The Ethics of Obstetric Care

2. The Ethics of Obstetric Care Dr. Evita Fernandez Hyderabad, INDIA Website : www.fernandezhospital.com All India Congress of Obstetrics and Gynaecology, 19.1.2013, Mumbai

3. Ethical principles and virtues should be understood to apply to ALL physicians, regardless of their personal, religious and spiritual beliefs

4. Obstetrics The branch of medicine that specializes in care of women before, during and after childbirth.

5. Ethical Dimensions Unique to Obstetrics • Two inter-woven patients – interest may be at odds • Vulnerability of pregnant woman undergoing tests and procedures • Pregnant woman’s autonomy and physician’s judgement

6. Principles

7. Beneficence • Best interests of the patient • Good over harm

8. Women who get pregnant should have the basic human right of humane and evidence based maternity care

9. It is NOT about the right to give birth It is about the right to receive appropriate care when you do.

11. Appropriate Care • The right to information and informed decision making

12. Informed Consent • Disclosure • Comprehension • Free consent Communication

14. Justice The fair distribution of health resources and the decision of who gets what treatment i.e. fairness and equality

15. All women should have support throughout labour and birth. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007

16. Support in Labour Spouse / Partner Family members Midwife / student trainee * Doulas

17. Single Most Important Intervention The need for analgesics Rate of oxytocin Instrumental deliveries Caesarean sections 5 min APGAR score of < 7

18. “They expose you, they shave you, they cut you, they leave you alone And don’t come when you call, and they won’t allow your relatives to be with you” Pauline Kolenda, birth in a hospital / village, India

19. Obstetric Violence(Venezuela)

20. Obstetric Violence(Venezuela)

21. Pain of Indignities • Enemas • Shaving of pubic hair • Lying flat on the back • Legs in stirrups for hours • Lack of privacy

22. Justice The fair distribution of health resources and the decision of who gets what treatment i.e. fairness and equality

23. Newborn carefacilitating early bonding

24. Obstetric Violence(Venezuela)

25. Early skin-to-skin contact for mothers and their healthynewborn infants Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2.

26. The Benefits of Early Skin to Skin Contact • Positive effects on breastfeeding (OR 1.82) • Improved maternal bonding • Infants cried for a shorter length of time • Better cardio-respiratory function • No adverse effects were found Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2.

27. Human Rights in Childbirth Birthing women have a fundamental human right to choose the circumstances in which they give birth.

28. Nonmaleficence First, Do no harm (Primum non nocere)

29. Obstetric Violence(Venezuela)

30. Interventions that may cause harm • Induction of labour • Oxytocin drip • Rupture of fore-waters • Repeated vaginal examinations

31. Autonomy The right to choose and follow one’s own plan of life and action

32. Caesarean Delivery upon Maternal Request (CDMR) ... in the absence of any specific medical indication

33. National Institute of HealthMarch 2006 “Insufficient evidence to issue a recommendation concerning the relative safety of planned Caesarean births and called for further study”

34. FIGO : Ethically not justified • ACOG : Not recommended for women “desiring several children”

35. Consent for Caesarean Section should be requested AFTER providing evidence based information in a manner that respects the woman’s dignity, privacy, views and culture, apart from the clinical consideration. NICE Guidelines, Nov. 2011

36. Caesarean Delivery upon Maternal Request (CDMR) International Caesarean Awareness Network (ICAN) - Unethical and immoral www.ican-online.net

37. Caesarean Delivery upon Maternal Request (CDMR) Proponents of natural births - Undermines a woman’s confidence in her own body and minimizes her participation in the birthing practices

38. CDMR : Potential Risks • ↑ Neonatal respiratory morbidity • Potential surgical complications • Future pregnancies – abnormal placentation – uterine rupture

39. CDMR : Potential Benefits • Convenient time • Lowered risk of haemorrhage • ↓ Neonatal injury

40. Ethical Question : CDMR • Do these surgeries represent Patient Choice Demand Request Am. Fam. Med 2006;34 : 265-8

41. Talking Points for Informed Consent on CDMR • Do not recommend / offer • Enquire WHY / EDUCATE / ADDRESS MYTHS • Be explicit in discussing risks / benefits • Risks to future pregnancies • Refer to another health care provider ACOG, ObstetGynecol 2007;110 : 1501-4

42. A woman giving birth is the final decision maker in the birth process. Doctors, midwives and others can inform, advise and support.

43. Informed Consent • Disclosure • Comprehension • Free consent Communication

44. The state of pregnancy does NOT deprive a woman of her right to decide what should happen to her body

45. Birth Plan • What are your wishes during a normal labour and delivery ? • How do you hope for your baby to be treated immediately after birth

48. Only one rule in medical ethics need concern you – that action on your part which best conserves the interests of your patient – Martin H. Fischer