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).