An independent panel convened by the National Institutes of Health announced today that the available information comparing the risks and benefits of Caesarean delivery on maternal request (CDMR) versus planned vaginal birth do not provide the basis for a recommendation in either direction.
The panel defined CDMR as a Caesarean delivery for a pregnancy with a single baby at the mother's request when she has no established medical indication for the procedure. CDMR is a subset of elective Caesarean delivery, and distinct from both emergency Caesarean delivery and Caesarean performed following attempted vaginal delivery.
Potential benefits of CDMR as compared with planned vaginal delivery include a decreased risk of hemorrhaging for the mother, and a reduced risk of certain birth injuries for the baby. Potential risks of CDMR include an increased risk of respiratory problems for the baby and a longer maternal hospital stay.
The panel added that each woman requesting CDMR deserves individualized counseling regarding the potential risks and benefits of both vaginal and Caesarean delivery. When counseling patients, providers should also consider such factors as societal and cultural conventions, ethical issues, available resources, and other factors pertaining to the individual patient.
Panel members did find evidence to suggest caution in certain situations. They concluded that CDMR should be avoided for women desiring large families. This is because the risk of serious complications for subsequent pregnancies increases with each additional Caesarean delivery.
The panel further stressed that CDMR should not be performed before the 39th week of pregnancy or without verification that the fetus' lungs have matured sufficiently to avoid newborn respiratory complications.
In its report, the panel also expressed concern that a woman might choose a Caesarean delivery because effective pain management would not be available at the facility in which she would give birth.
"CDMR should not be motivated by unavailability of effective pain management," the panel wrote. "Efforts must be made to assure availability of pain management services for all women."
To address the weaknesses they identified in the available scientific literature, the panel made a variety of recommendations for future research, including:
* Surveys of women (before and after birth), providers, insurers, and health care facilities regarding CDMR,
* Development of strategies to predict and influence the likelihood of successful vaginal birth,
* Establishment of uniform documentation of CDMR, to accurately reflect prevalence of the procedure,
* Examination of existing large databases to assess incidence of various complications, including rare but critical outcomes, and
* A thorough assessment of the costs of CDMR.
The panel released its findings this morning, following two days of expert presentations and panel deliberations. Full text of the panel's draft state-of-the-science statement will be available late today at http://consensus.nih.gov. The final version will be available at the same Web address in three to four weeks. Statements from past conferences and additional information about the NIH Consensus Development Program are also available at the Web site, or by calling 1-888-644-2667.
The 18 members of this State-of-the-Science panel were nominated for selection by peers who were confident that these individuals' areas of expertise would significantly contribute to the process of critically examining scientific evidence on Caesarean section on maternal request. The panel included educators, researchers, statisticians, and practitioners in obstetrics and gynecology, preventive medicine and biometrics, family planning and reproductive physiology, nurse midwifery, anesthesiology, patient safety, epidemiology, pediatrics, perinatal medicine, urology, urogynecology, general nursing, inner city public health sciences, law, psychiatry, and health services research. The panel was chaired by Mary D'Alton, M.D., chair of the Department of Obstetrics and Gynecology at Columbia University Medical Center and Chief of Obstetrics and Gynecology at the New York-Presbyterian Hospital.
In addition to the material presented at the conference by speakers and the comments and concerns of conference participants presented during discussion periods, the panel considered pertinent research from the published literature and the results of a systematic review of the literature commissioned by the NIH Office of Medical Applications of Research (OMAR). The systematic review was prepared through the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program, at the RTI International-University of North Carolina Evidence-based Practice Center. The EPCs develop evidence reports and technology assessments based on rigorous, comprehensive syntheses and analyses of the scientific literature, emphasizing explicit and detailed documentation of methods, rationale, and assumptions.
The panel's statement is an independent report and is not a policy statement of the NIH or the federal government. The NIH Consensus Development Program, of which this conference is a part, was established in 1977 as a mechanism to judge controversial topics in medicine and public health in an unbiased, impartial manner. NIH has conducted 118 consensus development conferences, and 26 state-of-the-science (formerly 'technology assessment') conferences, addressing a wide range of issues. A backgrounder on the NIH Consensus Development Program process is available at http://consensus.nih.gov/forthemedia.htm.
The conference was sponsored by the Office of Medical Applications of Research (OMAR) and the National Institute of Child Health and Human Development (NICHD). Cosponsors included the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the Office of Research on Women's Health (ORWH), and the National Institute of Nursing Research (NINR).
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