Research Article: How is women’s demand for caesarean section measured? A systematic literature review

Date Published: March 6, 2019

Publisher: Public Library of Science

Author(s): Clémence Schantz, Myriam de Loenzien, Sophie Goyet, Marion Ravit, Aurélien Dancoisne, Alexandre Dumont, Kelli K. Ryckman.


Caesarean section rates are increasing worldwide, and since the 2000s, several researchers have investigated women’s demand for caesarean sections.

The aim of this article was to review and summarise published studies investigating caesarean section demand and to describe the methodologies, outcomes, country characteristics and country income levels in these studies.

This is a systematic review of studies published between 2000 and 2017 in French and English that quantitatively measured women’s demand for caesarean sections. We carried out a systematic search using the Medline database in PubMed.

The search strategy identified 390 studies, 41 of which met the final inclusion criteria, representing a total sample of 3 774 458 women. We identified two different study designs, i.e., cross-sectional studies and prospective cohort studies, that are commonly used to measure social demand for caesarean sections. Two different types of outcomes were reported, i.e., the preferences of pregnant or non-pregnant women regarding the method of childbirth in the future and caesarean delivery following maternal request. No study measured demand for caesarean section during the childbirth process. All included studies were conducted in middle- (n = 24) and high-income countries (n = 17), and no study performed in a low-income country was found.

Measuring caesarean section demand is challenging, and the structural violence leading to demand for caesarean section during childbirth while in the labour ward remains invisible. In addition, the caesarean section demand in low-income countries remains unclear due to the lack of studies conducted in these countries.

We recommend conducting prospective cohort studies to describe the social construction of caesarean section demand. We also recommend conducting studies in low-income countries because demand for caesarean sections in these countries is rarely investigated.

Partial Text

Caesarean section (c-section) rates are increasing worldwide. According to two iterative surveys involving 259 facilities and 20 countries, the overall c-section rate increased from 26.4% in 2004–2008 to 31.2% in 2010–11; furthermore, c-section rates have increased in all countries except Japan [1]. The increasing c-section rate is a multifactorial phenomenon. Indeed, technological, professional, legal, ethical, and cultural factors have contributed to the rise in c-sections in the past few decades and have been extensively studied, with a growing consensus that clinical factors alone cannot explain the observed increases [2].

We followed PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) Guidelines in conducting this systematic literature review. Under the concept of women’s demand, we mean women’s social demand, and we included women’s preferences and women’s requests. We defined preference for c-section as the choice expressed by a pregnant or non-pregnant woman declaring that she would prefer to give birth by c-section in the future. We defined caesarean delivery on maternal request (CDMR) as any c-section that was requested by the woman and performed in the absence of obstetric or medical indications.

The search strategy retrieved 390 studies. Two additional studies were identified through other sources. After reviewing the titles and removing duplicate studies, 379 studies remained for screening. In total, 297 articles were excluded after reviewing the abstracts, and 82 articles were fully assessed for eligibility. Ultimately, 41 studies met the inclusion criteria and were included in the data collection (Fig 1), representing a total sample of 3 774 458 women.

We found that demand for c-section was measured using two different study designs; demand was measured before pregnancy, during pregnancy, and/or after delivery. Demand for c-section was not measured during the childbirth process. We also found that demand for c-section was measured in high- and in middle-income countries, but demand for c-section was not measured in low-income countries.

Driven by continually increasing c-section rates worldwide, studies have recently been conducted to measure women’s demand for c-section. However, certain determinants remain unknown. We recommend establishing prospective cohort studies to develop a holistic approach to determining women’s preferences and requests for their delivery mode. The social construction of caesarean section must be investigated, and the structural violence in which many women are delivering, without proper pain management and/or social support, must be exposed. We also recommend establishing studies in low-income countries where demand for c-section is rarely considered, and details regarding this demand are unknown.




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