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Cesarean delivery on maternal request in the United States from 1999 to 2015: a response

      We would like to thank Dr David L. Newfield for their interest in our article. The limitations of our study were clearly stated in the manuscript, including the retrospective nature of our study, the absence of a specific diagnostic code for cesarean delivery on maternal request (CDMR), and the possibility of misclassification of diagnostic codes.
      • Trahan M.J.
      • Czuzoj-Shulman N.
      • Abenhaim H.A.
      Cesarean delivery on maternal request in the United States from 1999 to 2015.
      The first point raised refers to the elective nature of CDMR. We used the absence of diagnostic codes for premature rupture of membranes and labor as criteria to identify cases of CDMR.
      • Trahan M.J.
      • Czuzoj-Shulman N.
      • Abenhaim H.A.
      Cesarean delivery on maternal request in the United States from 1999 to 2015.
      The second point suggested that reporting an increased risk of sepsis among our CDMR group (adjusted odds ratio, 5.6; 95% confidence interval, 4.7–6.6) is “not logical.” Given that our CDMR group was composed of 100% cesarean deliveries, by definition, compared with 10% cesarean deliveries in our comparison group, this is not surprising or illogical. Dr Newfield himself referenced the study by Acosta et al,
      • Acosta C.D.
      • Kurinczuk J.J.
      • Lucas D.N.
      • et al.
      Severe maternal sepsis in the UK, 2011-2012: a national case-control study.
      which found that prelabor cesarean delivery was a substantial risk factor for puerperal sepsis. The third point raised refers to the increased risk of transfusion among women who underwent a CDMR despite a decreased risk of postpartum hemorrhage (PPH) among this group. This can be explained if we consider the definition of PPH before 2017, which was based on the mode of delivery.
      Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: postpartum hemorrhage.
      In the context of a vaginal delivery (90% of our “no CDMR” group), a 500-mL blood loss would be considered a PPH but may not require transfusion. In contrast, in the context of a cesarean delivery (100% of our CDMR group vs 10% of our “no CDMR” group), a 1-L blood loss may be more likely to require transfusion. Therefore, even though there are fewer cases of PPH in the CDMR group, more of these may require transfusion because of the increased blood loss associated with PPH in the context of a cesarean delivery compared with a vaginal delivery.
      Nonetheless, we understand Dr Newfield’s perspective. It is easy to perceive an elective cesarean delivery as being safe, particularly when one only considers their own anecdotal experience. Our study has reported on a population effect, including data on 228,586 CDMR births, allowing us to report on rare outcomes. We hope that our results will lead to the realization that rare maternal morbidities may be more common with CDMR than may be perceived. Therefore, caution should be exercised when counseling patients.

      References

        • Trahan M.J.
        • Czuzoj-Shulman N.
        • Abenhaim H.A.
        Cesarean delivery on maternal request in the United States from 1999 to 2015.
        Am J Obstet Gynecol. 2022; 226: 411.e1-411.e8
        • Acosta C.D.
        • Kurinczuk J.J.
        • Lucas D.N.
        • et al.
        Severe maternal sepsis in the UK, 2011-2012: a national case-control study.
        PLoS Med. 2014; 11e1001672
      1. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: postpartum hemorrhage.
        Obstet Gynecol. 2017; 130: e168-e186

      Linked Article

      • Cesarean delivery on maternal request in the United States from 1999 to 2015: a comment
        American Journal of Obstetrics & Gynecology
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          Community physicians are appreciative of the original research, which helps guide their daily practices. However, there are certain aspects of the maternal outcomes in this study that must be questioned.1 One would assume that most cesarean deliveries on maternal request (CDMRs) would be performed on a scheduled, elective basis (most likely at 39 weeks of gestation) in the absence of ruptured membranes.2 Therefore, the more than 6-fold increase in sepsis is not logical as chorioamnionitis is the most common precursor to sepsis in this setting.
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