Hospitals should not control the decisions of pregnant women

Hospitals should not control the decisions of pregnant women

Doctors, hospitals and judges have over the years attempted to control the decisions of pregnant women. In a recent Florida case, it’s not clear whether the controllers sought to protect the fetus, the woman or both. They may have wanted to protect the hospital from potential liability.

The case involved a 39-week-pregnant woman.

According to a press release issued by the National Advocates for Pregnant Women (NAPW), the hospital threatened to force the woman to have cesarean surgery against her will or risk being reported to child-welfare authorities. The woman, 29-year-old Jennifer Goodall of Cape Coral, had had three previous cesarean sections; based on those experiences, she elected to have a trial of labor for a normal vaginal delivery before agreeing to a c-section if it became necessary.

According to NAPW, the chief financial officer of Bayfront Health Port Charlotte sent a letter Goodall, threatening to report her to the Department of Children and Family Services, seek a court order to perform surgery and perform cesarean surgery on her “with or without [her] consent” if she went to the hospital. The hospital has declined comment on the case, citing patient confidentiality.

There are risks involved with repeated cesarean sections, as well as risks to women who have vaginal births after having had cesarean sections (known as VBAC). According to guidelines issued in 2010 by the American College of Obstetricians and Gynecologists (ACOG), ”attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.”

ACOG reports that before 1970, VBAC was rarely performed, but the practice increased steadily, reaching 28% of women who had had previous c-sections by 1996. After that, the practice steadily declined, reaching 8.5% only a decade later. The apparent reason for the decline was the restrictions placed by hospitals and insurers on a trial of labor following previous cesarean sections. This shows that it is not only physicians, but also hospitals and insurance companies, who try to control pregnant women.

In 2005 the ACOG Committee on Ethics issued an opinion that included the following points:

  • Coercive and punitive legal approaches to pregnant women who refuse medical advice fail to recognize that all competent adults are entitled to informed consent and bodily integrity.
  • Court-ordered interventions in cases of informed refusal, as well as punishment of pregnant women for their behavior that may put a fetus at risk, neglect the fact that medical knowledge and predictions of outcomes in obstetrics have limitations.
  • Coercive and punitive policies are potentially counterproductive in that they are likely to discourage prenatal care and successful treatment, adversely affect infant mortality rates, and undermine the physician–patient relationship.

Despite these statements issued by the leading professional society of obstetricians and gynecologists in the United States, a federal district judge in Florida denied the request, set forth in a formal complaint filed by NAPW, for a temporary restraining order preventing the hospital from carrying out its threats.

The judge said that Ms. Goodall had no “right to compel a physician or medical facility to perform a medical procedure in the manner she wishes against their best medical judgment.” Apparently, one of the hospital’s concerns was malpractice liability in case of a bad outcome.

For her part, according to NAPW, the patient was willing to undergo a cesarean section if the trial of labor resulted in complications that would require a c-section for her or her baby’s health. The patient stated that her decision was “based on years of research, careful consideration of the risks to me and my baby, and my family’s needs.” This is not a woman whose decision was capricious or uninformed.

Over the weekend, Goodall gave birth to a healthy boy — at a different hospital. The hospital allowed her to choose VBAC; however, when it became obvious that the labor was not progressing, she elected to have a c-section. She reportedly stated on her Facebook page that all she wanted was to be given the option.

If this were an isolated case of an attempt to control the behavior of a pregnant woman, we could chalk it up to an excessively paternalistic medical environment and a judge who is ignorant of precedents set in other court cases that granted pregnant women the right to refuse coerced cesarean sections. But although appellate courts have upheld the right of pregnant women to refuse medical treatments, including c-sections, other actions continue to violate the decision-making autonomy of pregnant women.

As the ACOG guidelines clearly state, if a pregnant woman is informed of all risks, she should be empowered to choose the delivery method of her choice.

Ruth Macklin is a professor, department of epidemiology and population health, Albert Einstein College of Medicine, Bronx, NY. She blogs at The Doctor’s Tablet.

Image credit: Shutterstock.com

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  • PrimaryCareDoc

    A VBAC after 3 sections is a bad idea. Period. I doubt the “research” abilities of someone who comes to any other conclusion.

    • querywoman

      That seems obvious to non-doctor me, non-mother me.

      I oppose a lot of labor interventions, but I never got to have a baby, so my opinions may be skewed.
      Three tummy incisions could easily burst open!

  • JR DNR

    According to the Mayo Clinic, three c-sections should be the limit:

    http://www.mayoclinic.org/tests-procedures/c-section/expert-answers/c-sections/faq-20058380

    Wouldn’t that mean it’s critical, for a women planning for a large family, to attempt a VBAC in the second or third pregnancy if possible?

    • FEDUP MD

      Yes.

      My own OB asked me in my second pregnancy how many kids I was planning on having (1st one was emergency c section). She told me if I was going to have more than 3 kids I should attempt VBAC.

  • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

    This article confuses the legitimate right of patients to make informed refusals of proposed medical treatment with the illegitimate assumption that patients can coerce doctors and hospitals to perform medical procedures they feel would be harmful. The latter “right” does not exist.

    Coming soon to a KevinMD blog near you: my post on balancing physician paternalism and patient choice. Neither carries the day.

    • PrimaryCareDoc

      Exactly. What about the rights of the physicians in this case?

      • JR DNR

        You’re right, the rights of the physicians aren’t being respected at all. It’s the insurance company making the decision by setting rules that the doctors have to follow.

    • JR DNR

      Patients have the right to refuse all treatments. That includes a c-section.

      • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

        Exactly so. And doctors (and hospitals) have the right to refuse to treat a patient who demands a plan of care they consider futile or dangerous. Arguing that people have the right to make foolish health care decisions for themselves is one thing; arguing that others are obliged to assist them is another.

        • JR DNR

          The problem is the OB agreed to it, then the hospital sent a letter to the patient invalidating the agreement between the patient and the OB.

          Of course, the hospital didn’t just refuse to allow the patient to be treated in their facility. They stated they were going to try and force her into treatment she didn’t want, AND try to get her children taken away as well.

          • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

            My 2 comments above relate to the tone of the article, not the facts of the case. If the hospital did anything illegal (the judge didn’t think so) or unethical, this wrongdoing was unrelated to the patient’s right to refuse treatment. She was free to go elsewhere, and did.

          • querywoman

            There have been instances of courts taking control of the unborn. Like I said, I had one instance of a pregnant woman whose born children had been taken away from her who told me in a public welfare office that CPS would take her unborn child.
            She came in the office to get food stamps, which she could not get after the other children were taken away.
            When I saw her, she was sober and appeared sensible.

    • guest

      I believe that the main problem being raised in the post is that the hospital went much farther than refusing to provide the treatment she was requesting.

      It threatened to report her to the child welfare authorities for trying to pursue a VBAC. This type of coercive response is becoming increasingly common in the healthcare system and creates a number of problems, not the least of which is that it violates a patient’s (or a parent’s) civil liberties.

      I also have to say I really don’t approve of a hospital resorting to threats to use the criminal justice system against a patient and then using “patient confidentiality” as a pretext for avoiding transparency once the patient goes to the media. It looks quite hypocritical.

      • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

        As I read it, this post quotes an obviously biased NAPW website in order to make a general point about “controlling the behavior of pregnant women.” I agree with ninguem above that NAPW likely mischaracterizes the hospital’s position, although none of us really know. Physician commenters with knowledge of VBAC seem to concur that the patient’s plan was risky at best, perhaps downright foolish.

        As I wrote yesterday, I’m not arguing for the hospital. They may be parroting their Risk Management bean counters, or have other nefarious aims. My only point, and I’m sticking with it, is that patient choice is not the only consideration. Doctors and hospitals are not obliged to provide services against their best medical judgment — exactly what the judge ruled.

        This has nothing to do with “controlling” patient behavior. It has everything to do with controlling our own behavior and maintaining the ethics of our profession. Using this case, where the judge ruled for the hospital AND the patient got exactly what she sought elsewhere, illustrates how hatred of physician paternalism has gone so far that even defense of good clinical practice is now viewed with suspicion.

        • guest

          As someone whose work consists of caring for patients under court orders for treatment, I am certainly no strong proponent of patient choice being the main determinant of clinical care.

          On the other hand, I feel like there’s been an alarming trend lately for doctors and medical establishments to use law enforcement to deprive parents of their rights to choose treatment for their children–the Justina Pelletier case in Boston and the Ashya King case in the U.K. In those cases, I think we do see medical paternalism going too far, and it makes our profession look bad.

          I would certainly heartily agree with you that hospitals and doctors should not be coerced to provide treatment that they feel is clinically inappropriate.

        • querywoman

          The ethics of the American medical profession have too often included surgical control of American women. In the 19th century, there was forced ovarian removal to control stuff like masturbation.
          Not all judges would agree with this judge.
          This is not about maintaining the ethics of your profession. The odds in the past century that too often the ethics of the American medical profession has included coerced surgery on female reproductive organs.
          Coerced surgical interventions are usually practiced on woman, but in the past few years, a man had a cancerous penis removed without his permission.
          C-sections are even higher in Brazil, where they don’t include a profit woman. Yet, in Brazil, breastfeeding is glamorized, with actress in TV ads talking about breastfeeding.

      • querywoman

        It’s really puzzling how the laws can put the rights of the soon to be born over the rights of the already born mother.
        When I worked in Texas welfare, I had one pregnant woman who came in for food stamps. CPS was going to take her baby at birth. They had already taken several from her.
        She was sober that day, but a coworker told me she didn’t take care of her kids, that she drank, etc.
        I saw a news article once about a woman whose neighbors had managed to get several children taken from her. She was pregnant again, and said if they took that baby, she’d just have another.
        I had a grandma in welfare who had taken all of her druggie daughter’s children at birth. I saw in the file that it was planned for her to take the very first baby from the beginning.
        Nice strong grandma! I don’t know what went wrong with the daughter.
        I am just not sure what the right answer is. If a woman is pregnant, mildly retarded or has some other reason she obviously cannot care for a baby, it’s good to have arrangements made in advance.

    • querywoman

      It’s putting the rights of the unborn child over the mother. I didn’t get to have a baby.
      I read an article once, trying to remember the name, something like, “Women of Color and the Violence of Law Enforcement.” Race was probably not an issue with the woman discussed in this blog.
      But, lots of times women of color who get admitted to hospitals near birth are subjected to paternalism, like forced drug screenings, etc. But, when police arrest pregnant women of color, they are not always that paternal and respectful of them.

      • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

        Obstetrician William Viner commented here yesterday that there is life-threatening risk to both mother and child. I don’t see how this case puts the interests of one over the other.

        There are a lot of political points being made here about controlling pregnant women, using law enforcement to deprive parents of their rights, putting fetal rights ahead of maternal rights, and discriminating against women of color. All are serious, important issues that happen to have no direct bearing on the case being discussed.

        • querywoman

          I was just rambling. I assume a rupture C-section scar provides risk to mother and baby. Then I remember the case of Angela Carder, who was dying of lung cancer. The ob/gyn insisted that her baby be removed by C-section, putting its rights above hers. The baby was dead. The dead baby and the surgery, both, hastened Angela’s own death.

        • querywoman

          A case from year 2000: Rebecca Corneau was forced into custody for monitoring of late term pregnancy, though she wanted no prenatal care. It’s a similar issue.
          Most legal experts think a pregnant woman should have the right to due what she wants with her own body.

        • querywoman

          Sorry, it’s very much a part of the issue. Since I had a noncompliant diabetic brother, I am well aware that adults cannot be forced into medical care.
          Yet, pregnant women are offered forced into care.
          As I researched Angela Carder again, the ACLU was “victorious” that C-sections could not be forced.
          Yet, they still are.
          The pregnant Florida woman was not terminally ill like Angela. She only wanted to try VBAC, and said she would under go a C if necessary.
          My mother and I could not force my brother to take his diabetes meds. We committed him for the 2nd amputation. The mental illness court people told us the court could order mental care, but not physical care.
          After we actually got him locked up, the rules apparently changed. The psychiatrist told my mother she could authorize the amputation, but I think he signed for it himself.
          So why are the courts allowed to legally order medical interventions against pregnant women?

        • JR DNR

          Everything you listed (except perhaps discrimination as I thought this mother was white) has direct bearing on the case being discussed.

    • querywoman

      The argument, perfectly logical, was that natural vaginal childbirth is not a medical procedure. A C-section is a medical procedure. The odds are that more women are coerced into C-sections than doctors are coerced into VBAC.
      Surgery is always an intervention.
      It seems most forced medicine is practice on women, though a man did get a cancerous penis amputated in recent years.
      I researched this woman, Jennifer Goodall, and she always said she was willing to have another C if needed. That’s logical. She seems in full possession of common sense.

      The hospital had a lot of nerve threatening to involve the local version of Child Protective Services.
      If my mother and I could have got my brother ordered to take insulin, we would have. He thought I was mean when I said I would not help him financially unless he took his medicine. I lied; I would have. But I got a hateful letter soon after about my telling him what to do when he wanted to live his life to a different drummer.
      Regardless of what he thought, I supported his right to refuse medicine until he ended up broke in Mama’s house with her paying his bills. I told her she didn’t have to support a total stranger who was willfully dying in her home.
      I also told her to tell him that if were in a homeless shelter, the other residents would be telling him to take his medicine. She did scream that at him one day.

  • Lisa

    No, the hospital didn’t just ask her to go to another hsopital:

    “According to NAPW, the chief financial officer of Bayfront Health Port Charlotte sent a letter Goodall, threatening to report her to the Department of Children and Family Services, seek a court order to perform surgery and perform cesarean surgery on her “with or without [her] consent” if she went to the hospital.”

    • ninguem

      The hospital “just ask[ed] her to go to another hospital”, AND made certain legal threats if she tried to go back to that hospital in active labor and tried to force the issue.

      Because that’s exactly what she would do. If she showed up in active labor, the hospital and the doctors would be hard-pressed to transfer her, risking EMTALA and abandonment charges.

      None of those threatened legal actions would happen if she went to a hospital willing to accommodate her. If any such hospital existed.

      She is free to make a martyr of herself. She is not free to make a martyr of her baby. With those legal threats, it was made clear that there would be consequences if she tried to force the hospital and the doctors to be part of her martyrdom.

      • Lisa

        She did go to another hospital and wound up delivering via cesarian after a trial of labor.

        Nowhere did I see any indication that the first hospital asked her to use another hospital before making a legal threat.

        • JR DNR

          They didn’t. Prior to the letter, she’d been given permission to do a trial of labor by the OB.

          • ninguem

            Well, that’s another matter, if the docs and the hospital are not speaking with a consistent voice.

            If the OB offers a trial of labor, that doc had bloody well better have the support of the professionals who will be needed, anesthesia, pediatrics, hospital blood bank come to mind, not to mention the hospital staffing for the O.R.

            The only thing worse than a patient forcing the issue like this, is the obstetrician forcing the issue, and using the patient as a pawn.

  • JR DNR

    “I was told that, although she was not thrilled with the idea of me laboring, that no one can ‘cut on me’ without my consent. We then spent the next few visits discussing my labor and whether I what our plans would be. This obstetrician told me that she would continue to oversee my care and that if she was on call when I went into labor that she would allow me a trial of labor.”

    She was open, from the beginning, that she wanted a trial of labor and not a scheduled C-section.

  • William Viner

    As an Ob, I can understand both sides, but not the involved Ob’s stance. As you may know, a TOL after 1 prior CS carries a risk near 1% of uterine rupture and 2 prior increases the risk to over 3%. From memory 3 prior CS raises the risk between 5 and 6%. Some of those newborns will die or have HIE. Some of the mom’s may die or have an emergency hysterectomy and massive blood transfusions. It’s good to know the time between CSs and if single layer uterine closure as that may also raise the risk. It’s also important to know the indications for her prior CSs as that will estimate the chance of success of a vaginal delivery.

    The OB agreed to manage this labour “if she was on call”. That places a large burden on her colleagues who may not have agreed to this as she very well may not be on call that day. At one time protocols required the OB to be “immediately available” or “in house” if a VBAC was in labour. That requirement is really what killed the TOL. No one wants to hang around the hospital for 24-36 hours, especially if you only make $900 for the delivery. Not to mention the liability if the baby is not delivered within 20 minutes. BTW that dollar amount is what I got for a Medicaid delivery in KY. And for those of you who think we make more for a CS, we don’t.

    I think this woman should have had her TOL after the 1st or maybe after the 2nd CS and not the 3rd. She should go to a tertiary centre with 24 hour Ob and Anesthesia cover and a good blood bank.

  • querywoman

    Since births are common and C-sections are a common result in the birthing process, just what kind of staffing do most hospitals that do labor and delivery have?

  • querywoman

    Legally, the Rebecca Corneau issue is the exact same issue as the attempt to coerce a C-section on a Florida mother.
    It’s saying that the unborn has more rights than the born, the mother, in both cases.
    I am wondering if the Florida judge order of a C-section will be appealed. The order coercing dying Angela Carder into a C-section was turned over three years after her death.

    • Elle

      It’s not that the unborn has “more” rights than the born – the way I see it, it’s basically saying that they have the same amount; no different than if Rebecca Corneau had actually been starving a born infant. They just had to keep her in custody for a while until they were actually able to take the child into safety.

      • querywoman

        It’s still a tradition of American law that the born person comes first, and that means a pregnant woman. She did not want prenatal care. I think they had a midwife on duty to assist with delivery, but it was not necessary.
        The court decided that the baby had more rights than the mother, by assuming they could ensure a safe delivery and get the baby to safety. Such conduct discourages mothers from even seeking prenatal care.
        This is a legal question. Most legal thought was that Corneau had the right to do as she wished with her own body, including refusing prenatal care.
        Corneau is an interesting. As I recall, she kept a large belt on her to use on her born children. As a recall, the last child was taken into foster care and eventually she and her husband lost custody permanently. They did not even visit the last baby much after she was taken from them.

      • querywoman

        In Corneau’s case, supposedly she beat her three surviving older children with a wooden paddle, leaving welts and callouses. She and her husband, David, lost custody of all three of those children as well as the baby born in custody.
        We’d have to read the case to see what other extenuating circumstances may have figured in.
        It’s interesting that they barely visited the baby born in custody, since they had no control over it.
        The woman who wanted to try VBAC in Florida appeared to be perfectly reasonable in her own decision, saying she would submit to a C if she thought it necessary.

  • querywoman

    Most pregnant women go to doctors voluntarily. Rebecca Corneau is an extreme exception. She also refused legal counsel, and the case was never appealed. One of the purposes of a society, a civilization, is to keep people interacting with, helping, and supporting each other.
    The fear with coercing women into C-sections and coercing pregnant into custody for failed alcohol and drug tests is that the fear will scare women from seeking help at all!

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