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Cover of Cesarean Delivery on Maternal Request

Cesarean Delivery on Maternal Request

Evidence Reports/Technology Assessments, No. 133

Investigators: , PhD, , MD, , MD, PhD, , MD, , MD, , MD, , BS, , PhD, , MPH, , BA, and , PhD.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 06-E009

Structured Abstract


The RTI International—University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on the trend and incidence of cesarean delivery (CD) in the United States and in other developed countries, maternal and infant outcomes of cesarean delivery on maternal request (CDMR) compared with planned vaginal delivery (PVD), factors affecting the magnitude of the benefits and harms of CDMR, and future research directions.

Data sources:

We searched MEDLINE®, Cochrane Collaboration resources, and Embase and identified 1,406 articles to examine against a priori inclusion criteria. We included studies published from 1990 to the present, written in English. Studies had to include comparison between the key reference group (CDMR or proxies) and PVD.

Review methods:

A primary reviewer abstracted detailed data on key variables from included articles; a second senior reviewer confirmed accuracy.


We identified 13 articles for trends and incidence of CD, 54 for maternal and infant outcomes, and 5 on modifiers of CDMR. The incidence of CDMR appears to be increasing. However, accurately assessing either its true incidence or trends over time is difficult because currently CDMR is neither a well-recognized clinical entity nor an accurately reported indication for diagnostic coding or reimbursement.

Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent.

Given the limited data available, we cannot draw definitive conclusions about factors that might influence outcomes of planned CDMR versus PVD.


The evidence is significantly limited by its minimal relevance to primary CDMR. Future research requires developing consensus about terminology for both delivery routes and outcomes; creating a minimum data set of information about CDMR; improving study design and statistical analyses; attending to major outcomes and their special measurement issues; assessing both short- and long-term outcomes with better measurement strategies; dealing better with confounders; and considering the value or utility of different outcomes.


Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-02-0016. Prepared by: RTI International-University of North Carolina, Research Triangle Park, North Carolina.

Suggested citation:

Viswanathan M, Visco AG, Hartmann K, Wechter, ME, Gartlehner G, Wu JM, Palmieri R, Funk MJ, Lux, LJ, Swinson T, Lohr KN. Cesarean Delivery on Maternal Request. Evidence Report/Technology Assessment No. 133. (Prepared by the RTI International-University of North Carolina Evidence-Based Practice Center under Contract No. 290-02-0016.) AHRQ Publication No. 06-E009. Rockville, MD: Agency for Healthcare Research and Quality. March 2006.

This report is based on research conducted by the RTI International-University of North Carolina (RTI-UNC) Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0016). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.


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Bookshelf ID: NBK38731


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