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Part Two: "But your child might die" the right to defy doctor’s orders

by Dr Hannah Dahlen
09 April 2015
HEALTH AND MEDICINE

This is part two in our debate between members of the medical community on the topic of what is natural and what is reasonable when it comes to birth and a mother’s right to choose her delivery method. Here, Dr Hannah Dahlen, rebuts Genevieve Tait’s argument that many mothers who insist on vaginal birth against medical advice are motivated by competitiveness and entitlement. 

I don’t know what disturbed me most about Genevieve Tait’s opening argument.

Was it that it was written by a woman, or by a student doctor who would one day care for women? Or was it that these thoughts were not just the naive reflections of youth and inexperience but attitudes I see commonly expressed in society and by medical professionals with years of experience?

Ms Tait and I agree on this much, “Every woman should have the right to make a choice about her birthing strategy and her body. This right is inalienable.” But with her following sentence, she loses my support, “But sometimes I worry that women get so concerned about how they are going to deliver the baby that they forget about the actual welfare of the baby.”

If an expecting mother defies an obstetrician’s advice against a vaginal birth, we need to assume and respect her decision is motivated by reasons other than “competitiveness and entitlement”. And if we don’t – if we coerce a woman already under duress – we may trigger a toxic postnatal experience.

Women have told us there is something worse than death – there is being alive but dead inside. There is being so traumatised by pressurised interventions in their birth plan that they can’t care for their newborn or have a relationship with their partner, and their own mental health is affected. Ms Tait’s comment that “whether a baby first glimpses the light of day via the stomach, in a pair of forceps, or via the vagina, what matters is that the baby arrives alive and the mother stays alive” is clearly naïve. We need women and babies to be more than simply alive; we need them to be well physically, emotionally and culturally.

 

We need women and babies to be more than simply alive; we need them to be well physically, emotionally and culturally.

A pregnant Jehovah’s Witness and her nearly 27-week foetus died after she refused a blood transfusion for acute Leukaemia in a Sydney hospital. This has been raised in the media this week and led to significant public debate. We might find this hard to comprehend, but the law is clear – the woman was an adult with the mental capacity to refuse treatment and the foetus is not a legal person in his or her own right until it is born.   

Inevitably we see the backlash and the comments that laws should be introduced to force pregnant women to consider the interests of their baby first. The innocent baby becomes the justification of our outrage; however, we cannot force someone who is not pregnant to have a medical procedure for the good of another. When a man refused to donate his bone marrow to save his cousin’s life and his cousin then tried to sue him for neglect, the court found that to compel a person to submit to intrusion of his body for the good of another “would change every concept and principle upon which our society is founded” (McFall v. Shimp).

 
The innocent baby becomes the justification of our outrage; however, we cannot force someone who is not pregnant to have a medical procedure for the good of another.

The USA demonstrates the ramifications of perching on such a slippery slope when it comes to foetal rights. The expansion of foetal rights in the USA and the recent debates over similar law reform in Australia, such as Zoe’s Law, are a warning sign to us. Do we really want to go the way of the USA where women have been charged with eating junk food, taking drugs or even having sex that could or did harm their baby? In Western Australia in 2012 when there was discussion of possible foetal homicide laws being introduced, the WA Australian Medical Association called for the laws to be extended to include women who chose homebirth or drank alcohol or took drugs. Shortly after this we saw the Right to Life Association calling for the laws to be extended to include abortion.

And so we see the ease with which we can slide down the slippery slope of women’s rights – and why a woman’s right to determine what happens to her body is and always should be enshrined in law. The World Health Organisation and the White Ribbon Alliance have recently produced statements warning against violations of the human rights of childbearing women to determine what happens to their bodies and to receive respectful care from health care providers.

Now to the real questions here. How often do women actually refuse medical advice and why do they? The answer to the first question is rarely; the answer to the second question is more complicated. In the last five years I have worked on several research studies with my PhD students investigating the question of why some women say ‘no’ to our recommendations and services. We have found the main reasons for this choice is a distrust of mainstream services due to trauma during a past birth experience, often due to unnecessary or forced intervention and disrespectful, at times downright abusive treatment from health care providers.

Australia has one of the highest rates of intervention in birth in the world and this is traumatising for many women. Unnecessary intervention in the private sector in Australia is leading to increased morbidity for mothers and babies and not saving lives. Giving birth is not just a physical act, it is an intensely emotional, social and psychological act. Suicide is now the leading cause of maternal death in the developed world. Post traumatic Stress Disorder (PTSD) affects up to one in ten women following birth. This is clearly not safe. 

Women are not stupid. They read and research their birth options and know the evidence, sometimes even better than health professionals who consider themselves the final authority. Expecting mothers talk on blogs, they tweet and they post on Facebook – something which our research has found is more than “peer-pressure for grownups”, it can be very constructive. So why are we so insulted when women become active, informed participants in their own welfare?

There is more and more scientific evidence showing that vaginal birth not only primes the immune system, impacting positively on the future health of the child, but there is emerging evidence of its impact on wiring the human brain and in epigenetic changes. So, are women so misled in “being proud of their vagina’s capacity to deliver children”? Or is vaginal birth much more important than we ever realised.

 
The answer is not to reject medical intervention but to get the balance right and to ensure that mothers don’t feel like a failure if they need intervention.

Vaginal birth is still the best option for most mothers and babies, but not all. I’ll grant the benefit of the doubt that this is a point Ms. Tait and I largely agree on. However, in situations where vaginal birth is not the best course of action, her argument that women should always defer to the obstetrician’s advice, is where I disagree. The answer is not to reject medical intervention but to get the balance right and to ensure that mothers don’t feel like a failure if they need intervention. Countries with low caesarean section rates and excellent maternal and perinatal outcomes show us that living ‘as nature intended’ for the most part is what is optimal. Iceland, with half our caesarean section rate, loses fewer mothers and babies than we do. Finland, Sweden, Norway and Iceland, are consistently rated as the best places in the world to be a mother and in all of these places midwives are the main providers of care.

In 2005, the World Health Organisation challenged health practitioners not to ask, “Why don’t women accept the service that we offer?” but to question, “Why don’t we offer a service that women will accept?" Let’s stop trying to criminalise women’s choices or bully them into submission and let’s start trying to understand why those choices are made. We need to put in place responsive, sensitive maternity care systems that cater for the individual. And we need to remember and respect that birth for a mother is more than the everyday medical event that is for an obstetrician.


 
Dr Hannah Dahlen is Professor of Midwifery at the University of Western SydneyImage Credit: Wikihow


This article is part of a debate on the right to defy doctor's orders. Click here to read the opposing argument.