Viswanathan Meera, Visco Anthony G, Hartmann Katherine, Wechter Mary Ellen, Gartlehner Gerald, Wu Jennifer M, Palmieri Rachel, Funk Michele Jonsson, Lux Linda, Swinson Tammeka, Lohr Kathleen N
Evid Rep Technol Assess (Full Rep). 2006 Mar(133):1-138.
The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on the trend and incidence of cesarean delivery (CD) in the United States and in other developed countries, maternal and infant outcomes of cesarean delivery on maternal request (CDMR) compared with planned vaginal delivery (PVD), factors affecting the magnitude of the benefits and harms of CDMR, and future research directions.
We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles to examine against a priori inclusion criteria. We included studies published from 1990 to the present, written in English. Studies had to include comparison between the key reference group (CDMR or proxies) and PVD.
A primary reviewer abstracted detailed data on key variables from included articles; a second senior reviewer confirmed accuracy.
We identified 13 articles for trends and incidence of CD, 54 for maternal and infant outcomes, and 5 on modifiers of CDMR. The incidence of CDMR appears to be increasing. However, accurately assessing either its true incidence or trends over time is difficult because currently CDMR is neither a well-recognized clinical entity nor an accurately reported indication for diagnostic coding or reimbursement. Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. Given the limited data available, we cannot draw definitive conclusions about factors that might influence outcomes of planned CDMR versus PVD.
The evidence is significantly limited by its minimal relevance to primary CDMR. Future research requires developing consensus about terminology for both delivery routes and outcomes; creating a minimum data set of information about CDMR; improving study design and statistical analyses; attending to major outcomes and their special measurement issues; assessing both short- and long-term outcomes with better measurement strategies; dealing better with confounders; and considering the value or utility of different outcomes.
RTI国际组织 - 北卡罗来纳大学教堂山分校循证实践中心（RTI - UNC EPC）系统回顾了美国及其他发达国家剖宫产（CD）的趋势和发生率、产妇要求剖宫产（CDMR）与计划阴道分娩（PVD）相比的母婴结局、影响CDMR利弊程度的因素以及未来研究方向。
我们检索了MEDLINE、Cochrane协作资源库和Embase，共识别出1406篇文章，并根据预先设定的纳入标准进行审查。我们纳入了1990年至今发表的英文研究。研究必须包括关键参考组（CDMR或替代指标）与PVD之间的比较。
一名主要审查员从纳入的文章中提取关键变量的详细数据；另一名资深审查员确认数据的准确性。
我们确定了13篇关于CD趋势和发生率的文章、54篇关于母婴结局的文章以及5篇关于CDMR影响因素的文章。CDMR的发生率似乎在上升。然而，由于目前CDMR既不是一个被广泛认可的临床实体，也不是诊断编码或报销的准确报告指征，因此很难准确评估其真实发生率或随时间的趋势。实际上几乎没有关于CDMR的研究，所以知识库主要基于具有独特且重大局限性的替代指标的间接证据。此外，大多数研究按实际分娩途径比较结局，导致其与计划分娩途径的相关性存在很大不确定性。原发性CDMR和计划阴道分娩在母亲或婴儿的个体结局方面可能确实存在差异。然而，我们对许多不同结局的综合评估表明，原发性CDMR和计划阴道分娩之间不存在重大差异，但证据过于薄弱，无法明确得出完全不存在差异的结论。鉴于现有数据有限，我们无法就可能影响计划CDMR与PVD结局的因素得出明确结论。
证据与原发性CDMR的相关性极低，严重受限。未来研究需要就分娩途径和结局的术语达成共识；创建关于CDMR的最小信息数据集；改进研究设计和统计分析；关注主要结局及其特殊测量问题；采用更好的测量策略评估短期和长期结局；更好地处理混杂因素；并考虑不同结局的价值或效用。
