caesarean sections ( css ) now exceed rates thought capable of delivering health benefits to mothers and babies . caesarean delivery on maternal request ( cdmr ) has been added to this list of indications and considered an important contributing factor in the cs rising rate [ 35 ] . the latter occurs when a woman asks to schedule a purely planned caesarean section on a date mutually convenient for her and her doctor , before the onset of labour , without any medical rationale , and in the absence of any clinical indication . women 's preference can be affected by tokophobia ( fear of childbirth ) , the risk of out - of - hour delivery , the belief that caesareans are safest for the baby , or because vaginal delivery has become stigmatised as archaic and disfiguring . however , in a review of the literature on women 's request for caesarean section , it turned out that few women request this procedure in the absence of current or previous obstetric complications [ 7 , 8 ] . a growing number of women achieve their first pregnancy late in life [ 911 ] . in flanders , from 1995 until 2010 the percentage of primiparous women being 35 years or older increased from 3.6% to 8.3% ( spe , annual reports ) . consequently , older women will make more use of assisted reproductive technologies ( art ) . babies , conceived after art , of older primiparous women may therefore be considered as  precious babies  . the aim of this study is to find out whether nulliparous women , aged 35 or more , giving birth after in vitro fertilisation ( ivf ) or intracytoplasmatic sperm injection ( icsi ) are more prone to a prelabour caesarean delivery by comparing them with nulliparous women of the same age who conceived spontaneously . an additional purpose is to evaluate the attitude among belgian gynaecologists in case of a fictitious primigravid woman of advanced maternal age , pregnant after years of infertility , who asks for a caesarean section . the region of flanders ( northern , dutch - speaking part of the constitutionally federal state of belgium ) covers 13,521  km and has about 6.2 million inhabitants . four of these units are in university hospitals , 15 in other teaching hospitals , and 49 in nonteaching hospitals . eighteen of the 68 hospitals have an art unit . patients from peripheral hospitals are sent to these hospitals , but the policy is that for further followup and delivery , they return to their original gynaecologist . for each newborn of at least 0.5  kg , an official perinatal form must be completed and sent to the flemisch centre for perinatal epidemiology ( spe , studiecentrum voor perinatale epidemiologie ) , where all data are controlled by an error detection program and feedback is provided . perinatal data for this retrospective cohort study is collected from the existing computer files maintained by the spe .    during the study period ( january 1 , 1995december 31 , 2009 ) , pregnancies with the following inclusion criteria are selected : nulliparous women , age 35 years or older , who delivered a live - born singleton infant in cephalic presentation with a gestational age at the time of delivery of 38 weeks or more and without congenital malformations . pregnancies conceived by ivf / icsi and pregnancies conceived spontaneously are compared with respect to maternal age , gestational age , and birth weight . rates of spontaneous vaginal and instrumental delivery , prelabour cs and cs following labour , and induction of labour are determined the belgian college of physicians for mother and newborn tried to determine , through an anonymous questionnaire that was sent to all belgian gynaecologists , the willingness of belgian gynaecologists to perform a caesarean section in some particular cases . the first part of the questionnaire included questions about the age and gender , the amount of years of practice as specialist , and the type of hospital and region in which the gynaecologist was practicing . the second part included questions about the personal preference of labour and delivery management in specific fictive case histories . one such case concerned a primiparous 38 years old and 165  cm tall woman who became pregnant after the 4th ivf attempt , with a singleton baby of 3  kg in cephalic presentation at 39 weeks of gestation . the woman requests a prelabour cs because of fear and because she assumed that it will probably be her only child . the gynaecologists could either agree or disagree with this demand or they could have no opinion . between 1995 ( january 1st ) and 2009 ( december 31st ) , 17,094 women are selected . of this population , women in both groups are comparable with respect to maternal age , duration of gestation , and birth weight ( table 1 ) . during the study period , the number of older primiparous women who conceived spontaneously increased from 595 in 1995 to 1472 in 2009 ( 2.5 ) . the number of women pregnant through ivf / icsi and having their first baby at advanced maternal age also increased more dramatically from 64 women in 1995 to 224 women in 2009 ( 3.5 ) in the study population . in a period of fifteen years , the amount of so - called  precious babies  more than tripled in flanders . table 2 shows that the labour and delivery characteristics are comparable for both groups , except for prelabour cs . the latter occurred significantly more frequently in those women who got pregnant after ivf / icsi  relative risk 1.42 ( 95% confidence interval 1.221.64)compared to spontaneous pregnancies . the neonatal mortality and morbidity was low and comparable in both groups ( table 3 ) .   from a total of 1172 survey forms that reached the belgian gynaecologist , the questionnaire reveals that 19% ( n = 117 ) gynaecologists would perform a prelabour caesarean section on maternal request ( figure 1 ) . univariate analysis shows that there is neither a significant difference according to gender nor according to the type of institution to which the gynaecologist belonged ( university institution , reference centres , and peripheral hospitals ) . however , the age of the gynaecologist ( p = 0.001 ) and the number of individual annual deliveries ( p = 0.008 ) significantly influence the response rate . the gynaecologists of 50 years and those performing less than 150 deliveries per year were more in favour to perform a caesarean section in the aforementioned particular case . this study shows a significant higher rate of prelabour cs in at term women of advanced maternal age ( 35 years old or more ) , who become pregnant after ivf / icsi and have a singleton baby in cephalic presentation , compared to women with the same characteristics who conceive spontaneously . although the prelabour cs rates are not very high ( 9.2% versus 6.3% ) , the data suggest that there is a lower threshold for performing a prelabour caesarean section when the pregnancy is artificially conceived . once in labour these objective data corroborate to some degree with the subjective data that nearly one in five belgian gynaecologists is willing to perform a cs on maternal request to deliver a  precious baby  . many studies indicate that rates of caesarean section are significantly higher after assisted than after natural conception [ 1316 ] . based on knowledge that the pregnancy is the result of art , gynaecologists may modify their practice to deliver by caesarean section . a systematic review of 25 studies , published between 1985 and 2002 , of singleton pregnancies after art and matched controls , shows that art pregnancies more often australian ivf term women , with singleton babies , underwent significantly more frequently ( 43.8% ) a caesarean section compared to controls ( 27.8% ) , or 2.02 ( 95% ci 1.952.10 ) . twin pregnancies , conceived with the aid of art , are also at increased risk to be delivered by caesarean section , compared to spontaneously conceived twin pregnancies [ 17 , 19 ] . a fairly robust literature shows that art pregnancies result more frequently in preterm delivery and a low - birth - weight infant [ 20 , 21 ] . in order to avoid the preterm birth bias , only at term ( 38 weeks or more gestation ) singleton pregnancies in cephalic presentation of nulliparous women of advanced maternal age ( > 35 years ) ivf / icsi and spontaneous conceived pregnancies were comparable with respect to duration of gestation and birth weight . it is unclear in this study whether the impetus for this higher rate of prelabour caesarean delivery is the result of a maternal request , a defensive attitude by the physician , or of a consensus between the physician and the pregnant woman . another possibility for the higher incidence of cs is the fear of the gynaecologist about the outcome of a pregnancy that was difficult to conceive . from 40% to 54% of physicians approve of a woman 's right to request and obtain a caesarean section without medical indication ( usa , denmark ) [ 3 , 23 ] . this is substantially higher than the 19% belgian gynaecologists that , according to the questionnaire , agreed to perform an cs on maternal request . in the usa , an important determinant for performing a prelabour caesarean section for no medical reasons is when the pregnant woman belongs to a high socioeconomic level . a recent study found the opposite , namely , that the frequency of having a prelabour cs level is inversely related to the level of maternal education . women getting pregnant for the first time at advanced age are even more under pressure . they are more at risk for complications , and they feel rushed into pregnancy if they want to have children before the window of opportunity closes . it is for sure that ivf / icsi is not an easy way to conceive : it is expensive , success is not assured , and the process itself entails daily injections of hormones , painful procedures , and a great expenditure in time and energy . all these stressful factors could play a role in the decision of mother and doctor to plan a prelabour caesarean section and schedule the delivery on a time convenient for both of them . in many countries governments lack funding for fertility treatment and the financial impact of paying for these treatments can be too much to bear for some families . a reason why the prelabour caesarean section rates for ivf / icsi pregnancies in flanders are quite low , compared to other countries [ 14 , 18 ] , may be explained by the high level of reimbursement for those expensive treatments . patients who fall under the belgian national health service system are reimbursed for the laboratory costs of fertility treatments and for the larger part of the cost of stimulation medication . the cost reimbursed per ivf / icsi cycle in belgium is  2426 ( 2004 ) , but the patients have to pay only  200 .   until evidence supports prelabour caesarean section as a birth option that optimizes outcomes for mothers and their infants , obstetricians should continue to support evidenced - based decision making that includes advocacy for vaginal delivery as the optimal mode of birth . fever , infection , pneumonia , and thromboembolic events are increased with caesarean delivery . besides , prelabour caesarean deliveries that are performed before 39 weeks of gestation are associated with adverse neonatal outcomes such as mechanical ventilation , newborn sepsis , hypoglycaemia , and admission to the neonatal icu . in northern belgium ( flanders ) , pregnancies after ivf / icsi are more prone to end in a prelabour caesarean section , putting an additional burden on the economic expenditure for obstetric care in assisted pregnancies . no matter how stressful an ivf / icsi pregnancy can be , indication for caesarean section should be evidence based . there was no conflict of interests nor a financial disclosure for any of the authors . e. gillet wrote the manuscript ; e. martens collected the data ; g. martens did the statistical analysis ; h. cammu designed the study and revised the manuscript .
objective . to compare prelabour caesarean section ( cs ) rates in older nulliparous women with a term singleton baby in cephalic presentation conceiving spontaneously and through ivf / icsi . 
 when the latter women would ask for cs , how willing are gynaecologists to comply with that request ? methods . 
 a population - based retrospective ( 19952009 ) cohort study , conducted in northern belgium . 
 a comparison of 1,866 nulliparous women pregnant after ivf / icsi and 15,228 controls is made . 
 an anonymous postal questionnaire is sent to all belgian gynaecologists . 
 result . 
 both groups are comparable with respect to maternal age , gestational age , and birth weight . 
 prelabour cs is more often performed in women who conceived through ivf / icsi compared to those who conceived spontaneously ( 9.2% versus 6.3% , p < 0.001 ) . 
 one in five gynaecologists agrees with the maternal request . 
 conclusion . 
 ivf / icsi pregnancies in older nulliparous women more often end in a prelabour cs and a substantial number of gynaecologists go along with a nonmedical reason for cs .