Friday, June 01, 2007

Pregnant women are second class citizens

A fundamental right of all adult Americans is that of physical self-determination and informed consent to medical procedures. During a 1914 court case (Schloendorff v. Society of New York Hospital), Justice Cardozo articulated a patient’s right to self-determination:
Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and the surgeon who performs an operation without his patient's consent commits an assault for which he is liable for damages. This is true except in cases of emergency, where the patient is unconscious and where it is necessary to operate before consent can be obtained.
Our current understanding of informed consent is based largely on that 1914 decision. Today, before any medical procedure can occur, a patient must be fully informed about the procedure, including potential risks and benefits as well as reasonable alternatives. The person obtaining consent must be sure the patient has understood what was explained, and the patient has to document in writing that she understands the risks and agrees to the procedure.
Except pregnant women, that is.
There are several examples of court-ordered obstetrical interventions—usually cesarean sections—where a woman’s fundamental right to determine what happens to her own body is blatantly disregarded. Even more disturbing, a large percentage of physicians and lawyers support forcing procedures on pregnant women despite their expressed refusal. A 1987 study in the New England Journal of Medicine surveyed heads of maternal-fetal medicine department. 46% of the respondents supported court-ordered obstetrical interventions. A 2007 study of attendees at the annual meetings of the American College of Obstetricians and Gynecologists and the American Health Lawyers Association found that “51% described themselves as highly likely to support a court order.”
The following story from Dr. Marsden Wagner’s new book, Born in the USA, illustrates the degree to which fundamental human rights are now at stake in the realm of maternity care. (Dr. Wagner was contacted by the family and their lawyers, reviewed the case, and followed the progress of the litigation to its end.)
A woman in northern Florida we will call Ms. P had a normal vaginal birth with her first pregnancy. Her second birth, however, ended with a C-section that she believed was unnecessary, so when she got pregnant a third time, she sought a local midwife and signed on for a planned home birth.
Ms. P had a normal pregnancy, and when she went into labor, her mid­wife came to her home to attend the birth. The labor progressed nicely, but after some hours Ms. P was having a hard time keeping fluids down. Since the local hospital was only a couple of blocks away, her midwife suggested that they go over to the emergency room for a short time to get an intra­venous drip (IV) to hydrate her, and then return home.
In the ER, Ms. P told the staff that she was giving birth at home and would like an IV for a short time. She was put in a room and told to wait for a doctor. When the doctor arrived, he asked if she had had a previous C-section, and when she replied yes, the doctor said that he wanted to admit her for an immediate C-section. Ms. P said, "No thank you, I just want the IV, and then I'm going home." The doctor became adamant, telling her that she "must" have a C-section, and said that he would con­sent to give her the IV only if she consented to the C-section. When she refused his attempt to coerce her, the doctor said that if she did not con­sent to the C-section, the hospital would get a court order to do the C-section. The doctor then asked her to wait, and left the room.
As is typical in any hospital, word of what was going on in the ER spread among the staff. After a few minutes, a nurse ducked into the room where Ms. P was waiting and whispered, "If you don't want to have a cesarean sec­tion by force, you better get out of here quick. There is a back entrance to the ER if you go out and turn right."
Ms. P escaped by the back entrance and went home, where she contin­ued her labor without the benefit of an IV. (Note that the hospital never offered Ms. P the option of having a vaginal birth in the hospital with a staff doctor handy.)
Meanwhile, the chief of obstetrics called an emergency meeting with the hospital administrator and told him that the woman's baby was in grave danger of dying due to a ruptured uterus if an emergency C-section was not done quickly. What he said is not true. Studies have shown that Ms. P's C-section meant that she had a slightly higher chance of uterine rupture than a woman who had never had a cesarean, but the risk was still small—espe­cially since labor was not being induced with drugs—and the chance that the baby would die was even smaller. The hospital administrator, however, was not an obstetrician and had no idea whether or not the information was accurate. He called a local judge and told him to rush over, as it was a life-and-death situation. The judge came to the hospital and was told the same story by the obstetrician. He signed a court order for an immediate C-section—by force, if necessary.
Ms. P was continuing her labor at home when there was a knock on the door. She opened the door to the local sheriff, who was a friend of hers and a member of her church. The sheriff said, "I'm really terribly sorry, Ms. P, but I have here a warrant for your arrest." Shocked, Ms. P said, "What on earth for?" The sheriff answered, "I'm terribly sorry. I don't know what the hell is going on. My orders are to take you to the hospital, in handcuffs if necessary."
Against her wishes and the repeated objections of her husband, Ms. P was taken to the hospital, taken to the surgery ward, tied down on an operating table, and given a forced C-section. The story doesn't end here. Ms. P and her husband sued the doctors and the hospital. However, in Florida a judge must decide if a case deserves to go to trial, and another local judge decided that Ms. P's case was not worthy of proceeding, so her case never went to trial—a shocking miscarriage of justice, given the serious violation of Ms. P's basic rights. Since then, Ms. P has had another baby, born vaginally at home with no problems. Needless to say, there was no visit to the hospital during the labor.
It is important that women in this country become aware of the danger to birthing women and join the movement to protect them. Ms. P's fam­ily's wishes were not honored, and her body was invaded against her will. Her human rights were violated.... Treating pregnant women in this manner goes against the Nuremberg Code and the Helsinki Accord, which explicitly state an individual has absolute rights over her or his own body and no medical treat­ment can ever be forced. Cases like this indicate a dangerous trend in U.S. maternity care toward totalitarian control of a woman's reproductive life by doctors.
References:

Samuels TA, Minkoff H, Feldman J, Awonuga A, Wilson TE. “Obstetricians, health attorneys, and court-ordered cesarean sections.” Womens Health Issues. 2007 Mar-Apr;17(2): 107-14.

Veronika E.B. Kolder, Janet Gallagher, and Michael T. Parsons. “Court-Ordered Obstetrical Interventions.” NEJM 316.19 (May 7, 1987): 1192-1196.

Patient’s Rights: issues in Risk Management

Marsden Wagner. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (University of California Press: 2006).

21 comments:

  1. jen.b.in.az6/1/07, 7:41 PM

    OMG. I'm speechless. I had to comment, even thought I have no comment...sorry for the incoherent ramble, but thank you for posting this. What is our country doing??

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  2. Wow. Just wow. Am I jaded if I say that I am not surprised this happened? Because I'm not surprised, not in the least.

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  3. Wow. Why was this doctor so power-, money-, whatever-hungry? What judge in his/her right mind could say that there was no basis for a trial here? Wow.

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  4. I find court-ordered obstetrical interventions deeply disturbing on so many levels. Our society can disregard fundamental human rights at will--essentially picking and choosing who "qualifies" as worthy of basic legal protection. That is Big-Brother kind of scary. What good are laws if they can be ignored or bypassed with no legal recourse?

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  5. The Florida story is quite a shocker, and I am equally disturbed by how many OBs would support court ordered interventions, leaving wide open the possibility that c-sections without consent become common practice.

    I guess I was not overly paranoid when my midwife requested that I get an ultrasound at 37 weeks, and I told her that that was out of the question because I wanted to have no proof of my baby's breech presentation. Ack, it makes me shiver though, to think...

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  6. This is my first comment on your blog, and while I wish it was a little more profound, all I have to say is "shiver."

    Carolyn

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  7. Sad article, really. In my country women cannot even deny undergoing epsistomy :P not to say a C-section, if the doctor orders.

    I'll have to check out the Nuremberg Code and Helsinka Accord... Good to know that there are some laws that regulate this sort of issues.

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  8. kettunainen6/2/07, 10:01 PM

    And once again, the US completely ignores accords and codes determined and agreed upon by the rest of the world. How is it that professionals (doctors, lawyers, politicians... presidents) think they're above the law and end up getting away with so much hideousness? It's absolutely frightening and I'm so glad I immigrated the heck out of there.

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  9. My husband keeps trying to get back to Canada...but when you're an academic you can't go picking and choosing your job, unfortunately. We'd particularly like eastern Canada, as that is where his parents are now. Quebec would be awesome--we'd love to live in a French-speaking community. Sigh...

    It's hard to say that it's the "US" that's doing this--it's individual doctors and judges. But that it even happens, ever, is appalling.

    One of the authors of the 1987 NEJM article, Veronika Kolder, was a guest speaker for a freshman rhetoric class I taught as a grad student. She was doing her medical training when she witnessed a court-ordered cesarean section. It was a couple from Nigeria (I think that's the right country, but I'd have to check on that detail), and the woman was pregnant with triplets. She insisted on a vaginal birth, since in her home country multiples aren't the big scary thing that they are here. She was forced to have a C/S against her will. Her husband was very traumatized by this and subsequently committed suicide. Anyway Dr. Kolder said this was a very formative experience for her. (By the way, Dr. Kolder, who is an OB, had a home birth. Cool, eh?)

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  10. ...now I'm in tears for the Nigerian couple. I can only imagine how much of their hopes were shattered by their "case".

    Whatever the perceived interest of the unborn baby/babies, this is not a medical question with medical answers. This really is an ethical and civil liberties issue. I think this is happening here because of our society's lack of consensus about the interests of an unborn person. I hate to have to put it this way, but if we are second class citizens, we are second to our babies inside us.

    Am I right that in each of these cases, surgery can be forced on the mothers in the name of protecting their babies? So it's not a matter of to what degree VBAC or triplets or breeches etc pose potential risk to babies. The question is, do I have the right to endanger my own (unborn) child TO ANY DEGREE at all, by making decisions autonomously. If our society can agree on that, we won't have to quibble with doctors about the safety of VBAC.

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  11. Rixa, as nice as it sounds to live in a French-speaking area, being an English-speaking family in Quebec is not fun. My husband grew up in Quebec (south shore Montreal actually) in an English-speaking home and was discriminated against - no chance of getting a job, he was afraid to walk down the street in some areas, he had people spit on him because he did not speak (good enough) French. Not a great place to live if you speak English sadly.

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  12. But I thought all Canadians were nice friendly people?? LOL. Tongue in cheek.

    We both speak French fluently so language wouldn't be a problem (although I definitely do not speak with a Quebecois accent!). We'd really like to raise Zari bilingually but unless we live in Canada with access to French immersion or bilingual schools, or in a predominantly French-speaking area, it is near impossible. Even though we're both fluent, it's still weird to speak in French to her all the time--not the same.

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  13. *gasps*

    *cries*

    How heartbreakingly awful. I want to run away screaming from the computer after reading that story! That poor woman! Thank heavens she went on to have a safe homebirth afterwards.

    I would be lying if I didn't admit that this is one of my major fears about having a homebirth. I'm afraid that A) I'll wind up having to go to the hospital for some reason and then get forced into a repeat C-section, or B) the police will come knocking on my door because I'm making too much noise, and I'll be arrested for not having my baby in a government-approved location. Both of these things seemed like irrational fears until I read this post.

    *shivers*

    *cries some more*

    -Jill

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  14. I think it is disgusting that in this country a woman can make the choice to KILL her unborn child through an abortion if she does not want it, yet a woman who wants her baby is not allowed to choose how it will be born. It is a total oxymoron. If a mother can choose an abortion, then she can choose where and when and with whom her child is born.

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  15. I'm so glad you shared this story, Rixa. I heard "Ms. P." speak at the National Advocates for Pregnant Women conference in January, and to hear her tell her story was incredible.

    If people are interested in issues like this, I'd recommend the book Making Women Pay by Rachel Roth. It documents several other instances of court-ordered medical procedures that are "justified" because the woman is pregnant.

    It's important to note that policies and precedents like this not only confer pregnant women second-class citizenship -- Pregnant women under this system currently have fewer rights than a corpse. It's illegal to perform medical operations on a dead body without consent, but pregnant women can be forced to undergo procedures they have refused.

    Pregnant women are also the only class of people who can be forced to undergo medical procedures in the interests of the life of another person. No one is ever forced to give up a kidney when someone else is dying of kidney failure, even their own child. But cases like this often rest on the justification that the cesarean is necessary to save the life of the baby.

    There is an organization that is raising awareness about this and other related issues: www.advocatesforpregnantwomen.org

    ~Monica

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  16. Wow Monica, that would have been a powerful talk to attend. Thanks for the link--I'll have to add it to my list on this blog. Now off to see if I can ILL that book...

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  17. rixa, thanks for putting this info up on your blog. Fortunately this does not happen that often, but when it does it is still an injustice.

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  18. Astonishing...and not.

    I think that as a VBAC/attempting HBAC woman you should not go anywhere NEAR a hospital unless you bring a full legal staff with you. Insane, right? But its true.

    Once during my last pregnancy, I hadnt felt the baby move in over a day, and my midwives suggested that I could alwasy go to the hospital for a check if I was really feeling worried. I was too afraid they'd fillet me right then and there and I didnt even go. The baby moved and was fine and is now almost 2 years old! But so sick that we as pregnant women would ever have to be wary of going to the hospital.

    So sick.

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  19. i just found your blog. good work!
    i along with two local midwives put out a quarterly magazine- The Birth Project. www.birthproject.com
    We are wondering if we could reprint this blog post in our next issue?
    Take care,
    Kate

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  20. Yes, feel free to publish it. Let me know when the issue comes out; I'd love to read it.

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  21. Hi Rixa and all, we went through this in B.C., Canada. It was called the "Baby R" case. In a nutshell: poor woman (living on skid row, Caucasian) admitted to hosp, 4th baby, 3 older kids had been apprehended but had been born vaginally. No medical visits in preg. Dx'ed breech at hosp in birth process. court order applied for and given but woman acquiesced to c/s against her original stated wishes before it was served. Baby apprehended after c/s. Local feminist lawyers took up case and decision was that no Canadian woman can be forced to have c/s. Baby R's mother had her 5th baby out of hosp.

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