Cesarean delivery on maternal request: wise use of finite resources? A view from the trenches

Cesarean section rates are rising in the United States and were at an all time high of 29 percent in 2004. Within this context, the issue of cesarean section on maternal request has been described as being part of a "perfect storm" of medical, legal and personal choice issues, and the lack of an opposing view. An increasing cesarean section rate adds an economic burden on already highly stressed medical systems. There is an incremental cost of cesarean section compared to vaginal delivery. The issue of cost must also be considered more broadly. Rising cesarean section rates are associated with a longer length of stay and a higher occupancy rate. This high occupancy rate leads to the diversion of critical care obstetric transports and has dramatically reduced patient satisfaction. These diversions, and the resultant inability to provide needed care to pregnant women, represent a profound societal cost. These critical care diversions and reduced patient satisfaction also negatively impact a health care institution's financial bottom line and competitiveness. The impact of a rising cesarean section rate on both short and long-term maternal and neonatal complications, and their associated costs, must also be taken into account. The incidence of placenta accreta is increasing in conjunction with the rising cesarean section rate. The added costs associated with this complication (MRI, Interventional Radiology, transfusion, hysterectomy, and intensive care admission) can be prohibitive. It has also been demonstrated that infants born by scheduled cesarean delivery are more likely to require advanced nursery support (with all its associated expense) than infants born to mothers attempting vaginal delivery. The practice of maternal request cesarean section, with limited good data and obvious inherent risk and expense, is increasing in the USA. Patient autonomy and a woman's right to choose her mode of delivery should be respected. However, in our opinion, based on the current evidence regarding cesarean delivery on maternal request, promotion of primary cesarean section on request as a standard of care or as a mandated part of patient counseling for delivery will result in a highly questionable use of finite resources. As of 2004, 46 million Americans did not even have basic health insurance. It is critical that we not allow ourselves to be dragged into the eye of a "perfect storm." This conference is an important step in the rational and objective analysis of this issue.