Abstract
Background: Caesarean Delivery on Maternal Request (CDMR) is increasingly seen as a viable option to vaginal delivery even in the absence of medical or obstetric contraindications to vaginal delivery.
Material and Methods: Self administered questionnaires were instituted to Senior Consultant Obstetricians attending the examiners' meeting of the faculty of obstetrics and gynaecology of the West African College of Surgeon in Ibadan, Nigeria on 17th April, 2013 and 23th October, 2013. This was to assess their experience and attitudes toward CDMR. The data were analysed with SPSS version 16.0
Results: The majority of the consultants, 94.4%(85/90) have had antenatal client(s) ask for CDMR and 81.2%(69/85) of them have operated on at least a patient for CDMR. The reasons for the CDMR were: precious pregnancy/infertility, previous traumatic delivery and to avoid the stress of labour in 33%, 20.7% and 16.2% respectively. Eighty percent(68/85) consultants have counseled the women but only 11.8%(10/85) of them have had their patients change their minds and opted for vaginal delivery. Eighty eight(97.8%) of the obstetricians sampled are aware of the FIGO stand on Caesarean section however, 80(88.9%) of them opined that it is important to accommodate the feelings of the women and offer CDMR for the respect of the patient's autonomy.
Conclusion: There are cases of CDMR in the West African sub region and increasing willingness of the consultants to oblige to the request. There is need to develop a treatment guidelines/protocols for CDMR that will suit our environment in order to avoid over burdening of the limited health resources.
Keywords: Caesarean, Delivery , Maternal request, Obstetricians , Consultants , West Africa
Introduction
Caesarean Delivery on Maternal Request (CDMR) refers to elective delivery by caesarean section at the request of a mother with no identifiable medical or obstetric contraindications to an attempt at vaginal delivery1. While uncommon in the past, a recent study in the southern part of Nigeria revealed that 4% of caesarean sections were performed for precisely this reason2.
Over the years there has been a dramatic evolution of the operation with increasing safety, mainly due to advances in asepsis, surgery and anaesthesia. This has resulted to both Obstetricians and expecting mothers electing caesarean delivery as a viable option to vaginal delivery even in the absence of any maternal or foetal indication. This shift in the balance of benefit versus harm in caesarean section, as compared to vaginal delivery, has logically resulted in a lowered threshold for caesarean sections. A study among Obstetricians in United Kingdom showed that 31% of female obstetricians would choose an elective caesarean section for themselves and 69% are willing to perform the procedure as requested by their patients3. Similarly, 53.1% of Nigerian Obstetricians will comply to CDMR in respect for patients autonomy and 48% of them have performed at least one caesarean operation on this premise4.
Also a study among antenatal attendees in Nigeria showed that 39.6% of the women are aware of CDMR but only 6.6% are willing to request for it5.
As it is, the decision to perform or refuse CDMR poses a moral and ethical challenge for the obstetrician in choosing between the patient's right to an autonomous decision and the caregiver's right to operate in accordance with accepted medical practice6. The principle of justice also requires the obstetrician to ensure fair and equitable distribution of the limited resource in the health sector7. In addition, the International Federation of Gynecology and Obstetrics(FIGO) has declared that Caesarean section should be reserved for purely maternal or foetal indication8. Based on the ethical principles of beneficence, nonmaleficence, and justice, it is difficult to offer CDMR in a resource constraints environment like ours.
In many developing countries with socialistic healthcare in most hospitals, performing CDMR may override the rights of the society if insufficient resource remains to provide for medically indicated caesarean sections and the CDMR may be refused for that reason alone. While this assertion may be acceptable, it still leaves us with the dilemma of whether to refuse or oblige, especially in a private setting if the woman is prepared to pay.
Previous studies have looked at the attitude of obstetrician to CDMR in Nigeria but we broaden the scope to study senior obstetricians and trainers across the west African sub-region. This finding may chart a way toward developing a treatment guideline/protocol for CDMR in the region.
Materials and Methods
Self administered pretested and validated questionnaires were instituted to Senior Consultant Obstetricians (with at least 10 years experience as a consultant and trainer in Obstetrics and Gynaecology) attending the examiners' meeting of the faculty of obstetrics and gynaecology of the West African College of Surgeon in Ibadan, Nigeria on March 17, 2013 and October 2013. This was to assess their experience and attitudes toward CDMR. Both open ended and close ended questions were asked.
Respondents were asked to indicate if they have been asked by their antenatal clients for CDMR and indicate the frequency of such consultation in the last 12 months. They were also asked if they have counselled their clients on the procedure and if they have ever succeeded in making their clients change their minds and go for vaginal delivery. Respondents were asked to highlight 3 common reasons why the women ask for CDMR and also highlight 3 non medical indications that will justify CDMR in their opinion.
The respondents were also asked if they had performed a CDMR and state the reason for their action. They were asked if they agree with FIGO's stand that Caesarean section should only be done for medical/obstetric indication. The questionnaire was pre-tested with other obstetricians in Maiduguri, North eastern Nigeria. The findings are illustrated as proportions and percentages. The data were analysed with SPSS version 16.0.
Reports
A total of 112 questionnaires were instituted and 80.4% (90/112) were fully completed and these formed the basis of this analysis. The majority of the consultants, 94.4% (85/90) have had their antenatal client(s) ask for CDMR while the remaining 5 (5.6%) had never had a patient ask for CDMR. The frequency of such consultation in the past one year is shown in table 1.
There were various reasons why the patients request for CDMR. The Obstetricians were asked to list the 3 most important reasons for the request and the common reasons are outlined in table 2.
Counseling is an important part of the management of CDMR and 80% (68/85) of the consultants have counseled the women about the risks and benefits of the operation but only 11.8% (10/85) of them have had their patients changed their minds about the procedure and opted for vaginal delivery. Up to 81.2%(69/85) obstetricians have operated at least a patient for CDMR.
The Consultants' opinion on justifiable indications for CDMR are similar but 16.2% would offer CDMR for no mitigating factor. Table 3 showed the 3 justifiable indications for CDMR in the opinion of the consultants.
Eighty eight (97.8%) of the obstetricians sampled are aware of the FIGO stand on Caesarean section and that should only be done for medically justifiable reason. However, 80(88.9%) of the obstetricians feel it is important to accommodate the feelings of the women and have respect for the patient's autonomy. In addition a similar number of the obstetricians called for a treatment guideline/protocol that will be suitable to our environment in order to take care of our women's diverse needs.
Discussion
CDMR is increasingly being seen as an option to vaginal delivery and its proliferation will pose a threat to spontaneous labour and vaginal birth. This can be seen from our study where more than 90% of the consultants have been confronted by women asking for that service. It is obvious that our women truly request for this service during antenatal care and to further buttress that, CDMR has featured prominently as an indication for C/S in a tertiary hospital in Nigeria2. What is more worrisome is the frequency with which such requests are granted, as 81.2% of the consultants have operated a patient for CDMR and this is higher than the finding of Chigbu et al in 20104. This finding may suggest increasing compliance to CDMR in this region especially that our sample consists of senior obstetricians and trainers with years of experience, who are more likely to have more patients. The low threshold for caesarean operation amongst the consultants could trigger an increase in Caesarean section rate in the region especially if the CDMR demand increases.
At the moment, awareness amongs the women is low. A study in Ibadan, South-western Nigeria has shown that only 39.5% of the antenatal women are aware that they can request for CDMR as mode of delivery and even fewer are willing to make that request5. This may be the reason behind the infrequent demand for such service during antenatal consultations in this region. In this study more than a 3rd of the consultants encounter CDMR less than once in 3 months. These sporadic requests mean that CDMR may remain low in the West African sub-region for years to come and it is unlikely to pose undue demand on the already overstretched health care resources in developing countries. However, the above assertion should not be taken for granted in this era of increasing westernisation.
Various reasons were advanced by the women for the CDMR and the common reasons for this demand were infertility or precious pregnancy, previous traumatic labour experience and avoidance of the stress of labour. This is similar to the finding by Okwonkwo et al where the common reasons were fear of labour pains and fear of poor labour outcome5. The concern over weakened pelvic floor is featured prominently as third common reason for CDMR in southwestern Nigeria5, where it ranked low as the 8th common reason in this study. Our finding also contrasts with the finding in UK where tocophobia is the commonest reason for CDMR9.
The consultants opined that CDMR is justifiable under certain conditions and are more willing to offer CDMR. A history of infertility or carrying a precious baby usually puts a lot of demand on the obstetrician to deliver a healthy baby. Additionally there is also the couple's quest for a perfect baby, devoid of poor labour outcome. These can easily sway the mother to demand CDMR and because of the perceived safety of Caesarean section in recent times, this concern is also shared by the obstetricians who can easily oblige. This choice is also supported by the study of Dahlgren et al which showed that CDMR decreases the risk of life threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery10.
Previous traumatic labour experience and the fear that such complications could reoccur in subsequent labour may also pose a challenge in decision making on the mode of delivery. But with the availability of modern methods of detecting fetuses in jeopardy and early recourse to caesarean delivery some women may elect to go for vaginal delivery after appropriate counseling. Unfortunately, not all the previous complications can be predicted with precision. The lack of data on some of the risk factors and benefits of vaginal delivery over caesarean section particularly in this region may be responsible for only a few consultants being able to make their clients change their mind after an initial request for CDMR to go for spontaneous labour as shown in the study. This underscores the need for a treatment guideline on CDMR for obstetricians practicing in the West African sub region. This guideline will be of immense value in counseling women who want CDMR and to allow better selection of patients for CDMR while still accommodating the consultants' respect for patients' autonomy. The need for caution and treatment guideline was also shared by about 80% of the consultants sampled in this study.
Conclusions
Our study has shown that there are cases of Caesarean Delivery on Maternal Request in the West African sub region and increasing willingness of consultants to oblige to the request. There is need to develop treatment guidelines/protocols for CDMR that will suit our environment in order to avoid over burdening of the limited health resources.
Table 1: The number of Caesarean Delivery on Maternal Request seen in the last 12 months.
| No. of cases in the last 12 months | Frequency | Percentage |
| 1 | 14 | 16.4 |
| 2 | 19 | 22.3 |
| 3 | 31 | 36.5 |
| 4 | 10 | 11.8 |
| 5 | 6 | 7.1 |
| 6 or more | 5 | 5.9 |
| Total | 85 | 100 |
Table 2: The women's reasons for Caesarean Delivery on Maternal Request
| S/No | Reasons for C/S | Frequency | Percentage |
| 1 | Precious pregnancy/infertility | 66 | 33.3 |
| 2 | Previous traumatic delivery | 41 | 20.7 |
| 3 | Avoid the stress of labour | 32 | 16.2 |
| 4 | Fear of labour pains | 23 | 11.6 |
| 5 | Choose specific birthday | 12 | 6.1 |
| 6 | Logistics/security challenges | 9 | 4.6 |
| 7 | Presence of relative/husband | 7 | 3.5 |
| 8 | Maintain pelvic floor integrity | 6 | 3.0 |
| 9 | Physician's convenience | 2 | 1.0 |
| Total | 198 | 100 | |
| # the total is more than 85 because of multiple responses. | |||
Table 3: Scenarios for Caesarean Delivery on Maternal Request acceptable to the Consultants
| S/no | Indication | Frequency | Percentage |
| 1 | Precious baby/infertility | 78 | 37.1 |
| 2 | Previous traumatic labour experience | 52 | 24.8 |
| 3 | No mitigating reason | 34 | 16.2 |
| 4 | Tocophobia | 28 | 13.3 |
| 5 | Maintain pelvic floor integrity | 18 | 8.6 |
| Total | 210 | 100 | |
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
References
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