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Testament to the timeliness of the topic was the Academy’s well-attended event, which elicited the interest of medical professionals, women’s rights activists, several members of the press, and a documentary filmmaker.
Dr. Alan Fleischman, Senior Advisor at The New York Academy of Medicine, served as moderator of the event, which was entitled, “Seeking the Perfect Baby Through Cesarean Delivery: What’s at Stake? Medical, Ethical and Legal Concerns in Forced Cesareans and Cesareans on Request.” “Three people who have a great deal of expertise in this issue and one of the country’s leading bioethicists are going to help us sort out this issue,” he stated. The speakers showed the great complexity of medical, ethical, and societal factors that influence the decision to proceed with elective or forced cesareans. Speakers included Howard Minkoff, MD, a Distinguished Professor of Obstetrics and Gynecology at SUNY Health Science Center and Chairman of the Department of Obstetrics and Gynecology at Maimonides Medical Center in Brooklyn; Maureen Corry, MPH, Executive Director of Childbirth Connection; and Lynn Paltrow, JD, Executive Director of National Advocates for Pregnant Women. Nancy Dubler, LLB, Professor and Director of the Division of Bioethics at Montefiore Medical Center and Albert Einstein College of Medicine, served as commentator and underscored the ethical ambiguity and complexity of many of the issues raised by speakers.
Should Obstetricians Be “Pro-Choice”?
Speaking from the perspective of his long career in perinatal medicine and ethics, Dr. Howard Minkoff explained that he would encourage, with qualification, obstetricians to support mothers’ requests for a cesarean delivery, even if it is not medically necessary. The research data on the safety of vaginal delivery versus that of planned cesarean delivery does not show that one delivery option is safer. Both have risks and benefits and the research findings “are neither unilateral nor simple,” Minkoff said. Vaginal delivery may be better for a mother’s health since it is associated with lower incidence of infection, anesthetic complications, and subsequent placenta previa than planned c-sections. With a c-section (planned or emergency), a woman is more likely to face higher risk in future pregnancies of placenta accreta and stillbirth, and a greater likelihood of operative morbidity from hemorrhage, infection, and visceral injuries. Yet planned c-sections are associated with lower maternal death rates than normal vaginal deliveries, Minkoff said. Women who get a planned cesarean also experience a lower incidence of urinary incontinence than women who deliver vaginally, and fewer surgical and traumatic complications than women who receive unplanned c-sections (especially those who go through labor for twelve or fourteen hours first). The incidence of uterine rupture during attempted “Vaginal Birth After Cesarean” procedures (VBAC) is significantly higher than experienced by women who have elective repeat c-sections, Minkoff said. There is also “weak-quality evidence” suggesting a reduced risk of anal incontinence in planned c-sections versus unplanned cesarean deliveries and vaginal deliveries using instruments.
Each delivery method also offers different benefits and risks for the unborn child. Mothers who deliver vaginally are more likely to begin breastfeeding early on and continue for a longer period of time, which promotes infant and child health. Babies vaginally delivered at gestational ages earlier than 39-40 weeks face less risk of respiratory problems than those delivered via elective c-sections. Alternatively, c-sections may reduce the rate of stillbirths (two per 1,000) that occur after 39 weeks in utero, as well as the extent of herpes transmission from mother to baby. More than 22 percent of all American women have herpes, and performing a c-section when a lesion is seen reduces transmission rates by 85 percent.
Planned cesareans also offer a significant scheduling advantage for women, a factor if timing is considered very important or highly desirable. A woman can choose the time of her child’s birth, enabling her to arrange for her mother to come in from out of state to be with her, for example, or to choose a certain day or time to be admitted to the hospital. “There are better times than others to be cared for in a hospital,” Minkoff said. A study conducted in Germany, he pointed out, shows that normal babies born at night are more likely to die than normal babies born during the day – perhaps the result of staff fatigue.
What to do, given the complexity of this data? Minkoff suggested that doctors utilize the deliberative model when mothers request a medically unnecessary cesarean delivery: that is, doctors should bring their own “health values” into the discussion “to guide patients, not to coerce them.” In the absence of medical research firmly establishing that vaginal delivery is safer than planned cesareans, he also advised obstetricians not to “stick their feet in the sand and refuse” if a patient requests a c-section. “I strongly discourage a cesarean-section,” he said. “I don’t think it’s in the best interest of everyone involved. But if the mother was informed and educated, I don’t think I would refuse it.”
Minkoff believes that “autonomy should rule the roost in the doctor-patient relationship.” “A woman has the right to say no to anything,” he said. “Obstetricians must respect the patient’s autonomy if there’s no medical reason to refuse the requested treatment. If it violates your professional judgment, however, if your patient says she wants to be induced at 32 weeks because she’s going to have out-of-town guests, you should refuse.”
National Listening to Mothers Survey: New Mothers Report Cesarean Views and Experiences
Maureen Corry, who has served as an advocate for women, their fetuses, and children for over 20 years, presented findings from Childbirth Connection’s “National Listening to Mother’s Survey II: New Mothers Report Cesarean Views and Experiences.” The survey was conducted in January and February of 2006 and elicited new mothers’ opinions on and experiences with cesareans, particularly those performed at a mother’s request. (The initial “Listening to Mothers Survey” in 2003 marked the first time women were nationally polled about their childbirth experiences).
Corry said the 2006 survey confirmed that, generally speaking, most women support cesareans that are medically necessary and few support—or request—elective cesareans. The survey included 1,574 mothers between the ages of 18 and 45 who gave birth in a hospital in 2005 to a single infant, nearly one-third via cesarean (a rate in line with national trends). For 252 of these women, it was their first c-section, and when asked the reason for getting a c-section, all but three said they believe their cesareans had been medically necessary for a variety of reasons, including concerns about fetal distress, the position of the baby, size of the baby, and prolonged labor. Only three indicated that there was no medical reason, with two women reporting that a health professional had initiated their scheduled cesareans, and one saying it had been her choice. Twenty-four percent said a c-section had been suggested by their providers before labor, and 64 percent said it was suggested by their providers during labor.
Based on this survey, Childbirth Connections concluded that “cesarean delivery on maternal request is not a major factor in the rising cesarean debate.” What should be more closely scrutinized, Corry suggested, is healthcare providers’ relationship to the issue of cesarean section and to their patients. The survey found that many women are ill-informed about the potential risks of c-section, and some felt pressured by their healthcare provider to have a c-section, induced labor, and/or an epidural.
Corry concluded her talk by stating that studies show a c-section rate of 4 percent is achievable in North America in low-risk pregnancies. To increase the numbers of vaginal deliveries in healthy women, she said that we must do more to promote the “natural physiology” of birth in the United States, attend to the “troubling liability environment in our country,” and look at loss of physician skills, such as turning breech babies in utero so they are positioned head-down and ready for safe vaginal delivery.
Do Women Lose Their Civil Rights Upon Becoming Pregnant?
Attorney Lynne Paltrow, who has had a distinguished career advocating for women’s rights, provided an overview of the legal and political times in which the debate over elective cesarean sections is being waged, focusing her comments on forced cesareans.
Paltrow stated that as a matter of law, individuals in the United States have the right to make medical decisions for themselves, a right to privacy, and a right to make decisions about what happens to their own bodies. She quoted from the final decision in McFall vs. Shimp, a landmark case from the 1970s regarding an individual’s legal sovereignty over his or own body: “Forcibly restraining someone to make them submit to surgery for the benefit of another would ‘raise the specter of the swastika and the inquisition, reminiscent of the horror it portends.’ ” Running counter to this legal right, however, were a series of high profile cases in the 1980s involving pregnant women and forced cesareans. Paltrow told many startling stories involving forced c-sections, including:
• In Georgia, a woman pregnant with her eighth child had full placenta previa. Her doctor told her that without a c-section she and/or the baby risked death. On the basis of her faith, the woman refused a c-section. A court order was obtained to force the mother to undergo a c-section. The woman fled and gave birth to a healthy baby.
• A Nigerian woman in the United States was pregnant with triplets and was told she needed a c-section, which she opposed because she expected to be in Nigeria upon her next pregnancy and knew that she wouldn’t have access to medical services for a c-section, which she assumed she would need if she had one for this current delivery. Though she and her husband vigorously opposed the procedure, the woman was strapped down with leather wrist bracelets and ankle cuffs and forced to undergo cesarean delivery.
• In Washington D.C., health providers wanted to do a c-section on a woman who had been in labor for over 30 hours, because they feared she was at severe risk of infection. She refused a c-section. An emergency hearing was called, a lawyer was appointed for the fetus, and the judge ordered a c-section, saying that: “All that stood between the mature fetus and its independent existence was, put simply, a doctor’s scalpel.” When the procedure was done, there was no evidence of infection.
Paltrow explained that her organization, National Advocates for Pregnant Women, brought an appeal in one forced c-section in which the mother died and the c-section was listed as a contributing cause. This marked the first time a c-section case was legally challenged. The court, citing cases recognizing that people of all kinds have the right to make medical decisions on their own behalf, ruled that the forced c-section should not have been performed. The court ruled: “If a competent pregnant woman makes an informed decision, her wishes will control in virtually all cases . . . Exceptions, if any, to the rule will be extremely rare . . . Indeed, some may doubt that there could ever be a situation extraordinary or compelling enough to justify a massive intrusion into a person’s body such as a c-section against the person’s will.” Paltrow said that today, both law and medicine agree that “coerced medical interventions on pregnant women are an abuse of medical and state authority.”
Nonetheless, forced medical treatments and other intrusions upon the rights of pregnant women continue, Paltrow said, and she is concerned that “we are going to see more of them, because the direction of the country’s politics and debate take us to a point where we see lessening respect for pregnant women and their rights.”
“It is as if there is a growing force of people saying that the universal declaration of human rights, which creates affirmative obligations to country’s citizens, applies to only one form of life, and that is unborn life,” Paltrow said. “Everyone else be damned.”
Founded in 1847, The New York Academy of Medicine is an independent, non-partisan, non-profit institution whose mission is to enhance the health of the public. The Academy is a leading center for urban health policy and action working to enhance the health of people living in cities worldwide through research, education, advocacy, and prevention.
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Posted on 06/16/2006
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