At the November 2019 Quarterly meeting of the California Medical Board of California as agenda item (11-B) was formally proposing that the Board carry a bill that would make it illegal for Ca LMs to provide care VBAC care.
This made me so angry I wanted to cry, as we already spent nearly 4 years (2002 to 2006) fighting with the Md Bd’s staff, CMA, ACOG, and representatives of CAM, CCM and C-Fam.
It was only through Divine Interventions (the only possible explanation given the massive resources stacked against us) that in 2005 we finally worked out a mutually satisfaction “VBAC Compromise” with the help of Dr. Richard Fantozzi (Board president), two ACOG representatives, and Md Bd members on the Midwifery Task Force in addition to CAM & CCM.
It breaks my heart to be have all the stripped out from under us by AB 1308 and now to have ACOG working aggressively to drag midwifery back into another fighting war over VBAC.
So I am reposting this as history of the war we already fought and won and now it seems we are going to have to start all over again.
faith gibson, LM ^O^
DRAFT Version
(so far not able to locate the final version)
California College of Midwives
Palo Alto, CA 94303
650 / 328-8491
Medical Board of California
1426 Howe Avenue
Sacramento, CA
July 29th 2005
Testimony: Continuation of Regulatory Hearing July 29th, 2005 // Oppose Midwifery Standard of Care Regulation as Currently Proposed (i.e. ACOG’s version)
The consensus belief of the California College of Midwives et al, is that the original regulatory proposal (July 2002) not only fulfills the legislative mandate of SB 1950, but is the superior choice.
That language read:
(b) The standard of care shall be that of the California community of licensed midwives.
Authority cited: Section 2018 and 2507(f) Business and Professions Code Reference: Section 2507.”
Editor’s Note — there are a few places in this draft that are still unfinished, but so far i haven’t been able to find the final draft submitted to the MBC.
Overview & Legislative History
SB 1950 directed the MBC
“to adopt regulations defining … the appropriate standard of care for the practice of (licensed) midwifery”.
According to conversations with Senator Figueroa, the bill’s author, before and after the passage of SB 1950, accompanied by letters from her to the MBC (copy enclosed) the legislative intent for this statute was to establish that the appropriate criteria for California licensed midwives was a midwifery-based standard and not an obstetrical standard.
This has become an issue because the MBC staff referred quality of care issues to obstetricians for expert review. The results are consistently negative assessments of the licensed midwife’s care, which were then became the foundation for disciplinary actions against the LM. However, obstetricians are not educated, trained or experienced in the discipline of midwifery, especially as provided in a community-based setting, and therefore do not have the knowledge base to define the appropriate ‘standard of care’ for licensed midwives.
The consensus of scientific research on maternal-infant outcome statistics for community-based midwifery care as currently practiced by California LMs is equal in perinatal mortality to those of hospital-based obstetrics.
However, midwifery care resulted in a three to five-fold reduction in medical interventions and Cesarean sections, thus it cannot be claimed that obstetrical review is more appropriate or more ‘expert’ for the non-medical discipline of midwifery . [copy enclosed of BMJ 6/18/05 research on CPM-attended home birth]
Midwives are experts in midwifery and obstetricians are not. SB 1950 (2002, Senator Liz Figueroa) was a legislative remedy mandating that an appropriate midwifery standard should be identified in regulation and that midwifery standards, in conjunction with expert review by licensed midwives (but not obstetricians), should be referenced whenever the Board was contemplating or pursuing disciplinary action against a midwife licentiate.
The legislative authority for the standard of care regulation (SB 1950) does not refer to, or authorize any change in the licensed midwife’s scope of practice. In fact, the words “scope of practice” do not appear anywhere in the language of SB 1950. Any desire by the American College of Obstetricians and Gynecologists (ACOG) to re-define the scope of practice under the LMPA of 1993 should be addressed to the Legislature. Restrictions to the licensed midwife’s scope of practice cannot lawfully be incorporated via the backdoor, through an unauthorized rewriting of the midwifery standard of care by ACOG as subsequently proposed by the MBC.
According to the original language of the LMPA of 1993 and the 2000 amendment (SB 1479, 2000, by Senator Figueroa), midwifery is a distinctly defined profession separate from both the practice of medicine and the practice of nursing. Distinct qualities of community-based midwifery practice are most clearly identified in the intent language of SB 1479, Sec. 4, particularly subsection “c”:
~ SB 1479 (2000) THE LEGISLATURE FINDS AND DECLARES THAT:
(a) Childbirth is a normal process of the human body and not a disease.
(b) Every woman has a right to choose her birth setting from the full range of safe options available in her community.
(c) The midwifery model of care emphasizes a commitment to
-
- informed choice
- continuity of individualized care
- sensitivity to the emotional and spiritual aspects of childbearing
and
-
- includes monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
- providing the mother with individualized education, counseling, prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
- minimizing technological interventions
- identifying and referring women who require obstetrical attention
(d) Numerous studies have associated professional midwifery care with safety, good outcomes, and cost-effectiveness in the United States and in other countries. California studies suggest that low-risk women who choose a natural childbirth approach in an out-of-hospital setting will experience as low a perinatal mortality as low-risk women who choose a hospital birth under management of an obstetrician, including unfavorable results for transfer from the home to the hospital.
(e) The midwifery model of care is an important option within comprehensive health care for women and their families and should be a choice made available to all women who are appropriate for and interested in home birth.
Adoption of a Midwifery Standard of Care that is consent with its authorizing legislation (SB 1950) and the the Licensed Midwifery Practice Act of 1993
It is the understanding of the midwifery community, specifically confirmed by Senator Figueroa’s office, that the Medical Board has only been mandated by SB 1950 to “adopt” (but not to draft) the standard defining the appropriate practice of midwifery. A formally documented (i.e., written) midwifery standard of care describes a retrospective process that records ‘standardized’ care as it is currently provided by licensed midwives. This definition would be in conjunction with scientific definitions of technically competent, ‘state of the art’ care.
Defining the appropriate practice of community-based midwifery, in light of the legislative language and intent of the LMPA and its two amendments (SB 1479 and SB 1950), would be a process entered into by those educated in, licensed in and experienced in the practice of midwifery in the state of California.
This process also takes into account that ‘standard practices’ would be consistent with science-based definitions of competent care, as can be identified from textbooks, other educational sources, scientific research as reported in peer-review journals and the testimony of ‘customary practices’ by practicing midwives.
California College of Midwives’ Conclusion and Recommendations
It is the official position of the membership of the California College of Midwives (CCM) that the specific language of the CCM Standard of Care (sections 1 & 2 — copyrighted Oct 2004) as originally “referenced” in the MBC proposed regulation (Nov 2004 and February 2005) and the general language of the MANA standards would both fulfill the intention and legal necessities of SB 1950.
However, we believe that the original (July 2002) regulatory proposal not only fulfills the legislative mandate of SB 1950, but is the superior choice.
That language reads:
(b) The standard of care shall be that of the California community of licensed midwives.
Authority cited: Section 2018 and 2507 (f) Business and Professions Code Reference: Section 2507.”
Furthermore California licensed midwives, uniformly and totally, reject ACOG’s unauthorized re-writing of the California Collage of Midwives Standard of Care. At the most basic level, it is copyright violation., this unauthorized version is falsely claimed to be a mere ‘modification’ of the former language proposed at the November 2004 and February 2005 regulatory hearing.
In addition, we strenuously object to this regulatory hearing being characterized as a “continuation” of the previous hearings. The changes proposed are not merely ‘substantive’ but in fact are massive and a complete break with all that has gone before.
Therefore, we believe that it is inappropriate for the OAL to proceed with any further review of this regulation as proposed.
In addition, we also believe that the ACOG authored so-called midwifery standard fails on all the formal parameters for regulatory conformation as noted below:
Lack of Authority: The appropriate standard of care for the practice of licensed midwifery would be a midwifery standard as designated by the California community of midwives. Therefore we believe that the MBC is not authorized to draft language separate from the California community of midwives.
Necessity:
Duplication:
Etc, etc, etc………..Unfinished
The Purpose and Goal of the LMPA
The purpose and goal of the LMPA was to make professional maternity services legally available to essentially healthy childbearing women who, for personal, philosophical, cultural, economic or religious reasons, have chosen non-obstetrical pregnancy and childbirth care.
Explicit and implicit in the licensing statue and its amendments is the acknowledgment that the safety of out-of-hospital midwifery care for healthy women with normal pregnancies, which is to take place in conjunction with access to appropriate obstetrical services for complications. {1} This form of midwifery care is statistically equal to hospital-based obstetrical care for the low and moderate risk population, while unattended childbirth {2}, especially in women with no prenatal care of orders-of-magnitude risker than either obstetrician or midwife-attended birth.
{1} Alternative in Childbirth, Peter Schlenzka, 1999;
{2} Study #1 Perinatal & maternal mortality in a religious group avoiding obstetric care – Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31:
(Note: Out of 344 births, the unattended birth group 6 maternal deaths and 21 perinatal losses. The baseline mortality rate for unattended childbirth was one maternal death per 57 mothers or MMR of 872 per 100,000 live births (92 times higher than Indiana’s MMR for the same period) and one perinatal death for every 16 births or PNM rate of approximately 45 per 1,000. {see addition note at the end of this document for further details}
When the statistical model is extended to include the downstream adverse events and complications generated by the high rate of cesarean delivery associated with the medical model (approximately 27%), the physiological management is identified as significantly safer for healthy women than the medicalization of normal childbirth in an essentially healthy childbirth population (70-85% of all childbearing women).
However perinatal mortality statistics for unattended birth (which for many women is the only acceptable or available alternative to obstetrical care) has been shown by researcher to be up to 30 times higher than the care of even lay (i.e., non-professional) midwives (3 out of a 1,000 vs. 60 to 120).
In the last few years, as women with a certain pregnancy status are increasingly refused non-surgical obstetrical care (i.e., only care offered by obstetricians was Cesarean delivery), a grass-roots movement promoting unattended childbirth has arisen. Members of this movement refer to themselves as “UCers” for “Unattended Childbirth” In more recent years a number of Internet web sites have been developed that circulate ‘how-to’ instructions and streaming video of unattended births. However, it is clear from statistical resources, as well as the common experience of professional midwives, that mothers and babies are always safer with a professional in attendance than they would be without such a safety net.
While it runs counter to the way most American think of the subject and may even offend some members of the medical profession, professional midwife-attended birth in any setting is safer for healthy women than either obstetrical intervention or unattended birth. This fact is consistent with the background and legislative intent of the 1993 LMPA, whose purpose was to reduce the number of women who were unable to find appropriate care and thus might instead choose unattended childbirth.
Standards and Guidelines vs. Scope of Practice
Midwifery standards and guidelines provide protective guidance to the practitioner by delineating minimum expectations. The goal of this official information is to provide safe, “state of the art” care to consumers, protect individual clients from substandard care and protect the practitioner from litigation and accusation of unprofessional conduct that may arise out of a lack of consensus from within the profession.
Standards of practice are not the same as a scope of practice, nor are standards interchangeable with “scope of practice”. The scope of practice for licensed midwives is fixed by statute, which authorizes licensed midwives to provide care for normal childbirth, prohibits the use of “artificial, forcible or mechanical means” and requires that significant complications be immediately referred to a physician.
SB 1950 mandate to the MBC does not authorized any re-definition of the scope of practice for California LMs.
The LMPA states that the license to practice midwife does not authorize the holder to practice medicine or surgery. In addition to this provision in the LMPA, other sections of Chapter five of the B&P code also define the unauthorized practice of medicine as any unauthorized use of drugs and surgical instruments. These limitations and prohibitions would prohibit podalic version (internally turning a head down baby into a breech and then extracting the baby by the feet). It also prohibits the use of pharmaceutical drugs to induce or accelerate labor and/or the use of forceps or vacuum extraction to facilitate delivery.
The Licensed Midwives Practice Act of 1993 specifically authorizes the LM to attend cases of ‘normal birth’. While it does not describe or otherwise define ‘normal birth’, the LMPA does define the obverse — abnormal birth would be parturition (i.e. intrapartum period of labor and birth) in which there is a need to use “artificial, forcible or mechanical means“.
This specific language tracks back to the midwifery licensing law passed by the municipality of Rochester, New York, in 1896. This language defining prohibited activities was then used in the 1917 non-nurse midwifery provision of the California Medical Practices Act, the 1974 California nurse-midwifery licensing act and most recently in the 1993 LMPA.
The message from physicians (who were the framers of these statutes) was clear and broke down along classic gender lines — boy-toys versus girl-toys. The girl-midwives got spontaneous, ‘nothing-to-do-but-stand-by-and-watch-the-baby-come-out’ normal, non-medical childbirth and the boy-doctors got to use the fun toys – drugs and forceps. The 1917 midwifery certification provision of the MPA clearly states in its introductory paragraph that the purpose of midwifery provision is to provide penalties for midwives who stray into the “boy-toy” category by using drugs or instruments.
The classical definition of ‘normal’ recognizes that normal equates with normal spontaneous biology (i.e., not artificially stimulated) that is not pathological in its progress or its effect. It refers to spontaneous physiological processes that are characteristic of healthy reproductive biology of childbearing women and can reasonably be expected to lead to normal or spontaneous conclusions.
Functional Definition of Normal and the Issue of Perceived Risk
Normal is also associated with a state of irreducible risk that is, all other responses add, rather than subtract, risk.
Normal childbirth may be distilled into the following definition (CCM Standard of Care:
“Normal as used by the LMPA would refer to a pregnancy that naturally advances to term with a live, growth-appropriate fetus/fetuses in a vertical lie, and culminating with a spontaneous labor that can reasonably be expected to lead to a spontaneous live birth of a viable neonate, with conservation of the health and wellbeing of both mother and baby.”
{{ Editor’s Note: Dr Pat Chase, an MD consultant assigned by the MBC in 2004-2005 to compile a midwifery standard of care (per SB 1950) for the Medical Board remarked in a letter that the ” …. definition of “normal birth” in the California College of Midwives 2004 Standard of Care and Practice Guidelines was the most complete and easy-to-understand definition of normal birth that she’d ever encountered”. }}
This simple definition of “normal birth” is generally accepted by midwives around the world is applied to a healthy mother who is pregnant with a fetus/fetuses in a longitudinal lie (either vertex or breech) with spontaneous onset of labor after 37 weeks of pregnancy and progresses in a timely manner through out the various stages and phases associated with physiological parturition while the mother and baby are able to remain adequately hydrated and free of pathological distress.
Risk vs. Complication: The Licensed Midwifery Practice Act of 1993 prohibits providing care to childbearing women with a medical complication. However, the LMPA is silent about the topic of risk, which is a mathematical equation for the future possibility of a complication.
Risk is an elevated possibility that a specific accident, illness or complication will occur. It is not a probability — merely a possibility — and that possibility is usually a small fraction expressed as ‘one out of a hundred’ or whatever is accurate for the particular topic.
This example would mean that for every one person that had the complication, 99 would not have any negative consequence. For instance, a history of heart disease in the family or a high cholesterol level is not the same as having a heart attack. Most people with either of those conditions never have a heart attack. Few people would be willing to have a surgical procedure done on their heart ‘prophylactically’, since the actual performance of surgery exposes one to the high level of immediate risk for surgical complications, as well as pain, expense and the possibility of having long-term disability or the need for additional surgeries to correct problems resulting from the initial surgery.
ACOG’s Proposal to Redefine the Midwife’s ‘Scope of Practice’
ACOG’s proposal for a midwifery standard of care advances the notion that a small specific list of risks, ones proposed by them, would henceforth constitute “abnormal” cases of childbirth.
They suggest in their letter to the MBC that should the Board define these situations as outside the scope of practice for LMs via the currently pending regulation, any midwife who subsequently provided care to women with these pregnancy circumstances would be considered guilty of an ‘illegal practice of medicine’. We refute this assertion based on three principles.
First Point: The plain reading of the LMPA does not support this idea. An uncomplicated pregnancy and spontaneously progressing normal labor with no identified, present-tense complication would be ‘normal’ in the meaning of the LMPA, with its high propensity to conclude with a normal birth, absent any intervening complication, in which case the requirement to refer to a physician would supersede.
For example, a 1999 ruling by the Office of Administrative Hearings judge in the Alison Osborn case in confirmed that a licensed midwife may provide care to a mother with a breech baby who has declined Cesarean delivery and withdrawn from obstetrical care, as long as the midwife obtains appropriate informed consent/informed refusal and the LM has appropriate additional training and specific protocols relative to the circumstances (copy OAL ruling enclosed).
Another document demonstrating this is a letter from a MBC investigator dated Jan 2004 to an LM regarding an investigated conducted by the Medical Board into her care of a planned home birth client who transferred to the hospital during labor. According to the text of the letter:
“the expert who reviewed the case concluded that there was no departure from the midwifery standard or care in regard to your handling of Ms. ——-‘s VBAC.”
“The investigation related to [client name]. has been closed. We would like to thank you for your cooperation with the investigation.” (copy MBC letter attached).
Second point: Any desire by organized medicine to modify the scope of practice for midwives would require a legislative remedy, which would provide for legislative hearings, testimony and letters and other forms of public participation, so as to guard against any self-serving limitation being put on midwifery practice by ACOG that were not consistent with the best interest of the public.
Third Point: It is not appropriate for either ACOG or the MBC to redefine the ‘illegal’ practice of medicine in regard to midwifery, as the MPA and the LMPA both provide a black-letter definitions. That definition does not extend to, or incorporate, the category of mere mathematical ‘risk’, but instead requires a specific action relative to unauthorized medical or surgical activities or critical omissions.
Section 2052 of the MPA prohibits unlicensed persons from diagnosing, treating, operating upon or prescribing drugs, prohibits the use of ionizing radiation and the severing or penetrating human tissue (beyond the severing of the umbilical cord).
The LMPA prohibits the furthering of childbirth by any “artificial, forcible or mechanical means” and it also notes an obligation to refer complications “immediately” to a physician, which means that the law prohibiting the unauthorized practice of medicine can be violated by omission (failure to refer) as well as commission (use of drugs and surgical instruments).
Neither legislative act mentions a scheme for parsing relative risks into specific categories and then requiring additional actions based on such categories.
ACOG asserts that neither the mother nor the midwife may “waive” what they define as the ‘restrictions’ of the LMPA against the unauthorized practice of medicine. The example they use is the notion that a chiropractor could not, under the theory of informed consent or informed ‘refusal’, perform a Cesarean section at the request of a patient.
We absolutely agree that performance of a CS would indeed be an illegal practice of medicine.
However we also absolutely disagree providing normal non-medical childbirth services to a healthy woman with a normal pregnancy who has an identified risk factor (and fully informed patient consent) would be defined as an illegal practice of medicine. This is premised on the notion that a childbearing woman with a risk factor has no right to refuse unwanted prophylactic medical intervention and thus qualifying the care provided by a Ca LM as an illegal practice of medicine.
Midwives performing surgery is obviously illegal (and had nothing to do with implementation of SB 1950), while midwifery providing normal midwifery care to an essentially healthy consenting adult woman with no signs or symptoms of a current complication is NOT equivalent to illegally performing surgery or illegally practicing medicine.
For healthy women, medical and surgical interventions increase the complication rate. In the US, deaths from iatrogenic causes is one of the top five causes of fatality, exceeding the annual deaths from breast cancer, all house fires and all plane crashes.
Once the mother-to-be has declined obstetrical treatment, nothing in the LMPA prevents the LM from providing physiological midwifery care to this mother, as physiological care is, by its very nature, non-medical and thus it is not an “illegal” practice of medicine (unlike the earlier example of performing a CS). Physiological care is a safety net (the mother’s ‘shield) which should not be interpreted as a ‘medical procedure’, thus turning it into a sword.
VBAC, breech, and twin pregnancies all have an identified risk factors associated with them, but none of these situations requires the administration of drugs or medical procedures to preserve the health of either mother or baby. These states do not require any medical treatments to initiate progressive labor, nor is surgical delivery mechanically necessary, unless a specific complication actually occurs.
In most parts of the world, healthy women with these pregnancies, who receive appropriate prenatal care, have their labors physiologically managed and have spontaneous vaginal births, with outcomes for both mom and baby equal to those of a first pregnancy. A several large recent studies of the VBAC risk to the neonate show that planning a natural labor in post cesarean mothers to results in the same neonatal mortality as first-time mothers, while the “risk-reduction” choice of Cesarean actually add the above list of 15 additional complications without improving outcomes for the baby.
The big issue in the United States is that physiological management is not an option offered by the obstetrical profession. In America, obstetricians routinely perform cesarean surgery in all of these cases, a situation brought about by liability concerns and physician preference. By its own reports, the science of obstetrics was not designed nor structured to promote normal birth or reduce the incidence of medicated labors or surgical interventions in normal births. It was and is organized around detecting and treating the rare complications, which makes its practitioners, who are trained as surgeons, ill-suited to provide routine care to health women, a fact attested to by a 27% Cesarean section rate.
The numbers of Cesareans needed to be performed to prevent a single adverse event (i.e., NNT or ‘numbers needed to treat’) for the above situations is in the hundreds (ObGynNews stats is 1:500. This meaning the other 499 Cesareans had no benefit to either mother or baby, but did expose the childbearing women to iatrogenic complications during the current birth and exposed both mother and baby to post-cesarean complications in future pregnancies. Given the long list of dramatically increased dangers associated with surgical delivery, not to mention pain and disability of surgical delivery, a healthy, mentally-competent woman has the constitutional right to decline obstetrical treatments that are not wanted, medically necessary and which increase the likelihood of serious complications.
Nothing in the plain reading of the LMPA would lead anyone to assume that an ‘informed refusal’ by a mentally competent woman of unwanted medical intervention would prevent her from seeking out the physiologically-based care of a professional midwife or prevent the midwife from providing such care as it was consistent with the parameters of the LMPA – no artificial, forcible or mechanical means, while any complications would be referred immediately referred to a physician. I have also provided a list of the 51 (out of 55) certified nurse and licensed midwives from three states (California, New Mexico and Florida) who had malpractice coverage with a professional liability consortium who stated, in their application to join the group policy, that they routinely attended VBAC labors in out-of-hospital settings.
Also included in the enclosures is a document produced in Australia that tracks the irreducible or “native” risks of childbearing and compares those numbers to mortality or morbidity associated with normal labor and vaginal birth, Cesarean delivery, VBAC and Cesarean risks that accrues during subsequent pregnancies, labors and VBAC.
Its conclusion is that:
“The likelihood of a fatal outcome from a uterine rupture is no higher than the general incidence of death in all births and is lower than that for Cesarean birth.”
When is a Risk a RISK?
While the 3 categories listed by ACOG – VBAC, breech and twin pregnancies — are ‘dramatic’ and easy to understand examples of risk, the real issue is the right of childbearing families with normal pregnancies to decline unwanted medical care when there is any possibility of an adverse event, which is basically most of the time.
For example, Christian Scientist patients legally (and consistently) decline all prenatal lab work, genetic testing and ultrasound examinations. This exposes them and their unborn or newborn babies to the risks associated with undiagnosed anemia, a high white cell count, low platelet levels, an RH negative baby with a positive titer, a misdated pregnancy or one with potentially-fatal congenital anomalies or that is a breech or twin pregnancy.
Other women refuse diabetic screening (risking a big baby with shoulder dystocia), some families live unusually far from a hospital or up in the hills in hard to reach places or go into labor during a snow storm. Many women refuse group-B testing or after testing positive for GBS refuse prophylactic antibiotics. Most clients of midwives decline sequential ultrasounds in the last trimester, risking the possibility of undiagnosed twins, breech or big baby.
Some women have their water break before active labor, have a slow (but not abnormal) labors or are carrying a bigger than average baby who is at added risk for shoulder dystocia and excessive maternal bleeding after delivery. All these risks can result in a perinatal death or disability, at rates approximately the same as the VBAC risk. What is the qualitative legal difference between the risks associated with VBAC, breech and twin pregnancies, which ACOG would like to have designated as an illegal practice of medicine, and all the other garden-variety types of ‘moderate’ risks that follow the informed refusal of medicalization by healthy, mentally competent childbearing women?
ACOG’s own policy manual [ ACOG Compendium, p. 160; No 214, April 1999], acknowledges the principles of body integrity for women in regard to reproductive biology. In a position statement on conflicts in the maternal-fetal relationship and patient choice, it states that
“Medicine aims to foster the greatest benefit with the least risk. Risks and benefits however may be valued differently by pregnant women and the obstetrician…”
In interactions with a woman who appears to resist following medical advise, it counsels that
“ the obstetrician must keep in mind that medical knowledge has limitations and medical judgment is fallible. … Existing methods for the detection of non-reassuring fetal status are not always reliable indicators of poor outcomes and there is often insufficient evidence for risk determination or risk-benefit evaluation for the fetus.”
It goes on to say:
“the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes, regardless of the consequences.”
In general ACOG already acknowledges the right of mentally competent women, under the theory of informed refusal, to refuse medical treatments even when the decline of these interventions is perceived by medical authorities to disadvantage the fetus. According to an appellate court decision in an ACOG case, the bar for over-riding the autonomy of the mentally competent women via court-ordered intervention is to be reserved for “extremely rare and truly unusual circumstances”.
The ethical principle here, which is predicated on both the autonomy of the childbearing unit and the fallibility of medical science and its historically paternalistic relationship to the topic, it that risk reduction must always be implemented with the consent of the parents. Otherwise we open the door for special interest groups to force all manner of competent adults into prophylactic medical treatment and drug regimes based on someone else’s idea of “what is good for us”.
(Note: The above language of “extremely rare and truly unusual” was taken from an appellate court decision (DC Appeals Court 1991-quoted Gabbe’s Obstetrics, Ch 42 – legal issues) in an ACOG case that confirmed the right of mentally competent women to decline unwanted medical or surgical interventions even if there is concern about the well-being of the fetus).