By Amanda Hunter (Staff Writer)
A recent commentary in BJOG highlighted the likelihood of UK courts supporting pregnant women in their attempts to resist unwanted medical procedures, whilst acknowledging the continued use of forced caesarean sections for severely mentally ill women (1). Five UK cases highlighting the persistence of involuntary caesarean sections for women experiencing severe mental illness received media attention between December 2013 and July 2014.
Alessandra Pacchieri’s story was highly publicized in December 2013 after the Italian woman underwent a caesarean section without being informed, in August 2012. After the birth, Pacchieri’s child was immediately taken into care over concerns that she had not taken medication prescribed for her bipolar condition. Shortly after this story broke, a Bangladeshi woman diagnosed with paranoid schizophrenia was ordered to have an involuntary caesarean, if required, following a medically advised induction. In February 2014, a court permitted doctors to perform a caesarean section on a “severely mentally ill” woman with diabetes at 32 weeks gestation. Another court ruled in May 2014 that a woman with a psychotic disorder would have a caesarean section on the grounds that a liver condition posed a threat to her and her baby. Finally in July 2014, a judge ruled that forced entry could be used to access the home of a woman with autism, borderline learning difficulties and an extreme phobia of hospitals to ensure that her sixth child is born through caesarean section. This judgement was based on the woman’s previous obstetric complications and child protection issues.
Three major concerns arise in relation to legally mandated caesarean sections (and other medical treatments) for mentally ill patients. There is a strong need to scrutinize how it is decided that such a treatment is medically necessary, what choices about care are deemed to be rational and the consequences mentally ill patients face after receiving involuntary treatment. However, insufficient information is available in the cases of forced caesareans for patients with mental illness in the UK to fully assess these issues. Therefore, examples from Ireland, Brazil and the US are used below to illustrate how these concerns relate to cases where mentally competent women have been subjected to forced caesareans.
When is medical intervention necessary?
In March 2013, an Irish hospital made a court application in a case in which a mentally competent woman initially refused a medically recommended caesarean section. Despite this drastic measure, relevant medical evidence did not necessarily support the hospital’s assertion that such a measure was essential, based on the information available (2).
The legal action sought by this Irish hospital and other rulings in support of involuntary caesarean sections reflect beliefs that the use of medical technology and listening to medical advice ensures better health (3). Using medical technology and hospitals, however, does not guarantee that birth will be safe for mother or child (4).This lack of assurance for maternal and infant safety is evident in the doubling of the US maternal death rate in recent decades despite the high use of medical technology (including caesarean sections) during childbirth (5) (6).
The pressure faced by some women to adhere to medical advice, and the risks associated with caesarean sections, require further exploration. Questioning medical advice, however, may be challenging for some, due to predominant beliefs that medical knowledge is objective and only based on biological facts (3).Despite such perceptions, anthropologists have found that medical knowledge (like other forms of knowledge) is subject to biases, politics and social factors including physician convenience (7).
Some medical recommendations are not as black and white as many people believe. The contradictory or inconclusive findings of some clinical trials illustrate the existence of medical uncertainty. Indeed, a lack of clarity is seen in the debates around contradictory medical findings regarding the necessity of caesarean sections for women who have had a previous caesarean section (8; 9) or with breech presenting babies (10; 11).
“Irrational” choices and dominant discourses
In April 2014, Adelir Carmen Lemos de Góes underwent a court-ordered caesarean section in Brazil. Her obstetrician believed that Lemos de Góes was putting her baby at risk despite a lack of evidence for the necessity of a caesarean section in relation to the baby’s breech position or Lemos de Góes’ two previous caesarean sections. Additionally, comments responding to the Guardian’s article on the case also demonstrated that some people believed her doctor’s actions to be justified and that Lemos de Góes was “obviously stupid” or lacking reason. One commentator posted the following statement:
“I can't understand why a rational person would choose to die alongside their child rather than have a cesarean and save the life of themselves and their child.”
In reality, some mentally competent women are considered to be ‘irrational’ when they make choices about pregnancy and childbirth that go against medical advice (12). Responses to women’s dissident choices often rely on the notion that babies’ lives should be ranked higher than women’s wishes. However, most mothers are more invested in the health of their baby than the healthcare professionals providing their care. Even in cases of severe mental illness, maternity care decisions should be made in consultation with women and consider their previous wishes and intentions for the birth (13).
We must also consider what decisions are perceived as being irrational and consider the medical evidence when forcing mentally ill women to undergo caesarean sections. Regardless of legitimacy, the knowledge of women or clinical trials that go against regularly taught or favoured medical practice are often considered to be irrational or irrelevant in medical care (14) (15).
The consequences of forced treatment
In the United States, Rinat Dray’s obstetrician forced her to have a third caesarean section in May 2014. The obstetrician justified his actions on the grounds that the baby was at risk. Dray, however, was left with a fear of childbirth and a bladder injury following this involuntary caesarean section.
Indeed, serious physical and emotional consequences could follow situations where a woman feels coerced or is forced to comply with medical ‘advice.’ Some women who have felt out of control or unable to participate in the decision making process around their childbirth experience have experienced emotional problems following childbirth including post-traumatic stress disorder (PTSD) (16). Additionally, a history of psychopathology and current depression are mental health problems that have been identified as important risk factors for PTSD following childbirth (17).
The Saving Mothers’ Lives Report also highlights the risks of mental illness recurrence and suicide for mothers with previous mental illness (18). The report’s authors attribute maternal suicides primarily to substandard mental healthcare provision. However, the links between mental illness and PTSD following childbirth suggest that we consider involuntary medical interventions during pregnancy in relation to mental illness recurrence and suicide rates. It has also been noted that the long-term consequences of forced treatments on mentally ill patients require further investigation (19).
Caring for patients deemed mentally incompetent
Clearly, closer attention should be given to medical evidence, rational choice and outcomes when considering medical treatments including caesarean sections for mentally ill women.
Some mentally healthy women often comply or feel they must comply with medical advice to ensure their babies are healthy as the doctor is often seen to “know best” (20). However, women detained for mental health problems are not even given the option of non-compliance.
Therefore, all available evidence should be reviewed and patients should be treated with as much consideration and compassion as possible before involuntary procedures are mandated. This would involve patients being given as much bodily control as possible and being informed before procedures are performed. These elements of care were missing in at least one UK case.
Providing such personalized care may be increasingly difficult given recent budget cuts and staff shortages in NHS mental health services. However, we should also consider the potential costs to women, their babies and the health service as a result of physical and psychological harm caused by involuntary procedures.
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