- Email: [email protected]
Cesarean section on request in a developing country
International Journal of Gynecology and Obstetrics (2007) 96, 54–56
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
SPECIAL ARTICLE
Cesarean section on request in a developing country C.O. Chigbu ⁎, I.V. Ezeome, G.C. Iloabachie Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria Received 11 August 2006; received in revised form 26 September 2006; accepted 30 September 2006
KEYWORDS Cesarean section; Cesarean section on request; Developing country
Abstract Objective: To assess the prevalence of cesarean sections (CSs) and women's reasons for requesting the procedure in a developing country. Method: Pregnant women scheduled for elective CS were interviewed to determine whether the procedure was requested by them or suggested by a physician. The women who personally requested a CS filled out questionnaires before surgery and at the postnatal visit 6 weeks later, and their answers were analyzed. Results: The prevalence of CS on request was 4.4%. Previous infertility and advanced maternal age at first pregnancy were the most common reasons for requesting a CS, but most women said they would prefer a vaginal delivery in subsequent pregnancies. Conclusion: The women who requested a CS in this study did so for reasons different from those put forth by women in developed countries. The view that a CS is the surest way toward a live birth was the critical factor underlying their choice. © 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction One of the most commonly performed surgical operation, cesarean section (CS) is indicated when a contraindication to labor is present or when completion of a vaginal delivery is thought to be unsafe [1]. In this situation, the risk of an adverse outcome without a CS outweighs the risk of an adverse outcome from a CS. In contrast, a non-medically indicated CS is performed for reasons other than a defined risk [2]. While there are no disagreements on the benefits of a medically indicated CS, there have been many debates about primary elective CS performed on the request of healthy women with uncomplicated pregnancies [3–5]. Primary elective CS performed on maternal request now represents ⁎ Corresponding author. E-mail address: [email protected] (C.O. Chigbu).
4% to 18% of all CSs and 14% to 22% of elective CSs in most reported series [6]. The fact that CSs on request constitute a significant proportion of all CSs in developed countries [7,8] has given rise to many reports and commentaries in these countries, in the medical and lay literature alike. The International Federation of Obstetricians and Gynecologists (FIGO) Committee for Ethical Aspects of Human Reproduction has argued that it is unethical to perform a CS without a medical indication because of inadequate evidence for a net benefit [9]. Others, however, argue that women's choices should be respected [3,10], especially since there is no evidence of an increased risk when the procedure is performed during the 39th or 40th week of pregnancy. While much intellectual energy has been spent on the ethical and legal implications of CS on request in developed countries [5,11], women's aversion for CS even in the face of obvious and compelling medical indications appears to be prevalent in developing countries [12]. Consequently,
0020-7292/$ - see front matter © 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.09.032
Cesarean section on request in a developing country reports from developing countries regarding CS on request are rare. A Medline search did not identify any study from the African continent on this topic. The present study examines requests for a CS in the absence of any medical indication at University of Nigeria Teaching Hospital Enugu and Aghaeze Specialist Hospital Enugu, Enugu, Nigeria. University of Nigeria Teaching Hospital Enugu is a tertiary health institution that serves as a referral center for the southeastern Nigerian states of Enugu, Ebonyi, Anambara, Imo, Abia, and Benue. Aghaeze Specialist Hospital Enugu is a women's center located in Enugu.
2. Methods This prospective study spanned 3 years, from January 2003 to January 2006. All pregnant women booked for an elective CS were interviewed to determine whether the procedure was requested by them alone or suggested by a physician, and those who requested the CS were recruited for the study. All women were then administered a previously tested oral questionnaire to determine, among other things, their reasons for the request, their physician's initial response, their awareness of the risks associated with CS, as well as their age, parity, and level of education. At the postnatal visit 6 weeks later they were given another oral questionnaire inquiring whether they had any regrets regarding the CS, their likely choice of delivery in any subsequent pregnancy, and the reasons motivating their answers. The women who did not attend the postnatal visit were asked the questions by telephone or during home visits. The answers were analyzed at the end of the study using the SPSS software package, version 10 (SPSS Inc., Chicago, Illinois, USA) and results expressed in descriptive statistics.
3. Results Of the 2340 deliveries performed during the study period 619 (26.5%) were CSs; and of these 619 CSs, 27 (4.4%) were performed at term on maternal request. Table 1 shows the women's distribution according to their given reasons for the request. The mean age of the women was 36 ± 4 years
Table 1 Reason
Nigerian women's reasons for requesting a CS No. of No. of women women (%) desirous of a CS in the future
Previous infertility 11 (40.7) Advanced maternal age at first 8 (29.6) pregnancy Previous explained, 4 (14.8) nonrecurrent perinatal loss Previous prolonged labor 2 (7.4) Desire for a male child, with 1 (3.7) ultrasonographic detection of a male fetus Previous child with cerebral 1 (3.7) palsy Total 27 (100)
0 0 0 2 0
1 3
55 (range, 26–43 years); their mean parity was 2 ± 1 (range, 1– 6); and 26 (96.3%) of them had a university education while 1 (3.7%) had secondary education. All responded that they had knowledge of the risks of undergoing a CS. The request was accepted without objection by their physicians in 23 cases (85.2%) whereas it was initially objected to, but then accepted upon the woman's insistence, in 4 cases (14.8%). The mean Apgar score at 5 min was 8 ± 1 (range, 5–10). None of the women had any regrets 6 weeks postpartum; and of the 3 (11.1%) who wanted an elective CS in subsequent pregnancies, 2 had requested the index CS because of previous prolonged labor and 1 because she had a child with cerebral palsy and wanted to avoid a recurrence. The 24 remaining women (88.9%) said they would prefer a vaginal delivery in subsequent pregnancies, and their reason was their desire to be ba real womanQ. However, 25 of the 27 women (92.6%) believed that CS offers the best chance for a live birth.
4. Discussion This study is the first conducted in Nigeria about CSs on maternal request. The rate of 4.4% found in this study falls at the lower limit of the reported range of 4% to 18% [7]. This is understandable, given the aversion of Nigerian women for CSs in general [12]. The reasons for the request seem to differ from those put forth in developed countries (Table 1). While convenience, fear of labor (tocophobia) [8], the perceived adverse effect of labor on the pelvic floor, the desire to maintain a honeymoon-fresh vagina [11], avoidance of vaginal trauma [13], and risks associated with trial of labor [14] rank as major issues for CS requests in developed countries, previous infertility and advanced maternal age at first pregnancy were the major reasons declared in this study. Since 96.3% of the women had a university education, it would be tempting to think that a high level of education had an influence on the women's choice of CS; however, this cannot be concluded from the study. Another finding worthy of note is that only 11.1% of the women who requested a CS in the index pregnancy indicated a willingness to request a CS in future pregnancies. These were the women whose reasons for the index request were previous prolonged labor and a child with cerebral palsy. Understandably, these women have developed a phobia for labor. All the other women, however, wanted to try labor in future pregnancies. These were the women whose reasons for the index request were previous infertility; previous explained, and nonrecurrent, perinatal deaths; their desire for a male child; and advanced maternal age at first pregnancy. Therefore, the underlying aim of this subset of women was a live birth to beat the problem of childlessness. Desperate for a live child, but not sure of ever achieving another viable pregnancy, they believed that a CS offered them the best chance of fulfilling their desire. This notion was so strongly held among these women that they were willing to accept the morbidity and mortality associated with CS — which underscores the premium placed on child-bearing in Nigeria. Now comes the paradox. Having fulfilled their desire for a live birth by means of a CS, they were now ready to try vaginal delivery, also with its risks. Because of the high social premium placed on vaginal delivery in Nigeria, women who took the risk of undergoing a CS without any medical
56 indication would thereafter take the risk of undergoing a vaginal birth — merely for satisfying the societal expectations associated with being breal women.Q This contrasts sharply with a finding of Davies and Edwards [13], who report that in a study conducted in a developed country 46.5% of women requesting a primary CS preferred repeated CSs in subsequent pregnancies. Only in 11.1% of cases did physicians initially object to their patients' request for a CS. Cotzias and colleagues reported on the increased willingness of obstetricians in a developed country to accept their patients' request for a CS in the absence of bmitigatingQ circumstances [15]. The ethical and legal issues pertaining to CS on request have yet been addressed neither by the Society of Obstetricians and Gynecologists of Nigeria nor by the Nigerian legal system. This is understandable, as the general aversion of Nigerian women for even well-indicated CSs has overshadowed the cases of CS on maternal request. The present study raises pertinent questions and ethical issues. How true is the notion that an elective CS offers the best chance for a live birth in the Nigerian social environment? Does the acceptance of requests for non-medically indicated CSs by obstetricians imply that these physicians share the women's beliefs, or are there other reasons underlying their response? Would proper counseling have changed the mindset of the women and make them opt for vaginal deliveries? These questions must be answered in the context of developing countries because of the different reasons underlying requests for CSs in developed countries. In conclusion, despite the documented strong aversion of women for CSs in developing countries, CSs on maternal request are also performed. However, the reasons requesting a CS differ from those put forth in developed countries. Some research, as well as a debate regarding the ethical questions that CS on request entails, also need to be carried out in developing countries.
C.O. Chigbu et al.
References [1] Sehdev HM. Cesarean delivery. eMed J 2002;3(2) Available at: http://www.emedicine.com. [2] Penna L, Arulkumaran S. CS for non-medical reasons. Int J Gynecol Obstet 2003;82(3):399–409. [3] Paterson-Brown S. Should doctors perform an elective CS on request? Yes, as long as the woman is fully informed. Br Med J 1998;317:462–3. [4] Amu O, Rajendran S, Bolaji II. Should doctors perform an elective CS on request? Maternal choice alone should not determine method of delivery. Br Med J 1998;317:463–4. [5] Bewley S, Cockburn J. The unethics of brequestQ cesarean section. Br J Obstet Gynaecol 2002;109(6):593–6. [6] Wax JR, Cartin A, Pinette MG, Blackstone J. Patient-choice cesarean: the Maine experience. Birth 2005;32(3):203. [7] Jackson NV, Irvine LM. The influence of maternal request on elective CS rate. J Obstet Gynecol 1998;18(2):115–9. [8] Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice cesarean: an evidence-based review. Obstet Gynecol Surv 2004;59(8):601–16. [9] FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical aspects regarding cesarean delivery for non-medical reasons. Int J Obstet Gynecol 1999;64: 317–22. [10] Nijhuis JG. A request for CS without medical reason should ultimately be granted. Ned Tijdschr Geneeskd 2006;150(14):788. [11] Bewley S, Cockburn J. The unfacts of brequestQ cesarean section. Br J Obstet Gynaecol 2002;109(6):597–605. [12] Kwawukume EY. CS in developing countries. Bailliere's Best Pract Res Clin Obstet Gynaecol 2001;15(1):165–78. [13] Edwards GJ, Davies NJ. Elective caesarean section: the patients choice. J Obstet Gynaecol 2001;21(2):128–9. [14] Hale RW, Harer WB. Elective prophylactic cesarean delivery. ACOG Clin Rev 2005;10(2):1, 15–16. [15] Cotzias CS, Paterson-Brown S, Fisk NM. Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. Eur J Obstet Gynecol Reprod Biol 2001;97:15–6.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
SPECIAL ARTICLE
Cesarean section on request in a developing country C.O. Chigbu ⁎, I.V. Ezeome, G.C. Iloabachie Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria Received 11 August 2006; received in revised form 26 September 2006; accepted 30 September 2006
KEYWORDS Cesarean section; Cesarean section on request; Developing country
Abstract Objective: To assess the prevalence of cesarean sections (CSs) and women's reasons for requesting the procedure in a developing country. Method: Pregnant women scheduled for elective CS were interviewed to determine whether the procedure was requested by them or suggested by a physician. The women who personally requested a CS filled out questionnaires before surgery and at the postnatal visit 6 weeks later, and their answers were analyzed. Results: The prevalence of CS on request was 4.4%. Previous infertility and advanced maternal age at first pregnancy were the most common reasons for requesting a CS, but most women said they would prefer a vaginal delivery in subsequent pregnancies. Conclusion: The women who requested a CS in this study did so for reasons different from those put forth by women in developed countries. The view that a CS is the surest way toward a live birth was the critical factor underlying their choice. © 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction One of the most commonly performed surgical operation, cesarean section (CS) is indicated when a contraindication to labor is present or when completion of a vaginal delivery is thought to be unsafe [1]. In this situation, the risk of an adverse outcome without a CS outweighs the risk of an adverse outcome from a CS. In contrast, a non-medically indicated CS is performed for reasons other than a defined risk [2]. While there are no disagreements on the benefits of a medically indicated CS, there have been many debates about primary elective CS performed on the request of healthy women with uncomplicated pregnancies [3–5]. Primary elective CS performed on maternal request now represents ⁎ Corresponding author. E-mail address: [email protected] (C.O. Chigbu).
4% to 18% of all CSs and 14% to 22% of elective CSs in most reported series [6]. The fact that CSs on request constitute a significant proportion of all CSs in developed countries [7,8] has given rise to many reports and commentaries in these countries, in the medical and lay literature alike. The International Federation of Obstetricians and Gynecologists (FIGO) Committee for Ethical Aspects of Human Reproduction has argued that it is unethical to perform a CS without a medical indication because of inadequate evidence for a net benefit [9]. Others, however, argue that women's choices should be respected [3,10], especially since there is no evidence of an increased risk when the procedure is performed during the 39th or 40th week of pregnancy. While much intellectual energy has been spent on the ethical and legal implications of CS on request in developed countries [5,11], women's aversion for CS even in the face of obvious and compelling medical indications appears to be prevalent in developing countries [12]. Consequently,
0020-7292/$ - see front matter © 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.09.032
Cesarean section on request in a developing country reports from developing countries regarding CS on request are rare. A Medline search did not identify any study from the African continent on this topic. The present study examines requests for a CS in the absence of any medical indication at University of Nigeria Teaching Hospital Enugu and Aghaeze Specialist Hospital Enugu, Enugu, Nigeria. University of Nigeria Teaching Hospital Enugu is a tertiary health institution that serves as a referral center for the southeastern Nigerian states of Enugu, Ebonyi, Anambara, Imo, Abia, and Benue. Aghaeze Specialist Hospital Enugu is a women's center located in Enugu.
2. Methods This prospective study spanned 3 years, from January 2003 to January 2006. All pregnant women booked for an elective CS were interviewed to determine whether the procedure was requested by them alone or suggested by a physician, and those who requested the CS were recruited for the study. All women were then administered a previously tested oral questionnaire to determine, among other things, their reasons for the request, their physician's initial response, their awareness of the risks associated with CS, as well as their age, parity, and level of education. At the postnatal visit 6 weeks later they were given another oral questionnaire inquiring whether they had any regrets regarding the CS, their likely choice of delivery in any subsequent pregnancy, and the reasons motivating their answers. The women who did not attend the postnatal visit were asked the questions by telephone or during home visits. The answers were analyzed at the end of the study using the SPSS software package, version 10 (SPSS Inc., Chicago, Illinois, USA) and results expressed in descriptive statistics.
3. Results Of the 2340 deliveries performed during the study period 619 (26.5%) were CSs; and of these 619 CSs, 27 (4.4%) were performed at term on maternal request. Table 1 shows the women's distribution according to their given reasons for the request. The mean age of the women was 36 ± 4 years
Table 1 Reason
Nigerian women's reasons for requesting a CS No. of No. of women women (%) desirous of a CS in the future
Previous infertility 11 (40.7) Advanced maternal age at first 8 (29.6) pregnancy Previous explained, 4 (14.8) nonrecurrent perinatal loss Previous prolonged labor 2 (7.4) Desire for a male child, with 1 (3.7) ultrasonographic detection of a male fetus Previous child with cerebral 1 (3.7) palsy Total 27 (100)
0 0 0 2 0
1 3
55 (range, 26–43 years); their mean parity was 2 ± 1 (range, 1– 6); and 26 (96.3%) of them had a university education while 1 (3.7%) had secondary education. All responded that they had knowledge of the risks of undergoing a CS. The request was accepted without objection by their physicians in 23 cases (85.2%) whereas it was initially objected to, but then accepted upon the woman's insistence, in 4 cases (14.8%). The mean Apgar score at 5 min was 8 ± 1 (range, 5–10). None of the women had any regrets 6 weeks postpartum; and of the 3 (11.1%) who wanted an elective CS in subsequent pregnancies, 2 had requested the index CS because of previous prolonged labor and 1 because she had a child with cerebral palsy and wanted to avoid a recurrence. The 24 remaining women (88.9%) said they would prefer a vaginal delivery in subsequent pregnancies, and their reason was their desire to be ba real womanQ. However, 25 of the 27 women (92.6%) believed that CS offers the best chance for a live birth.
4. Discussion This study is the first conducted in Nigeria about CSs on maternal request. The rate of 4.4% found in this study falls at the lower limit of the reported range of 4% to 18% [7]. This is understandable, given the aversion of Nigerian women for CSs in general [12]. The reasons for the request seem to differ from those put forth in developed countries (Table 1). While convenience, fear of labor (tocophobia) [8], the perceived adverse effect of labor on the pelvic floor, the desire to maintain a honeymoon-fresh vagina [11], avoidance of vaginal trauma [13], and risks associated with trial of labor [14] rank as major issues for CS requests in developed countries, previous infertility and advanced maternal age at first pregnancy were the major reasons declared in this study. Since 96.3% of the women had a university education, it would be tempting to think that a high level of education had an influence on the women's choice of CS; however, this cannot be concluded from the study. Another finding worthy of note is that only 11.1% of the women who requested a CS in the index pregnancy indicated a willingness to request a CS in future pregnancies. These were the women whose reasons for the index request were previous prolonged labor and a child with cerebral palsy. Understandably, these women have developed a phobia for labor. All the other women, however, wanted to try labor in future pregnancies. These were the women whose reasons for the index request were previous infertility; previous explained, and nonrecurrent, perinatal deaths; their desire for a male child; and advanced maternal age at first pregnancy. Therefore, the underlying aim of this subset of women was a live birth to beat the problem of childlessness. Desperate for a live child, but not sure of ever achieving another viable pregnancy, they believed that a CS offered them the best chance of fulfilling their desire. This notion was so strongly held among these women that they were willing to accept the morbidity and mortality associated with CS — which underscores the premium placed on child-bearing in Nigeria. Now comes the paradox. Having fulfilled their desire for a live birth by means of a CS, they were now ready to try vaginal delivery, also with its risks. Because of the high social premium placed on vaginal delivery in Nigeria, women who took the risk of undergoing a CS without any medical
56 indication would thereafter take the risk of undergoing a vaginal birth — merely for satisfying the societal expectations associated with being breal women.Q This contrasts sharply with a finding of Davies and Edwards [13], who report that in a study conducted in a developed country 46.5% of women requesting a primary CS preferred repeated CSs in subsequent pregnancies. Only in 11.1% of cases did physicians initially object to their patients' request for a CS. Cotzias and colleagues reported on the increased willingness of obstetricians in a developed country to accept their patients' request for a CS in the absence of bmitigatingQ circumstances [15]. The ethical and legal issues pertaining to CS on request have yet been addressed neither by the Society of Obstetricians and Gynecologists of Nigeria nor by the Nigerian legal system. This is understandable, as the general aversion of Nigerian women for even well-indicated CSs has overshadowed the cases of CS on maternal request. The present study raises pertinent questions and ethical issues. How true is the notion that an elective CS offers the best chance for a live birth in the Nigerian social environment? Does the acceptance of requests for non-medically indicated CSs by obstetricians imply that these physicians share the women's beliefs, or are there other reasons underlying their response? Would proper counseling have changed the mindset of the women and make them opt for vaginal deliveries? These questions must be answered in the context of developing countries because of the different reasons underlying requests for CSs in developed countries. In conclusion, despite the documented strong aversion of women for CSs in developing countries, CSs on maternal request are also performed. However, the reasons requesting a CS differ from those put forth in developed countries. Some research, as well as a debate regarding the ethical questions that CS on request entails, also need to be carried out in developing countries.
C.O. Chigbu et al.
References [1] Sehdev HM. Cesarean delivery. eMed J 2002;3(2) Available at: http://www.emedicine.com. [2] Penna L, Arulkumaran S. CS for non-medical reasons. Int J Gynecol Obstet 2003;82(3):399–409. [3] Paterson-Brown S. Should doctors perform an elective CS on request? Yes, as long as the woman is fully informed. Br Med J 1998;317:462–3. [4] Amu O, Rajendran S, Bolaji II. Should doctors perform an elective CS on request? Maternal choice alone should not determine method of delivery. Br Med J 1998;317:463–4. [5] Bewley S, Cockburn J. The unethics of brequestQ cesarean section. Br J Obstet Gynaecol 2002;109(6):593–6. [6] Wax JR, Cartin A, Pinette MG, Blackstone J. Patient-choice cesarean: the Maine experience. Birth 2005;32(3):203. [7] Jackson NV, Irvine LM. The influence of maternal request on elective CS rate. J Obstet Gynecol 1998;18(2):115–9. [8] Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice cesarean: an evidence-based review. Obstet Gynecol Surv 2004;59(8):601–16. [9] FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. Ethical aspects regarding cesarean delivery for non-medical reasons. Int J Obstet Gynecol 1999;64: 317–22. [10] Nijhuis JG. A request for CS without medical reason should ultimately be granted. Ned Tijdschr Geneeskd 2006;150(14):788. [11] Bewley S, Cockburn J. The unfacts of brequestQ cesarean section. Br J Obstet Gynaecol 2002;109(6):597–605. [12] Kwawukume EY. CS in developing countries. Bailliere's Best Pract Res Clin Obstet Gynaecol 2001;15(1):165–78. [13] Edwards GJ, Davies NJ. Elective caesarean section: the patients choice. J Obstet Gynaecol 2001;21(2):128–9. [14] Hale RW, Harer WB. Elective prophylactic cesarean delivery. ACOG Clin Rev 2005;10(2):1, 15–16. [15] Cotzias CS, Paterson-Brown S, Fisk NM. Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. Eur J Obstet Gynecol Reprod Biol 2001;97:15–6.