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\begin{document}

\title{Towards to a lower rate of cesarean delivery on maternal request : stick
to indication}



\author[1]{Rui-Hong Xue}%
\affil[1]{International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{Towards to a lower rate of cesarean delivery on maternal request
: stick to indication}

Rui-Hong Xue\textsuperscript{1,MD}

\emph{\textsuperscript{1}International Peace Maternity and Child Health
Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,
China}

\textbf{Correspondence:} Rui-Hong Xue, \textsuperscript{MD}

Postal address: No.910 Hengshan Road, Shanghai, China

Postal code: 200030. Work phone: +86-021-64070434

E-mail: \emph{wfmcxrh@alumni.sjtu.edu.cn}

\textbf{Disclosure of interests:} The author declares no conflict of
interests.

\textbf{Funding:} None

\textbf{Word Count: 1013}

In the past several decades, a pattern of rapid increase in cesarean
delivery rates has been observed worldwide, though this increase has
varied across regions, cesarean delivery without an medical indication
has become a major public health concern,among which cesarean delivery
on maternal request(CDMR) without benefits for maternal or neonatal
health~could not be neglected.

In the United States around 30~\% of women deliver by cesarean section,
and across Europe general cesarean section rates vary from 17\% to
52~\%.~In European countries, the cesarean delivery rates vary from
52.2\% in Cyprus to 14.8\% in Iceland, with rates in the United Kingdom
ranging from 24.6\% in England to 29.9\% in Northern
Ireland.~Australia's cesarean delivery rate increased from less than
20\% in 1998 to approximately 30\% in 2008. ~In 2014, the cesarean
delivery rate in China was 34.9\%, with geographic variation ranging
from greater than 60\% in some supercities to less than 10\% in some
rural areas. The cesarean delivery rates in China from 2008 to 2018
showed an overall increasing trend. However,~the increases in Cesarean
rates were not associated with improved perinatal outcomes, regardless
of whether starting Cesarean rates were already high or not. On the
contrary neonatal intensive care unit admissions increased with
increasing Cesarean section rate. After the outbreak of COVID-19, the
condition seems to have been getting worse. It is time to stick to
medical indication towards to a lower rate of cesarean section before it
is too late.

The reasons for the increase of cesarean delivery remain controversial,
while it is believed that this increase is largely driven by CS without
clinical indication, of which, cesarean delivery on maternal request is
one of the important reasons. It is estimated that 2.5\% of all births
in the United States are cesarean delivery on maternal request. While in
China, the cesarean section rate has been high, because of the lack of
research on cesarean section without medical indication, the surgery is
facing huge risks. A 18-year retrospective study included 1317774
primiparous women with singleton pregnancy from 1993 to 2010 in 26
counties/cities in 3 provinces in China, they found that the prevalence
rates of cesarean delivery and CDMR were 37.6\% and 10.0\% respectively.
CDMR accounted for 26\% of all cesarean births. While what really
shocked us was the alterations of the trend of CDMR, of which in South
cities. The prevalence rates of cesarean delivery and CDMR were 37.6\%
and 10.0\% respectively.CDMR accounted for 26.0% of all cesarean
births.The prevalence of cesarean delivery increased from 29.4\% during
the 1993-1995 period to 58.7\% during the 2006-2010 in Southern urban
area, from 18.2\% to 58.3\% in Southern rural area and from 4.3\% to
49.5\% in Northern rural area.The prevalence of CDMR increased by 34
folds from 0.6\% during the 1993-1995 period to 21.3\% during the
2006-2010 period in Southern urban area by 40 folds from 0.6\% to 24.4\%
in Southern rural area and by 44 folds from 0.6\% to 27.3\% in Northern
rural area.The proportions of CDMR in all cesarean deliveries
significantly increased in all three regions.

How should the doctor do when a pregnant woman request for cesarean
delivery without medical indication? In our clinical practice, we found
that medical staff taking positive interventions, including the method
of persuasion and encouragement, could alter the decision that pregnant
woman request for cesarean delivery without medical indication. When a
woman desires a cesarean delivery on maternal request, the doctor should
first be a listener, ask why she want to choose cesarean delivery, and
what her main concerns are, and evaluate if she is lack of confidence in
vaginal delivery. Some women may specific risk factors, such as age,
body mass index, accuracy of estimated gestational age, reproductive
plans, personal values, and cultural context.~Secondly, the health care
provider should be an educator to correct the wrong concepts. The
pregnant woman should be informed the advantages of vaginal delivery and
disadvantages of cesarean delivery, including the risks of placenta
previa, placenta accreta spectrum, and gravid hysterectomy risks.
Thirdly, encouragement, encouragement, and also encouragement. In our
practice, some women worry that the baby might be macrosomia as the
B-ultrasound evaluated and thus have no confidence to try vaginal
delivery. Some women fear that the process of vaginal delivery might be
too painful to tolerant. Some women afraid that the mode of vaginal
delivery could result in laceration~of~perineum,~which might affect the
quality of future sexual life and sometimes this is their
shameful~secret. As a doctor, we should promote the
popularization~of~science and encourage the pregnant women, and save
them from these wrong concepts. Last but not least, the extension of
epidural~analgesia~during~labor could reduce the fear of pregnant woman
for vaginal labor. In my clinical practice, I always encourage that the
darkness before dawn will not be long,
analgesia~used~in~latent~phase~of~the~first~stage~of~labor greatly
alleviated the pain. Finally, interventions based on scientific
evidence, such as the Robson 10-group classification method could
contribute to reduce CS rates.A multi-center cross-sectional study
included a total of 73977 randomly selected deliveries in 94 hospitals
across 23 provinces in China, in which the authors used a modified
Robson classification to characterize CDs, and the WHO C-Model to
calculate reference CD rates, they found that The cesarean rate was
38.9\% in China in 2015--2016 while the reference rate was 28.5\%. This
method of Robson classification has not been widely known in China, thus
it was rarely used. The promotion of the Robson 10-group classification
method might help to reduce the cesarean delivery rates.

All in all, in the absence of maternal or fetal indications for cesarean
delivery, a plan for vaginal delivery is safe and appropriate and should
be recommended. Furthermore, the government should increase expenditure
and train more highly educated obstetricians. Therefore, only with the
joint efforts from the government, society, colleges, and medical
personnel, can we step towards to a lower rate of cesarean delivery and
benefit the maternal and neonatal health.

\textbf{Disclosure of interests:} The author declares no conflict of
interests.

\textbf{Funding:~} None.

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