Cesarean delivery on maternal request in Brazil: an analysis based on the perceptions of survivors of the placenta accreta spectrum

Abstract Objective: To analyze maternal request cesarean section (CDMR) through the perceptions of placenta accreta spectrum (PAS) survivors. Methods: This retrospective observational study was conducted at a university hospital, a reference center for the management of placenta accreta spectrum (PAS). Case identification was performed through a review of medical records, based on diagnoses related to placental disorders and postpartum hemorrhage. Only women who underwent puerperal hysterectomy between 2005 and 2023, with a PAS diagnosis confirmed by ultrasound conducted at the institution, were included. Eligible participants were contacted via instant messaging apps and invited to complete an online structured questionnaire, which included questions about their prior knowledge and post-event perceptions regarding cesarean delivery. Responses were compared between women in the cesarean delivery on maternal request (CDMR) group and those who underwent cesarean delivery for other indications. Results: A total of 89 cases of hysterectomy for PAS were identified during the study period. Of the 60 eligible women contacted, 41 responded to the questionnaire. Among them, 11 (26.8%) reported having requested the cesarean delivery, while 30 (73.2%) underwent the procedure for other reasons. It was found that 81.8% of women in the CDMR group had private health insurance, compared to 46.6% in the "other indications" group. High parity (≥3 pregnancies) was more common in the "other indications" group (80.0%) than in the CDMR group (36.4%). Overall, 36.6% were unaware of the risks of cesarean delivery, 48.8% did not receive adequate counseling during prenatal care, and 85.4% of participants were unaware of PAS. In the CDMR group, these values were 36.4%, 45.5%, and 72.7%, respectively. After the adverse experience, 51.2% of participants reported a change in their perception of cesarean delivery, 53.7% stated that they would have made a different choice if they had more information at the time, and 78.0% believed that the general population was unaware of the risks associated with cesarean delivery. Conclusion: The perceptions of women who experienced a "near miss" contributed to a better understanding of the process behind Brazilian women's preference for cesarean section. Decisions influenced by a pro-cesarean cultural context and misinformation tend to be poorly founded and more prone to regret. In Brazil, while CDMR is framed as an expression of autonomy, inadequate information and limited freedom can exacerbate inequalities, disproportionately affecting women in vulnerable situations.