New ACOG Committee Opinion on Maternal Request

ACOG has just published a new Committee Opinion on Cesarean Delivery on Maternal Request (Number 559, April 2013), and says, "In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended."
However, the accompanying press release says ACOG "recommends that pregnant women plan for vaginal birth unless there is a medical reason for a cesarean."

It's subtle, but look again and you'll see that the two statements do differ.

The first one informs us that vaginal delivery is the birth mode that should be recommended when there are no indications, but the second one - especially taken out of context - could be interpreted by some that ACOG is recommending against CDMR, which is not the case.

This is potentially further exacerbated by the PR statement, "Cesareans involve risks and require longer hospital stays than uncomplicated vaginal births."

Of course they do - no one is disputing this fact - but the Committee was supposed to be comparing planned birth modes, which makes the statement irrelevant in this context.

The PR presentation of any recommendation is crucial, given that the majority of media reports will never refer to the original full text, and as such, I hope that ACOG's PR here is not misinterpreted.

Controversy and Politics

We discussed the role of controversy and birth politics in obstetrics in our book, and how these can adversely affect discussions on CDMR.

The words of two Australian doctors in 2003, for example: "What a disaster it would be if it was found elective cesarean was safer than vaginal birth." (Robson and Ellwood, 2003)

For years and years, the CDMR debate has been desperate for research, called for again by ACOG here today:

"This includes surveys on cesarean delivery on maternal request, modification of birth certificates and coding to facilitate tracking, prospective cohort studies, database studies, and studies of modifiable risk factors for cesarean delivery on maternal request versus planned vaginal delivery. Short-term and long-term maternal and neonatal outcomes as well as cost need further study."

I wholeheartedly agree with this, but when will it happen?

Important to note

The Committee Opinion refers to birth plans "in the absence of maternal or fetal indication", and we know that individual women and indivudual health professionals can have very different opinions on what constitutes these indications. For example, a previous stillbirth at 40.5 weeks' gestation, a family history of long labor with emergency surgery or suspected macrosomia (large baby).

There are also prophylactic considerations around the mother and baby's wellbeing that are not adequately addressed in ACOG's new Committee Opinion -- the publication only cites 11 references, four of which date from the 1990s, the rest ranging between 2002 and 2007.

It's literally incredible for the Committee to conclude that the maternal risks fistula, anorectal function or pelvic organ prolapse "seemed to favor neither delivery route".

In due course, and when time permits, I plan to publish a list of studies that do not appear to have been considered by the Committee -- some of which appeared in our book, and some which have been published in the last 12-18 months.

Remember - when there are no direct comparisons between CDMR/PCD and PVD, then the way researchers select and interpret available research can lead to some very diverging opinions.

ACOG's new recommendations for CDMR

First, ACOG does not state that CDMR should not be allowed in the absence of maternal or fetal indication.

Second, ACOG does not state that CDMR in the absence of maternal or fetal indication is unethical.

In fact, ACOG provides recommendations for CDMR when it is planned:

*Cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks.

*Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management.

*Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.