The ethics of cesarean section on maternal request: A feminist critique of the American College of Obstetricians and Gynecologists' position on patient-choice surgery

Bioethics

Volumn 21, Issue 9, 2007, Pages 478-487

  Bergeron, Veronique ^a,b  

^a MCGILL UNIVERSITY   (Canada)

^b NONE   (Canada)

Author keywords

ACOG; CDMR; Cesarean section; Contextual ethics; Maternal request; Medicalization; Patient choice surgery

Indexed keywords

BREECH PRESENTATION; CESAREAN SECTION; CHILDBIRTH; COLLEGE; CONFERENCE PAPER; COST BENEFIT ANALYSIS; ETHICS; FEMINISM; FINANCIAL MANAGEMENT; HEALTH CARE SYSTEM; HUMAN; INFORMED CONSENT; MATERNAL ATTITUDE; MATERNAL WELFARE; MEDICAL PRACTICE; MEDICAL TECHNOLOGY; PATIENT PARTICIPATION; REPRODUCTIVE HEALTH; SOCIAL ASPECT; SURGICAL TECHNIQUE;

ATTITUDE OF HEALTH PERSONNEL; CESAREAN SECTION; DECISION MAKING; FEMALE; HUMANS; OBSTETRICS; PATIENT SATISFACTION; PERSONAL AUTONOMY; PREGNANCY; SOCIETIES, MEDICAL; UNITED STATES;

EID: 35248826398     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2007.00593.x     Document Type: Conference Paper

References (45)

1. G. Corea. 1993. Introduction: First Words. In Misconceptions: The Social Construction of Choice and the New Reproductive Technologies. G. Basen, M. Eichler & A. Lippman, ed. Hull: Voyageur: vol. 1, 13-21.
2. The Boston Children's Medical Centre. 1972. Pregnancy, Birth and the Newborn Baby, Publication for parents. New York, NY: Delacorte Press: 51.
3. See e.g. Amy O'Brian. 2005. For and Against Birth by C-Section. The Vancouver Sun 21 November: c-1C.
4. A. Dochin. Understanding Autonomy Relationally: Toward a Reconfiguration of Bioethical Principles. J Med Philos 2001 26 : 365 386.
5. S. Arms. 1975. Immaculate Deception: A New Look at Women and Childbirth in America. Boston: Houghton Mifflin: 23 [Arms].
6. W.R. Arney. 1982. Power and the Profession of Obstetrics, Chicago, MI: The University of Chicago Press.
7. Roundtable Discussion. Why Do Women Go Along with This Stuff? Birth 2006 33 : 245.
8. A.D.J. Smeenk ten Have, A.M.J. Henk. Medicalization and obstetric care: An analysis of developments in Dutch midwifery. Med Health Care Philos 2003 6 : 153
9. Thomas Schlich. Forthcoming 2007. In The Cultural History of the Human Body. L. Kalof & W. Bynum, eds. London: Berg Publishers. Schlich uses cosmetic surgery and sex-reassignment surgery as examples of the medical 'reification' of the body and the movement to pursue surgical solutions to social, cultural or psychological problems.
10. W.R. Arney. op. cit. note 6: table 1.1.
11. V.A. Sharpe. Justice and Care: The Implication of the Kohlberg-Gilligan Debate for Medical Ethics. Theor Med 1992 13 : 295 318.
12. W. Goodell, 1996. When and Why Were Male Physicians Employed as Accoucheurs? in The Medicalization of Obstetrics: Personnel, Practice and Instruments. P.K. Wilson, ed. New York, NY: Garland.
13. In this perspective, a study of the influence of gender on the ethical analysis of medical interventions in childbirth using Carol Gilligan's concepts of ethics of care and ethics of justice could be the object of an entire paper. Carol Gilligan observed that women's failure to conform to established representations of human development had lead to the conclusion that there was a problem with women's moral development rather than a problem with the representations of moral development. I believe that in similar fashion, the medical discourse has addressed women's emotional and physical needs in childbirth by seeing pain and fear as problems with childbirth rather than problems with their representation of what childbirth should be. C. Gilligan. 1982. In a Different Voice: Psychological Theory and Women's Development. Cambridge: Harvard University Press.
14. Without suggesting that femininity or womanhood are contingent upon childbearing, I do believe that many women conceptualize their femininity in relation to their ability to bear children, especially when they are willing but unable to conceive or deliver without medical assistance.
15. K.P. Morgan. Women and the Knife: Cosmetic Surgery and the Colonization of Women's Bodies. Hypatia 1991 6 : 27 53 Benedetti et al. Professional Liability Issues and Practice Patterns of Obstetrics Providers in Washington State. Obstet Gynecol 2006 107, p. 1238.
16. L. Dubay, R. Kaestner T. Waidmann. The Impact of Malpractice Fears on Cesarean Section Rates. J Health Econ 1999 18 : 491.
17. L.R. Burns, S.E. Geller D.R. Wholey. The Effect of Physician-Factors on the Cesarean Section Decision. Med Care 1995 33 : 365.
18. However, it should be noted that in a recent newspaper interview, the executive vice-president of the Society of Obstetricians and Gynecologists of Canada (SOGC) linked the rising c-section rate in the Ottawa, Ontario, area to increasing maternal age, increasing prevalence of obesity among expecting women and increasing recourse to new reproductive technologies causing a higher prevalence of multiple births. All these clinical risk factors are likely to bring about one of the four clinical indications for c-section. J. Laucius. 2007. Older, Heavier Mothers Responsible for Jump in C-Section Births. The Ottawa Citizen 25 July: C1.
19. ACOG Committee on Ethics. Surgery and Choice: The Ethics of Decision Making. BJOG 2004 84 : 188 193.
20. Canadian Association of Midwives. Position Statement on Elective Cesarean Section. Available at: http://www.canadianmidwives.org/electiveCS.pdf [Accessed 1 Dec 2006]; Society of Obstetricians and Gynecologists of Canada. 2004. C-section on demand - SOGC's position. Available at: http://www.sogc.org [Accessed 1 Dec 2006]. It is noteworthy that the Canadian Institute for Health Information does not list CDMR as a birthing trend in its most recent report: Institute for Health Information. 2004. Giving Birth in Canada Providers of Maternity and Infant Care. Available at: http://secure.cihi.ca/cihiweb/products/ GBC2004_report_ENG.pdf. 23. [Accessed 1 Dec 2006].
21. In France for instance, male obstetricians became de rigueur after they started attending the courtisanes' labours. W. Goodell, 1996. When and Why Were Male Physicians Employed as Accoucheurs? op. cit. note 12. The same tendency can be observed in matters regarding the use of anaesthetics for labour pains. The use of chloroform during childbirth became fashionable after Queen Victoria was convinced to take it for the birth of her child in 1853. S. Arms, op. cit., note 5, on the practice of anaesthesia à la Reine. The practice of obliterating all memory of the birth experience culminated in 1914 with the introduction of Twilight Sleep where women were given a cocktail of morphine and scopolamine and woke-up with a baby at their bedside. See D.C. Wertz. 1996. What Birth Has Done for Doctors: A Historical View. In The Medicalization of Obstetrics: Personnel, Practice and Instruments. P.K. Wilson, ed. New York, NY Garland: vol.2 Childbirth Changing Ideas and Practice in Britain and America, 14.
22. ACOG Committee Opinion, op. cit. note 19, 189.
23. W.R. Arney, op. cit. note 6, 191.
24. ACOG Committee Opinion, op. cit. note 19, 189.
25. Ibid.
26. The lack of reliable evidence on the risk-benefit ratio of elective primary c-section was again highlighted in the National Institutes of Health State-of-the-Science Statement, 'Cesarean Delivery on Maternal Request', Obstet & Gynecol 2006 107 : 1386 97.
27. J.L. Ecker. Once a pregnancy always a cesarean? Rationale and feasibility of a randomized controlled trial. Am J Obstet Gynecol 2004 190 : 314.
28. J.R. Scott. Cesarean Delivery on Request: Where do we go from here? Obstet Gynecol 2006 107 : 1222.
29. ACOG Committee Opinion, op. cit. note 19, 188.
30. Ibid: 192.
31. Evidence-based medicine as described by the ACOG in its Committee Opinion requires that treatment decisions be made in light of the strongest medical evidence available, not on a physician's perception of what the best treatment should be. In the case of CDMR, evidence pointing to the greater safety of vaginal deliveries over surgical deliveries is available. What is not yet available is evidence on the relative safety of CDMR over other occurrences of cesarean sections. Since planned c-sections are safer than emergency c-sections, it is expected that CDMR will prove safer than c-sections in general but still riskier than vaginal deliveries for uncomplicated pregnancies. Stating, as the ACOG does, that 'the ethical evaluation [of CDMR] is clouded by the limitation of data regarding short and long-term risks and benefits of cesarean versus vaginal delivery' clearly ignores available data on the subject. In light of the ACOG's support of evidence-based medicine, CDMR should be considered as a treatment option proven to be riskier than vaginal delivery and presented to women accordingly.
32. th, 2000, cited in D.R. Williams & M.D. Avery. Preserving Vaginal Birth: A Call to Action. J Midwifery Womens Health 2006. Available at: http://www.jmwh.org [Accessed 1 Dec 2006].
33. AGOC Committee Opinion, op. cit. note 27, 191.
34. Arguably, any choice of childbirth intervention could replace CDMR in the previous sentence: electronic fetal monitoring, episiotomy, epidural anesthesia, unphysiological position, mother-infant separation etc. See Roundtable Discussion, op. cit. note 7, 245.
35. V.A. Sharpe. op. cit. note 11.
36. Ibid: 301.
37. J. Rebick, 1993. Is the Issue Choice? In Misconceptions: The Social Construction of Choice and the New Reproductive Technologies. G. Basen, M. Eichler & A. Lippman, eds. Hull: Voyageur: 1: 87-88.
38. The frank breech presentation is the most common fetal malpresentation (the baby comes out bum first with the legs flexed at the hips and the feet up near the face). Complete breech (baby sits crossed-legged across the cervix) and footling breech (one or both feet come first) are far less common.
39. L.M. Leeman L.A. Plante. Patient-Choice Vaginal Delivery? Ann Fam Med 2006 4 : 465 Queenan. Editorial: Teaching Infrequently Used Skills: Vaginal Breech Delivery. Obstet & Gynecol 2004 103 : 405.
40. Ibid: J.T. Queenan.
41. While it is hard to imagine how our bodies could forget how to give birth, psychophysical factors have an important role to play in the process of labour and delivery. See The Boston Children's Medical Centre, op. cit. note 2: p. 24, on the psychophysical aspects of labour: 'Society in general makes every possible effort to prevent the pregnant woman from accepting pregnancy and labour as a natural physiologic function. The same amount of attention to eating would make most of us have a nervous indigestion.' See also R.E. Davis-Floyd. 1996. The Technocratic Model of Birth. In The Medicalization of Obstetrics: Personnel, Practice and Instruments. op. cit. note 12.
42. J. Rebick, op. cit. note 36, 87-88.
43. M. De Koninck. 1998. Reflections on the Transfer of 'Progress': The Case of Reproduction. In The Politics of Women's Health. S. Sherwin, ed. Philadelphia, PA: Temple University Press: 150-177: 153.
44. Ibid.
45. M.D. Christian et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006 175 : 1377.