The Journal of Maternal-Fetal and Neonatal Medicine, September 2011; 24(9): 1133–1137

Why women request cesarean section without medical indication?

POLAT DURSUN, FILIZ B. YANIK, HULUSI B. ZEYNELOGLU, ERALP BASER, ESRA KUSCU, & ALI AYHAN
Department of Obstetrics & Gynecology, Baskent University School of Medicine, Ankara, Turkey
(Received 7 September 2010; accepted 27 September 2010)
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Florida International University on 10/18/13

Abstract
Objective. To understand the reasons of the cesarean delivery on maternal request (CDMR) without medical indication
would help to reduce the rates of unnecessary cesarean-delivery (CD). The objective of this study is to determine the basal
knowledge of women regarding normal delivery (ND) and CD and also to assess their attitudes about CDMR, and to find
out the reasons influencing those attitudes.
Methods. The study included 400 women who completed a 45-item questionnaire that assessed their basal knowledge of
ND, CD, and their attitudes and beliefs about the mode of delivery and CDMR.
Results. Mean age of the study population was 32 + 10.2 years (range 18–66). Majority of the women would choose the ND
because of its ‘being completely natural’ (89%) and no anesthesia and operative risk related with ND (76%). Only 33% of the
women indicated that ND might cause genital organ prolapse and/or stress urinary incontinence and just 26% and 24% of
the women would choose CD to prevent pelvic organ prolapse and stress urinary incontinence, respectively. On the other
hand, 50% and 54% of the women would indicate that they could choose CD in order to prevent labor pain and to minimize
the risk of fetal distress during the labor. Furthermore, 47% of the women had an opinion that that CD could be performed
by maternal request without medical indication. Educational level had no effect of CDMR although more educated women
For personal use only.

had more accurate knowledge about the some risk and benefits of ND and CD. Binary logistic regression analysis revealed
that fear of labor pain (p ¼ 0.02, OR: 15.0, CI: 0.494–0.966), maternal age (p ¼ 0.01, OR: 6.3,CI: 1.00–1.05), and
knowledge about the relation between the ND and pelvic organ prolapse/urinary incontinence (p 5 0.001, OR: 4.8, CI:
0.549–0.966) were the independent prognostic variables for the CDMR .
Conclusion. Although majority of the women had wrong idea or no idea about the risks and benefits of CD, nearly half of
them indicated that women can always demand CDMR. This study shows that basal knowledge of the women should be
improved by education.
Keywords: Cesarean delivery, vaginal delivery, knowledge, attitudes, cesarean delivery on maternal request, cesarean delivery
without medical indication

Introduction
Dramatic increase in the cesarean delivery (CD) rates is a
major concern in both developed and developing coun-
tries. Although CD has evolved in order to protect
maternal and fetal health, today we quite often observe
that it is being performed on maternal request without any
medical or obstetric indications. Primary and repeat CD
rates for all women have reached their highest levels within
the last decades, and it is obvious that cesarean delivery on
maternal request (CDMR) is one of the major reasons of
this trend [1].
NIH [1] and ACOG [2] in USA and FIGO [3,4]
published guidelines on this subject in order to provide
reliable information and to increase the awareness of both
the women and the health-care providers. Although there is
limited evidence for benefits of CD without medical
indication, the increasing rates of CD require explanation.
Both local and international authorities and policy makers
try to understand and reduce the reason of the increasing
rates of CD [1–4].
It is known that the reasons for this rising trend are many
and complex. However, it is clear that to understand the
reasons of the maternal request without medical indication
could help to reduce the rates of unnecessary CD. The aim
of this study is to evaluate women’s opinion, basal
knowledge, and their attitudes about vaginal delivery
(ND), CD, and CDMR.
Material and method
After gaining the approval of the Baskent University Ethics
Committee, questionnaires were distributed between April
2009 and June 2009 to the gynecology and obstetrics
outpatients unit of the Baskent University hospital in
Ankara, Turkey.
Every woman presenting for a consultation was asked to
fill out a questionnaire while waiting for consultation in the
attendance room. There was no age limit. Potential
subjects who were unable to read, write, or understand
the questionnaires were excluded. Participants were

Correspondence: Dr. Polat Dursun, Baskent University School of Medicine, Department of Obstetrics & Gynecology, Kubilay Sk. No: 36 Maltepe, Ankara,
Turkiye. Tel: 0090-532-3845158. E-mail:pdursun@yahoo.com
ISSN 1476-7058 print/ISSN 1476-4954 online Ó 2011 Informa UK, Ltd.
DOI: 10.3109/14767058.2010.531327
 1134 P. Dursun et al.

approached by the consultant specialist (PD) to determine
their willingness to participate in the survey; if they agreed
to participate, the 45-item questionnaire was administered.
The questionnaire was written in Turkish and collected
demographic data, including age, marital status, educa-
tional level, number of children, monthly family income,
and number and type of previous deliveries and included
questions to measure the basal knowledge about vaginal
delivery (ND) and CD. Questionnaires with missing values
for either of the dependent variables were excluded from
data analysis (n ¼ 44). The final sample size was 366.
Data were analyzed using SPSS version 11.5 (SPSS Inc.,
Chicago, IL). Descriptive statistics were used to evaluate
patients’ responses. w2Chi-squared analysis was performed
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this and had no idea, respectively. In another question,
54% of the women declared they could always demand CD
even if medically not indicated while 15% and 31% of the
women were against this and had no idea on this question,
respectively. Among the surveyed women, 33%, 27%, and
40% of the participants said that the cost of the CDMR
should be paid by the patients, government and govern-
ment with the contribution of the patients, respectively.
The results of the survey were summarized in Tables I–III.
When we categorized our data according to the level of
education of the women (university degree vs. other
degrees), we saw that women with university degrees had
statistically significantly better knowledge about the some
risks and benefits of ND and CD (Table IV). However,

to compare the results from these groups. Multivariate there was no significant differences with respect to CDMR
analysis was performed by binary logistic regression test.

Table I. Questions about the basal knowledge of ND and the

Results reason of the selection of ND.
Questionnare was performed on 400 women aged 18–66
Yes No No
years but 44 of them were excluded due to incomplete
(%) (%) opinion (%)
data. Final analysis was performed on 366 women. Mean
age of the study population was 32 + 10.2 years (range 18– Completely natural 89 3 8
66 years). Of the respondent, 54% of the patients had No operation and 76 8 16
university degree while 30%, 6%, and 9%, had high school, anesthesia risk
secondary school, and primary school degrees, respec- Less occurrence of serious 66 8 26
tively. Seventy-one percent of the patients were married problems compared with CD
while 25% were single. Among the women, 182 (50%) had Babies born by normal 59 11 29
previous birth experience and among them 68%, 29%, and route are more healthy
For personal use only.

3.3% of these women had previous ND, CD, and both. Normal delivery is more 16 62 22
Among the women who had previous CD, 82%, 15%, and cheaper than CD
3% of the women had one, two, and three CD, Normal delivery may cause 33 10 57
respectively. genital organ prolapse and/or
Majority of the women would choose the ND because of stress urinary incontinence
its ‘completely being natural’(89%) and no anesthesia and
operative risk related with ND (76%). Also, ‘less occurence
of serious problems compared with CD’ and babies born
by ND being more healthy were other main reasons for the
Table II. Questions about the basal knowledge on cesarean-section
women to opt normal ND. Only 33% of the women
and the reasons for choosing cesarean-section without any medical
indicated that ND might cause genital organ prolapse and/
indication.
or stress urinary incontinence. Forty-three percent of the
women knew that anesthetic drugs could pass to the baby Yes No No opinion
and might cause respiratory depression while 44% had no (%) (%) (%)
opinion on this subject. Just, 37%, 23% knew that babies
born by CD might need longer hospital stay and CD might To determine the birth date of baby 14 63 23
cause higher risk of lung problems in newborns, respec- To prevent pelvic organ prolapsus 26 38 36
tively. Among the sampled women, 52% and 37% of the To preserve genital organ appearance 24 41 35
women knew that CD had a higher risk compared with ND and functions
and CD might increase the risk of future pregnancies. Half To prevent stress incontinence 24 30 46
of the women would indicate that they could choose CD in To prevent the labor pain 50 30 20
order to prevent labor pain. Fifty-four percent of the Minimize risk of fetal distress during 54 19 27
women emphasized that they would prefer CD in order to labor
minimize the risk of fetal distress during the labor. Of the To prevent emergent CD 40 31 29
respondent, 26% and 24% of the women would choose To avoid from the vaginal tears 44 29 27
CD to prevent pelvic organ prolapse and stress urinary To prevent long lasting labor 49 27 24
incontinence while 74% and 76% of the women had no Vaginal delivery may cause sexual 18 39 43
opinion or wrong idea about the effect of CD on prolapse dissatisfaction
and incontinence, respectively. Furthermore, only 18% of Cesarean delivery is better and 13 54 33
the sampled women indicated that ND may cause sexual modern
dissatisfaction and 44% would prefer CD in order to Cesarean delivery has become the gold 8 57 35
prevent vaginal tears. Of all, 68% of the women in this standard for delivery in modern
survey had previous experience of normal delivery, but just countries
13% of the all women indicated that they would prefer CD Previous bad experiences of vaginal 13 54 33
due to previous poor experiences of ND. delivery,
In this survey, 47% of the women indicated that CD To avoid from the repetitive vaginal 23 53 24
could be performed by maternal request without medical examinations
indication while 28% and 25% of the women were against
 Cesarean delivery on maternal request 1135

Table III. Knowledge about the risks of CD. Table IV. Comparison of women’s knowledge about VD and CD
with respect to educational levels.
Yes No No opinion
(%) (%) (%) Women with Women
University with others
Babies born by CD may need longer 37 20 43 degree degrees*
hospital stay (n ¼ 197) (n ¼ 169) p
Anesthetic drugs can pass to the baby 43 13 44 (%) (%) value
and may cause depression
CD may cause higher ND
risk of lung problems 23 15 62 Completely natural 93 85 0.01
CD may increase the risk in future 37 20 43 No operation and anesthesia 78 72 0.13
pregnancies risk
CD has a higher risk compared with 52 17 31 Less occurrence of serious 65 67 0.36
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normal delivery problems compared

CD can be performed by maternal 47 28 25 with CD
request without medical indication Babies born by normal 61 58 0.34
Women can always demand CD even 54 15 31 route are more healthy
if medically not indicated Vaginal delivery may cause 35 30 0.16
genital organ prolapse
and/or stress urinary
incontinence
(49% vs 45%, p ¼ 0.25) and more educated women believe CD
that women could always demand CD even if there was no Babies born by CD may 44 28 0.001
medical indication (60% vs. 46%, p ¼ 0.006). Binary need longer hospital stay
logistic regression analysis using age, occupation, educa- Anesthetic drugs can pass 50 34 0.001
tion, family income, and knowledge about duration of to the baby and may
newborn hospital stay, anesthetic drug passage into new- cause depression
born during CD, lung problems of newborn, sexual CD may cause higher
dissatisfaction, labor pain, pelvic organ prolapse/urinary risk of lung problems 26 20 0.076
For personal use only.

incontinence, problems in future pregnancies about ND CD may increase the risk in 44 28 0.001
and CD revealed that that fear of labor pain (p ¼ 0.02, OR: future pregnancies
15.0, CI: 0.494–0.966), maternal age (p ¼ 0.01, OR: 6.3, CD has a higher risk 56 47 0.051
CI: 1.00–1.05), and knowledge of relationship with ND compared with vaginal
and pelvic organ prolapse/urinary incontinence (p 5 0.001, delivery
OR: 4.8, CI: 0.549–0.966) were the independent prog- Prevention of pelvic organ 32 19 0.003
nostic variables for the CDMR. prolapsus
Preservation of genital 31 16 50.0001
organ appearance and
functions
Discussion Prevention of stress 29 18 0.008
CD is the most common surgical operation performed in incontinence
developed countries. Recent studies showed that CD rates CD can be performed on 49 45 0.25
have increased dramatically in the United States, and in maternal request without
other countries. Primary elective CD performed on a medical indication
patient’s request now comprises 4–18% of all cesareans Women can always demand 60 46 0.006
and it consists of 14–22% of elective CD in the literature. for CD even if medically
Patient choice cesarean, maternal request cesarean, and not indicated
cesarean on demand, CD on maternal request (CDMR) all
refer to primary elective CD in the absence of a medical or *High school, secondary school, primary school.
obstetric indication [5].
In 2005, the CD rate was 30.3% of all live births in USA
[6] and approximately 1.2 million women in the United suggests that patient choice should be respected and
States had a cesarean birth during this period. In 2004, it is supported so long as it does not negate ethical medical
estimated that 2.5% of the US births were CDMR. CDMR treatment for both mother and fetus [2,8–10]. On the other
rates in other countries are generally reported to range hand, FIGO recommendations are contrary to the ACOG
from 2 to 16% in the studies. Rates of CDMR were 9%, opinion. Although ACOG respects mothers’ autonomy,
15.8%, 7.6%, and 3.5% in Italy, Sweden, Norway, and FIGO states ‘performing cesarean section for non-medical
Taiwan, respectively, in the studies performed between the reasons is ethically not justified’ [3,4].
years 1996 and 2001. However, there is little data to clarify Although the listed reasons of the CDMR indicated a
why women ‘choose’ CD, so the reasons for CDMR complex and multidimensional problem, there are two im-
remain a mystery [7]. portant factors related with the increasing rates of CDMR.
The American College of Obstetricians and Gynecolo- The first one is the knowledge and attitudes of the women
gists (ACOG) argued that requests for any surgery should about the risks and benefits of the ND and CD and the
be carefully discussed between physician and patient. This second one which is not the subject of this study is the
informed consent process should incorporate the major attitudes of the prenatal care provider. Literature reports
tenets of ethical medical practice beneficence, nonmalefi- show the inconsistency about performing CDMR among
cence, patient autonomy, justice, etc. Essentially, ACOG the obstetricians. An ACOG survey of approximately 600
 1136 P. Dursun et al.
USA based obstetrician–gynecologists assessed respon-
dents’ practice patterns related to previous CDMR. More
than half of respondents (53%) reported having performed
CDMR. Approximately 58% of this sample noticed an
increase in maternal requests for unindicated CD over the
past years [6,11]. Another nationwide study performed in
2008 reported that 29% of Swedish obstetricians and
gynecologists would perform a CDMR [12]. A study from
UK reported that 17% of obstetricians would choose
CDMR for themselves even in, and 31% of female
obstetricians said they would choose CDMR [13]. Another
study which was performed on obstetrics and gynecology
trainees from UK reported that 15.8% of the trainees
would prefer a CD for themselves [14]. In a European
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multicenter study which investigates the attitudes of
obstetricians about CDMR in the absence of medical
indication, the percentage varied from 15 to 79% [15]. On
the other hand, it has been reported that some Scandina-
vian obstetricians seem to have a more restrictive behavior
on CDMR; in Denmark only 1% and in Norway 2% of
obstetricians would prefer elective CD in an uncompli-
cated pregnancy at term for themselves. The variations in
the attitudes about CDMR between countries are difficult
to interpret and might be related to cultural differences and
discrepancies in the medico-legal system [12,16,17].
Concerns about medical-legal disputes, demand of
women, and higher financial charge by the hospital for
CD may be important contributors to liberal use of CD in
different countries and different healthcare systems [18].
Mancuso et al. reported that the reason of this increasing
For personal use only.
CDMR trend are complex, vary from one region to
another and are influenced by local socio-cultural and
healthcare background [19]. Although the frequency of this
CDMR phenomena became an important debateful issue
in obstetrics practice, just a few studies have attempted to
identify the reasons of CDMR in the literature [20].
Results from one national US survey of mothers found
just 6% of the primiparous mothers are interested in
elective primary cesarean in the future [20]. Another study
from USA reported that 13.3% of the non-pregnant
women may prefer CDMR [21]. In 2002, Hildingsson
et al. reported that only 8.2% of Swedish-speaking
pregnant women would prefer to be delivered by CD.
However, CDMR increased by 80% between 1990 and
2001 in Sweden [12,22]. Among the Asian women only
3.7% would prefer an elective CD [23].
In our study, great majority of the women indicated that
they prefer ND due to its natural process (89%) and lack of
operative risk (76%). However, 47% of the same popula-
tion indicated CD can be performed on maternal request
without medical indication and 54% emphasized that
women can always demand CD even if medically not
indicated. Our data show that although majority of the
women may demand CDMR, their knowledge about the
risks and benefits of the CD was limited. It has been
reported that women in developed countries may demand
CDMR due to, fear of labor, to protect genital trauma in
order to avoid sexual dissatisfaction, and risks associated
with trial of labor on fetus [6]. On contrary, Chigbu et al.
reported that just 4% of the women may demand CDMR
due to previous prolonged labor, a child with cerebral
palsy, previous infertility and advanced maternal age in
developing countries [24]. Our study revealed that age, fear
of labor pain, and risks related with genital trauma were
independent prognostic factors for CDMR among the
women sampled in this study. In our study, although less
than three-third of women had basal knowledge about the
risks of anesthetics, lung problems of newborn, and pelvic
organ prolapse/stress incontinence, and more than half of
the women indicated that they may demand CD without
medical indication. Therefore, it can be speculated that
long lasting labor pain and the fear of fetal damage could
be the one of the major explanation of this high prevalence
of CDMR in this cohort.
Although the defensers of the CDMR claim that CD
prevents the genital prolapse/stress incontinence and
women have right to protect their uro-genital integrity
[25], majority of the women sampled in this study had
wrong opinion about the relation of urogenital trauma with
normal delivery (Table II). In a previous report, Zhang
et al. found that nulliparity, higher education, older
maternal age, having been delivered at provincial or county
hospitals, and women’s occupations were associated with
rate of CD on maternal request [18]. Similar to our
findings, Chong and Mongelli reported that avoiding labor
pains and lowering the risk of fetal distress were important
factors to choice CDMR among the Asian women [23].
In our study, we found that more educated women had
significantly more accurate knowledge about the risks and
benefits of VD and CD. However, paradoxically, there was
no significant difference in the attitudes about CDMR and
more educated women indicated at a significantly higher
rate that one could request for CD even if medically not
indicated. This situation shows, although education is
important on the decision process about CD, it has no
positive effect on opting against CDMR in this study. Our
study also demonstrates that women are often inadequately
informed about risk and benefits of child birth, VD, and
CD. As emphasized by Zhang et al., some women have fear
of labor pain and lack confidence in their ability to go
through vaginal birth and have little tolerance for risk of
VD on newborn [18].
Although we did not investigate the effect of media (TV,
radio, internet, youtube, facebook, internet groups, blogs,
etc.) on the knowledge and attitudes of the women about
CDMR, we believe that, unfortunately, media is an
important negative contributor in their decisions about
the route of delivery. News on the media about CD of the
movie or pop stars and other famous women might also be
an important negative contributor and direct the women to
CD. The effect of the media on the decision process about
the delivery route should be investigated and may reveal
interesting results in our opinion.
This study is important in that it is the first one to be
reported from Turkey about CDMR. In conclusion, it
shows that although most of the women have no true
knowledge about the risks and benefits of the VD and CD,
majority of them have a trend to choose CD without
medical indication. These high rates of positive attitudes of
the women about CD require further investigation. Lack of
knowledge is an important information that we have
obtained from this study and it is obvious that women’s
knowledge about the mode of delivery should be improved
by education. Further studies could then be performed on
educated women to reveal the underlying reasons for their
attitudes about CDMR.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
References
1. NIH Consensus and State-of-the-Science Statements on
Cesarean Delivery on Maternal Request. NIH Consens State
Sci Statements 2006;23:1–29.

2. American College of Obstetricians and Gynecologists. ACOG
Committee Opinion No. 386 November 2007: cesarean
delivery on maternal request. Obstet Gynecol 2007;110:
1209–1212.
3. Schenker JG, Cain JM. FIGO Committee Report: FIGO
Committee for the ethical aspects of human reproduction and
women’s health. International federation of gynecology and
obstetrics. Int J Gynaecol Obstet 1999;64:317–322.
4. Recommendations on Ethical Issues in Obstetrics and Gynecol-
ogy by the FIGO Committee for Ethical Aspects of Human
Reproduction and Women’s Health. London (UK): FIGO;
2003. Electronic Citation. http://www.figo.org/content/PDF/
ethicsguidelines-text_2003.pdf. Last accessed 22 February
2006.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Florida International University on 10/18/13
5. Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice
cesarean: an evidence-based review. Obstet Gynecol Surv
2004;59:601–616.
6. Coleman VH, Lawrence H, Schulkin J. Rising cesarean
delivery rates the impact of cesarean delivery on maternal
request. Obstet Gynecol Surv 2009;64:115–119.
7. Andrist LC. The implications of objectification theory for
women’s health: menstrual suppression and ‘‘Maternal Request’’
cesarean delivery. Health Care Women Int 2008;29:551–565.
8. Gossman GL, Joesch JM, Tanfer K. Trends in maternal
request cesarean delivery from 1991 to 2004. Obstet Gynecol
2006;108:1506–1516.
9. Surgery and patient choice. In: American College of
Obstetricians and Gynecologists. Ethics in obstetrics and
gynecology. 2nd ed. Washington (DC): American College of
Obstetricians and Gynecologists; 2004, ACOG Committee on
For personal use only.
Ethics. Committee Opinion No. 289. Surgery and patient
choice: the ethics of decision making. Obstet Gynecol
2003;102:1101–1106.
10. Harer WB Jr. Elective cesarean: an option for primiparas?
OBG Manag 2002;14:38–44.
11. Bettes BA, Coleman VH, Zinberg S, Spong CY, Portnoy B,
DeVoto E, Schulkin J. Cesarean delivery on maternal request:
obstetrician-gynecologists’ knowledge, perception, and prac-
tice patterns. Obstet Gynecol 2007;109:57–66.
12. Gunnervik C, Sydsjö G, Sydsjö A, Selling KE, Josefsson A.
Attitudes towards cesarean section in a nationwide sample of
obstetricians and gynecologists. Acta Obstet Gynecol Scand
2008;87:438–444.
Cesarean delivery on maternal request 1137
13. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians’
personal preference and discretionary practice. Eur J Obstet
Gynecol Reprod Biol 1997;73:1–4.
14. Wright JB, Wright AL, Simpson NA, Bryce FC. A survey of
trainee obstetricians preferences for childbirth. Eur J Obstet
Gynecol Reprod Biol. 2001;97:23–25.
15. Habiba M, Kaminski M, Da FrÒ M, Marsal K, Bleker O,
Librero J, Grandjean H, Gratia P, Guaschino S, Heyl W,
Taylor D, Cuttini M. Caesarean section on request: a
comparison of obstetricians attitudes in eight European
countries. Br J Obstet Gynaecol 2006;113:647–656.
16. Bergholt T, O’Østberg B, Legarth J, Weber T. Danish
obstetricians’ personal preference and general attitude to
elective caesarean section on maternal request: a nation-wide
postal survey. Acta Obstet Gynecol Scand 2004;83:262–
266.
17. Backe B, Salversen KA, Sviggum O. Norwegian obstetricians
prefer vaginal route of delivery. Lancet 2002;59:629.
18. Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z. Cesarean
delivery on maternal request in Southeast China. Obstet
Gynecol 2008;111:1077–1082.
19. Mancuso A, De Vivo A, Fanara G, Albiero A, Priolo AM,
Giacobbe A, Franchi M. Caesarean section on request:
are there loco-regional factors influencing maternal
choice? An Italian experience. J Obstet Gynaecol
2008;28:382–385.
20. Menacker F, Declercq E, Macdorman MF. Cesarean delivery:
background, trends, and epidemiology. Semin Perinatol
2006;30:235–241.
21. Thurman AR, Zoller JS, Swift SE. Non-pregnant patients’
preference for delivery route. Int Urogynecol J Pelvic Floor
Dysfunct 2004;15:308–312.
22. Hildingsson I, Radestad I, Rubertsson C, Waldenstrom U.
Few women wish to be delivered by caesarean section. Br J
Obstet Gynaecol 2002;109:618–623.
23. Chong ES, Mongelli M. Attitudes of Singapore women
toward cesarean and vaginal deliveries. Int J Gynaecol Obstet
2003;80:189–194.
24. Chigbu CO, Ezeome IV, Iloabachie GC. Cesarean section on
request in a developing country. Int J Gynaecol Obstet
2007;96:54–56.
25. Feldman GB, Freiman JA. Prophylactic cesarean at term? N
Engl J Med 1985;312:1264–1267.