REPRODUCTIVE JUSTICE

MEDICALIZATION IN MATERNAL HEALTHCARE

**NOTE** Medical advancements have saved the lives of women and babies at risk for injury or death during pregnancy and birth. This site is not about the doctors who properly use interventions to save lives; it is about those who use them unethically for profit or convenience. Improperly used interventions have led to harm and death of women and babies and obstetrics is the only field in which mortality rates are rising and non-medically needed interventions such as c-sections are related to 66% of maternal deaths.

**NOTE** This site is designed to share valid evidence for those working to change the maternal healthcare system who do not have access to databases of peered research.

**NOTE** Chronological order allows users to find new data. It also begs the question of why, when we have known for decades that such practices are harmful, do they not only continue to be used but are increasingly used.

INFORMED CONSENT AND INFORMED DECISIONS (BIRTH PLANS)

Lack of informed consent often leads to mothers acceptance of planned (non-medically necessary) C-sections; however, few mothers are given valid information about the possible harm to the baby. Doctors often use the excuse of "autonomy" in when encouraging planned c-sections, but true autonomy requires that mothers have full information about ALL possible risks including those to their baby.

1.IRB teaches that all possible harms including that to unborn children must be shared. Review of online informed consent forms for C-sections shows that “minimal” risk to mothers is included, but none found in a search of the Internet, talked about risk or possible harm to babies other than some that mentioned that the baby could be cut during the procedure. This violates informed consent (Zeidenstein, L, 2005; Sacala, C. and Corry, M., 2010). Where information is given, it emphasizes that risk “minimal” almost encouraging the procedure. Seeking consent for c-sections usually done during delivery or late labor rather than earlier in pregnancy which would allow mothers time to make informed decisions IF they are truly given information about possible risks to the baby.

2.Mothers who receive full information about possible harm to not just them, but also to their babies much less likely to agree to non-medical C-sections.

American Medical Association (2022). Informed Consent. Accessed https://www.ama-assn.org/delivering-care/ethics/informed-consent AND Code of Medical Ethics Accessed https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-consent-communication-decision-making AND Withholding Information from Patients Accessed https://www.ama-assn.org/delivering-care/ethics/withholding-information-patients

COMMENTS: While it is impossible to review all informed consent forms, a general review indicates that valid informed consent is rarely given in the case of non-medical C-sections or other interventions. Although there is a plethora of research developed over decades indicating possible negative outcomes for both mothers and babies, the only discussion of possible harm to babies is that the baby could be cut during the procedure and that is far from the only possible negative outcome. Hiding known information is a violation of informed consent..

U.S.Department of Health and Human Servicxes (2022) Informed Consent FAQ. Accessed https://www.hhs.gov/ohrp/regulations-and-policy/guidance/faq/informed-consent/index.html and additional protections for pregnant women, human fetuses and neonates involved in research at https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/common-rule-subpart-b/index.html

COMMENTS: Although from HSS, almost every country in the world has similar statutes. Informed consent from a pregnant woman must include information about possible harm to the fetus or neonate.

WHAT DOES THE LITERATURE SAY?

2022

COMMENTS: While it is impossible to review all informed consent forms, a general review indicates that valid informed consent is rarely given in the case of non-medical C-sections or other interventions. Although there is a plethora of research developed over decades indicating possible negative outcomes for both mothers and babies, the only discussion of possible harm to babies is that the baby could be cut during the procedure and that is far from the only possible negative outcome. Hiding known information is a violation of informed consent..

Joint Commission (2022). Informed consent; more than getting a signature. Accessed https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-21-informed--consent-more-than-getting-a-signature/informed-consent-more-than-getting-a-signature/#.Y93IJujMJN8

There are numerous challenges to implementing an effective informed consent process – that is, one in which the patient fully understands the health care treatment or surgical procedure they are agreeing to undergo

Monteagudo, M. (2022). Informed consent and unauthorized treatment. Accessed https://www.findlaw.com/injury/medical-malpractice/unauthorized-treatment-and-lack-of-informed-consent.html

The informed consent process isn't only an ethical obligation for doctors. It's also a legal one. State laws often take a patient-centered approach. Doctors must discuss with patients all possible risks related to the procedures

New York City Department of Health (2022). Understanding your rights during pregnancy, labor and childbirth and after giving birth. Accessed https://www.nyc.gov/assets/doh/downloads/pdf/ms/birth-rights-companion-guide.pdf

Informed consent is a legal right in the United States (U.S.). Informed consent means that, by law, you deserve to know and make your own decisions about all medical procedures, tests and treatments. The law protects your right to be informed. Understanding all of your options can help you make the decision that is best for you and get the safe and respectful care you deserve. Ask as many questions as you need to.

Richardson, A. (2022) The Case for Affirmative Consent in Childbirth. Berkeley Journal of Gender, Law and Justice. Accessed https://web.p.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=19331045&AN=160727303&h=2Rj1pvwjqpYtfeHwo3WBnD3ZuyjnibhQ09480a4CO3v3O7bfa1%2fSqHpI323x17X5sdd4HpqQs3HQLtc9N8pczQ%3d%3d&crl=c&resultNs=AdminWebAuth&resultLocal=ErrCrlNotAuth&crlhashurl=login.aspx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcrawler%26jrnl%3d19331045%26AN%3d160727303

Legislated affirmative consent in childbirth has the potential to shift the power relationship between providers and birthing people, clarify communication, and reduce the incidence of unwanted procedures. It would rectify deep inconsistencies in the legal treatment of pregnant people and bring the law in line with prevailing standards of medical ethics. As in sex, the effectiveness of affirmative consent in birth would be limited by the extent to which providers can coerce birthing people into saying "yes." Even so, affirmative consent in childbirth would significantly shift the legal endowment in favor of birthing people, ensuring them greater control over what the birthing process is now and can be in the future.

University of Baltimore Law Review (2022). Medical coercion during pregnancy and childbirth. Accessed https://ubaltlawreview.com/2022/11/06/medical-coercion-during-pregnancy-and-childbirth/

Women’s reports of their care indicate that interventions are routinely performed without meaningful consent, violating their autonomy in medical decision-making.[2] These interventions may include medical inductions, medications, mobility-limiting fetal monitoring methods, episiotomies, and cesarean-section surgeries.[3] Using coercive tactics to induce compliance with providers’ medical recommendations is one category within a broader range of mistreatment in pregnancy and childbirth termed “obstetric violence.”

COMMENTS: Although from HSS, almost every country in the world has similar statutes. Informed consent from a pregnant woman must include information about possible harm to the fetus or neonate.

2021

Birthrights (2021). What does informed consent mean in maternaity care? Accessed https://www.birthrights.org.uk/2021/09/17/birthrights-and-gmc-what-does-informed-consent-mean-in-maternity-care/

It could also be said that pregnancy is exceptional because it involves two people – the person carrying the baby and the unborn baby itself. However, in the eyes of the law, this doesn’t make any difference. An unborn baby has no legal rights until it is born. Even when your baby is born, you have the final decision about what is best for you and your baby, which only a court can overrule. Your decisions cannot be overruled because a doctor is concerned that your decision might harm your baby – it is always your decision. The only exception is if you are not able to make these decisions for yourself (you lack mental capacity) which is very rare.

Campbell, C. (2021). Medical violence, obstetric racism and the limits of informed consent for black women. https://doi.org/10.36643/mjrl.26.sp.medical Accessed https://repository.law.umich.edu/mjrl/vol26/iss0/4/

Abstract: "This Essay critically examines how medicine actively engages in the reproductive subordination of Black women. In obstetrics, particularly, Black women must contend with both gender and race subordination. Early American gynecology treated Black women as expendable clinical material for its institutional needs. This medical violence was animated by biological racism and the legal and economic exigencies of the antebellum era. Medical racism continues to animate Black women’s navigation of and their dehumanization within obstetrics. Today, the racial disparities in cesarean sections illustrate that Black women are simultaneously overmedicalized and medically neglected—an extension of historical medical practices rooted in the logic of biological race. Though the principle of informed consent traditionally protects the rights of autonomy, bodily integrity, and well-being, medicine nevertheless routinely subjects Black women to medically unnecessary procedures. This Essay adopts the framework of obstetric racism to analyze Black women’s overmedicalization as a site of reproductive subordination. It thus offers a critical interdisciplinary and intersectional lens to broader conversations on race in reproduction and maternal health."

Harvard Law Review (2021) The legal infrastructure of childbirth. Accessed https://harvardlawreview.org/2021/04/the-legal-infrastructure-of-childbirth/

CONCLUDED "The legal infrastructure of birth, through tort law incentives and regulation of midwives, drives lack of access and choice in birth. By shaping the provision of healthcare, law encodes particular values in the birthing process, promoting a fetal-centric and physician-controlled approach. In seeking solutions, advocates should focus on bringing the regulation of childbirth into alignment with healthcare and constitutional law more broadly, and on reforming areas of the law that can improve access to a broader spectrum of care."

2019

Mirghafourvand, M., Mohammad Alizadeh Charandabi, S., Ghanbari‐Homayi, S., Jahangiry, L., Nahaee, J., & Hadian, T. (2019). Effect of birth plans on childbirth experience: A systematic review. International Journal of Nursing Practice, 25(4), e12722–n/a. https://doi.org/10.1111/ijn.12722

CONCLUDED: "There is no strong evidence in favour of the acceptance or rejection of the effect of a birth plan on childbirth experience or women's satisfaction. A recommendation is to perform clinical trials with rigorous methodologies by limiting bias in relation to the effect of birth plan on the experiences of childbirth"

New York State Codes, Rules and Regulations (2019) Patient Rights. Accessed https://regs.health.ny.gov/content/section-4057-patients-rights

Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.

Oster, E. and McClellan, W. (2019)Why the C-section Rate is So High. The Atlantic. Accessed https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/

CONCLUDED: "A doctor and an economist note that doctors are generally paid quite a bit more for a C-section than for a vaginal birth. This financial nudge might just have something to do with the rate of non-indicated C-sections in the U.S. Evidence and expert consensus are consistent on the message that C-sections, on average, come with greater risks than vaginal births: more blood loss, more chance of infection or blood clots, more complications in future pregnancies, a higher risk of death. Even if serious complications don’t occur, C-section recovery tends to be longer and harder."

2018

Attanasio, Kozhimannil, K. B., & Kjerulff, K. H. (2018). Factors influencing women’s perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth. Patient Education and Counseling, 101(6), 1130–1136. https://doi.org/10.1016/j.pec.2018.01.002

CONCLUDED (from intro) "Nearly 4 million women give birth in the U.S. each year; 32% deliver by cesarean, and at least 22% give birth following an induction of labor [1,2]. There is broad agreement that cesarean delivery is currently overused in the U.S., given that maternal and neonatal morbidity and mortality have not decreased as cesarean delivery has become more common [3]. Furthermore, cesarean delivery is a major abdominal surgery and carries increased risk of complications for the mother and baby, as well as increased risk of placenta problems in future pregnancies compared to vaginal delivery [3,4]. There is less consensus on whether labor induction is overused, but the major concern is that induction of labor when it is not medically necessary may lead to a higher risk of delivering by cesarean [3,5–7]. Despite these concerns about overuse of obstetric procedures, little is known about how procedure utilization in childbirth relates to women’s involvement in decision making during labor."

Georgia Birth Advocacy Coalition (2018). Can a doctor force me to have a c-section? Accessed https://georgiabirth.org/blogcontent/2018/11/30/this-is-the-first-blog-post

CONCLUDED "The short answer is that doctors, hospital administrators, and hospital lawyers are taking advantage of women’s ignorance about their own rights. Except in very rare circumstances, a doctor absolutely cannot force you to have a c-section. In fact, doing so is almost always illegal. If your doctor is attempting to coerce you into a c-section, here are five things you need to know"

Stohl, H. (2018). Childbirth is not a medical emergency: Maternal right to informed consent throughout labor and delivery. The Journal of Legal Medicine, 2018, vol 38. pg 329-353.

CONCLUDES: "Labor is not a de facto medical emergency within the meaning of the informed consent doctrine. Except under extreme and unusual circumstances, a laboring woman remains competent throughout the childbirth process. Accordingly, a laboring woman retains her right for decision making during labor and delivery, and treatments cannot be initiated without her consent. Similarly, the laboring woman’s withdrawal of consent must be honored. The American College of Obstetricians and Gynecologists (ACOG)151 upholds the maternal right to informed consent and bodily integrity. Accordingly, ACOG strongly discourages medical professionals from turning to the courts to compel a pregnant woman to undergo medical interventions"

2017

Benyamini, Y., Molcho, M. L., Dan, U., Gozlan, M., & Preis, H. (2017). Women’s attitudes towards the medicalization of childbirth and their associations with planned and actual modes of birth. Women and Birth : Journal of the Australian College of Midwives, 30(5), 424–430. https://doi.org/10.1016/j.wombi.2017.03.007

CONCLUDED: "At an era in which childbirth is extensively medicalized, arousing the need for healthcare professionals to better define normal physiologic birth,2 it is not surprising that many women favour a medicalized birth. However, these births are more likely to result in a less positive birth experience, due to feelings of less control, less support, and less participation in decision-making.30 As studies have shown, a major factor in women’s dissatisfaction with giving birth within a medicalized system is the lack of informed decision-making, which takes into account women’s Y. Benyamini et al. / Women and Birth 30 (2017) 424–430 429 preferences and provides them with the full range of options that are open to them.12 We join the calls to develop interventions aimed at providing women with trustworthy information and decision aids23 and promoting informed shared decision-making, within a relationship with a trusted provider. Assessing attitudes towards the medicalization of childbirth could provide an opportunity to listen to women’s voices and openly discuss with them their preferences and the sources of their attitudes and choices, in relation to the local birth culture."

De Vries. (2017). Obstetric Ethics and the Invisible Mother. Narrative Inquiry in Bioethics, 7(3), 215–220. https://doi.org/10.1353/nib.2017.0068

CONCLUDED: (Abstract.) These mother-told stories of birth, describing disrespectful and harmful care, make the invisibility of birthing women visible. The concerns and needs of women in labor fade in the face of hospital policies and the perceived needs of their soon-to-be-born babies. Bioethics contributes to this lack of regard for mothers by framing the moral problems of birth in terms of maternal-fetal conflict, where the autonomy of the mother is weighed against the obligation of beneficence to the baby. Replacing the principlist commitment to autonomy with respect—an obligation that does not compete with beneficence—is a first step toward correcting the problems in care identified here."

Morris, & Robinson, J. H. (2017). forced and coerced cesarean sections in the united states. Contexts (Berkeley, Calif.), 16(2), 24–29. https://doi.org/10.1177/1536504217714259 Accessed https://journals.sagepub.com/doi/full/10.1177/1536504217714259

CONCLUDED (from article) "One bureaucratic issue deals with informed consent. Hospitals may require patients to sign a blanket informed-consent form upon hospital admission, including, for pregnant women, consent for a cesarean. A patient’s not signing may lead to the hospital staff’s refusing admission. Lusero laments, “A lot of times I have to tell them, ‘You actually signed a consent form when you got to the hospital saying that you consented to this procedure.’”

DeBaets. (2016). From birth plan to birth partnership: enhancing communication in childbirth. American Journal of Obstetrics and Gynecology, 216(1), 31.e1–31.e4. https://doi.org/10.1016/j.ajog.2016.09.087

CONCLUDED (from abstract) "Birth plans were developed with the intention of enhancing a woman’s prepared decision-making in the labor and delivery process and to offer obstetric care providers with important details about those decisions. Through the use of birth plans, women can reflect on their values and choices regarding what care practices and interventions they do and do not want in birth; they can communicate these values in advance to their care providers. However, birth plans are often ineffective at accomplishing their goals for a number of reasons. They may reflect outdated concerns about routine practices or overly emphasize minor matters. Many popular pregnancy websites offer birth plans that use checklist formats, and women who use these are not counseled about which options may require or preclude other options. Some women may have inappropriately rosy expectations of how their labor and delivery processes will progress or have received poor advice. The use of a birth plan may invoke hostility from hospital staff members who may disregard the plans and look down on the women who make them. An alternative approach to the use of birth plans to enhance a woman’s participation and informed consent in the birth process is the birth partnership, in which women and their obstetric care providers take time to discuss thoroughly the choices to be made in birth in advance to have those choices best reflect the values of the woman giving birth. Meeting to discuss values and choices before labor offers the opportunity for mutual education between provider and patient about the choices to be made and the values that inform those choices. Effective communication and working to build mutual trust can serve as preventive measures to avoid many conflicts that arise in the birth process"

Stohl, H. (2017). Childbirth is not a medical emergency; Maternal right to informed consent throughout labor and delivery. Accessed https://www.tandfonline.com/doi/abs/10.1080/01947648.2018.1482243

Labor and delivery often involves medical interventions for which a pregnant woman must provide consent. The expectant mother consents on her own behalf and on behalf of her unborn child. The medical emergency exception to the doctrine of informed consent permits health care practitioners to provide life-saving treatments in the absence of explicit assent by the patient. Though emergent interventions may be necessary in the context of childbirth, the pregnant woman—except under extremely limited and rare clinical circumstances—retains capacity for decision making throughout her labor and delivery course. The physical pain, emotional stress, or medical interventions commonly associated with childbirth do not remove a laboring woman’s legal competence. No treatments or therapies, even if with the best of intentions, can be given to her (or her fetus) without her consent.

2012

Almand, A. (2012). A Mother's Worst Nightmare, What's left Unsaid: The Lack of Informed Consent in Obstetrical Practice. Accessed https://scholarship.law.wm.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1340&context=wmjowl

From Article: While the doctrine of informed consent1 has been continually strengthened in the fields of traditional medicine by numerous judicial decisions,2 the presence of the doctrine is virtually absent from the field of obstetrics and gynecology.3 By virtually absent, it is meant that the doctrine of informed consent has not been sufficiently delineated, applied and required in the field of obstetrics.4 In the vast majority of jurisdictions across the United States, there is no legal compulsion placed upon an obstetrical practitioner to disclose anything more than highly significant risks.5 Therefore, only the most egregious of failures to provide basic information to an expectant mother, which result in physical injury to her or her child, are likely to result in malpractice liability to the attending practitioner for want of informed consent.6 Consequently, expectant mothers learn only a fraction of the vital information necessary to make decisions about the various medications, practices and procedures that are commonly a component of their pregnancy.7

2010

Sakala, C and Corry, M. (2010) Evidence Based Maternity Care… Accessed https://www.nationalpartnership.org/our-work/resources/health-care/maternity/evidence-based-maternity-care.pdf

CONCLUDED: "Studies of decision making in maternity facilities indicate that women often have little understanding of interventions that are recommended and that there is concern about the adequacy of informed consent being obtained. Surveys indicate that mothers had little knowledge of interventions performed by obstetricians indicating that there is a lack of truly informed consent being obtained."

2009

Iger, Betsy. (2009) Understanding informed consent; your legal rights. Accessed https://www.hss.edu/conditions_understanding-informed-consent.asp

Patients have the legal and ethical right to direct what happens to them, and physicians have the ethical duty to involve patients in their health care. The concept of "informed consent" is an important way in which you participate actively in choices about your health care. While such consent may be informal in day-to-day medical care, it becomes more important if you are having a procedure such as surgery - and critically important if you are participating in research.

2005

Zeidenstein, L. (2005). Elective Caesarean Section: How Informed is Informed? Online Journal of Health Ethics. Accessed https://aquila.usm.edu/cgi/viewcontent.cgi?article=1016&context=ojhe

CONCLUDED: "The ethical dilemma of elective Cesarean involves confusion about what constitutes informed consent (Mappes & Degrazia, 2001).The informed consent process can be analyzed as containing three elements: information, comprehension, and voluntariness. Of course, the motives for obstetricians are not to do harm to either mother or fetus when they decide that an elective Cesarean is an ethical choice. But in a typically paternalist physician-patient relationship, the physician might present only information on risks and benefits of a procedure that he or she thinks will lead the patient to making the right (i.e., the physician-supported) decision regarding care. How well can we expect the surgically trained obstetrician to present the risks and benefits of natural childbirth? "

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Last updated June 2024