Doctors, hospitals and judges have over the years attempted to control the decisions of pregnant women. In a recent Florida case, it’s not clear whether the controllers sought to protect the fetus, the woman or both. They may have wanted to protect the hospital from potential liability.

The case involved a 39-week-pregnant woman.

According to a press release issued by the National Advocates for Pregnant Women (NAPW), the hospital threatened to force the woman to have cesarean surgery against her will or risk being reported to child-welfare authorities. The woman, 29-year-old Jennifer Goodall of Cape Coral, had had three previous cesarean sections; based on those experiences, she elected to have a trial of labor for a normal vaginal delivery before agreeing to a c-section if it became necessary.

According to NAPW, the chief financial officer of Bayfront Health Port Charlotte sent a letter Goodall, threatening to report her to the Department of Children and Family Services, seek a court order to perform surgery and perform cesarean surgery on her “with or without [her] consent” if she went to the hospital. The hospital has declined comment on the case, citing patient confidentiality.

There are risks involved with repeated cesarean sections, as well as risks to women who have vaginal births after having had cesarean sections (known as VBAC). According to guidelines 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.”

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 reason for the decline was the restrictions placed by hospitals and insurers on a trial of labor following previous cesarean sections. This shows that it is not only physicians, but also hospitals and insurance companies, who try to control pregnant women.

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.

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, set forth in a formal complaint filed by NAPW, for 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.

Over the weekend, Goodall gave birth to a healthy boy — at a different hospital. The hospital allowed her to choose VBAC; however, when it became obvious that the labor was not progressing, she elected to have a c-section. She reportedly stated on her Facebook page that all she wanted was to be given the option.

If this were an isolated case of an attempt to control the behavior of a pregnant woman, 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, other actions continue to violate the decision-making autonomy of pregnant women.

As the ACOG guidelines clearly state, if a pregnant woman is informed of all risks, she should be empowered to choose the delivery method of her choice.

Ruth Macklin is a professor, department of epidemiology and population health, Albert Einstein College of Medicine, Bronx, NY. She blogs at The Doctor’s Tablet.

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