Ethicality of Child Birthing Practiced: Using Medically Justifiable Caesarean Sections

BY MAIYA PACLEB

ABOVE: Tools and method used to close a cesarean incision. From “Le guide des accoucheurs” [The guide for birth attendants] by Jacques Mesnard, 1753

The World Health Organization (WHO) has declared and defended that the cesarean section operation (CS) rate should not exceed 15% (1). WHO’s 15% rate explicitly includes those parents who are foreseen to require rapid and skilled medical intervention due to possible complications during childbirth (2). However, with a current rate of 31.9%, CSs are the most frequently performed surgical procedure in the United States (3). CSs are used for non-medical reasons, either due to practitioner misuse or misguided patient choice, leading to the current consistent and highly undesirable rate, despite the practice being condemned by the medical field (4). In this piece, I argue that non-medically justifiable or ‘excess’ CSs root from the technomedical model that has medicalized childbirth, instigating an unnecessary threat to parental and fetal health. To use CSs ethically, the medical field must shift from its technomedical model and implement humanistic methods to respect the parents’ child birthing experience and well-being, considering a CS only when it is medically justifiable to use one.

Historically, the technomedical model of medicine has depicted women’s bodies and the process of childbirth as a defective, dangerous, and untrustworthy bodily process (5). Rather than a natural function of the human female body, the historically-male dominated medical profession of obstetrics depicts childbirth as an unruly and uncontrollable event (6). The CS’s development and purpose is to be a technological medical intervention to combat the possible and immediate danger or complication for the birthing parent or child during delivery (7). Some argue that CSs empower a parent’s autonomy because it gives those with pre-determined birthing complications or traumatic birthing experiences a choice in receiving a CS to provide them with a more manageable outcome. Medicalizing childbirth causes obstetricians to employ their medical knowledge and institutional dominance to unreasonably use a CS without any medical implications, and rather for purposes of ease and convenience (e.g., when labor is taking longer than expected/desired) (8).

ABOVE: C-section performed in New Ulm, Minnesota. Photographed by Flip Schulke for the EPA, August 1974

One must consider that the birthing process poses an incidence where a physician is an active participant in the decision-making process and can use their expertise to convince the parent to choose a cesarean (2, 5). Further, the medical depiction of childbirth as uncontrollable and dangerous is ingrained into a society that has set standards on parents’ responsibility for their child’s outcome (9). The parents are conditioned to engage in measures deemed ‘best’ by the medical field to control their future child’s health during childbirth, directly constraining the birthing parent’s autonomous decision (6, 9). The influence of technomedical authority on societal standards and parental perspective of child birthing leads to medically unjustifiable CSs that are performed to make the birthing process more convenient and benefit the obstetrician’s efficiency of practice, rather than respecting the birthing parent’s autonomy.

Ideally, hospitals are developed systems that focus on risk-averse practices to improve patient safety. When dealing with childbirth, however, the overriding medicalized conceptions of this process push obstetricians to approach it as a dangerous process that requires medical intervention by its very nature. The medicalization of childbirth has led to the idea that CSs—because they are controlled by the physician—are safer for the patient, making it the medically superior birthing method (2). This perception has translated into future parents taking advantage of CSs because of the procedure’s convenience for planning as well as concerns about vaginal delivery complications (10). However, the CS should not be regarded as a safer birthing route. It is major abdominal surgery. For those who do not have the complications that mandate the use of an emergency CS, delivery through CS can dramatically increase the likelihood of both parental and fetal mortality. Studies have shown that any rate of CSs over 10% directly impacts parental and neonatal mortality and morbidity (11). To the birthing parent, a CS presents complications like the infection of the uterus, pelvis, and bladder, postpartum hemorrhage, or anesthetic reactions (7). There are also potential complications for the child when performing a CS, like an increased risk of respiratory problems, trouble breastfeeding, and a greater chance of being admitted to the neonatal intensive care unit (7, 10). For a procedure that is supposed to produce a safer and more effective birthing option, the CS poses significant dangers to the parent and child enduring the procedure and therefore should not be used unnecessarily.

Additionally, the CS sustains long-term reproductive detriments for parents like increasing the likeliness of complications in future pregnancies, as well as increasing the emotional difficulties of postpartum depression and a negative conception of childbirth (12). Using CSs for medically unjustifiable reasons prioritizes the short-term efficacy of childbirth rather than the birthing parent’s long-term health. The performance of excess CSs shows the deviation of the medical practice from the Hippocratic oath to do no harm and, therefore, choosing to act with maleficence. The objectification of patients and lack of understanding over the child birthing experience shows that physicians have forgotten that they are trying to produce the best possible outcome for the parent’s health as well as the child’s. Electing to use a CS with the lack of medical incidence means that the physician is actively choosing to threaten the parent’s health with various short and long-term dangers. Through the practice of excess CS, the medical field has lost its purpose of serving the patient and prioritizing their health, proving to be harmful to the child birthing experience and outcome.

The ethical practice of CSs requires alternative birthing care models that are safe and effective in promoting non-interventionist approaches that remove the tolerance for surgical interventions in the physiological birthing process. The medical field must step back from its natural tendency to think that the more predictable or more controllable outcome is the safer outcome (5). To do this, the medical field must rationalize CS with backing from education and research that can better inform the physician about the medical necessity of the procedure. It is essential to adopt the concept of childbirth as a normal physiological process that is often described by birthing parents as empowering when done without medical intervention (12). If obstetricians become more educated on this research, it would allow them to approach childbirth with a more positive perspective. Furthermore, educational emphasis should be given on preventing medical bias of low-income and minority parents, as they are at a disproportionate risk for experiencing more interventions during delivery and experiencing poorer birthing outcomes overall (11). Obstetricians must understand the culturally relevant societal stigmas that exist in vulnerable patients during childbirth to ensure a positive effect and outcome.

ABOVE: Iroquois woman giving birth in a standing position, which increases space in the pelvis and decreases the risk of fetal heart rate abnormalities. From “Histoire des accouchements chez tous les peuples”[History of Childbirth in All Peoples] by Gustave Joseph Witkowski, 1887

The parent and family must also be educated about the risks of CSs and the situations in which it is appropriate to use the delivery method to respect the patient’s autonomous choice in their child birthing experience. To adhere to the doctrine of informed consent for the procedure, the patients have the right to understand their diagnosis and prognosis, their proposed treatment and its risks and benefits, and their treatment options (5). Unless it is a dire medical emergency, the parent must be informed and consent to a CS if they can and decide without undue influence from others (5). With the implementation of the CS’s ethical practice, the physician must be educated to recognize childbirth’s natural process and not intervene without justifiable medical reasoning and the parent’s informed consent.

Reforming the patient-physician interaction to prioritize the relationship and partner-oriented decision making is essential to upholding the parent’s autonomy and justice during childbirth. Adopting a humanistic approach does more than produce a more pleasant labor experience, it is also the key to a positive birthing outcome (5). To further support physicians in performing ethical child birthing practices, wide-spread implementation of midwives should be adopted. This would allow for a consistent and knowledgeable advocate for the parent throughout the entire labor and delivery. Midwives receive education about the process of childbirth and non-interventional practices that can alleviate labor sensations. Midwife-attended births are associated with improved birthing outcomes, specifically for parents who are minorities or vulnerable, resulting in fewer cesarean interventions and improving parent satisfaction (11). With the presence of midwives, the parent has another resource that can keep the physician accountable and ensure that the use of a CS is medically necessary and ethically sound. Shifting the medical field’s perception of childbirth and establishing a humanistic standard of care with the support of midwives, the use of CS would be for medically necessary situations that prioritize the well-being of the parent.

ABOVE: Midwives attending to a new mother and child in Ancient Greece. From “Histoire des accouchements chez tous les peuples” [History ofChildbirth in All Peoples] by Gustave Joseph Witkowski, 1887

The use of excess or medically unnecessary CSs is unethical because it violates the birthing parent’s autonomy and poses a substantial threat to their health and well-being. The medical field must become more expansive in its scope of education with regard to the process of childbirth, and it must clarify the clinical gray area that permits medically unjustifiable CSs. The medical field should use a more humanistic approach to supporting parents during labor by promoting patient-physician collaboration and midwifery practices to combat the injustice it poses toward the parent and implement an ethical practice of CSs. Only when a CS is medically necessary should it be viewed as the most appropriate and ethically admissible decision.