I’m already on record as a strong supporter of a woman’s right to refuse a C-section:
Our right to bodily autonomy is one of the most important rights that we have. Simply put, a woman (or a man) has a right to refuse medical or surgical treatment, regardless of whether or not the refusal might lead to death. In the case of a pregnant woman, that means that she has an absolute right to refuse a C-section regardless of whether the C-section is life saving for either her or her unborn baby.
Therefore, I believe that Jennifer Goodall, the Florida mother who wanted to attempt a VBAC (vaginal birth after cesarean) after 3 C-sections has an absolute right to make an informed medical decision to refuse a repeat Cesarean. It doesn’t matter that the refusal might lead the death of her baby or even her own death.
Nonetheless, I am extremely disappointed that mainstream media outlets got the case wrong in two important ways. First they neglected the fact that the medical decision must be an INFORMED decision. Second, they presented faulty statistics on the safety of VBACs. Specifically, every article I have seen presented the statistics for a VBAC after one previous Cesarean, instead of the statistics for a the far more dangerous VBAC after 3 Cesareans that was being contemplated by Goodhall.
The piece in RH Reality Check is a case in point.
Editor-in-Chief Jodi Jacobson writes:
Goodall is now 41 weeks pregnant and has told her lawyers she is terrified to enter a hospital. Given this and the weight of medical evidence in Goodall’s favor regarding the safety of the delivery she wanted to have, it is unclear whether the hospital or the courts are considering “best medical judgment” and in whose interest they are acting.
What would we need to know to determine “best medical judgement”? We’d need to know the specific outcome rates that Goodall is facing. First, we’d need to know quite a bit about Goodall herself. What were the reasons for her previous C-sections? How many times (if any) had she tried and failed to have a vaginal birth? How old is she? How much does she weigh? How big were her previous babies and how big is this baby estimated to be? These factors have a DIRECT impact on the chance of success for Goodall’s attempt at vaginal birth, as well as the risk that her uterus might rupture, the risk that her baby might die, the risk that she might lose her uterus, and the risk that she herself might die.
We’d also need to know the specific statistics for women attempting a VBAC after 3 Cesareans. Those statistics differ appreciably from the statistics for women attempting a VBAC after 1 Cesarean. The chance of success is considerably lower after 3 C-sections that after one, and the chance of a fatal outcome is considerably higher.
But Jacobson pulls a bait and switch. She starts with the standard misinformation spread by VBAC activists:
Medical and public health bodies have long criticized the high rate of cesarean sections in the United States. The World Health Organization points out that at the current rate of 30 percent of all deliveries, cesarean sections in the United States far exceed what should normally be between 5 to 10 percent of all deliveries…
Wrong! Jacobson is apparently unaware that the WHO recommendation was WITHDRAWN 5 years ago, with the WHO acknowledging that there was NEVER any evidence to support that recommendation. Indeed, the average C-section rate in countries with low rates of perinatal and maternal mortality is 22%.
Jacobson continues by misrepresenting the position of every medical source she quotes (out of context). According to Jacobson:
ACOG agrees. “The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” ACOG President Richard N. Waldman said in a statement. “[ACOG's] VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.”
But that has NOTHING to do with Goodhall since she is a poor candidate for VBAC, not a good candidate.
Even more egregious:
“The risks associated with a vaginal delivery are lower than the risks associated with a C-section overall, as long as you can deliver the baby at a facility equipped to handle a C-section in case of emergency,” Roger W. Harms, an obstetrician at the Mayo Clinic in Rochester, Minnesota, and medical editor-in-chief of MayoClinic.com, said in a statement. And the recovery time is faster. Undergoing a cesarean surgery for the fourth time carries a 1 in 8 chance of major complications. In short, VBAC deliveries are safer for both the pregnant person and the fetus and lead to fewer complications.
But the obstetrician is NOT talking about women like Goodhall or situations like hers. He’s talking about women who have had one previous C-section NOT three, and it is utterly misleading for Jacobson to quote him out of context. Jacobson writes that these facts did not escape Goodall, without mentioning (and probably without understanding) that these fact DO NOT APPLY to Goodall.
While Jacobson quotes the risk of having 4th Cesarean, she utterly fails to mention (and probably doesn’t know) the risk of attempting a VBAC after 3 C-sections, the only valid comparison. The risk of a bad outcome in that setting is as high as 3.5% or more.
In other words, Jacobson’s entire piece is premised on the notion that VBAC is safer than elective repeat C-section and that Goodhall’s doctors are wrong in their assessment of the risk. But that’s simply false. There is no obstetrician or obstetric organization that would recommend a VBA3C as safe. So it is Goodall and her supporters who are WRONG in their assessment of the risk.
And that brings us back to Goodhall’s right to make an informed medical decision to refuse C-section regardless of the potentially deadly consequences. Goodall’s decision is not informed because it appears to be based on her understanding of the risks that apply to women who have had one previous C-section, not the much larger risks that apply SPECIFICALLY to her.
No one knows what Goodall would decide if she were in possession of accurate information and it is morally incumbent on those who are supporting her decision to opt for a vaginal birth to provide ACCURATE information so she can make an informed decision. The hospital, therefore, is caught between a rock and a hard place. Goodall claims (and probably believes) that she is making an informed decision, but her doctors know that she is making a decision based on erroneous information. In other words, her decision is anything but informed.
In the end, the issue was rendered moot when Goodall chose to go to a different hospital where someone agreed to honor her wishes. She labored without progress and ended up with the C-section that she had wanted to avoid, further emphasizing the fact that she was never a good candidate for a VBAC.
The issues raised in the Goodall case are extremely important, and therefore it is deeply unfortunate that they have been muddled by misinformation about the real risks involved. It is also deeply disappointing that journalists like Jacobson based their commentary on faulty medical information and the twisting and misrepresentation of the statements of obstetricians and obstetric organizations.
Jacobson may think that her piece advances the cause of reproductive freedom, but she more than most ought to understand that misrepresenting risks, taking quotes out of context, and misrepresenting professional organizations is wrong. It’s unethical when abortion opponents do it. It’s no better when proponents of reproductive freedom employ the same tactics. In her defense, Jacobson may have literally no idea that she is presenting inaccurate information, but as a journalist, she should have checked before repeating the propaganda of VBAC activists.