The controllers of pregnant women are at it again. In this case, however, it is not clear whether the controllers are seeking to protect the fetus, the woman, or both. They may even be seeking to protect the hospital against potential liability. The case is taking place in Florida, where doctors have ordered the woman to undergo a cesarean section against her will. According to a press release issued by the National Advocates for Pregnant Women (NAPW), the hospital has threatened to force a pregnant patient to have cesarean surgery against her will and to report her to child welfare authorities. The woman, who is 39 weeks pregnant, had three previous cesarean sections and based on those experiences, she chose to have a trial of labor for a normal vaginal delivery before agreeing to a c-section if it becomes necessary. The Chief Financial Officer of Bayfront Health Port Charlotte sent a letter to the woman, Jennifer Goodall, with the threat of reporting her to the Department of Children and Family Services, seek a court order to perform surgery, and to perform cesarean surgery on her “with or without [her] consent” if she came to the hospital.

There are risks to repeated cesarean sections, as well as risks to women who have a vaginal birth after having had cesarean sections (known as VBAC). According to guidance 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.” It is interesting to note the history of VBAC. 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 reasons for the decline are restrictions placed by hospitals and insurers on a trial of labor following previous cesarean sections. This shows that it is not only physicians that try to control pregnant women, but also hospitals and insurance companies.

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.
  

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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, in a formal complaint filed by NAPW, seeking 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.

If this were an isolated case of attempts to control the behavior of pregnant women, 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, a variety of other actions continue to violate the decision-making autonomy of pregnant women. These efforts will be addressed in future blogs.