WHO) On CDMR
• Recommends a cesarean rate of 15% in developed nations.
• “Unnecessary cesarean section is a classic example of the
mismatch between evidence and practice in obstetrics.”
• The increasing cesarean rate does not automatically lead to
better outcomes and could be associated with harm.
• Cesarean section with no medical indication is associated with
with increased risk of maternal mortality and morbidity.
• Cesarean section for breech presentation is associated with
improved perinatal outcomes.
• Mothers who choose cesareans need to make the decision
informed of the increased risks.
Lumbiganon, Pisake, et al. (2010).Method of delivery and pregnancy outcomes in Asia: the WHO Global Survey on maternal and perinatal health
2007-08. The Lancet.375. 490-499.
Villar, J. et al. (2006). Cesarean delivery rates and pregnancy outcomes in the WHO Global Survey for monitoring maternal and perinatal health in Latin
America.The Lancet. 367. 1819-29.

22. Federation of Obstetrics &
Gynecology (FIGO) on CDMR
• CDMR is not ethically justified.
• Factors: medical, legal, psychological, social, and financial.
• Surgical intervention with potential risks to mother and child.
• It uses more resources than vaginal delivery.
• Physician duty not to harm and to allocate resources wisely.
• No hard evidence on risks/benefits of CDMR
• Vaginal delivery is safest for mother and child.
• “Natural concern at introducing an artificial method of
delivery in place of the natural process with out medical
justification.”
Christlaw, J.E. (2006). Cesarean section by choice: Constructing a reproductive rights framework for the debate. International Journal or Gynecology and
Obstetrics. 94. 262-268.

23. American College of
Obstetrics and Gynecology
(ACOG) on CDMR
• Currently a lack of conclusive data for benefits/
risks.
• “Burden of proof ” lies on CDMR advocates.
• Ethical justification for CDMR depends on how it
will effect the overall health of the woman and her
fetus.
• Not ethically necessary to include CDMR in
discussions of birthing options for every patient.
Surgery and patient choice: The ethics of decision making. (2003) ACOG Committee Opinion 289. International Journal of Gynecology & Obstetrics. 84. 188-93.

24. Recent Trends of
Cesarean Delivery on
Maternal Request (CDMR)
• Cesarean delivery with “no risk indicated”
– Rose from 3.3% of live births in 1991 to 5.5% in 2001
• Cesarean delivery with no labor or medical indication
– Rose from 1.9% of live births in 2001 to 2.6% in 2003
• Cesarean delivery by choice
– Italy: Rose from 4.5% in 1996 to 9% in 2000
– Sweden: Rose 8.9% in 1994 to 15.8% in 1995
– Taiwan: Rose from 2% in 1997 to 3.5% in 2001
• Rates may be lower because costs of cesareans are reimbursed at the
lower vaginal delivery cost.
National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements.
23 (1) 1-29.

25. So, Why are more women
requesting Cesareans?
Possible Reasons May Include:
• Fear of…
– Birth experience
• Pain
• Terror Management (i.e. previous adverse birth experience)
– Potential maternal consequences
• pelvic organ prolapse
• Urinary and anal incontinence
• Sexual side-effects
• needing an emergency C-section
– Potential fetal consequences
• Health of baby (i.e. birth defects; complications from birth)
• Potential death of baby during birth
• Control and Convenience
– Scheduling
Fenwick, J., et al. (2009). Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. Journal of Clinical
Nursing. 18, 667-77.
Kjærgaard, H., et al. (2008). Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. Journal of Reproductive and Infant Psychology.
26:4, 340-350.

26. So, Why are more women
requesting Cesareans?
Possible Reasons May Include:
• Fear of…
– Birth experience
• Pain
• Terror Management (i.e. previous adverse birth experience)
– Potential maternal consequences
• pelvic organ prolapse
• Urinary and anal incontinence
• Sexual side-effects
• needing an emergency C-section
– Potential fetal consequences
• Health of baby (i.e. birth defects; complications from birth)
• Potential death of baby during birth
• Control and Convenience
– Scheduling
Fenwick, J., et al. (2009). Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. Journal of Clinical
Nursing. 18, 667-77.
Kjærgaard, H., et al. (2008). Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. Journal of Reproductive and Infant Psychology.
26:4, 340-350.

27. Suggestions for
moving forward
Include a check
box for
“maternal CDMR data is vague
request” on birth
certificates. - practices in the collection of data by
institutions and the government
Lack of standardized
definition of CDMR
and use of proxies in
the literature.
CDMR findings are indirect
- limiting availability of data

28. Suggestions for
moving forward
After proper data collection is established:
- Research trends of CDMR
- Possible relationships of CDMR and other
variables
-Possible reasons why women are requesting
CDMR
- Design interventions to address concerns that
become apparent.

29. Suggestions for
Develop moving forward
interventions to
address
psychological Fear of pain during birth experience
needs of mothers
and CDMR as a terror management
Implement health
technique.
interventions to
increase
knowledge and
Fear surrounding the birth experience
dispel uninformed
fear of birth.
and possible maternal and neonatal
physical consequences.
Education on the
risks and benefits
associated with any All mothers who request CDMR
cesarean section
should be informed.

30. THANK YOU
Pregnancy and Labor Resources
www.marchofdimes.com www.ican-online.org
www.childbirthconnection.org