Continuation of the “Injustice in Maternity Care” Series
Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?! Are you SERIOUS!? Oh come ON!” Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series. If you are pregnant or planning on becoming pregnant, this series is dedicated to you! If haven’t already read it, I invite you to check out part 1 & 2 of this post: DLTHTY #22: Gina & Tony’s “Elective” Primary C/S PART 1 and PART 2.
I would like to start this discussion with some definitions I offered at the end of Part 2.
* Elective Primary Cesarean Section (EPCS): A planned first or “primary” cesarean section in a healthy woman for the birth of a baby when there is no medical, fetal, or obstetric reason for the surgery. May be influenced by non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability, insurance coverage, liability fears, hospital economics, efficiency, convenience, and reimbursement rates, as well as other factors not listed. (American College of Nurse-Midwives, Position Statement: Elective Primary Cesarean Section & Citizens for Midwifery, News Release: “Patient Choice” Cesareans Almost Non-Existent)
* Maternal Request Cesarean Section or Cesarean Delivery on Maternal Request (CDMR): A subcategory of elective primary cesarean sections. A planned (before labor begins) first or “primary” cesarean initiated by the mother with the understanding that there is no medical, obstetrical, or fetal indication requiring cesarean delivery, and after a through review of the risks and benefits of cesarean delivery vs. vaginal birth by the obstetrician, the woman’s decision is to have a planned cesarean section. The primary decision maker for a CDMR is the woman. (National Institute of Health (NIH) Cesarean Conference definition, March 2006 & Childbirth Connection, Listening to Mothers II Survey)
To reiterate, according to these definitions, it is misleading and inaccurate to assume that every woman who has an “elective primary cesarean section” actually had a “maternal request cesarean section.” In order for a c-section to be truly considered a “maternal request” cesarean, the following FIVE criteria must be met:
Necessary Criteria for Maternal Request Cesarean Section:
#1 The request for the cesarean and the scheduling of the cesarean must have been made prior to the onset of labor.
#2 The request for the cesarean must have been initiated by the mother.
#3 The mother must have the understanding that there is NO medical, obstetrical, or fetal indication requiring a cesarean delivery.
#4 The obstetrician must personally review and assure the mother’s understanding of the risks and benefits of elective cesarean surgery vs. planned vaginal birth.
#5 The woman is the primary decision maker.
So what does a consent form for an “elective primary cesarean section” look like? Since my post “Consent for Anesthesia: Do You Know What You Are Signing?” was such a big hit, I have decided to follow suit and post a copy of an actual hospital consent form for this type of surgery. At my hospital, every mom undergoing an elective primary cesarean section (EPCS) has to sign a form like this. However at this point in time, any mom undergoing a scheduled or unscheduled cesarean section for an obstetrical, medical, or fetal indication just signs a generic hospital operative consent form (with a “fill-in-the-blank” for the type of procedure). This unfortunately includes any mom undergoing a repeat cesarean section who is a candidate for but declined (or was bullied to decline) a vaginal birth after cesarean (VBAC).
What is worse is that at my hospital and many many others, if a mom desires a VBAC many of the obstetricians make them sign an additional consent form (not required by the hospital) special for VBAC that explicitly outlines all of the risks of VBAC (with the phrases “catastrophic uterine rupture” and “fetal death” smeared all over the page) but is conveniently lacking of any risks of cesarean section. I am currently working (so far unsuccessfully) with the “powers that be” on my floor to change this; I would like to see every mom who is a candidate for VBAC have to sign a form that specifically lists the risks/benefits of repeat cesarean section side by side of the risks/benefits of VBAC if they chose to have an elective repeat cearean.
So here it goes…an actual hospital consent form for elective primary cesarean section:
Consent for Elective Primary Cesarean Section
A cesarean section (c-section) is the surgical delivery of a baby through an incision in the abdomen and uterus. An incision is made on the abdomen just above the pubic area. The second incision is made in the wall of the uterus. The physician can then open the amniotic sac and remove the baby. The patient may feel tugging, pulling, and pressure. The physician detaches and removes the placenta; incisions in the uterus and abdomen are then closed.
I authorize and direct _______________________________, M.D. with associates or assistants of his/her choice, to perform an elective cesarean section on _______________________________.
(Print Patient Name)
_____ I have informed the doctor of all my known allergies.
_____ The details of the procedure have been explained to me in terms I understand.
_____ Alternative methods and their benefits and disadvantages have been explained to me.
_____ I understand and accept the possible risks and complications of a cesarean section, which include but are not limited to:
* Pain or discomfort
* Wound infection; and/or infection of the bladder or uterus.
* Blood clots in my legs or lungs
* Injury to the baby
* Decreased bowel function (ileus)
* Injury to the urinary tract of GI tract
* Increased blood loss (2x that of a vaginal delivery)
* Risk of additional surgeries
* Post surgical adhesions causing pain/complications with future surgeries
* Increased risk of temporary breathing problems with the baby that could result in prolonged hospitalization
_____ I understand and accept the less common complications, including the risk of death or serious disability that exists with any surgical procedure.
_____ I understand in a future pregnancy that I have an increased risk of complications including, but not limited to:
* Placenta previa, where the placenta covers the cervix.
* Placenta accreta, where the placenta grows into the muscle of the uterus.
* This may lead to a hysterectomy and excessive blood loss at the time of the cesarean section.
* An increased risk of uterine rupture (with or without labor) and that this risk increases with each subsequent cesarean section. Uterine rupture can lead to the death of the baby or myself.
_____ I have been informed of what to expect post-operatively, including but not limited to:
* Estimated recovery time, anticipated activity level, and the possibility of additional procedures.
_____ The doctor has answered all of my questions regarding this procedure.
_____ I am aware and accept that no guarantees about the results of the procedure have been made.
I certify that I have read and understand the above and that all blanks were filled in prior to my signature.
________________________________ Patient Signature/Date
________________________________ Witness Signature/Date
I certify that I have explained the nature, purpose, benefits, and alternatives to the proposed treatment and the risks and consequences of not proceeding, have offered to answer any questions and have fully answered all such questions. I believe that the patient fully understands what I have explained.
________copy given to patient ________copy placed in office chart
I hope that every mother out there who is reading this post takes a good hard look at what exactly women are agreeing to when they sign a form like this. That is why when my readers get upset at the stories I write about and leave comments like, “Clearly this mother was not given full explanation of the risks and benefits! Can’t you bring this to someone higher up!? Can’t you get this doctor in trouble!? Can’t this woman sue!?” I feel like my hands are tied BECAUSE IT’S RIGHT THERE IN BLACK AND WHITE! When a woman puts her initials next to each one of those bulleted points and signs her name at the bottom she is basically signing away all of her control over to the physician. So if the case comes before a review board or a judge in court, they are going to see, right there on the paper, what the woman agreed to, whether her rights to informed consent were truly upheld or not. This is no different than any other CONTRACT.
If you have a minute, take another look at that consent form. Just LOOK at what a woman is acknowledging when she signs it:
She authorizes the doctor to perform the surgery with any associates/assistants (and yes, that means residents) that HE chooses (NOT the patient).
She acknowledges and confirms that all the details of the procedure have been reviewed in terms she understands.
She acknowledges and confirms that alternative methods (which includes vaginal delivery) have been explained to her.
She acknowledges and confirms that she understands and accepts the risks and possible complications of the cesarean section.
She acknowledges and confirms that the doctor has answered all of her questions.
She acknowledges and confirms that she is aware and accepts that there are NO GUARANTEES about the results of this procedure!
The physicians who drafted this consent and consents like it are really friggin’ smart. Why? Because this consent completely protects the interests of the physician and assures that the physician maintains complete control over the situation. Guess what ladies, unless you were in a coma at the time of signing, you can’t go before a judge and cry “But I just didn’t KNOW!!” when your signature is on the paper in black and white. I am not commenting on this to upset anyone. I just wish that all women really knew how important it is to KNOW WHAT YOU ARE SIGNING!
Okay so now that we have all learned a bit more about elective primary cesarean sections (EPCS) and cesarean delivery on maternal request (CDMR), it’s time to see what major health organizations and groups are saying about them across the country and the world. The following is a list of quotes from published committee opinions, position statements, official editorials, journal articles, and other media from FIFTEEN major health organizations/advocacy groups. Full text of the articles referenced can be obtained (where available) by clicking on the links below each quote:
“Elective primary cesarean section has recently been proposed as a substitute for vaginal birth. It is the position of the ACNM that this practice is not supported by scientific evidence. The ACNM identifies vaginal birth as the optimal mode of birth for women and their babies. Cesarean section is valued as a surgical procedure used to decrease morbidity and mortality in specific clinical situations. The ACNM promotes decision-making about mode of delivery that is evidence based and not unduly influenced by factors such as liability, convenience or economics.”
“Cesarean deliveries on maternal request (CDMR), a subset of elective Cesareans, are a reality in the United States and one we need to take seriously and investigate thoroughly. Consistent with the NIH State-of-the-Science expert panel’s conclusions, the AWHONN strongly supports dissuading women from having non-medically indicated c-sections prior to 39 weeks due to the risk for prematurity related to imprecise estimation of gestational age. Such c-sections contribute to the prevalence of near-term (most recently referred to as late preterm) birth and its associated serious health concerns including neonatal respiratory distress.
[AWHONN urges women] considering non-medically indicated c-sections to thoroughly discuss this choice with their health care providers and ask about how the surgery might affect their babies. AWHONN agrees with the NIH State-of-the-Science expert panel’s conclusion that CDMR is not recommended for women desiring several pregnancies. AWHONN also supports research that will help the health care community support and promote a women’s choice of planned vaginal birth.”
“It is ironic that the AMA should have a quarrel with a known safe birth option such as homebirth at the same time when the epidemic rise in coerced or elective cesarean sections puts healthy mothers and infants at greater risk than normal vaginal birth and causes excess strain on the limited resources of our healthcare system. The rate of cesarean sections in the United States is unacceptable—one in three pregnancies end in major abdominal surgery—and the decline in availability of vaginal birth after cesarean (VBAC) is deplorable. It is unethical to expect that women and infants should continue to bear the brunt of increasing medical malpractice risks by over-treating them with obstetric technologies such as c sections while denying them safe evidence-based options such as VBAC.
Modern medical ethics have evolved to embrace autonomy—patient choices and patient rights— over medical recommendations based on paternalism or physician preference. In almost all areas of modern medicine, except obstetrics, the locus of control rests firmly with the client or patient and not with the medical provider.
All maternity care providers should band together to reduce the unacceptably high rates of maternal and infant mortality and morbidity in the United States, increase access to maternity care for all women, reduce unnecessary cesarean sections, encourage vaginal birth and VBACs for healthy women, reduce health disparities of women and infants in minority populations, and promote increased breastfeeding.”
#4 The Society of Obstetricians and Gynaecologists of Canada (SOGC) (Note: The “ACOG” of Canada):
“Some women or health professionals may elect to have a scheduled C-section, rather than attempt a vaginal birth. The SOGC is concerned that there may be an emerging trend towards more scheduled childbirth and routine medical intervention.
The Society of Obstetricians and Gynaecologists of Canada has always promoted natural childbirth, believes that the decision to perform a C-section during labour and delivery should be based on medical indications, [and] believes that the safety of a woman and her baby should be the driving factors in a decision to conduct a C-section.”
“Cesarean section is a surgical intervention with potential hazards for both mother and child. It also uses more resources than normal vaginal delivery. Physicians have a professional duty to do nothing that may harm their patients. They also have an ethical duty to society to allocate health care resources wisely to procedures for which there is clear evidence of a net benefit to health. Physicians are not obligated to perform an intervention for which there is no medical advantage.
Available evidence suggests that normal vaginal delivery is safer in the short and long term for both mother and child. Surgery on the uterus also has implications for later pregnancies and deliveries. In addition, there is also a natural concern at introducing an artificial method of delivery in place of the natural process without medical justification.
Physicians have the responsibility to inform and counsel women in this matter. At present, because hard evidence of net benefit does not exist, performing cesarean section for non-medical reasons is not justified.”
Recommendations on Ethical Issues in Obstetrics and Gynecology, FIGO Committee for the Ethical Aspects of Reproduction and Women’s Health, London, 2003.
#6,#7,#8,#9 The Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada (AWHONN Canada), The Canadian Association of Midwives (CAM), The College of Family Physicians of Canada (CFPC), The Society of Rural Physicians of Canada (SRPC), & The Society of Obstetricians and Gynaecologists of Canada (SOGC):
“Professional associations are concerned about the increase of intervention during childbirth, as it introduces unnecessary risks for mother and baby. According to a review of the evidence by Romano and Lothian, social and cultural changes have fostered an insecurity in women regarding their ability to give birth without technological intervention.
A normal birth does not include: elective induction of labor prior to 41+0 weeks, spinal analgesia, general anaesthetic, forceps or vacuum assistance, caesarean section, routine episiotomy, continuous electronic fetal monitoring for low risk birth, and fetal malpresentation. Childbirth is considered to be natural childbirth if there is little or no human intervention.
[We] believe health care professionals should be committed to protecting, promoting, and supporting normal childbirth according to evidence-based practice. Normal birth should be accessible and encouraged in all hospital settings. [We] believe all candidates for normal birth should be encouraged to pursue it.
[We] believe vaginal birth following a normal pregnancy is safer for mother and child than a Caesarean section. [We] believe Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby [and] caesarean section should not be offered to a pregnant woman when there is no obstetrical indication.”
Joint Policy Statement on Normal Childbirth, SOGC, 2008
“Recently, a few physicians have claimed that elective primary cesareans and elective repeat cesareans are safer for babies, and even for mothers, than vaginal birth. While selective use of the medical literature might seem to back up this claim, a review of the studies which consider short- and long-term risks of cesareans does not. Elective cesareans put babies and mothers at risk, use valuable and limited healthcare resources, have negative psychological and financial consequences for families, and substantially increase serious risks in subsequent pregnancies. The high rate of cesarean in the United States has not resulted in improved outcomes for babies or mothers. Additionally, vaginal birth after cesarean (VBAC) is still less risky for mothers and babies than cesarean section, despite recent claims to the contrary. ICAN is opposed to cesarean sections performed without true medical indication.”
#11 Lamaze International:
“The concept of “maternal request” cesarean presents a number of serious problems: Elective cesarean surgeries, that is, surgeries without medical indication, should not be equated with “patient” or “maternal choice” cesareans because they could equally well represent “physician choice“ cesareans.
Studies of maternal preference for cesarean fail to assess whether women were told of the potential harms of cesarean surgery, whether alternatives were discussed, the accuracy of the information women were given, and what opinion the care provider held. What women hear from obstetricians powerfully influences what they think. Some obstetricians think so little of the risks, pain, and recovery of cesarean surgery that they feel that “convenience,” “certainty of delivering practitioner,” and “[labor] pain” justify performing this major operation on healthy women.
Obstetricians champion a woman’s right to choose elective surgery on grounds of “patient autonomy” but deny her right to refuse one. Access to vaginal birth after cesarean (VBAC) has declined precipitously in recent years and is currently unobtainable in whole regions of the United States. This has occurred despite numerous studies concluding that VBAC is a reasonable option for most women. Until such time as obstetricians support a woman’s right to refuse as well as choose surgery, the promotion of “maternal request” cesarean must be viewed with extreme suspicion.”
The Problem with “Maternal Request” Cesarean, Lamaze International
“While we appreciate your coverage of the alarming all-time high rate of cesarean births in the United States, the American College of Obstetricians and Gynecologists’ (ACOG) recent statement on elective cesareans also calls attention to the need for women to be cautious when making that decision. No evidence supports the idea that cesareans are as safe as vaginal births for mother or baby, and pregnant women should be given the facts they need to make an educated decision.”
Letter to the Editor: The Washington Post, DONA, November 5, 2003
“CIMS is eagerly anticipating the results of the upcoming NIH State-of-the Science Conference: Cesarean Delivery on Maternal Request, March 27-29, 2006 and trusts that the NIH will provide much needed guidelines and recommendations for decreasing cesarean surgeries performed for no medical indications (elective cesareans). Existing evidence that both women and babies are at increased health risks with a cesarean surgery is clear. A key objective of the US Public Health Service Healthy People 2010 initiative is to reduce the number of cesarean sections for low risk women. Additional objectives are to lower overall maternal deaths and reduce the number of babies born preterm and low-birth weight, all factors associated with cesarean surgery. [Also] The Centers for Disease Control (CDC) has identified cesarean section as having a negative effect on breastfeeding. Mothers are less likely to initiate and successfully continue to breastfeed.
To reduce current maternal deaths by 50% is a major goal of Healthy People 2010. The risks of [cesarean section] itself substantially increase the risk of maternal death compared with women having vaginal births regardless of their health status.”
“Although NIH has just completed a conference on “Cesarean Sections by Maternal Request,” recently-released results of a new “Listening to Mothers” survey from Childbirth Connection indicate that it is extremely rare for a woman to ask for a cesarean section.
Most obstetricians sincerely care about their patients and do their best to provide what they believe is the best care. However, non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability insurance coverage, liability fears, hospital economics, efficiency and convenience, and reimbursement rates, may influence physicians to try to perform more cesarean sections.
Citizens for Midwifery suggests that NIH recommend research to find out what is driving the wasteful and unconscionable increase in cesarean sections for no medical reason, and why women are being given misunderstood, incomplete or inaccurate medical justifications for them.”
“Emphasis on “maternal request” is generating confusion in the media, within the general public and among health professionals and pregnant women. The only national data collected from women themselves has found that this was a highly infrequent occurrence among women who gave birth in the U.S. in 2005. Continuing misplaced focus on “maternal request” cesareans draws attention from the legal, clinical, financial and social factors that continue to drive the U.S. cesarean rate to unprecedented heights in an overwhelmingly healthy population.
All mothers should have access to safest vaginal birth practices. We should not ask mothers to choose between vaginal birth with avoidable harms and cesarean section.
[The NIH panel concluded] that ‘Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.’ [However our position is that] without clear justification based on confident results about this comparison regarding the full range of outcomes of interest, extreme caution is warranted when considering elective major abdominal surgery in healthy mothers and babies.”
NIH Cesarean Conference: Interpreting Meeting and Media Reports, Childbirth Connection, 2006
As you can see there are a plethora of organizations that represent obstetricians, family practice physicians, certified nurse midwives, practical midwives, nurses, childbirth advocates, and childbearing families that DO NOT SUPPORT elective primary cesarean sections and cesarean delivery on maternal request. You might be left thinking, however, about ACOG (American College of Obstetricians & Gynecologists). How does the “almighty” ACOG feel about elective primary cesarean sections? Funny you should ask…
“Based on these principles [beneficence, autonomy, nonmaleficence, veracity, and justice] is it ethical to agree to a patient request for [or offer] elective cesarean delivery in the absence of an accepted medical indication? The response must begin with the physician’s assessment of the current data regarding the relative benefits and risks of the two approaches. In the absence of significant data on the risks and benefits of cesarean delivery, the burden of proof should fall on those who are advocates for a change in policy in support of elective cesarean delivery (i.e. the replacement of usual care in labor with a major surgical procedure).
If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal delivery, he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.
Given the lack of data, it currently is not ethically necessary to initiate discussion regarding the relative risks and benefits of elective cesarean delivery versus vaginal delivery with every pregnant patient.”
Two things jump out at me with this statement:
#1 ACOG flat out denies that there is any “ significant data on the risks and benefits of cesarean delivery” which is outrageous, misleading, harmful, and untrue.
#2 Although ACOG claims that one of their main legislative objectives is to “maintain high-quality patient care” and two of their mission statements include “Promoting excellence in maternal and neonatal health care” and “Facilitating direct patient awareness and education in women’s health” it seems like on the topic of elective major abdominal surgery, it is more important for them to protect their own interests and open and maintain an ethical loophole so that physicians like Dr. M can continue to promote unnecessary cesarean surgery as long as she personally feels it will “promote the overall health and welfare of the woman and her fetus.” However, I hope that the above quotations from 15 other major health organizations have shown you that there are some obstetricians that think so little of the risks, pain, and recovery of cesarean surgery that they personally feel the “convenience,” “certainty of delivering practitioner,” and “labor pain” actually justify performing this major operation on healthy women. By ACOGs committee opinion, these “Dr. Ms” would be ethically justified in promoting, offering, and performing unnecessary elective cesareans sections without medical, fetal, or obstetrical indications. Gross.
In closing I leave you with a quote from Dr. Robert K. DeMott, MD:
“Let’s face it-someone is trying to get away with something. This ultimate intervention (cesarean section), which is relatively dangerous and potentially life-threatening (compared with vaginal delivery), interferes with a normal physiologic process (labor) that we have no right to circumvent without evidence of compelling benefit. The compelling benefits simply are not present in most pregnancies.
Why are we treating pregnancy as a disease? “Offering” cesarean delivery or consenting to perform it electively at term is irresponsible, dangerous, and ultimately unfair to many women. The lack of fairness centers about informed consent. Like it or not in medical care a great deal of perceived power and influence is present, and the advice of physicians is seriously heeded by many under our care. Are we truly able to relate all of the surgical risks of cesarean delivery versus a vaginal delivery to the majority of patients? I would suggest that only a small number truly understand the relative risks. The less informed woman is merely agreeing to our recommendation without true knowledge of the consequences. This is inherently unfair and a blatant misuse of power.
Simply put, it is not worth it. Who is trying to get away with something and for what reason? Stay the course of the normal physiologic process. Use cesarean delivery for truly indicated obstetric conditions and no more. It is medically inappropriate, unfair, and unethical to offer anything less.”
Commentary: A Blatant Misuse of Power? By Robert K. DeMott, MD, Birth 27:4 December 2000