Coercive C-Sections Don't get forced into having a surgery you don't need

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http://www.freewebs.com/forcedc-sections/

 

By Lisa Collier Cool

 

Amber Marlowe anticipated an easy delivery when she went into labor on

January 14, 2004. But after a routine ultrasound, doctors at

Wilkes-Barre General Hospital, in Pennsylvania, decided that the baby ?

at what looked like 13 pounds ? was too big to deliver vaginally and

told her that she needed to have a cesarean. The mom-to-be, however,

wasn't convinced: After all, she'd given birth to her six previous kids

the natural way, including other large babies. And monitoring showed

that the fetus was in no apparent distress.

 

After she said no to surgery, doctors spent hours trying to change her

mind. When that didn't work, the hospital went to court, seeking an

order to become her unborn baby's legal guardian. A judge ruled that the

doctors could perform a " medically necessary " c-section against the

mom's will, if she returned to that hospital. Meanwhile, she and her

husband checked out against the doctors' advice and went to another

hospital, where she later gave birth vaginally to a healthy 11-pound

girl. " When I found out about the court order, I couldn't believe the

hospital would do something like that. It was scary and very shocking, "

says Marlowe. " All this just because I didn't want a c-section. "

 

She and her husband, John, turned to the National Advocates for Pregnant

Women (NAPW), in New York City, for help in contesting the judge's

ruling ? the first of its kind in Pennsylvania. The couple is also

considering legal action against the hospital. " It's not about us, " says

John Marlowe. " What's going to happen to the next lady who goes there?

We want everyone to know what's going on. What they did was wrong, and

our goal is to put a stop to it so that other women don't end up with

c-sections they don't need. "

 

Coercive medicine

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Increasingly in the United States, pregnant women are encountering legal

or more subtle pressures to have c-sections. Currently, more than a

million expectant women have the operation annually, as America's rate

of surgical deliveries has hit an all-time high. In 2003, cesareans

accounted for nearly 28 percent of births in this country, compared with

just 5 percent in 1970. Many factors contributed to this rise ?

increasing numbers of repeat c-sections, doctors' fears of malpractice

lawsuits, and women waiting longer to have kids (which is related to

higher rates of complications), to name a few. But while the procedure

is usually quite safe and can be potentially lifesaving for mother and

baby, it also poses a number of potential risks, including severe

bleeding, infection, injury to the fetus, blood clots, and even the

mother's death in extremely rare cases. Yet hospitals in at least a

dozen states have obtained court orders to compel unwilling women to

undergo this major abdominal surgery. And while Marlowe was able to

escape the scalpel, other patients were operated on ? despite their

verbal or even physical resistance. In a tragic 1984 case, staff at a

Chicago hospital forcibly tied a pregnant Nigerian woman who had

declined a c-section to her hospital bed with leather wrist and ankle

restraints. The woman objected to the surgery because she planned to

return to Nigeria where the operation wasn't readily available, and she

rightfully worried about health risks, including a ruptured uterus, if

she became pregnant again and had another child vaginally back home. As

she screamed for help and frantically tried to free herself, doctors,

with a judge's permission, wheeled her off to the O.R. to perform the

procedure.

 

Defying doctors' advice can even lead to criminal prosecution, as

Melissa Rowland discovered last year. While pregnant with twins, the

28-year-old Utah mom initially declined a recommended c-section, even

though doctors warned that without it her babies might die due to low

levels of amniotic fluid and other problems. Several days later, on

January 13, 2004, she changed her mind and had the operation. Her

daughter, Hannah, survived after treatment with oxygen and antibiotics,

but a twin boy was stillborn. Contending that the initial refusal caused

his death, prosecutors charged Rowland with first-degree murder. After

spending three months in jail, she accepted a deal in which the murder

charge was dismissed in return for her guilty plea to two counts of

child endangerment (unrelated to her c-section refusal). She's now free,

and serving 18 months of probation.

 

" This case is a tragedy compounded by a shocking abuse of legal

authority, " contends Lynn Paltrow, executive director of NAPW and a

lawyer specializing in reproductive issues. " It shouldn't be a crime for

pregnant women to disagree with doctors and make their own medical

decisions. Nor should they be punished for a bad outcome when there's

always some risk to giving birth, regardless of whether it's vaginal or

by c-section. "

 

And you can't be legally compelled to undergo any other medical

procedure for the benefit of another person. " You don't have to donate

your kidney, your bone marrow, or your blood, even if someone else might

die without it, " explains Howard Minkoff, M.D., chair of obstetrics and

gynecology at Maimonides Medical Center, in Brooklyn, New York, and

coauthor (with Paltrow) on an analysis of the Rowland case published in

the December 2004 issue of Obstetrics and Gynecology. You also can't be

prosecuted for murder if you refuse. " So why should c-sections be any

different? " the doctor adds. " That's saying pregnant women have fewer

rights than anyone else, including a fetus. "

 

A subtle pressure

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Of course, only a minute fraction of the c-sections performed in this

country are court ordered. Far more women undergo the procedure at the

recommendation of their doctor. The most common reason a woman is

encouraged to have a c-section is if she previously delivered a child

this way. These " repeat c-sections " have become so common that they now

account for nearly 410,000 births annually in the United States, about

10 percent of births each year. And it doesn't seem that this number

will be getting any lower, as an increasing number of hospitals that

formerly permitted women to try for vaginal birth after cesarean (VBAC)

now prohibit the practice, making a return trip to the O.R. mandatory

for moms-to-be with a previous surgical delivery. Because it's getting

harder and harder to find medical centers that allow VBAC, the rate has

plunged by nearly two-thirds, from 27.5 percent in 1995 to 10.6 percent

in 2003.

 

Ask doctors what's behind the ban, and you'll hear the same answer: fear

of lawsuits. Trying for a VBAC carries with it a 1 percent risk of

uterine rupture. This dangerous complication is an emergency that

requires surgical repair ? or, in some cases, a hysterectomy ? to stop

potentially life-threatening blood loss. " Medical liability is a huge

problem for obstetricians, because people are losing their practices

over malpractice claims, " reports medical ethicist Anne Lyerly, M.D.,

assistant professor of obstetrics and gynecology at Duke University in

Durham, North Carolina. " So it's understandable that a lot of us

practice defensive medicine by avoiding risky deliveries that might have

adverse outcomes. " A 2004 American College of Obstetricians and

Gynecologists (ACOG) survey bears this out, since 15 percent of its

members say they've stopped doing VBACs to protect themselves from

malpractice claims, and another 14 percent no longer deliver babies at

all for the same reason.

 

In 1999, ACOG responded to concerns about VBAC risks with new practice

guidelines, saying that the delivery should only be provided at

hospitals equipped to do an immediate c-section if anything went wrong,

instead of within 30 minutes' notice, as was previously required.

 

That's fine for big medical centers that have anesthesiologists and

surgeons on duty 24/7, like the one where Dr. Minkoff delivers babies,

but not for smaller hospitals. " Often, they can't afford to have doctors

standing by in case a woman who arrives in early labor needs surgery

later on, so in many parts of the country, especially rural areas,

pregnant patients can't find anywhere to have a VBAC, " he explains.

 

An ethical debate

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How far should ob-gyns go to save an unborn baby they consider at risk?

Some of the very doctors you'd most expect to advocate for pregnant

women actually support forced c-sections, a 2003 University of Chicago

study found. When the researchers surveyed directors of 42

maternal-fetal medicine programs around the country, 14 percent reported

that their hospital had used court orders to compel unwilling women to

have O.R. deliveries. What's more, 21 percent of these specialists in

the care of pregnant patients consider coerced c-sections " ethically

justified " to spare a fetus possible harm ? even over the woman's

physical resistance, as long as her struggles weren't strenuous enough

to endanger her or the baby. ACOG adamantly disagrees. In 2004, its

ethics committee ruled that it's never right for health care providers

to subject pregnant women to physical force, even with a court order

authorizing a c-section or other procedure. The committee also said that

seeking such orders against a patient's wishes is " rarely if ever

acceptable. " The American Medical Association, another prominent

doctors' group, has a similar policy.

 

what should happen if a doctor is convinced that a vaginal birth would

be disastrous? " Personally, I'm willing to counsel women very strongly

in that situation ? and bring in another physician to offer a second

opinion about the risks of not having a c-section, " says Dr. Lyerly. " I

also tell patients that it's a very safe operation ? and I should know,

since I've had three c-sections myself. "

 

ever, doctors' opinions can also be tragically wrong. Years ago, a

Washington, D.C., hospital got a court order to perform a c-section on

Angela Carder, who was gravely ill with cancer. Since the mom was in

such poor health, the hospital's doctors believed that delivering the

26-week fetus immediately would give it a better chance of survival than

waiting for a natural delivery. The result? Carder and her baby both

died soon after the operation. Later, in a landmark 1990 ruling, an

appeals court overturned the order, finding that Carder had a right to

make medical decisions for herself and her unborn child. Her family also

received an undisclosed financial settlement from the hospital.

 

hope that doctors and judges are humbled by this terrible mistake that

never should have happened, " says Dr. Lyerly. " We can make dire

predictions and think patients are too irrational to weigh the risks for

themselves, but we're not infallible. And since doctors and moms can

both be wrong, and if they can't agree on the best way to give birth,

ultimately it has to be the woman's choice. "

 

When surgery is being considered, experts say pregnant women need to

feel confident that their wishes will prevail, whether they consent to

an elective or emergency c-section or decline one they deem medically

unnecessary, as Amber Marlowe did. In 25 years of delivering babies, Dr.

Minkoff has learned to respect his patients' decisions about how they

want to give birth ? even if he doesn't always agree. " It's my duty to

fully explain why I think a c-section should be seriously considered and

the risks of not following my advice, " he says. " But in the end, the

strongest advocate for the safety and health of an unborn child is the

baby's mother. And that's the way it should be, because she has the most

at stake. "