Planning your cesarean means planning your family size

There is evidence that the risks associated with planned cesarean delivery increase with subsequent deliveries. This is why the NIH and ACOG advise that planned cesarean delivery on maternal request (particularly where there is no medical indication) should only be undertaken by women who are planning a small family with only one or two children.

Now broadly speaking, if you look at national fertility rates in the majority of the developed world, women today are giving birth to fewer and fewer children; in fact, it is not unusual to find fertility rates of less than two in many countries.

That said, new research out this month has demonstrated that 'planning' a small family is not always synonymous with 'having' a small family. American researchers Keeton et al asked women via an online survey to recall the maximum number of children they planned to give birth to while pregnant with their first child. This estimate was then compared with the number of children they actually had. Out of 458 women who had planned a maximum of two or fewer children, and had now completed childbearing, 39% were found to have underestimated their final parity. The researchers conclude "This raises questions about making an estimate of parity a consideration for offering cesarean delivery on maternal request."

My thoughts on the research

I think that the research is interesting, and serves as an important reminder to women requesting cesarean delivery that they really do need to carefully consider their future family plans, and indeed evaluate their likelihood of commitment success, as part of their risk-benefit analysis.

I would like to find out whether the babies of the 458 women referred to above were born via cesarean delivery or vaginal delivery. This could be an important distinction to make, because there is the possibility that women who prefer a planned cesarean birth are more likely to plan other areas of their reproductive life too, while women who choose vaginal delivery are more open to allowing nature to take its course. I have no evidence of this of course but if it turns out that the research above surveyed mixed birth groups, it would be very useful to track the family sizes of women following "maternal request" alone.

Despite the researchers' focus on maternal request in their conclusion, I think that this research is of greater concern to the wider, general population of pregnant women who have "unrequested" cesarean deliveries. Whether their cesarean is scheduled pre-labor due to medical reasons or occurs during labor in an urgent or emergency situation , the fact remains that these women are very likely to have a repeat cesarean delivery in subsequent births, and may have never considered future family size as a maternal morbidity risk. With increasing maternal age, increasing levels of obesity, and an increasing cesarean delivery rate nationwide, I would think that it is just as important to discuss the issue of parity with ALL pregnant women, not just those requesting a cesarean.