Cesarean delivery on maternal request: Trends, predictors, and short-term outcomes using propensity score analysis

This study determines short-term maternal and neonatal outcomes associated with cesarean delivery on maternal request (CDMR) compared with planned vaginal delivery.

This retrospective cohort study included singleton pregnancies at term (37 + 0 to 41 + 6 weeks) delivered at a single tertiary medical center between January 2013 and December 2024. Women with prior cesarean delivery, multiple gestation, preterm or post-term delivery, and cesarean delivery for medical indications were excluded. Propensity score weighting was used within an intent-to-treat framework. Maternal outcomes included postpartum hemorrhage, prolonged hospitalization (postpartum stay exceeding 4 days), gynecological surgical re-intervention, and venous thromboembolism. Neonatal outcomes included intensive care unit admission and respiratory morbidity.

Of 146 955 deliveries over the study period, 74 717 met the inclusion criteria, of whom 904 (1.2%) underwent CDMR, accounting for 7.2% of all cesarean deliveries. CDMR rates increased significantly from 1.1% in 2013 to 2.5% in 2022 (P < 0.001). Independent predictors of CDMR included nulliparity (adjusted odds ratio [aOR] 3.33), smoking (aOR 2.46), fertility treatment (aOR 1.67), and advancing maternal age (aOR 1.19 per year). Compared with planned vaginal delivery, CDMR was associated with lower risk of postpartum hemorrhage (adjusted relative risk 0.40, 95% CI 0.22-0.72, P = 0.002) but higher risk of prolonged hospitalization (adjusted relative risk 1.36, 95% CI 1.12-1.65, P = 0.002). Among women planning vaginal delivery, 7.6% required intrapartum cesarean, associated with the highest rates of prolonged hospitalization (16.3%) and neonatal intensive care unit admission (2.0%).

Cesarean delivery on maternal request is an increasingly common practice with comparable short-term maternal and neonatal outcomes to vaginal delivery when appropriately selected and timed.