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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 56-58

“Too powerful to push”: A rise in “on demand” caesarean section

1 Consultant Obstetric Anesthesiologist, Breach Candy Hospital; Department of High-Risk Labour and Delivery, SRCC Children's' Hospital, Mumbai, Maharashtra, India
2 Department of Anaesthesia, Perioperative Medicine and Critical Care, AIG Hospitals, Gachibowli; Department of Anaesthesia, Pain and Obstetric Critical Care, Fernandez Hospitals; Founder Director, PACCS Health Care Pvt. Ltd, Hyderabad, Telangana, India

Date of Submission10-Jun-2021
Date of Acceptance23-Jul-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Ketan S Parikh
15, Asha Mahal, 46-B, Pedder Road, Mumbai - 400 026, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOACC.JOACC_42_21

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How to cite this article:
Parikh KS, Pandya ST. “Too powerful to push”: A rise in “on demand” caesarean section. J Obstet Anaesth Crit Care 2021;11:56-8

How to cite this URL:
Parikh KS, Pandya ST. “Too powerful to push”: A rise in “on demand” caesarean section. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2023 Feb 3];11:56-8. Available from: https://www.joacc.com/text.asp?2021/11/2/56/327409

Increase in caesarean section (CS) rate is a global phenomenon and a major concern for women's health. With the advent of modern medicine and newer techniques, safety of surgery and anaesthesia are taken for granted and even misused at times, leading to unwarranted CSs. The World Health Organization has recommended an optimal CS rate of 10 to 15%.[1] The number of CS for childbirth has shown a rapid increase, worldwide, from 12% in 2000 to 21% in 2015, and in India, from 8.5% in 2005–06 to 17.2% in 2015–2016.[2],[3] The CS rate is found to be higher in the private sector compared to public hospitals in India and it increased from 27.7 to 40.9% and even up to 70% in some states of India in 2015–2016.[3] Globally in 2008, approximately 6.2 million caesarean sections of the 29.7 million caesarean deliveries were performed unnecessarily commanding a disproportionate share of global economic resources. The total cost of 'excess' caesarean sections in 2008 was approximately 5.4 times the cost of the 'needed' procedures, having negative implications for health equity both within and across the countries.[4] Various indications both, medical and non-medical, for the CS are looked at and analysed in the literature however, one indication which is overlooked and alarmingly rising is 'maternal request' or 'on demand' CS. Begum T, et al.[5] in their systematic review and meta-regression of CS reported an incidence of maternal demand for a CS of 0.2 to 42% (as a proportion of all deliveries) and 0.9 to 60% (relative to all CS deliveries). The highest rates for on-demand CS were reported from the Middle Eastern and East Asian countries. They also reported an 11-fold increase in on-demand CS in upper–middle-income countries compared with either high or low–middle-income countries. This leads to various questions, why do parturients opt for elective CS? Is it justified? Why do the obstetricians oblige? Is there a need to address this trend or should we just go with the flow?

On-demand CS may be defined as “elective caesarean deliveries performed at term for a singleton pregnancy without obstetric and/or any medical reasons”.[6] The reasons for on-demand CS are multifactorial and involve complex interplay between maternal and social factors and factors related to the perceived quality of childbirth care services during labour and delivery. Among the various reasons for on-demand CS, labour pain and perineal trauma are the prime causes. Posttraumatic psychosis and postnatal blues are closely related and known entities. Higher maternal age is being increasingly identified as a factor for on-demand CS and is possibly related to patient and physician concerns about childbirth outcomes in older women.[7],[8] Increased testing for medical co-morbidity and chromosomal or genetic abnormalities in the foetus of older women may also contribute to anxiety about childbirth outcomes. Women empowerment, education, working-class women wanting undisturbed professional life, and urban location are all reported as risk factors for on-demand CS possibly related to lifestyle choices.[9],[10] They prefer planned schedule events for the fear of losing control over the situation. Psychological factors related to fear of childbirth and possible foetal demise and previous bad experiences with childbirth may also impact the decision to opt for on-demand CS.[11],[12],[13],[14],[15] With increasing use of ART and IVF, in elderly primigravida, with associated comorbidities, many a times the precious pregnancy is being cited as the reason for CS. Apart from this, disruption of modesty may also be a hidden concern. In Indian culture of religion and beliefs, a good “Mahurat”, auspicious time, also plays a role in on-demand CS even in educated and elite class of women.

Complications of vaginal deliveries are also to be blamed for increased maternal request for elective CS. Cervical lacerations, vaginal tear, uterine prolapse, vaginal laxity affecting the future sexual life and stress associated with healing may be playing at the back of their minds when they ask for planned CS. Sometimes, neonatal complications associated with vaginal delivery like use of forceps and its complications, shoulder dystocia, prolonged second stage, and birth asphyxia are discussed out of context in antenatal classes and/or social media without medical moderation. Lack of awareness about complications associated with CS and missing constructive comparison between the two modes of delivery leads to over-projection of the problems during vaginal birth causing unnecessary anxiety and fear in the mind of the parturient.

When a request is made to the obstetrician, sometimes, it's very tempting for them to fall for it. For a busy practitioner, an on-demand CS will cause minimal disruption in their routine and the day can be planned with ease. Maternal and neonatal complications of difficult vaginal birth and associated increasing rate of medico-legal litigation are well known and worrisome to the obstetricians. Demotivated mothers and obliging obstetricians are a perfect combination for planned caesarean. Lack of art and experience as well as exposure to vaginal birth during training can also be a contributory factor. With more and more obstetricians yielding to the request of the parturient, the requests for elective caesarean are only going to increase as the demands and wishes of powerful parturient are being pampered. This is a win-win situation for all!

On-demand CS raises several medical and ethical concerns. Medical practice has usually been paternalistic with patients expected to follow instructions provided by the physician. On-demand CS can raise conflicts with patient autonomy and the principles of beneficence and maleficence (or benefits and harm) and justice. What is the balance between autonomy for the patient to choose the mode of childbirth and perceived benefits and risks from on-demand CS? How do obstetricians and obstetric anaesthesiologists deal with such a demand? Additional concerns to keep in mind besides ethics include the cost and comparative use of resources for on-demand CS compared to vaginal delivery, and the evidence for improved outcomes in the short and long term with an elective on-demand CS.

Obstetric and Obstetric Anaesthesia programs must work together to develop audit processes and indicators to measure reductions in on-demand CS. These must include establishment and/or improvement in pain relief services, empowering the mother to choose appropriate modality for pain relief not only during the labour but even after vaginal delivery. This becomes a pertinent factor for a small percentage of women who end up with birth trauma and babies requiring unplanned Neonatal ICU admissions. Every effort must be made to improve overall experience of parturient during vaginal delivery keeping in mind the universal implementation of ERAD (Enhanced Recovery After Delivery). With the rise of CS, the role and responsibility of obstetric anaesthetist is also challenged. Following ACOG recommendation,[16] practising and making the mother and family understand the concept of “Normal Caesarean Birth” and with implementation of ERAS for CS, as per the consensus statement and recommendation from SOAP,[17] we will be underplaying the inherent risk associated with the surgery. The advent of modern anaesthesia techniques, highly improved safety margins, and minimal or nil anaesthesia-related complications will only add fuel to the fire, encouraging more and more women to opt for on-demand planned surgical delivery.

Interviews and counselling of the mother early in pregnancy about preferred childbirth modes may help to identify women who are likely to choose CS and provide them with appropriate counselling. As per the FIGO position paper on approach to this increasing epidemic, the counselling must also include evidence-based information from the local institute aligned with regional or national data as appropriate.[18] Increasing CS rates are associated with both short- and long-term consequences, both maternal as well as perinatal. These include increased maternal morbidity and mortality and respiratory problems in neonates due to iatrogenic preterm delivery. These iatrogenic risks should be discussed with parturient while making an informed decision of medically unindicated CS. The impact of on-demand CS on medical decision making including a possible reduction of confidence with a vaginal delivery as more childbirths are done through CS must be considered carefully. Non-judgmental Initiatives to improve recognition and acknowledgement of the problem by healthcare practitioners with pragmatic strategies including quality improvement processes are essential. External cephalic version (ECV) for breech presentations where indicated, and Trial of Labour After Caesarean (TOLAC) under epidural analgesia are just two examples where a concerted effort from obstetricians and obstetric anaesthesiologists can enhance the success of vaginal deliveries.[19],[20] Reduction of on-demand CS is a team process that involves not only the childbirth care team, and the woman, but also support from her immediate family.

Strategies to reduce on-demand CS are a priority if we consider the rapidly increasing CS rates in India as there are long-term medical, social and financial impacts. Further, there are implications on women's healthcare and an overall impact on society. We stand by the RCOG statement that women's choice in the matter must be respected as long as they give informed consent after being provided with accurate evidence-based information regarding their options, and a thorough understanding of the pros and cons of their decision.[21] Ultimately, it's a concept of mind over body. Determination to deliver vaginally is important both for the parturient as well as for the obstetrician. Quality improvement processes, system-driven protocols, clinical audits, pain relief services and midwifery support, can certainly pave a safe pathway for vaginal delivery and keep the art of normal vaginal birth alive! A parturient once said, “Every woman has a story to tell about her birth experience”, we must do our best to make that story memorable and worth telling.


The authors would like to acknowledge Prof. Dr. Anjan Trikha, who first suggested us, this topic for an editorial. We have no other conflict of interests.

  References Top

Chien P. Global rising rates of caesarean sections. BJOG 2021;128:781-2.  Back to cited text no. 1
Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018;392:1341-8.  Back to cited text no. 2
International Institute for Population Sciences. (2017). NFHS-4 (National Family Health Survey-4)-2015–16-India fact sheet. Retrieved from: http://rchiips.org/nfhs/pdf/NFHS4/India.pdf.  Back to cited text no. 3
Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Report 2010;30:3-10.  Back to cited text no. 4
Begum T, Saif-Ur-Rahman KM, Yaqoot F, Stekelenburg J, Anuradha S, Biswas T, et al. Global incidence of caesarean deliveries on maternal request: A systematic review and meta-regression. BJOG 2021;128:798-806.  Back to cited text no. 5
National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006. Obstet Gynecol 2006;107:1386-97.  Back to cited text no. 6
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Byrom A. Advanced maternal age: A literature review. Br J Midwifery 2004;12:779-83.  Back to cited text no. 8
Loke A, Davies L, Li SF. Factors influencing the decision that women make on their mode of delivery: The Health Belief model. BMC Health Serv Res 2015;15:274.  Back to cited text no. 9
Faisal I, Matinnia N, Hejar AR, Khodakarami Z. Why do primigravida requests caesarean section in a normal pregnancy? A qualitative study in Iran. Midwifery 2014;30:227-33.  Back to cited text no. 10
Poikkeus P, Saisto T, Unkila-Kallio L, Punamaki R, Repokari L, Vilska S, et al. Fear of childbirth and pregnancy-related anxiety in women conceiving with assisted reproduction. Obstet Gynecol 2006;108:70-6.  Back to cited text no. 11
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