A condensed version of this post was originally published on Albert Einstein College of Medicine’s The Doctor’s Tablet blog.
According to the CDC’s most recent National Vital Statistics Report, in 2009, Cesarean section rates reached an all-time high of 32.3 percent of all births in the U.S. A Cesarean section is a major surgical procedure involving anesthetics, incision-making, and stitching of a woman’s abdomen, and like any surgical procedure, or any medical treatment in general, requires informed consent of the patient it is performed on.
There are many situations in which performing a Cesarean section instead of delivering a baby vaginally can be beneficial to the mother, fetus, and physician involved. Cesareans often lower risk when complications, such as slow labor, breech presentation, and heart abnormalities arise. Unlike vaginal births, Cesareans can be scheduled and therefore are ultimately more convenient for physicians and patients, and this may add to the alarming increase in Cesarean rates.
There are many concerns, however, about rising pressures for pregnant women to choose to have a C-section instead of a vaginal birth. There have been a number of cases in which hospitals have sought court-ordered intervention when a pregnant woman has refused a medically advised C-section, and even some cases where mothers have lost custody of their children, or been charged with murder when the fetus did not survive. Patients have the right to refuse medical treatment, but a pregnant mother refusing an advised procedure for both her and her fetus brings up complicated issues for all parties involved. Many fetal rights activists advocate that a fetus should be protected as a separate entity from the woman. According to the American Council of Obstetrics and Gynecology (ACOG), “these actions and policies have challenged the rights of pregnant women to make decisions about medical interventions and have criminalized maternal behavior that is believed to be associated with fetal harm or adverse perinatal outcomes.”
If a mother refuses a procedure that could save her and/or her child’s life, a quick response is to assume she is unreasonable or incapable of making decisions about her body. These assumptions compromise her right to informed consent. In reality, there are many motivations for a woman to refuse a recommended Cesarean. For example, if she is planning on having future children, it might be more difficult for her to have them delivered vaginally, because some doctors today do not perform VBAC (vaginal birth after cesarean) deliveries. For some, surgery may be against their cultural traditions or religious beliefs. Assumptions that lead to court-ordered cesareans may stem from sexist, racist, or classist stereotypes of how a “good mother” should act. In a 1987 survey done by obstetricians, it was found that 17 out of the 21 cases in which hospitals petitioned for Cesarean after a patient’s refusal involved women of color. According to Lisa Ikemoto, a bioethicist at UC Davis, these cases play off of “implicit assumptions that women of color, especially those who live in poverty, are not fit for motherhood”.
In situations involving refusal of a medically advised procedure leading to issues of maternal-fetal conflict, it is important that (instead of seeking legal intervention) that the physician and patient work together in establishing a plan that respects the voice and autonomy of the patient and the concerns of the physician. In time-sensitive emergencies (e.g., labor complications) this can be a difficult thing to do, so it is important that these decisions be established during pre-natal care meetings. After a conversation in which all the risks of refusing a Cesarean procedure are made very clear to the patient, she may still choose to decline the procedure. ACOG has come to the consensus that efforts to protect a fetus by restricting a woman’s autonomy are not ethically or legally justified, and ultimately recommends that pregnant women’s decisions must be respected.
Kelly Walters is an intern at the Montefiore-Einstein Center for Bioethics. She is a recent graduate of Wellesley College, where she studied mathematics, pre-medical sciences, and women’s and gender studies. She is most interested in health disparities, feminist bioethics, and global health, and is considering a career in medicine and/or public health.
 Ikemoto, Lisa C. “Furthering the Inquiry: Race, Class, and Culture in the Forced Medical Treatment of Pregnant Women.” Tennessee Law Review. 59.487 (1992)