In recent years, cesarean delivery on maternal request (CDMR)—cesarean section performed at the pregnant woman’s request without medical indication for the mother or fetus—has been on the rise globally. This phenomenon not only drives up the overall cesarean section rate but also poses severe ethical challenges and clinical decision-making dilemmas for obstetricians. An expert review published in the American Journal of Obstetrics & Gynecology (AJOG) points out that while CDMR is regarded as an optional procedure by some professional organizations, it is intertwined with complex ethical challenges behind the scenes.
Data shows that the cesarean section rate in the United States reached as high as 32.3% in 2023, and the CDMR rate varies drastically across countries, ranging from 0.2% to 42%. In China, the rate is even as high as 16%, though the accuracy of this data is limited by the lack of a standardized coding system. Behind these figures lies an intricate balance for physicians between respecting patient autonomy and fulfilling their professional duty of beneficence.
Source: AJOG Official Website
01 Clinical Dilemmas: Multiple Risks and Controversial Foci of CDMR
CDMR is defined as an elective primary cesarean section performed solely based on the pregnant woman’s preference in the absence of medical indications for the mother or fetus, which can be planned before labor or initiated after the onset of delivery. For physicians, this choice entails not only considerations of the surgical risks themselves but also short-term and long-term impacts on maternal and infant health.
As a major surgical procedure, cesarean section carries risks of surgical complications such as infection, hemorrhage, and organ injury. The maternal mortality risk associated with cesarean section (1 in 4,200) is higher than that with vaginal delivery (1 in 25,000), and the risk of complications like placenta previa and placenta accreta in future pregnancies also increases. For newborns, CDMR may lead to respiratory diseases and alterations in the intestinal microbiota; in the long term, it is associated with a slightly higher risk of chronic conditions such as obesity and asthma. CDMR performed before 39 weeks of gestation significantly elevates the incidence of morbidity and mortality in newborns.
Source: AJOG Official Website
02 Ethical Tug of War: The Art of Balancing Autonomy and Evidence-Based Medicine
The core controversy surrounding CDMR lies in the conflict between respecting maternal autonomy and physicians’ altruistic duty based on evidence-based medicine. Although international guidelines (e.g., those from the International Federation of Gynecology and Obstetrics [FIGO] and the American College of Obstetricians and Gynecologists [ACOG]) generally support respecting patient choice after adequate counseling, all explicitly recommend vaginal delivery as the first choice in the absence of medical indications.
Physicians have a dual obligation: to respect the pregnant woman’s right to control her own body—including requests for CDMR stemming from fear of labor pain, a history of birth trauma, or tokophobia—and to be accountable for the short-term and long-term health of the mother and fetus by providing evidence-based professional advice.
Notably, cognitive biases play a significant role in CDMR decision-making. The availability heuristic leads pregnant women to overestimate the probability of complications from vaginal delivery, while loss aversion makes them more inclined to avoid potential risks of vaginal delivery. Affective heuristics and framing effects also influence decision-making judgments. Physicians need to identify these psychological factors during counseling, help patients make rational choices by objectively presenting the risks and benefits of the two delivery modes, and avoid allowing their own self-interests—such as time management and financial incentives—to compromise the objectivity of counseling.
03 Practical Approaches: Standardized Informed Consent and Multidisciplinary Support Systems
To address the challenges posed by CDMR, physicians must follow a systematic informed consent process that runs throughout the prenatal and intrapartum periods.
Prenatal counseling should be initiated as early as possible. Through open-ended questions, physicians can explore the underlying reasons for the patient’s request for CDMR, assess her health status, obstetric history, and long-term reproductive plans, and conduct trauma-informed care and psychological screening to correct misconceptions about the two delivery modes. Counseling materials should be tailored to health literacy levels to ensure that patients with different educational backgrounds can fully understand the information provided.
For emergent CDMR requests during labor, physicians need to complete a multidimensional assessment in a short time: clarify the reasons for the patient’s request, evaluate labor progress and fetal status, optimize pain management and emotional support, and clearly inform the patient of the additional risks of performing CDMR during labor. When physicians refuse a CDMR request due to the absence of medical indications, they should communicate clearly and compassionately, and assist the patient in being referred to a qualified physician who is willing to provide the service to ensure continuity of care.
Multidisciplinary collaboration and institutional support are crucial safeguards for physicians in providing CDMR-related care. Healthcare institutions should develop clear guidelines for CDMR counseling, informed consent procedures, and dispute resolution mechanisms, and provide physicians with ethical training and decision-making aids. At the same time, a multidisciplinary team consisting of obstetricians, midwives, anesthesiologists, and mental health professionals should be established to provide comprehensive support for patients with psychological trauma, tokophobia, and other conditions—respecting patient autonomy while maximizing the safety of the mother and fetus.
Summary
The ethical controversies and clinical challenges of CDMR persist. For physicians, this is not only a technical clinical choice but also a dual test of professional responsibility and humanistic care. Under the core goal of safeguarding maternal and infant health, achieving a dynamic balance between patient autonomy and physicians’ duty of beneficence through standardized counseling processes, objective evidence presentation, and multidimensional support systems has become an important issue in current obstetric practice.
Editor: Ma Ye