Consent - International Cesarean Awareness Network

No One Truly Benefits from Defensive Medicine

January 15, 2011 by blog 2 Comments

This is a cross-post from The Unnecesarean, which is in the midst of a fantastic series on defensive medicine. If you haven’t been reading the posts in this series, you can get caught up here.

By Desirre Andrews, President of ICAN

A woman’s pregnancy should be a positive time as she prepares for the birth of her baby. Unfortunately, in this age of defensive medicine, a pregnant woman must arm herself with evidence-based information and self-advocacy skills. She must be willing to act in a self-protective way to be certain she is getting individualized patient care versus the cookie cutter care modern medical practice normally affords.

This phenomenon of defensive medicine may largely be born out a very human response to the expectation of perfection we have in society today, especially with care providers. We have developed a willingness to hand personal authority over to our care providers.

For years, doctors have been deified, treated as being better than everyone else. Perhaps it is in their ability to save lives. We simply expect them to be able to do everything, but they can’t. They are human.

Doctors and patients might be able to see the human face of medicine if the traditional practice style that valued provider-patient relationship came back into use.

Today, with OB appointments being no more than ten minutes each visit, how can a personal, trusting relationship build between the two parties? It cannot. A woman can not be sure she can fully rely on her provider to know her well and help her make decisions that are in the best interest of her and her baby. The provider must rely on what he or she is comfortable with offering and doing to patients instead of taking each mother and baby into consideration individually. It is no surprise the circle of distrust and fear is palpable by all sides.

Prior to ever practicing medicine, the defensive attitude comes with the education a physician receives in medical school and the training in residency. The lesson is that your patients are not as educated as you are, always practice to defend yourself and get the patient to agree to the course of action you want no matter what.

With this attitude, what sort of “care” practices is a woman facing? Higher induction rates to lessen the rare fetal demise that can occur “post dates”. Higher cesarean rates because a physician does not want to incur risk of a VBAC mother going for a vaginal birth, even though catastrophic uterine ruptures are not common place. Viewing all OB patients through a lens of high risk or as an emergency waiting to happen.

All aspects of managed and medicalized birth occur because a physician is not comfortable, has fears, has worries and/or is not willing to practice outside of that mode because tolerate risk has been depleted. The physician desires to create a zero risk environment because of a lowered risk threshold either by training or by an adverse outcome in the years of practice. The humanness of the mother has been left out of the equation, while the ideal of a “healthy” baby is elevated in this physician centered point of view.

We as ICAN believe that every mother has the ability, responsibility and intrinsic right to make medical care decisions for her pregnancy, labor birth and baby. She should be able to obtain true and complete informed consent from her provider. We believe it is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective), to refuse to support VBAC (vaginal birth after cesarean) across the board without individualized assessment, or to skew cesarean as the easier, safer choice as a standard course of practice.

In the big picture no one truly benefits from a defensive medicine practice style. Providers and patients all lose.

VBAC Bans in Illinois

February 20, 2010 by blog 4 Comments

ICAN President Desirre Andrews was quoted today in the Chicago Tribune. The article discusses VBAC bans in Illinois and the overuse of repeat cesareans (ERCS).

Repeat C-sections have become so routine that 90 percent of pregnant women who have the surgery give birth that way again. That is a concern to health experts, who say vaginal births after a cesarean, or VBACs, should be far more common.

Successful VBACs result in better health outcomes for the mother and the baby and cost several thousand dollars less than cesarean deliveries, according to the American Congress of Obstetricians and Gynecologists, or ACOG. The organization recommends that VBACs be offered in low-risk cases.

Experts point out that although the attempt carries a risk of uterine rupture, the chance it will happen is relatively low: 0.5 percent. Meanwhile, C-sections carry all the risks of a major surgery. Compared with having a vaginal birth, a woman delivering by C-section experiences more physical problems, longer recovery and more emotional issues on average, studies show. Research also has found babies born by cesarean are less likely to be breastfed and more likely to experience breathing problems at birth and asthma as they get older.

Yet the VBAC rate, 9.2 percent, is a far cry from the objective set by the Centers for Disease Control and Prevention: 37 percent. In Illinois, the rate was 11 percent in 2008, down from 38.6 percent a decade earlier.

In the rural parts of the state, the dictum “once a cesarean, always a cesarean” rings particularly true: In northwest Illinois, the VBAC rate is as low as 3.9 percent, according to the Illinois Department of Public Health. Twenty-two percent of Illinois hospitals don’t offer the procedure, according to a survey by the International Cesarean Awareness Network, a grass-roots group that works to lower the rate of unnecessary cesarean sections.

The article points to liability issues as one of the driving factors of ERCS over VBAC:

Safety fears, however, were just one factor. Legal pressures, professional guidelines, and patient and physician preferences also created a VBAC backlash. In March, the National Institutes of Health will hold its first-ever VBAC conference to explore why the rate continues to fall, even though 73 percent of the women who try VBACs are successful.

“The liability issue is huge,” said Dr. Joseph Pavese, chairman of the obstetrics department at Advocate Christ Medical Center in Oak Lawn, where 97 percent of pregnant women with a previous C-section have another one. “Parents expect good outcomes, and physicians are reluctant to try difficult deliveries. If the baby is not perfect, there is possible litigation.”

Risk adversity feeds into this dynamic as well:

Over the years, “The risk of uterine rupture has not changed,” said Dr. Howard Strassner, director of maternal and fetal medicine at Rush University Medical Center. “What has changed is individual tolerance for risk. It reached the point where no one wants to be associated with an adverse outcome.”

In the 1990s, research that suggested VBACs were dangerous — and a pro-cesarean editorial — published in the New England Journal of Medicine immediately affected practice, said Gene Declercq, a professor of community sciences at the Boston University School of Public Health. But more recent and balanced research showing VBACs are as safe — if not safer — than repeat C-sections hasn’t had the same effect, said DeClercq, who researches maternity care practice and policy in the U.S. and abroad.

The result has been an increase in VBAC bans in hospitals across in country, including Illinois.

What crippled the idea of a VBAC, however, was a simple word change. In 1998, ACOG advised that physicians should be “readily available” to provide emergency care because of the dangers of a uterine rupture. Eight months later, the American Congress of Obstetricians and Gynecologists changed the wording to “immediately available,” and many small hospitals in rural areas stopped doing VBACs.

Katherine Shaw Bethea Hospital in Dixon, which handles about 365 deliveries a year, was one of more than a dozen Illinois hospitals that subsequently dropped VBACs because an on-site anesthesiologist wasn’t always immediately available.

VBACs are also banned at Blessing Hospital in Quincy, which touts itself as “the largest and most sophisticated medical center in a 100-mile radius.” Hospital officials declined to explain why.

Desirre comments on this trend:

“It’s illegal to enforce a ban on how our bodies are designed,” said doula and childbirth educator Desiree Andrews, of Colorado Springs, president of the International Cesarean Awareness Network. “But evidence-based practice has been crowded out of the hospital setting in favor of defensive medicine. As a result, too many women are subject to coerced cesareans because hospitals have banned VBACs.”

Whither the rights of pregnant women?

January 27, 2010 by blog Leave a Comment

Samantha Burton’s legal battle to appeal a judge’s ruling that confined her to a hospital’s care and, ultimately, the cesarean birth of a her stillborn baby, continues to garner national media attention. The Washington Post reports:

And six months after the pregnancy ended, the dispute over the legal move to keep her in the hospital continues, raising questions about where a mother’s right to decide her own medical treatment ends and where the priority of protecting a fetus begins.

“The entire experience was horrible and I am still very upset about it,” Burton said through her lawyer. “I hope nobody else has to go through what I went through.”

Burton, who declined to be interviewed, is appealing the judge’s order. She isn’t asking for money but hopes to keep her case from setting a precedent for legal control over women with problem pregnancies. She also worries it could prevent women from seeking prenatal care.

At the heart of the matter are the rights of pregnant women to make their own informed medical decisions and refuse unwanted care.

American Civil Liberties Union lawyer Diana Kasdan said if the ruling stands it could lead to the state virtually taking over the lives of pregnant women, including telling them what they should or should not eat and drink and what medications they must take.

“It would be a horrible precedent,” Kasdan said.

And…

The judge ruled the best interests of the fetus overrode Burton’s privacy rights, but Abrams [Burton’s lawyer] disputes that. He notes the Florida Constitution, unlike its federal counterpart, has an explicit and strong privacy right, which the state Supreme Court has said guarantees a competent person the right to “choose or refuse medical treatment.”

“If you apply the best interest of the child standard, the woman becomes nothing more than a fetal incubator owned by the state of Florida,” Abrams said.

Jacob M. Appel sums it up well on Huffington Post:

One of the most essential principles of modern medical care — possibly the fundamental underpinning — is that competent patients have the right to make their own medical decisions. Pregnant women have as much authority to control their course of care as does anybody else.

The Washington Post further reports:

There have been a few other cases nationwide that involve similar efforts by courts to intervene in pregnancies:

– In 1987, a Washington, D.C., judge ordered a woman who was dying of cancer to have a C-section, which she had refused, to save her fetus. The baby died within two hours of delivery and the mother died two days later. An appeals court later ruled the judge should not have ordered the C-section.

– In 2003, prosecutors in Salt Lake City charged an acknowledged cocaine addict who had a history of mental health problems with murder when she refused to have a C-section for two weeks before finally agreeing to the procedure. One of her twins died in the womb during the delay. Through a plea deal, the charge was later reduced to child endangerment.

– In 2004, a hospital in Wilkes-Barre, Pa., obtained a court order to force a woman to have a C-section because her seventh baby was oversized, but the order was too late. The mother, whose first six children each weighed nearly 12 pounds at birth, went to another hospital and delivered an 11-pound, 9-ounce girl naturally.

– Also in 2004, a judge in Rochester, N.Y., ordered a homeless woman not to get pregnant again without court approval after she lost custody of several neglected children.

Dr. Michael Grodin, a physician and professor of health law, bioethics and human rights at Boston University, said doctors should never resort to court orders.

“People have the absolute right to refuse treatment …,” Grodin said. “It’s unconscionable. … It’s an affront to women.”

And Appel adds this advice:

Pregnant women and those planning pregnancies should also take away a lesson from the Samantha Burton tragedy. Ask your obstetrician directly: Is there any circumstance under which you will refuse to let me make my own medical decisions or will prevent me from leaving the hospital? That is a question no woman should ever have to ask her doctor. Unfortunately, as long as rogue OBGYNs continue to impose their values upon unsuspecting patients, it is a prudent question to ask.

For more information on the legal rights of pregnant women, see here and here.