Cesarean deliveries on maternal request, which are planned cesarean deliveries before the onset of labor without medical or obstetrical indications, account for approximately 2.5% of births in the US.1 Although the American College of Obstetricians & Gynecologists (ACOG) recommends planned vaginal delivery for pregnant individuals without maternal or fetal indications for cesarean delivery, the increased safety of cesarean delivery over the past 2.5 decades has led to reconsideration of maternal requests for cesarean delivery.1 ACOG acknowledges patient autonomy and honors the choice of planned cesarean delivery on maternal request after appropriate counseling regarding the risks and benefits of planned vaginal vs cesarean delivery, and states that planned cesarean delivery on maternal request should not be performed before 39 weeks of pregnancy.1 In contrast, the World Health Organization recommends cesarean delivery only for medical indications. Fear of labor pain, potential adverse fetal outcomes, and pelvic floor damage are cited as reasons pregnant individuals might choose cesarean delivery over vaginal delivery.
Maternal Outcomes: Vaginal Delivery
Vaginal delivery occurs for 75% of nulliparous individuals in the US with a term, singleton, vertex pregnancy, and is associated with fewer days to pain- and opioid-free recovery (median [IQR], 19 [11–26] days vs 27 [19–40]days) and decreased postpartum infection (0.94% vs 2.87%), thromboembolism (0.08% vs 0.19%), and anesthetic complications (0.10% vs 0.39%) compared with cesarean delivery performed in the absence of any complications of labor and delivery and without maternal medical risk factors that may have constituted a medical indication.2
Planned vaginal delivery is also associated with a shorter hospital stay compared with planned cesarean birth (adjusted mean difference, 1.47 [95% CI, 1.46–1.49] days).1 However, compared with pregnant individuals who undergo planned cesarean delivery, those who plan a vaginal delivery and undergo labor induction experience higher risks of chorioamnionitis (20.6% vs 0.6%; odds ratio, 7.06 [95% CI, 3.27–15.24]) and postpartum hemorrhage (6.8% vs 1.1%; odds ratio, 7.13 [95% CI, 1.73–29.33]) due to unforeseen labor complications or unplanned cesarean delivery.3
Although data from longitudinal observational and cross-sectional studies do not allow inferences about causality, multiple epidemiological studies identify vaginal delivery as the leading risk factor for all pelvic floor disorders, including pelvic organ prolapse and urinary or anal incontinence. In a large Ohio Medicaid study, individuals undergoing vaginal delivery from July 1991 through April 1996 (n = 137 702) compared with those who underwent cesarean delivery without maternal or fetal indication (n = 5393) experienced more vaginal and cervical lacerations or damage to pelvic organs or joints, such as the pubic symphysis (7.32% vs 1.09%).2
Maternal Outcomes: Cesarean Delivery
In a random sample of 4458 women enrolled in a large US health maintenance organization, the lifetime risk of pelvic floor disorders was 27% among those who underwent cesarean delivery for any indication compared with 42% who underwent vaginal delivery (P < .05), with rates of pelvic organ prolapse of 4% vs 8%, stress urinary incontinence of 11% vs 18%, and overactive bladder of 9% vs 15% (P < .05 for all comparisons).4 The risk of pelvic organ prolapse increases for women older than 35 years at the time of first childbirth, with each subsequent vaginal delivery, and with the use of forceps-assisted vaginal delivery.4 A 2023 meta-analysis of 15 randomized clinical trials (North America [6], Africa [1], Europe [3], Middle East [1], Asia [3], Australia [1]), including 3265 pregnant individuals randomized to undergo planned cesarean delivery and 3353 randomized to undergo planned vaginal delivery, reported that urinary incontinence rates at 1 to 2 years after delivery were lower in the planned cesarean delivery group than the planned vaginal delivery group (16.9% vs 22%; relative risk [RR], 0.77 [95% CI, 0.67–0.88]).5
However, individuals who undergo planned cesarean delivery on maternal request are at increased risk of adverse events during subsequent pregnancies, including uterine rupture (incidence of 0.21% with a prior cesarean delivery vs 0.0038% in those without previous cesarean delivery)6 and placenta accreta spectrum, which involves abnormal placental adherence to the uterine wall (incidence of 0.31% of pregnancies after 1 cesarean delivery vs 0.2% in those without previous cesarean delivery).7 Hemorrhage due to placenta accreta spectrum can be severe and may require hysterectomy at the time of cesarean delivery. The risk of placenta accreta by the third cesarean delivery increases to 0.6% and is 40% when the placenta implants over or within 2 cm of the internal cervical os (placenta previa).7 For patients undergoing a third cesarean delivery, there is a 1% overall risk that a hysterectomy will be required, most commonly to manage placenta accreta spectrum.7
Cesarean Delivery on Maternal Request vs Planned Vaginal Delivery: Infant Risks
In the aforementioned meta-analysis of 15 randomized clinical trials comparing planned cesarean with planned vaginal delivery, overall perinatal mortality was similar in both groups (1.3%).5 Planned cesarean delivery was associated with a lower risk of low umbilical artery pH, an indicator of fetal hypoxia (0.3% vs 2.4%; RR, 0.18 [95% CI, 0.05–0.67]); neonatal birth trauma, including nerve injury, skull fracture, or long bone fracture (0.3% vs 0.7%; RR, 0.45 [95% CI, 0.22–0.96]); tube feeding requirement (2.5% vs 7.1%; RR, 0.36 [95% CI, 0.19–0.66]); and hypotonia (0.4% vs 3.5%; RR, 0.11 [95% CI, 0.03–0.47]) compared with planned vaginal delivery.5
Composite Outcomes, Shared Decision-Making, and Patient Autonomy
Research comparing composite outcomes, such as the Adverse Outcome Index, a composite measure that includes maternal and fetal morbidity, among women who underwent planned cesarean delivery on maternal request vs planned vaginal delivery (spontaneous or induced labor) are conflicting, with studies reporting lower risk (Adverse Outcome Index: 3.8% vs 8.3%; adjusted RR, 0.42 [95% CI, 0.33–0.54])8 or higher risk (2.7% vs 0.9%; RR, 3.1 [95% CI, 3.0–3.3]).9 Decisions about planned cesarean delivery should incorporate patient goals, including desired family size. A cross-sectional study from the US reported that individuals who had a planned cesarean delivery (n = 44) regarded their birth experience as more fulfilling and less difficult than those who planned vaginal delivery (n = 160). This difference was partially due to the substantial negative effect of unplanned cesarean deliveries on maternal satisfaction for pregnant individuals who planned a vaginal delivery.
ACOG specifically notes that counseling should include a discussion about the reasons for the patient’s request and should inform pregnant individuals about the increased risk of placental abnormalities and the risk of hysterectomy at the time of delivery in subsequent pregnancies.1 Although hospitals may be reimbursed at a higher rate for cesarean delivery, in many states, obstetric services are billed by the physician using global obstetric codes, which are similar for each mode of delivery. Additionally, in the US, the cesarean delivery rate for nulliparous individuals with a term singleton fetus in vertex presentation is a health quality measure that is publicly available through health care nonprofit watchdog organizations, such as Leapfrog and America’s Health Rankings, and financially incentivizes vaginal delivery over cesarean birth for both hospitals and physicians.
Conclusions
Cesarean delivery on maternal request currently accounts for approximately 2.5% of births in the US. ACOG recommends planned vaginal delivery for pregnant individuals without indications for cesarean delivery, but honors the decision for planned cesarean delivery on maternal request after counseling. Shared decision-making should include a discussion of the risks and benefits of planned vaginal vs cesarean delivery for both birthing individuals and their infants, future childbearing plans, and the risk of pelvic floor injury.
Conflict of Interest Disclosures:
Dr Alperin reported receiving research support from the National Institutes of Health (NIH; R01 HD102184, R01DK128639) and California Institute for Regenerative Medicine and an editorial honorarium from Elsevier. Dr Artsen reported receiving research support from the NIH’s Office of Research on Women’s Health Building Interdisciplinary Research Careers in Women’s Health (K12AR084218).
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