In Reply

We are pleased that our article (1) has initiated a critical discussion of this difficult topic. Our review article attempts, as noted by Dr Lütje, to analyze the paradigm change in the acceptance of cesarean section. Unfortunately, given the scope of this topic, it is not possible to address all aspects in a comprehensive and detailed manner.

The aspect of the protective effect of cesarean section regarding urinary incontinence and genital prolapse has been raised by Dr Lenzen-Schulte and Dr Dietz. For a number of years, there has been great controversy about this subject. Dr Lenzen-Schulte mentions two studies, which were available only after the publication of our review article. In the meantime, several additional studies evaluating the prophylactic effect of cesarean section on the development of urinary incontinence have been published, albeit with conflicting results (2– 4). However, it remains to be seen if these studies will result in a substantial reconsideration of the preventative role of cesarean section, leading to new recommendations. Until then, a cesarean section on request is not recommended (5); however, the individual decision regarding therapeutic options remains unaffected.

As stated by Dr Uphoff, when it comes to assessing the potential risks, the decision ultimately lies with the expectant mother. Consequently, Dr Dietz’s concerns that obstetricians’ or midwifes’ disrespect for women’s legitimate wish for a cesarean section could lead to paternalism appear as largely unfounded in respect of the legal situation in Germany.

Unlike in English-speaking countries, where ethical and economic issues as well as the concept of autonomy and loss of control are of far greater importance, the validity of the respective medical indications and the distinction between absolute and relative indications are at the center of the discussion in Germany. However, for obstetricians practicing in Germany, it is difficult to evaluate the political, socioeconomic and cultural background influencing the development of guidelines and the daily clinical practice in these countries, as highlighted by Dr Dietz. For example: In the case report of a patient wishing for a primary cesarean section after she had experienced three miscarriages, including a life-threatening complication along with placental abruption, a committee consisting of an obstetrician, a neonatologist, an ethics expert and a coordinator of the perinatal center was formed to discuss with this patient her request for a cesarean section (6). In the light of today’s limited personal and financial resources in Germany, this approach might be considered inexplicable.

As Dr Uphoff mentions, the German Federal Court of Justice (BGH) regards cesarean section as a treatment alternative to vaginal delivery “provided that the child is exposed to significant risk in case of performance or continuation of vaginal delivery and cesarean section is a medically acceptable alternative treatment, taking into consideration the mother’s constitution and current state of health”. There is no question that in cases of maternal or fetal emergency (i.e. hypoxia during childbirth) it is medically required to end the parturition as soon as possible, including by means of a cesarean section, to avoid any adverse outcome for the baby. It is coherent that the “clear advantages” of cesarean section in such situations refer to the prevention of these damages. With regard to an elective/planned cesarean section (i.e., request of the mother to prevent pelvic floor injuries or initiated by maternal anxiety), the primary objective is to take the risks, advantages and disadvantages into consideration and discuss them with the patient. Ultimately, from a legal perspective, the final decision is with the expectant mother.

It is very likely that the undisputed increase of cesarean section rates is due to the increasing tendency toward risk avoidance or risk minimization of the expectant parents, risk-adapted obstetrics in respect of increasing legal and liability-related issues, changes in the training of obstetricians as well as socioeconomic and cultural changes. Some of the comments of Mrs Striebich and Dr Lütje, such as the development of guidelines or the establishment of regular cooperative basic and advanced training sessions for midwives and doctors, have become an essential part of obstetrical training in numerous hospitals, improving the medical care we provide to our pregnant patients.