**1. Introduction**

Caesarean delivery is 'the birth of a foetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy)' [1]. Historically, caesarean delivery has been linked to a high rate of complications, often resulting in maternal death. However, caesarean sections are globally practiced in the advanced era of medicine to facilitate improved pregnancy outcomes [2, 3]. A caesarean section (CS or C-section) can be classed as either elective or emergency depending on its urgency and/or timing. A planned or elective caesarean section is performed before the onset of labour. Contrarily, an emergency C-section is a procedure performed before or during labour out of concern for the mother or the foetus [4].

In the absence of maternal or foetal indications for caesarean birth, vaginal delivery is safe and appropriate and should be advised, according to the American College of Obstetricians and Gynecologists' committee [5]. In addition, performing C-section in the absence of any medical indication is against the norms and guidelines of the World Health Organization (WHO). However, reports from the Global Network for Women's and Children's Health Research indicate an alarming increase in caesarean delivery rates, which is consistent with the global trend. One potential driver of the escalating rates is caesarean birth by maternal request [6].

Caesarean section on maternal request (CSMR) is defined as 'a procedure performed in the absence of a standard medical or obstetrical indication in order to avoid vaginal delivery' [7]. In the recent years, the number of caesarean deliveries has increased tremendously worldwide. A high caesarean section rate has become a pressing issue, which raises the concern on its implications to maternal health as well as long-term consequences. The growing trend in C-section rates has been attributed to changes in maternal characteristics and professional practice approaches, as well as to rising malpractice pressure and economic, organizational, social and cultural variables. Inequities in the use of surgery, both between and within nations, as well as the expenditures that unnecessary caesarean sections impose on financially strapped health systems, are additional issues and debates surrounding C-section [8]. Planning a favourable delivery route requires balancing the risks and advantages of any medical procedure, including CSMR and planned vaginal deliveries [9]. More importantly, it demands higher awareness among women regarding the risks and advantages of planned and unplanned C-sections using evidence-based information and updated recommendation from the National Institute for Health and Clinical Excellence (NICE) [10].

Therefore, this chapter aims to review the current stature of scientific literature in order to (i) explore and link the determinants of increased CSMR; (ii) highlight the potential risks and benefits of elective CS procedure; (iii) and discuss the ethical, medico-legal concerns surrounding this controversial health issue.

#### **1.1 Prevalence of caesarean sections**

According to the World Health Organization (WHO) data, the recommended CS delivery rate ranges between 10% and 15%, while rates exceeding 15% are considered medically unnecessary [5]. In recent decades, the use of C-sections has risen dramatically worldwide, especially in middle- and high-income countries, despite scarce evidence on significant maternal and perinatal benefits and the possible link between increasing CS rates and worsening health outcomes [8].

Globally, C-sections have been rising rapidly since the early 1990s. Approximately 21% of the entire world's births have been ceased by CS, ranging from 6% in low- and middleincome countries (LMICs) to 27% in the developed nations. Regionally, an increased rate is observed in Eastern Asia (35%), Central America (38%), North America and Oceania (32%). According to recently estimated projections, the cumulative rates may escalate further to 50% by 2030, accounting for a global CS prevalence of 29% [11].

According to a 2010 WHO survey, 27.3% of deliveries in Asian regions were caesarean sections, with these statistics being much higher in China since they have adopted the two-child policy [12]. These figures were surprisingly much higher than the advised rate of 10–15% by WHO. In fact, in the developing nations, private facilities perform C-sections on maternal requests twice more frequently than the public hospitals [13]. In Thailand, nearly 53% of obstetricians would consider C-section on maternal request [14]. Similarly, in a province in China, CSMR accounted for 8.42%

*Caesarean Section on Maternal Request DOI: http://dx.doi.org/10.5772/intechopen.109589*

of CS delivery out of 36.01% of caesarean cases [15]. The overall caesarean section rate in Malaysia ranged from 18.8% to 31.5%, and the prevalence was unexpectedly much higher among low-risk women [16]. The following data show an upsurge in the number of C-sections performed globally and necessitates a review of current regulations and policies in clinical practice.

The prevalence of CSMR varies widely across different nations, ranging between 0.2% and 42% of all deliveries, although most studies reported a prevalence of <5%. The lack of information on birth certificates and discharge sheets limits the data availability since it fails to address CS on maternal request, while the study year and diverse characteristics of the study population affect the prevalence of CSMR [9].

#### **1.2 Economic burden**

The financial incentives linked to CS delivery are crucial factors to consider from a healthcare professional's perspective. In comparison with vaginal birth, CS delivery results in increased net profitability for healthcare providers [17]. A caesarean surgery or a difficult vaginal delivery can cost between US\$50 and US\$100, while a regular delivery at a hospital in underdeveloped regions of Africa and Latin America costs between US\$10 and US\$35.

According to the World Health Report 2010, 6 million non-medically indicated CS procedures were carried out in 2008, costing approximately \$2.32 billion in the United States [18]. The increment in salary of healthcare providers might be one of the leading contributors to unnecessary CS births [19]. Non-medically indicated C-sections place a disproportionately higher financial burden on women and lead to adverse health implications. Medical costs are typically higher if CS procedures are performed at private healthcare facilities. In addition, CS necessitates a lengthier hospital stay, which increases healthcare expenditure and results in financial deprivation [17, 19].

#### **1.3 Indications and recommendations**

CS can be a significantly life-saving intervention for medically indicated cases [19]. In ideal circumstances, C-sections are performed when vaginal delivery (VD) is contradicted to protect the newborn and the mother from a potentially adverse event [11].

Medically adopted classifications for performing CS deliveries are 'based on primary clinical indications', 'the degree of urgency or absolute need for caesarean delivery' and 'Robson classification'. The Robson classification also known as the 'Ten Group Classification System (TGCS)' has been endorsed by the WHO as a 'global standard' tool for CS evaluation. It classifies CS into 10 mutually exclusive and exhaustive groups based on the category of the pregnancy, the previous obstetric record of the woman, the course of labour and delivery, and the gestational age of the pregnancy [20].

Caesarean sections are widely performed for various maternal or foetal indications. Obstructed labour (including a severely malformed pelvis and a failed attempt at labour), extensive antepartum haemorrhage, grade 3 or 4 placenta praevia, malpresentation (including transverse, oblique and brow) and uterine rupture are all absolute maternal indicators. Non-absolute indications include maternal request, 'precious' pregnancy and psychosocial signs such as failure to progress in labour (including prolonged labour), failed induction, previous caesarean delivery, genitourinary fistula or third-degree tear repair, antepartum haemorrhage, maternal medical diseases, severe preeclampsia or eclampsia, foetal compromise (including foetal distress, cord compression and severe intrauterine growth retardation) and breech presentation [3].

A recent study in China reported maternal request (23.38%), foetal distress (22.73%) and pregnancy complications (9.96%) as the leading indications for CS [15].

The frequency of unnecessary caesarean births has considerably decreased due to foetal cardiac monitoring and blood collection procedures. In the absence of the aforementioned indications, a VD is considered safe, and it improves the mother's recuperative process as well as her caring ability and bonding with newborn. However, not all women prefer the conventional VD over a planned CS, possibly owing to social, cultural and psychological factors. Necessary information should be provided to women while choosing the most suitable and safest mode of delivery. Women who request for CS should be evaluated and given the appropriate counselling. It is prudent to consider the motivation behind her request since it directs the obstetrician to explore, counsel and prepare her for the desired mode of delivery. This is crucial as an operative abdominal delivery carries significant morbidities such as post-partum haemorrhage, anaesthetic complications, surgical site infections and thromboembolic events [21]. Owing to these issues, the obstetrician should look into specific risk factors such as age, parity, body mass index and past obstetric history [11]. A woman's reproductive plans and personal values should also be taken into consideration before opting for elective CS and/or CSMR.

Women who opt for CSMR should be delivered no earlier than 39 weeks of gestation unless there are other clinical indications. It is crucial for women to be well informed about the risks of placenta praevia, placenta accreta spectrum, intrauterine mortality and caesarean hysterectomy in subsequent pregnancies [4]. Therefore, it is essential to provide these women with adequate knowledge before they can make significant decisions and exercise their autonomy competently as patients. Instead of declining the CS request, the obstetrician should use sound judgement to cater to the patient's needs and maximize an improved health outcome.

### **2. Determinants of CS on maternal request**

Globally, the number of caesarean deliveries has significantly increased in recent years. This situation demands an urgency to address the high CS rate since it may lead to maternal health implications and long-term repercussions. Medical, psychological and psychosocial, economical, social and cultural determinants might serve as some of the potential influencing factors owing to this serious healthcare concern.

Multiple factors account for women requesting a caesarean delivery. The perception of the community that a CS is an almost low-risk alternative to VD may very well contribute to the rising number of cases in recent years [22]. The most prevalent causes for CSMR are psychological. Tocophobia or 'fear of childbirth' is one of the major reasons contributing to CSMR. The estimated prevalence of severe tocophobia is 14%, which appears to have increased recently [23]. Primary tocophobia affects nullipara, while secondary tocophobia affects women with previous obstetric history [24].

Tocophobic women frequently perceive childbirth as a dread of labour pain, pelvic floor damage resulting in incontinence of the urine or foeces, fear of requiring an emergency surgical delivery, dreading child loss and facing a fear of being left alone while in labour [25]. Therefore, the most significant risk factors for secondary tocophobia are prior unpleasant overall birth experience, combined anxiety and depression, and poor social support [26]. Due to the unpredictable nature of labour and the vaginal birth process, women who have faced previous difficulties that

resulted in emergency caesarean sections or instrumental deliveries may request a caesarean section [25].

Whereas some women choose CSMR to have a planned and organized delivery [25], career-oriented women are more likely to prefer elective CS since it is more convenient to have a scheduled birth. A multicentre study conducted in Brazil discovered that women with higher education levels and income are more likely to give birth via caesarean section [27]. In addition, some cultures' astrological beliefs may also impact the decision to undergo CSMR since they believe there is a lucky day for childbirth [28]. Women with advanced maternal age, prior miscarriages, infertility and assisted reproductive technology have demonstrated higher rates of CSMR [22, 29]. These women consider their first pregnancy to be 'precious' and therefore decide to have an elective C-section because they believe it will be safer for their child [30].

According to a systematically analysed review, there may be several social and individual factors that have contributed to the rise in C-section deliveries on maternal requests, for instance, the fear of labour pain and the perception of inequity and inadequate treatment [31]. Similarly, women who had previously undergone a C-section contributed to the highest CS delivery rate. Additionally, cultural considerations such as religious acceptance, societal views towards the procedures, prior experiences and encounters with medical experts also influence women to request an elective CS for non-medical reasons [32]. The choice of delivery is significantly influenced by the partners as well [33]. A study in China [34] highlighted five key psychosocial elements that influenced the choice of delivery method by women, and included level of education, financial situation, parity, anxiety, and confidence of lying-in (i.e. pre-/postpartum confinement). Other factors contributing to the rise in C-section deliveries include increased socio-economic status and diversity in the cultural and societal contexts. Women from higher socio-economic background delay childbearing until their late 30s to achieve higher education, build a career and establish financial security, which leads them to elective CS delivery. In addition, CS rates have been considerably higher among urban populations and private healthcare settings [5, 20].

### **3. Potential risks and benefits of elective CS**

Over the last 10 years, CS rates in developed nations have increased considerably, leading to controversial debates regarding the benefits of planned procedures on maternal and neonatal health outcomes [3]. Evidence shows that CS procedures globally avert 2.9 million neonatal deaths and around 187,000 maternal deaths [11]. Although CS leads to a significant mortality reduction, nevertheless, non-medically indicated CS might increase the short- and long-term health hazards for both mother and child [8]. Post-partum haemorrhage and infection, visceral damage, placenta accrete and placental abruption are among the short-term risks, whereas obesity and asthma are long-term risks [20, 35]. Additionally, mothers with CS have greater rates of miscarriage, ectopic pregnancy and stillbirth in subsequent pregnancies. Uterine rupture, placental accrete and placental abruption are also more prevalent among mothers with a previous history of CS [11].

Data suggest that CS increases the baby's risk of developing asphyxia, respiratory distress and other pulmonary infections. Maternal mortality is higher with CS than VD in some settings, most likely due to the adoption of non-medically elective CS [5, 19]. Increased illness, injury, and short- and long-term disability have been often linked to CS. In some circumstances, an emergency hysterectomy may seem

potentially necessary to manage severe post-partum haemorrhage. CS cases may result in chronic pain, delay in the initiation of breastfeeding and criticality in future pregnancies [36]. Past studies reported that CS presents with an increased risk of childhood illnesses by 5% and imposes higher risk to maternal health [5].

Non-medically indicated and/or CS on maternal request should not be promoted since it is a major surgery and involves significant risk compared with the conventional VD [19]. Multiple risk factors should be assessed before adopting the CS procedure to ensure better health of the mother and the baby. Maternal age, weight, parity, extended labour, HIV-positive status, previous CS, dystocia, breech presentation, placenta praevia and potential foetal complications are some significant risk factors to consider. Therefore, it is important to control these risk factors at individual level and then opt for elective CS [19].

Although CSMR has several risks, it has some notable benefits as well that should be highlighted. One of the essential goals of C-sections is to ensure improved maternal and neonatal outcomes [19]. Here are some of the benefits associated with a planned caesarean section.

#### **3.1 Anxiety and depression**

Stress and anxiety can adversely affect maternal well-being and their ability to care for the newborn. PTSD has been recognised as a possible consequence of childbirth with a prevalence between 2% and 7%, while post-partum depression has been found to be around 10% [24]. Women with severe tocophobia have an increased risk for PTSD and depression after childbirth. Therefore, after exploring their worries and fears, opting for caesarean section for women with this background can increase the satisfaction with childbirth and reduce this psychological morbidity.

#### **3.2 Urinary incontinence**

The EPICONT study observed 8.4% higher prevalence of urinary incontinence among women who had vaginal deliveries compared with those who had caesarean deliveries [37]. A study by Gyhagen et al. in 2013 found that the prevalence of urinary incontinence at more than 10 years after a single vaginal birth was 40.3% compared with 28.8% after one birth *via* caesarean section [38]. Nevertheless, National Institutes of Health consensus statement concluded that there was not enough evidence to recommend caesarean section for the sole prevention of urinary incontinence.

#### **3.3 Pelvic organ prolapse**

Up to 50% of all parous women have some degree of clinical prolapse and about 10–20% are symptomatic worldwide. Pregnancy and childbirth especially operative vaginal deliveries are known risk factors for pelvic organ prolapse (POP). A Swedish study found that the prevalence of symptomatic POP 20 years after one birth was doubled after a vaginal delivery compared with caesarean section [39].

#### **3.4 Foetal complication**

Foetal or newborn morbidity and mortality linked to labour and vaginal delivery are reduced or eliminated by caesarean birth. At the same time, intrapartum

*Caesarean Section on Maternal Request DOI: http://dx.doi.org/10.5772/intechopen.109589*

complications such as brachial plexus injury due to shoulder dystocia, bone trauma, and asphyxia related to intrapartum events may be prevented or avoided [9]. However, less than 10% of cerebral palsies are attributed to intrapartum events [40, 41]. Despite increasing rates of caesarean section, cerebral palsies rates have remained the same. Foetal neurological injuries affect 2–3% of births and are more common with operative vaginal deliveries. Current data suggest that the number of caesarean sections needed to prevent one cerebral palsy is 5000 and to prevent one permanent brachial plexus injury is 10000 [24]. Therefore, women should be counselled that elective caesarean section has no benefit in preventing cerebral palsy and brachial plexus injury. Nevertheless, the foetal outcome in terms of birth asphyxia, meconium stained liquor and need for Neonatal ICU admission are significantly higher in emergency caesarean section than in elective caesarean section [42].

#### **3.5 Maternal morbidity**

Vaginal delivery can be an unpredictable process even in a low-risk pregnancy. Situations such as foetal distress and poor progress of labour require emergency caesarean section, which carries an increased risk of morbidity compared with planned caesarean section. Post-operative wound infection, post-partum haemorrhage, need for blood transfusion, urinary tract infection, maternal pyrexia and need for intensive care unit admission are significantly higher in emergency caesarean section than elective caesarean section [42]. Limited data reporting showed that fatal injuries, including iatrogenic surgical injury, damage to the bladder or ureter, and pulmonary embolism seemed to be lower with planned CS than VD [9].

### **4. Ethical and medico-legal concerns**

The infant is more likely to experience short- and long-term difficulties if a planned CS is performed on the mother's desire without a valid medical reason [35]. Over the past few years, numerous guidelines have emerged, including the one by NICE, issued in response to the discussion around the medical, ethical and financial effects of increased rates of caesarean sections on maternal request [43]. Given the considerable amount of uncertainty regarding the therapeutic benefits and risks of CSMR compared with vaginal birth, professional guidelines do not require addressing this option with every patient [9]. Even though the increases in absolute risk are frequently minimal, it may still be an unethical practice. Additionally, the fact that various maternity facilities and medical personnel might diversely respond to women's requests for C-sections may also lead to ethical dilemmas and healthcare inequities [35].

The choice of delivery frequently occurs based on the obstetrician's beliefs and experiences, the patient's gravidity, the hospital's environment and internal protocols, the rising prevalence of labour induction, the medico-legal implications and, finally, the mother's right to request a caesarean section without a doctor's recommendation [29]. An obstetrician's decision making and counselling may frequently be guided by the fear of litigation [38]. In obstetric practice, a lawsuit is a frequent occurrence that can be stressful for healthcare professionals, so they try to avoid legal action [29]. Worldwide, the number of lawsuits involving obstetric care is steadily increasing. Therefore, meticulous counselling and explanation about the risk versus benefits should be done on a case-to-case basis during the antenatal period.
