Maternal request caesareans and COVID-19: the virus does not diminish the importance of choice in childbirth

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections (MRCS) as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people's health and autonomy in childbirth and argue that this remains crucial during the current emergency. We consider some potential arguments-based on pregnant people's health and resource allocation-that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital's ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances.

Pre-post implementation survey of a multicomponent intervention to improve informed consent for caesarean section in Southern Malawi

OBJECTIVE

Surgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women's recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care.

DESIGN

Pre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge.

SETTING

Rural 150-bed mission hospital in Southern Malawi.

PARTICIPANTS

A total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation.

INTERVENTION

Based on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Individual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using χ² test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process.

RESULTS

The proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(β)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (β=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly.

CONCLUSION

Recollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care.

Medical Compromise and Its Limits: Religious Concerns and the Postmortem Caesarean Section in Nineteenth-Century Belgium

Situated on the intersection of medicine and religion, postmortem caesarean sections exposed ideological boundaries in nineteenth-century medicine. According to clerical guidelines circulating in Catholic territories, Catholics who had not necessarily received medical training had to perform operations on deceased women in the absence of medical staff. Most doctors, on the other hand, objected to surgical interventions by unqualified Catholics. This article uses the Belgian debates about the postmortem caesarean section as a means to investigate methods of negotiation between liberal and Catholic doctors. The article analyzes, first, how doctors incorporated religious concerns such as baptism in the medical profession. Second, physicians' strategies to come to a compromise in ideologically diverse settings are examined. Overall, this article casts light on the dynamics of medical debate in times of both ideological rapprochement and polarization.

Revisiting the Jewish Ethical Approach Toward Perimortem Cesarean Section in Light of Emerging Medical Evidence

BACKGROUND

Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus.

OBJECTIVES

To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized.

METHODS

Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother's vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother.

RESULTS

We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered.

CONCLUSIONS

The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible.

The importance of clinically and ethically fine-tuning decision-making about cesarean delivery

In obstetric practice, each pregnant woman presents with a composite of maternal and fetal characteristics that can alter the risk of significant harm without cesarean intervention. The hospital's availability of resources and the obstetrician's training, experience, and skill level can also alter the risk of significant harm without cesarean intervention. This paper proposes a clinical ethical framework that takes these clinical and organizational factors into account, to promote a deliberative rather than simplistic approach to decision-making and counseling about cesarean delivery. The result is a clinical ethical framework that should guide the obstetrician in fine-tuning his or her evidence-based, beneficence-based analysis of specific clinical and organizational factors that can affect the strength of the beneficence-based clinical judgment about cesarean delivery. We illustrate the clinical application of this framework for three common obstetric conditions: Category II fetal heart rate tracing, prior non-classical cesarean delivery, and breech presentation.

RESPONDING PROFESSIONALLY TO REQUESTS FOR CESAREAN DELIVERY

Patients' requests for non-indicated cesarean delivery challenge the professionalism of obstetricians. This is because physicians should not provide clinical management in the absence of an evidence-based indication for it. The ethics of responding professionally to requests for non-indicated cesarean delivery would appear to be simple: just say "No." This paper presents an ethically and clinically more nuanced approach, on the basis of the professional responsibility model of obstetric ethics, emphasizinga preventive ethics approach. Preventive ethics deploys the informed consent process to minimize ethical conflict in clinical practice. This process should focus on when to recommend against cesarean delivery - rather than simply saying no. There is no evidence of net clinical benefit for pregnant, fetal, and neonatal patients from non-indicated cesarean delivery. Obstetricians should therefore respond to such requests by recommending against cesarean delivery, recommending vaginal delivery, and explaining the evidence base for these recommendations.

Ethical issues in cesarean delivery

Cesarean delivery is the most common and important surgical intervention in obstetric practice. Ethics provides essential guidance to obstetricians for offering, recommending, recommending against, and performing cesarean delivery. This chapter provides an ethical framework based on the professional responsibility model of obstetric ethics. This framework is then used to address two especially ethically challenging clinical topics in cesarean delivery: patient-choice cesarean delivery and trial of labor after cesarean delivery. This chapter emphasizes a preventive ethics approach, designed to prevent ethical conflict in clinical practice. To achieve this goal, a preventive ethics approach uses the informed consent process to offer cesarean delivery as a medically reasonable alternative to vaginal delivery, to recommend cesarean delivery, and to recommend against cesarean delivery. The limited role of shared decision making is also described. The professional responsibility model of obstetric ethics guides this multi-faceted preventive ethics approach.

Electronic fetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence

Given evidence that cerebral palsy is not reduced by electronic fetal monitoring, Karin Nelson, Thomas Sartwelle, and Dwight Rouse ask why routine monitoring and related litigation continue to contribute to high rates of caesarean births

[Informed Consent in the Humanization of the Cesarean: A Preliminary Study]

The informed consent (IC) is a process based on dialogue between the professional and the patient in which he freely decides on possible interventions in their health. This is applicable to caesarean delivery and if it meets a number of conditions will help to improve the process of ″humanization″ of birth. The overall objective of this study is to analyze preliminarily in several hospitals in the Region of Murcia the IC in caesarean delivery. To this end, we have revised the documents of IC and we studied who, where, when and how the IC process is done. The results show that all hospitals are based on the same document, and although the documents take into account all the elements of a IC, do not indicate the date of their design or subsequent revisions. It does not contemplate the risks and complications that caesarean section can have on the newborn, mother, and mother-child relationship later. It is noted that the document of IC normally is delivers by gynecologist in the consultation, when intervention is programmed, although it are sometimes nurses, who after admission to the hospital give it to sign the patient. In urgent caesarean sections, there are some hospitals that in life-threatening situation, do not offer the document of IC to women. In others, it is offered hastily by the gynecologist or midwife. In conclusion, the IC is a process which used correctly, favors the relationship between women and health professionals in the intervention of cesarean section. Although this process and the documents of IC examined in our study, have presented many positive aspects, the humanization of caesarean could be increased improving with the preparation and updating of these documents and coordinating the various professionals.

[Caesarean section: History, epidemiology, and ethics to diminish its incidence]

Cesarean section has become the most performed surgery and it has been enhanced with the use of antibiotics and improvement in surgical techniques. The aim of this systematic review is to describe and clarify some historical and ethical characteristics of this surgery, pointing out some aspects about its epidemiological behavior, becoming a topic that should be treated globally, giving priority to the prevention and identification of factors that may increase the incidence rates. Today, this "epidemic" reported rates higher than fifty percent, so it is considered a worldwide public health problem. Consequently, in Mexico strategies aimed at its reduction have been implemented. However, sociocultural, economic, medicolegal and biomedical factors are aspects that may difficult this goal. As we decrease the percentage of cesarean section in nulliparous patients, we diminish the number of iterative cesarean and its associated complications. This aim must be achieved through the adherence to the guidelines which promote interest in monitoring and delivery care in health institutions of our country.

[Caesarean section in conflict with the patient's right to self-determination?]

Competent patients have the right to refuse treatment and healthcare workers should acknowledge their wishes. In the Netherlands there are conflicting (constitutional) rights of the foetus and of mentally ill patients. This paper describes the legal and ethical problems in the case of a mentally ill patient at 37 weeks of pregnancy who refused an obstetric examination. The patient refused to cooperate and have her physical condition and mental status examined. Her refusal endangered the life of the foetus. The obstetrician decided to perform a caesarean section, even if this would be in conflict with the patient's right to self-determination. In these cases no legal framework exists for providing the best medical care. New legislation should be drawn up to prevent similar cases occurring in the future. If a caesarean section is in conflict with a patient's right to self-determination, it should always be performed as a last resort.

Maternal request for caesarean section: an ethical consideration

Caesarean section (CS) is a method of delivering a baby through a surgical incision into the abdominal wall. Until recently in the UK, it was preserved as a procedure which was only carried out in certain circumstances. These included if the fetus lay in a breech position or was showing signs of distress leading to a requirement for rapid delivery. CS is perceived as a safe method of delivery due to the recommendation by the National Institute for Health and Care Excellence (NICE) in these situations. As a result, the opportunity for maternal request for CS arose, whereby the mother requests the operation despite no medical indication. There are risks associated with CS, as with all surgery, however, these risks in current and future pregnancies may not be fully understood by the mother. The ethics of exposing mothers to these risks, as well as performing surgery on what is otherwise a healthy patient, become entangled with the demand for patient choice, as well as the increasing financial strain on our healthcare system. The main question to be examined in this essay is whether it is ethical to allow women to choose a CS in the absence of obstetric indication, taking into account the increased risk to the mother and her future offspring in order to potentially decrease the risk to the current baby. Alongside a case report, this analysis will apply Beauchamp and Childress' four principles of biomedical ethics and an exploration of the scientific literature.

[Cesarean section through history]

According to historic documents, delivery by abdominal and uterine incision was already known to mankind at the beginning of the second millennium BC. This delivery method was eventually referred to as "Cesarean Section" because it was wrongfully attributed to the way by which Julius Caesar was born. The indications for cesarean sections performed in ancient cultures and to the end of the medieval period were mainly kings law, that mandated burial of the fetus separately from his mother, legal rights regarding inheritance of the father or religious motives mandating baptism of the newborn in order to ensure him eternal life in heaven. As from the second half of the 19th century AD, and with improvement in surgical techniques, as well as in the perioperative environment (asepsis, antibiotics, anaesthesia, blood transfusion, etc.), the obstetric outcome of cesarean sections was dramaticay improved, both in terms of maternal, as well as fetal, outcome. Hence, it became very prevalent throughout the world. The emergence of medico-legal medicine and medical ethics issues, have further contributed to the use of cesarean sections as the ultimate solution of every unusual delivery.

[Elective cesarean section on maternal request--what's new?]

Elective cesarean section on maternal request is a debatable issue with regard to all of its aspects. Current literature discusses topics such as its prevalence, risks and benefits in comparison with vaginal delivery, as well as ethical, judicial and economical questions regarding its execution. We reviewed the relevant literature from the last decade. There are no clear research findings which indicate that overall, elective cesarean section on maternal request is better, or alternatively, more perilous, in comparison with vaginal delivery, from both maternal and fetal or neonatal aspects. Due to its prevalence, there is a need for the obstetric establishment in Israel to make a formal statement regarding its attitude towards this issue.

Elective cesarean delivery on maternal request

IMPORTANCE

Some pregnant women prefer cesarean delivery and request it without maternal or fetal indication rather than proceeding with a plan for vaginal delivery.

OBJECTIVE

To review approaches for counseling women who ask for cesarean delivery without maternal or fetal indication (known as cesarean delivery on maternal request [CDMR]).

EVIDENCE REVIEW

An Agency for Healthcare Research and Quality evidence report of studies published after 1990, a 2006 National Institutes of Health state-of-the-science conference report, and published literature were examined.

FINDINGS

The prevalence of CDMR in the United States is not precisely known but probably occurs in less than 3% of all deliveries. Most practicing obstetricians have received requests for CDMR from patients. Compared with a plan for vaginal delivery, CDMR may be associated with lower rates of hemorrhage, maternal incontinence, and rare but serious neonatal outcomes. However, CDMR is associated with a higher risk of neonatal respiratory morbidity. Adverse consequences of CDMR may be manifested only in future pregnancies. Repeated cesarean deliveries have higher rates of operative complications, placental abnormalities such as placenta previa and accreta, and consequent gravid hysterectomy.

CONCLUSIONS AND RELEVANCE

There is no immediate expectation for CDMR to reduce the health risks of mothers or infants. Accordingly, counseling and decisions regarding CDMR should be made after considering a woman's full reproductive plans.

Women's perceptions of childbirth risk and place of birth

In the United States, clinical interventions such as epidurals, intravenous infusions, oxytocin, and intrauterine pressure catheters are used almost routinely in births in the hospital setting, despite evidence that the overutilization of such interventions likely plays a key role in increasing the need for cesarean section (CS).' In 2010, according to the U.S. Centers for Disease Control and Prevention, approximately 32.8 percent of births in the U.S. were by CS.2 The U.S. National Institutes of Health has reported that CS increases avoidable maternal and neonatal morbidity and mortality.3To increase understanding of what might motivate the overuse of CS in the U.S., we investigated the factors that influenced women's decision making around childbirth, because women's conscious and unconscious choices about giving birth could influence whether they would choose or allow delivery by CS. In this article, we report findings about women's decisions related to place of birth-at home or in a hospital. We found that choosing a place of birth was significant in how women in our study attempted to mitigate their perceptions of the risks of childbirth for themselves and their infant. Concern for the safety of the infant was a central, driving factor in the decisions women made about giving birth, and this concern heightened their perceptions of the risks of childbirth. Heightened perceptions of risk about the safety of the fetus during childbirth were found to affect women's ability to accurately assess the risk of using clinical interventions such as the time of admission, epidural anesthesia, oxytocin, or cesarean birth, which has important implications for clinical practice, prenatal education, perinatal research, medical decision making, and informed consent.

The effect of malpractice claims on the use of caesarean section

Malpractice fears are believed to influence various aspects of obstetrical practice. They seem to have contributed in small part to the rising primary caesarean section rate, but have also played a considerable role in the downtrend in vaginal birth after caesarean statistics. The rising vaginal birth after caesarean section rate between 1981 and 1995 was interrupted by a spate of lawsuits associated with broadened indications for vaginal birth after caesarean section in conjunction with requirements for immediate clinician availability. These factors dramatically reduced the availability of hospitals and clinicians willing to offer vaginal birth after caesarean section. This reversal, however, has not diminished the demand for vaginal birth after caesarean section from various stakeholders in the name of patient autonomy, clinician beneficence and optimal care. Nevertheless, as long as stringent requirements remain for clinician attendance during vaginal birth after caesarean section, and as long as the spectre of preventable error and the lingering dread of lawsuits retain their hold on obstetrical practice, caesarean section trends are unlikely to change.

On the cutting edge: ethical responsiveness to cesarean rates

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. Reproductive autonomy is at stake since a technological imperative undermines patients' ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates.

[Non-indicated cesarean section--does the "Golem" counteract?]

Cesarean section rate is steadily increasing and in Israel it has risen to 20%. MultipLe and different reasons have led to this phenomenon, among them are non-indicated cesarean sections. Although health care providers disagree whether this development is medically, ethically and publically justified, national associations allow it, while respecting those obstetricians who decline to do so. In Israel there are some hospitals which allow non-indicated cesarean sections, whereas others reject them. When discussing this issue with the patients, documentation is advised concerning the reasons for approval or rejection of the patients' request in order to avoid future complaints in the case of adverse outcome. Low risk vaginal delivery should be regarded as a natural process and not as a medical treatment and keeping balanced and reasonable decisions may help to contain the phenomenon and avoid a situation in which the "Golem" created by the medical system, counteracts.

Finding autonomy in birth

Over the last several years, as cesarean deliveries have grown increasingly common, there has been a great deal of public and professional interest in the phenomenon of women 'choosing' to deliver by cesarean section in the absence of any specific medical indication. The issue has sparked intense conversation, as it raises questions about the nature of autonomy in birth. Whereas mainstream bioethical discourse is used to associating autonomy with having a large array of choices, this conception of autonomy does not seem adequate to capture concerns and intuitions that have a strong grip outside this discourse. An empirical and conceptual exploration of how delivery decisions ought to be negotiated must be guided by a rich understanding of women's agency and its placement within a complicated set of cultural meanings and pressures surrounding birth. It is too early to be 'for' or 'against' women's access to cesarean delivery in the absence of traditional medical indications--and indeed, a simple pro- or con- position is never going to do justice to the subtlety of the issue. The right question is not whether women ought to be allowed to choose their delivery approach but, rather, taking the value of women's autonomy in decision-making around birth as a given, what sorts of guidelines, practices, and social conditions will best promote and protect women's full inclusion in a safe and positive birth process.

[Caesarean section--indication or choice?]

Currently, caesarean section is the most commonly indicated procedure. The proportion of caesarean deliveries continues to rise. And the spectrum of surgical indications has dramatically broadened. This contemplation is focused on the general outcome of surgical indications. The procedure is indicated on the basis of scientific evidence only in a limited manner, more often it is indicated on the basis of empiric results and significant subjective motivation of the participants - the indicating physician and pregnant patient. There is insufficient proof to conclusively demonstrate an increased or decreased risk of elective caesarean section as compared to a trial of labor. Thus making it ethical and professionally acceptable to perform a caesarean section based on the wish of a competent and well-informed pregnant woman.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Case study: an ethical dilemma involving a dying patient

Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. A 20-year-old, pregnant, Black Hispanic female presented to the Emergency Department (ED) in critical condition following a single-vehicle car accident. She exhibited signs and symptoms of internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and the fetus. She refused to accept blood or blood products and rejected the surgery as well. Her refusal was based on a fear of blood transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to respect the patient's autonomy and compromise standards of care or ignore the patient's wishes in an attempt to save her life. This paper presents the clinical case, identifies the ethical dilemma, and discusses virtue ethical theory and principles that apply to this situation.

The ethics of cesarean section on maternal request: a feminist critique of the American College of Obstetricians and Gynecologists' position on patient-choice surgery

In recent years, the medical establishment has been speaking in favor of women's autonomy in childbirth by advocating cesarean delivery on maternal request (CDMR). This paper offers to look at the ethical dimension of CDMR through a feminist critique of the medicalization of childbirth and its influence on present-day medical ethics. I claim that the medicalization of childbirth reflects a sexist bias with regard to conceptions of the body and needs to be used with caution when applied to women's reproductive health. I then use this perspective to critically analyze the position of the American College of Obstetricians and Gynecologists (ACOG) on the ethics of decision-making in patient-choice surgery. I claim that informed consent cannot be meaningfully exercised unless women are made aware of the sexist underpinnings of the medical model of childbirth and its influence on the ethical reasoning of the American College of Obstetricians and Gynecologists. I also express concern about the effects of normalizing patient-choice cesarean sections on the choices available to pregnant women using as examples the institutional rules on mandatory cesarean sections for women with a previous cesarean delivery or breech presentation. I conclude with a call for more research into the real cost of convenience in CDMR, particularly as our increasingly strained publicly funded healthcare system would greatly benefit from the de-medicalization of normal body functions rather than an increased dependence on costly surgical technology.

A reflective case study in the obstetric theatre: focusing on the principles of care involved

This article focuses on the principles of care involved in a reflective case study of a patient undergoing a caesarean section. Unplanned caesarean sections are often emotionally charged procedures. Often a mother has had no warning of a surgical intervention for the birth of her child and is understandably both distressed and frightened.

Patient Refusal of Emergency Cesarean Delivery

OBJECTIVE

To compare the attitudes of a large sample of obstetricians from eight European countries toward a competent woman's refusal to consent to an emergency cesarean delivery for acute fetal distress.

METHODS

Obstetricians' attitudes in response to a hypothetical clinical case were surveyed through an anonymous, self-administered questionnaire. The sample included 1,530 obstetricians (response rate 77%) from 105 maternity units (response rate 70%) in eight countries: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden and the United Kingdom.

RESULTS

In every country, the majority of obstetricians would keep trying to persuade the woman, telling her that failure to perform cesarean delivery might result in the fetus surviving with disability, or even that her own life might be endangered. In Spain, France, Italy, and, to a lesser extent, Germany and Luxembourg, a consistent proportion of physicians would seek a court order to protect fetal welfare or avoid possible legal liability or both. In the United Kingdom, Sweden, and Netherlands, several respondents (59%, 41%, and 37%, respectively) would accept the woman's decision and assist vaginal delivery. Only a small minority (from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without a court order.

CONCLUSION

Case law arising from a few countries (United States, Canada, and the United Kingdom) and professional guidelines favoring women's autonomy have not solved the underlying ethical conflict, and in Europe acceptance of a woman's right to refuse cesarean delivery, at least in emergency situations, is not uniform. Differing attitudes between obstetricians from the eight countries may reflect diverse legal and ethical environments.

LEVEL OF EVIDENCE

III.

The ethics of cesarean section by choice

In responding to patient requests for cesarean section, physicians must consider ethical principles. Obstetricians have autonomy and beneficence-based obligations to the mother, and the mother and the obstetrician have beneficence-based obligations to the fetus. Maternal autonomy is usually accepted as the most compelling ethical canon. However, the physician has a right to refuse requests. Thus, when a patient requests surgery, the physician may attempt to dissuade her and failing that either acquiesce or, feeling that professional conscience would not allow him/her to honor that request, refuse. Which choice is made should reflect the provider's believe about the strength of the supporting data. Given the need to recognize patient autonomy, to respect patient values even as one tries to motivate patients to work toward the highest health values, and to acknowledge women's primacy as fetal champions, a physician should be loathe to refuse unless the data regarding cesarean section by choice are wholly tilted away from maternal-child interests. If the data are in the realm of equipoise, even if not at the tipping point, discussing options, attempting to dissuade patients but ultimately acquiescing to their judgment would not be incompatible with obstetrical ethics.

Cesarean section by choice: Constructing a reproductive rights framework for the debate

The question of cesarean section by choice (that is, cesarean delivery in the absence of medical indications) has been hotly debated by the obstetrical profession in recent years. The debate has focused around questions of risks and benefits, and has revolved around questions of obstetrical practice. In this paper, the question will be framed in a reproductive rights context. How does the phenomenon of CSBC (cesarean section by choice) impact women's empowerment? Which reproductive rights might be affected by this question, and what policies are related to its use? FIGO's 1998 statement "Ethical Aspects regarding Cesarean Delivery for Non-Medical Reasons" is revisited, and, in light of these considerations, its contents are endorsed once again.