The Ethics of Access: Who Is Offered a Cesarean Delivery, and Why?

Abstract

Much of the discourse in the bioethics literature on what is often called “cesarean delivery on maternal request” has focused on balancing respect for patient autonomy with attention to the short‐ and long‐term risks of this procedure to maternal and neonatal well‐being. And while there has been some analysis of the social and economic costs inherent in performing cesareans, much of the clinical and ethical analysis has concluded that, given the degree of risk to the mother and neonate from a primary or single repeat cesarean delivery, there is sufficient justification for pregnant women to request and obtain this procedure from obstetricians willing to meet such requests. However, these same analyses often caution that physicians should not offer these elective cesareans to all women, but only to those who initiate the request. This paper analyzes recommendations that do not promote universal access to these procedures and concludes that such a policy is ethically unjustifiable, as it treats women who do not inquire about such procedures differently. Depriving appropriate candidates—for example, healthy women who are good surgical candidates and desire only one or two children—of information about elective cesarean delivery is a form of undue influence on women's decision‐making.

Use of Shared Decision‐Making in Response to Maternal Request for Elective Cesarean Birth

“…These options may result in vaginal birth, cesarean birth, or operative vaginal birth. It has been suggested that the possibility of CDMR be discussed with all women just as the use of epidural analgesia is an available option for women for pain management in labor 18 . The ethical principle of justice requires that if CDMR is a possible option, then all women should know about this opportunity and not just those who are good candidates or who only desire one child.…”

“…The ethical principle of justice requires that if CDMR is a possible option, then all women should know about this opportunity and not just those who are good candidates or who only desire one child. This means that midwives and physicians should not wait for women to initiate the request but should give them information about cesarean birth along with the risks and benefits to women and newborns 18 . To prevent any suggestion that an elective cesarean birth is the best option, midwives and physicians need to be cautious in how they give this information.…”

Cesárea ¿Alternativa al parto vaginal? Consideraciones éticas

“…Existe en la literatura ciertos estudios que han sido capaces de medir como el personal sanitario puede ejercer un tipo de coerción médica sutil a mujeres en trabajo de parto para las realización de CSP; se ha recogido también evidencia donde las mujeres refieren haberse sentido presionadas por el proveedor de salud para que se realice un parto por cesarea (15). Esta coerción puede darse durante el trabajo de parto donde las mujeres pueden ser especialmente vulnerables a tales influencias, con argumentos que van desde el posible daño genital y sus complicaciones (desgarros perineales), dolor, tiempo prolongado del trabajo de parto, entre otros (16,17).…”

“…Estas decisiones también pueden ser empujadas por experiencias personales o familiares de violencia obstétrica propiciada por el personal sanitario. Por tanto, es responsabilidad del mismo personal educar a los pacientes sobre las diferentes alternativas y procedimientos sustentados en la práctica de medicina basada en la evidencia científica que tiene en cuenta no solo el accionar médico, sino, también las preferencias de los pacientes que deben ser reconocidas y consideradas cuidadosamente en la planificación de la atención y realización de un procedimiento quirúrgico (16).…”

Assistência ao parto na saúde suplementar

“…Esta abordagem é baseada na ideia de justiça (que todas tenham as mesmas oportunidades) e respeito a autonomia, para que cada paciente tome a sua decisão ponderada com as informações apresentadas. Nesta perspectiva, a cesárea eletiva sem indicação clínica deveria ser incorporada nas conversas com a gestantes no planejamento do parto, bem como a discussão das experiências que ela deseja ter ou evitar, do mesmo modo como ocorre com a oferta de analgesia57 .Cirurgias cesarianas devem ser realizadas apenas para melhorar o bem-estar e os aumentar os resultados favoráveis para mães e bebês. Como até o momento há evidências de que os benefícios não existem, cesarianas sem indicações médicas não são eticamente justificáveis"60 .…”