Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Cesarean delivery on maternal request

Errol R Norwitz, MD, PhD, MBA
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


Cesarean delivery on maternal request (or "on demand") refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications for avoiding vaginal birth. A woman’s right to be actively involved in choosing the route of her delivery is now widely accepted by clinicians and patients [1-3]. In a well-informed patient, performing a cesarean delivery on maternal request is considered medically and ethically acceptable; in-depth reviews of the ethical issues are available elsewhere [1,2,4-9]. However, obstetricians are not obliged ethically or professionally to perform these procedures. Early referral to another healthcare practitioner is appropriate in such cases [1].


Estimates of the prevalence of cesarean delivery on maternal request range from 1 to 18 percent of all cesarean deliveries worldwide, and <1 to 3 percent of all cesarean deliveries in the United States [9-12]. These are crude estimates since birth certificates and discharge codes usually do not indicate whether a cesarean was performed at maternal request. The prevalence of the procedure appears to be increasing and correlated with increasing affluence [13,14].

Surveys of obstetricians, urogynecologists, and colorectal surgeons have reported a preference for cesarean by request for themselves and their family members [15,16].


The Agency for Healthcare Research and Quality (AHRQ) has published a detailed report on Cesarean Delivery on Maternal Request [17]. A synopsis of their findings, as well as subsequently published data, is provided below. These data are limited because no randomized trials on cesarean delivery for nonmedical reasons have been performed [18]. Thus, conclusions about the risks and benefits of cesarean delivery on maternal request are not based upon high-quality evidence. Available studies have serious methodological issues or provide indirect evidence because the cesareans were performed for breech presentation [19].

As with any medical procedure, the risks and benefits of cesarean delivery on maternal request need to be balanced with the risks and benefits of a planned vaginal delivery. Patient-specific issues that can affect the choice of delivery route include comorbid medical conditions, body mass index, future reproductive plans, prior childbirth experiences, outcome of previous surgical procedures, and the woman's personal philosophy about childbirth.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2017. | This topic last updated: Apr 04, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 559: Cesarean delivery on maternal request. Obstet Gynecol 2013; 121:904.
  2. Gonen R, Tamir A, Degani S. Obstetricians' opinions regarding patient choice in cesarean delivery. Obstet Gynecol 2002; 99:577.
  3. Paterson-Brown S. Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. BMJ 1998; 317:462.
  4. Kalish RB, McCullough LB, Chervenak FA. Patient choice cesarean delivery: ethical issues. Curr Opin Obstet Gynecol 2008; 20:116.
  5. Demontis R, Pisu S, Pintor M, D'aloja E. Cesarean section without clinical indication versus vaginal delivery as a paradigmatic model in the discourse of medical setting decisions. J Matern Fetal Neonatal Med 2011; 24:1470.
  6. Minkoff H, Powderly KR, Chervenak F, McCullough LB. Ethical dimensions of elective primary cesarean delivery. Obstet Gynecol 2004; 103:387.
  7. Obstetrics and Gynecology Risk Research Group, Kukla R, Kuppermann M, et al. Finding autonomy in birth. Bioethics 2009; 23:1.
  8. Nilstun T, Habiba M, Lingman G, et al. Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach? BMC Med Ethics 2008; 9:11.
  9. National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request March 27-29, 2006. Obstet Gynecol 2006; 107:1386.
  10. Report by HealthGrades, a health care quality company.
  11. Gossman GL, Joesch JM, Tanfer K. Trends in maternal request cesarean delivery from 1991 to 2004. Obstet Gynecol 2006; 108:1506.
  12. MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008; 35:293.
  13. Alves B, Sheikh A. Investigating the relationship between affluence and elective caesarean sections. BJOG 2005; 112:994.
  14. Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. BMJ 2002; 324:942.
  15. Bettes BA, Coleman VH, Zinberg S, et al. Cesarean delivery on maternal request: obstetrician-gynecologists' knowledge, perception, and practice patterns. Obstet Gynecol 2007; 109:57.
  16. Turner CE, Young JM, Solomon MJ, et al. Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. BJOG 2008; 115:1494.
  17. Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment. Number 133. Cesarean Delivery on Maternal Request. March 2006. available at www.ahrq.gov/clinic/tp/cesarreqtp.htm#Report. Accessed December 5, 2007.
  18. Lavender T, Hofmeyr GJ, Neilson JP, et al. Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev 2012; :CD004660.
  19. Visco AG, Viswanathan M, Lohr KN, et al. Cesarean delivery on maternal request: maternal and neonatal outcomes. Obstet Gynecol 2006; 108:1517.
  20. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013; 309:1930.
  21. Amu O, Rajendran S, Bolaji II. Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery. BMJ 1998; 317:463.
  22. Hall MH, Bewley S. Maternal mortality and mode of delivery. Lancet 1999; 354:776.
  23. van Ham MA, van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74:1.
  24. Fisher J, Astbury J, Smith A. Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study. Aust N Z J Psychiatry 1997; 31:728.
  25. Feldman GB, Freiman JA. Prophylactic cesarean section at term? N Engl J Med 1985; 312:1264.
  26. Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002; 287:2684.
  27. Hovatta O, Lipasti A, Rapola J, Karjalainen O. Causes of stillbirth: a clinicopathological study of 243 patients. Br J Obstet Gynaecol 1983; 90:691.
  28. Hemminki E, Meriläinen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996; 174:1569.
  29. Rosenstein MG, Cheng YW, Snowden JM, et al. Risk of stillbirth and infant death stratified by gestational age. Obstet Gynecol 2012; 120:76.
  30. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999; 341:1709.
  31. Martinez-Biarge M, Madero R, González A, et al. Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events. Am J Obstet Gynecol 2012; 206:148.e1.
  32. McFarland LV, Raskin M, Daling JR, Benedetti TJ. Erb/Duchenne's palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol 1986; 68:784.
  33. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians' personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol 1997; 73:1.
  34. Al-Mufti R, McCarthy A, Fisk NM. Obstetricians' personal choice and mode of delivery. Lancet 1996; 347:544.
  35. Hannah ME, Hannah WJ, Hodnett ED, et al. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. JAMA 2002; 287:1822.
  36. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191:917.
  37. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000; 107:1460.
  38. Handa VL, Blomquist JL, Knoepp LR, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol 2011; 118:777.
  39. http://www.nice.org.uk/guidance/cg132/resources/caesarean-section-update-full-guideline2 (Accessed on October 16, 2014).
  40. Miller ES, Hahn K, Grobman WA, Society for Maternal-Fetal Medicine Health Policy Committee. Consequences of a primary elective cesarean delivery across the reproductive life. Obstet Gynecol 2013; 121:789.
  41. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. First-birth cesarean and placental abruption or previa at second birth(1). Obstet Gynecol 2001; 97:765.
  42. Jackson S, Fleege L, Fridman M, et al. Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Am J Obstet Gynecol 2012; 206:139.e1.
  43. Moraitis AA, Oliver-Williams C, Wood AM, et al. Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG 2015; 122:1467.
  44. Bahtiyar MO, Julien S, Robinson JN, et al. Prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy: analysis of U.S. perinatal mortality data, 1995-1997. Am J Obstet Gynecol 2006; 195:1373.
  45. McMahon MJ, Luther ER, Bowes WA Jr, Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996; 335:689.
  46. Hemminki E. Impact of caesarean section on future pregnancy--a review of cohort studies. Paediatr Perinat Epidemiol 1996; 10:366.
  47. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004; 103:907.
  48. Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 2007; 176:455.
  49. Declercq E, Barger M, Cabral HJ, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol 2007; 109:669.
  50. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356:1375.
  51. Zanardo V, Simbi AK, Franzoi M, et al. Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery. Acta Paediatr 2004; 93:643.
  52. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101.
  53. Zanardo V, Padovani E, Pittini C, et al. The influence of timing of elective cesarean section on risk of neonatal pneumothorax. J Pediatr 2007; 150:252.
  54. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008; 336:85.
  55. Moore HC, de Klerk N, Holt P, et al. Hospitalisation for bronchiolitis in infants is more common after elective caesarean delivery. Arch Dis Child 2012; 97:410.
  56. Black M, Bhattacharya S, Philip S, et al. Planned Cesarean Delivery at Term and Adverse Outcomes in Childhood Health. JAMA 2015; 314:2271.
  57. Black M, Bhattacharya S, Philip S, et al. Planned Repeat Cesarean Section at Term and Adverse Childhood Health Outcomes: A Record-Linkage Study. PLoS Med 2016; 13:e1001973.
  58. Le Guennec JC, Bard H, Teasdale F, Doray B. Elective delivery and the neonatal respiratory distress syndrome. Can Med Assoc J 1980; 122:307.
  59. Flaksman RJ, Vollman JH, Benfield DG. Iatrogenic prematurity due to elective termination of the uncomplicated pregnancy: a major perinatal health care problem. Am J Obstet Gynecol 1978; 132:885.
  60. Annibale DJ, Hulsey TC, Wagner CL, Southgate WM. Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med 1995; 149:862.
  61. Kolås T, Saugstad OD, Daltveit AK, et al. Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Am J Obstet Gynecol 2006; 195:1538.
  62. Kaplan JL, Shi HN, Walker WA. The role of microbes in developmental immunologic programming. Pediatr Res 2011; 69:465.
  63. MacDorman MF, Declercq E, Menacker F, Malloy MH. Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an "intention-to-treat" model. Birth 2008; 35:3.
  64. De Luca R, Boulvain M, Irion O, et al. Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics 2009; 123:e1064.
  65. Cesarean childbirth: Report of a consensus development conference sponsored by the National Institute of Child Health and Human Development, Washington, D.C.: Government Printing Office, 1980 (DHHS publication no. NIH82-2067).
  66. Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of caesarean section: a new classification. J R Soc Med 2000; 93:346.
  67. Yoles, I, Maschiach, S. Increased maternal mortality in cesarean section as compared to vaginal delivery? Time for re-evaluation. Am J Obstet Gynecol 1998; 178:S78.
  68. Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol 2000; 183:1187.
  69. Groom K, Brown SP. Caesarean section controversy. The rate of caesarean sections is not the issue. BMJ 2000; 320:1072.
  70. Belizán JM, Althabe F, Barros FC, Alexander S. Rates and implications of caesarean sections in Latin America: ecological study. BMJ 1999; 319:1397.
  71. D'Souza R. Caesarean section on maternal request for non-medical reasons: putting the UK National Institute of Health and Clinical Excellence guidelines in perspective. Best Pract Res Clin Obstet Gynaecol 2013; 27:165.
  72. Klein K, Worda C, Leipold H, et al. Does the mode of delivery influence sexual function after childbirth? J Womens Health (Larchmt) 2009; 18:1227.
  73. Little MO, Lyerly AD, Mitchell LM, et al. Mode of delivery: toward responsible inclusion of patient preferences. Obstet Gynecol 2008; 112:913.
  74. Chervenak FA, McCullough LB. The professional responsibility model of obstetric ethics and caesarean delivery. Best Pract Res Clin Obstet Gynaecol 2013; 27:153.