The Baby Friendly Hospital Initiative is coercive and violates women’s medical autonomy

coercion

The American College of Obstetrician Gynecologists Committee on Ethics recently issued an important position paper entitled Refusal of Medically Recommended Treatment During Pregnancy. Their most important conclusion is this:

Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.

I agree completely, but I have one question. When will ACOG condemn the Baby Friendly Hospital Initiative for its coercive approach to breastfeeding?

The Baby Friendly Hospital Initiative represents a deliberate and fundamental assault on women’s bodily autonomy.

The BFHI — whose cornerstones include forced lectures on the benefits of breastfeeding, prohibitions on formula supplementation and pacifiers, and mandated 24/7 rooming in of babies  — is profoundly (and proudly) coercive, violating patient rights, respect for women’s autonomy, power differentials and gender equality.

The ACOG opinion brilliantly lays out the issues and principles at stake. These issues and principles apply equally to breastfeeding, another medically recommended treatment. Among them:

Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.

Breastfeeding is also not an exception to the principle that a decisionally capable patient has the right to refuse to medical recommendations. Therefore her decision should be respected.

The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge… Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.

The use of coercion to promote breastfeeding is also ethically impermissible as well as medically inadvisable because of the realities of prognostic uncertainty as well as the limitations to the benefits of exclusive breastfeeding. Lactation consultants, nurses and physicians should be discouraged in the strongest possible terms from use of duress, manipulation or coercion to motivate a woman to breastfeed.

Forced lectures on the benefits of breastfeeding, forced visits by lactation consultants, and prohibition of formula supplementation and pacifiers represent both coercion and duress. The closing of well baby nurseries, justified by the desire to promote breastfeeding, represents duress, manipulation and blatant coercion.

Eliciting the patient’s reasoning, lived experience, and values is critically important when engaging with a pregnant woman who refuses an intervention that the obstetrician–gynecologist judges to be medically indicated for her well-being, her fetus’s well-being, or both…

Respect for a patient’s reasoning, lived experience and values is critical to engaging with a woman who cannot or does not want to breastfeed. When a woman tells you that she does not want to breastfeed, that decision should be respected, not viewed as an opportunity to change her mind.

It is not ethically defensible to evoke conscience as a justification to attempt to coerce a patient into accepting care that she does not desire.

There is no ethical justification for most of the principles of The Baby Friendly Hospital Initiative. Indeed, there is less justification for coercive treatment around breastfeeding, which has only small benefits for term babies, than there is for coercive treatment around medically recommended procedures designed to save a baby’s life or brain function, like C-sections.

The Baby Friendly Hospital Initiative represents a deliberate and fundamental assault on women’s bodily autonomy, and as such is deeply sexist. Men have the right to control their reproductive organs free from interference by governments, hospitals and providers. Women are entitled to the exact same right and the fact that the BFHI treats women and their breasts as if they constitute an exception to basic principles of patients’ rights is deeply disconcerting.

That’s why the rush to close well baby nurseries is profoundly unethical. Not only is it bad for babies because it increases the risk of in hospital deaths from falling out of bed or being smothered; not only is it bad for mothers because it keeps them from getting the sleep they desperately need to heal from labor and birth; but it is unethical because it is a deliberate effort to coerce women into 24 hour rooming in against what they might actually wish.

The truth is that there is nothing special about breastfeeding. It isn’t life saving for term babies and its benefits are trivial — a few less colds and episodes of diarrheal illness across the entire population of infants in the first year. If women have the absolute right to an informed refusal of a potentially life saving C-section — and they do — they most certainly have the right to opt out of every single provision of the BFHI.

The Baby Friendly Hospital is deliberately both manipulative and coercive. It depends on power differentials, violates women’s’ fundamental right to bodily autonomy, and is deeply sexist because it treats women’s bodies differently than men’s bodies.

ACOG is absolutely right that it is ethically indefensible to coerce women into accepting obstetric care that they do not desire. Will they affirm the fact that it is equally indefensible to coerce women into breastfeeding?

  • JA_Get_Real

    My OB only delivers at what I just discovered is a BFHI hospital. I was not amused when, during the maternity ward tour, the nurse presented a baby-free nursery with the explanation that babies room in. I intend to breastfeed this baby as I did with the one before; however, I refuse to be deprived of sleep and to subject my infant to the dangers of rooming-in with an exhausted post-partum mommy.
    I intend to bring formula with me too because I expect this child, like the last, to have hyperbilirubinemia due to ABO incompatibility.
    But re rooming-in: Is it sufficient to assert my wishes when they try to room the baby with me? What are my rights?

  • Karen in SC
  • Close to heather

    I don’t think that it’s fair or reasonable to call the BFHI coercive in a blanket statement. Our hospital encourages bf, which EVIDENCE shows improves long-term health, not just the first year of life. Forcing a mom to do something that can be very difficult is a waste of time. These moms won’t be successful. Mothers that have the desire and commitment to bf are given our support and resources. Allowing mom to make a fully informed decision is important in any aspect of care, and that is why all mothere are give. The risks of formula and benefits of breastfeeding. We have a respite nursery. We allow pacifiers for procedures etc… mothers are welcome to bring a pacifier from home. It’s all about educating patients, not coercing.

    • The Bofa on the Sofa

      which EVIDENCE shows improves long-term health

      What evidence is that?

      I know that many studies have found associations, but as the level of controls have been improved (as in the PROBIT and concordant sibling studies), accounting for confounders, all the long term health benefits disappear.

      The only thing that remains to any extent long term is the small difference in IQ (which is not health), but even that gets smaller and smaller as the level of control improves, calling into question that is left-over.

      • demodocus

        i.e. oh, if only my ff spouse had been bf’d! then he’d have scored 130 on the IQ test rather than 127! *eyeroll*

        • sdsures

          LOL!

    • Megan

      How about the risks of breastfeeding (especially following BFHI protocols)? Do you educate mothers about that?

    • Heidi

      In your own words, you are giving partial information to try to convince women to do something. Mothers are given the benefits of BFing and the risks of formula. If it was about an INFORMED decision, you’d highlight the risks and benefits of both breastfeeding and formula and you wouldn’t make any exaggerations about it. So it still very much is coercion.

    • Amazed

      I am sure it does wonders for a mother’s self-esteem when she finds out that she’s one of the 5% (actually much higher but let’s go with the bare minumum) of new mothers who don’t make enough milk. Being educated about the risks of formula is SO condicive to her mental health! Or do you also offer your own loving breast to the children who cannot be breasted by their mothers since formula is so risky?

      I’ll say it again, just for the likes of you: during the WWII, my uncle was fed all they could find that was even remotedly edible, included bread in wine. Because there was no milk in those breast for this 40 day old baby. Zero. Nada. None. And you’re talking about the risks of FORMULA? How do you sleep at night knowing that you make new mothers who can’t breastfeed feel like shit? When they aren’t the shit and someone else is. Or is it formula risky only for the babies who can be breastfed but their moms don’t want to try? How do you moralize your way out of this?

    • Amazed

      I’m voting this up because it illustrates Dr Amy’s point beautifully. The risks of formula and the benefits of breastfeeding – that’s the BFHI’s version of informed consent for you.

    • Charybdis

      How about the benefits of formula feeding and the risks of breastfeeding? Because, you know, there are benefits to formula and risks to breastfeeding and pretending otherwise is ridiculous.

    • CSN0116

      Can you link to those studies showing long term benefits? Thanks!

    • sdsures

      What exactly are the risks of formula?

      OT: I’m not a parent yet. But when I was at the store yesterday, I stopped to have a look at the formula aisle, which we know we’ll be using. I had no idea there were so many different types! #fedisbest

  • The Bofa on the Sofa

    OT for the post, but not for the blog: I have been catching up lately on the http://www.naturopathicdiaries.com/ blog by Britt Hermes. Britt is a trained Naturopath who left the profession after learning about how wrong it is in pretty much everything.

    Whenever I read her stuff about naturopaths, I am reminded a ton of CPMs. Basically, that’s that what naturopaths are – they are the MD equivalent of CPMs. They aren’t recognized as legitimate providers by any medical organization, so they make up their own, along with their own accrediting agency. It sounds great, because hey, they got their degree from an accredited school of naturopathy!

    Of course, the most prestigious of these is Bastyr, just like for CPMs.

    Britt isn’t near as prolific as Dr Amy or Orac, but man, when she writes, it’s scathing. That’s because she has inside information. She is like the former homebirth midwives who comment here. They KNOW what’s going on. That’s why naturopaths hate Britt so much. They can’t claim she is ignorant of naturopathy. She knows it, much too well for their comfort.

    Dr Amy, you need to add Britt’s blog on the blogroll. I wish Britt would write more. I love her stuff.

  • cookiebaker

    We’re not planning more children, but if I had another, I was really worried about the BFHI. I’d always breastfed in the hospital, but ironically, I was less successful with each of my 6 kids. The last 2 were utter BF failures, they were unable to transfer any milk and I couldn’t establish or maintain a supply via pumping, they were losing weight, so I began supplementing with more and more formula until they were entirely formula fed.

    If we did have another, I don’t want to breastfeed. I don’t want to endure the nipple soreness, the non-stop feedings, and the brutal sleep deprivation when I’m fairly certain it’s not going to work, even if I follow all the rules. I was so worried how I’d be treated if I was a formula feeding mother.

    It turns out my son went to preschool with the son of the supervisor of the mother-baby unit at our local BFHI hospital, so I asked her how the staff felt about this BFHI business and it seems our hospital is very reasonable. They have a nursery, which includes a full-time nursery nurse. She said they especially need it for the post-surgery mothers who need the help. Also, the nursing staff is very pro-formula and would much prefer to see a well-fed baby. So, if I could just avoid the LC’s, then it sounds like I won’t be harassed for formula feeding. I don’t know why I was so worried about it, since I’m fairly certain we’re done with babies, but after reading so many horror stories, it’s nice to know where our hospital stands.

    • Megan

      Ironically, our nurses were more judgmental that the LC’s. Then again, the LC’s there know my history from my first daughter. They remember me (helps that they work with me too) but the nurses aren’t necessarily the same as a year and a half ago. And I’m sure IGT isn’t listed in my chart (though it probably should be!!)

  • The Bofa on the Sofa

    I am not clear. Sure, the patient has the right to refuse treatment. However, does that mean that they can force the provider to provide the treatment they want?

    For example, can a patient insist that the OB provide a VBACS even when the hospital is not properly equipped to do one safely?

    Our doctor was clear: if you want a VBACS, you will have to go to another hospital and go with one of their doctors, because I cannot do one at my hospital because it does not have adequate facilities.

    Is that a violation of autonomy? Could we show up at the hospital, refuse to leave and refuse a c-section and insist that she deliver the baby?

    I sure as hell hope the ACOG does not expect that.

    • Mattie

      This is interesting because “Could we show up at the hospital, refuse to leave and refuse a c-section and insist that she deliver the baby?” is pretty much the case here (in the UK). A pregnant person can show up on delivery suite and the doctors/midwives have a duty of care as soon as they arrive. They can’t refuse to care for someone, even if the person refuses certain treatment. Same if the person decides to stay at home, they have to send a midwife out. Otherwise it’s seen as neglect on the part of the HCP I think.

      • The Bofa on the Sofa

        Is that what people mean when they talk about autonomy? “Forcing the doctor to treat me the way I want to be treated?”

        • Mattie

          Arguably, but then doctors and midwives kinda agree to that when they decide to do the job. They provide care, but they can’t force care on someone, they also don’t have final say, they have to get consent from the patient so really the patient does kind of call the shots. As AirPlant says above, patient cannot force a doctor to do a procedure, but they can refuse treatment so they get what they want.

        • fiftyfifty1

          “Is that what people mean when they talk about autonomy? “Forcing the doctor to treat me the way I want to be treated?””

          No, it means the doctor can’t force me to take the treatment s/he recommends. It’s an asymmetric right. You have the right to avoid procedures that are recommended, but not the right to insist on getting ones that aren’t recommended.

          • Erin

            As demonstrated by my recent discussion about a future baby with a Consultant OB as advised by the mental health team I’m still seeing. We both agree that should I go to 39 plus 4/5, a repeat c-section would be the best option. Before that, we agreed that a sensible option would be to “suck it and see”.

            I want a General Anesthetic for mental health reasons.

            OB wants a spinal, skin to skin in theater and all the other “Hippy” rubbish that I think is amazing if you want it but torture if you don’t. (She actually recommended hypnobirthing…)

            I can refuse a spinal but I can’t force them to give me a GA unless certain criteria are met.

            1. Absolute emergency, no time to get a spinal working.

            2. I’m a hysterical screaming wriggling nightmare during surgery and they have no choice but to sedate me. Only despite my history, they might decide that holding me down is a better option.

            I could refuse a section but since last baby couldn’t get past mid pelvis, that doesn’t seem wholly sensible.

            So yes, I can refuse treatment but I can’t force them to do something they don’t want to (in theory).

            Not sure what would happen if it became obvious that I needed a section but it wasn’t an “oh god get him or her out now” moment. However I’m not convinced that maternity hospitals are the place for games of brinkmanship.

          • CSN0116

            I had two cesareans under GA for mental health preferences (PTSD from a head-on car accident caused by a drunk driver where I temporarily lost feeling in my legs). While unconventional, nobody gave me grief about it and they were happy to oblige (same OB but two different anesthesiologists).

            Each surgery was totally uncomplicated and my experiences were peaceful. I couldn’t imagine having that option withheld from me. It would have been inhumane and torturous. From a cost perspective, the bill for the GA was hundreds lower than the epidural bills from my vaginal deliveries!

          • Erin

            Really glad they listened to you. I keep being told how dangerous it is and how it will ruin our relationship. Pointing out that I missed my son’s birth, thought he was a doll, didn’t believe he was a baby let alone my baby for a good few months, tried to kill myself, wanted to leave him in hospital and still ended up with a two way bond means that a GA without all the mental issues, the dehydration, the fever etc should mean that we bond just fine has so far been ignored.

            The NHS is wonderful in many ways but when it comes to choice in Maternity, it seems very limited. One of my friends who is currently 7 months pregnant really wants an epidural as she struggled to cope with the pain of having her daughter. The new baby is back to back at the moment, the first one wasn’t and so she’s terrified worrying that if it’s more painful, she just won’t be able to get through it. However here we have two Midwife units, one attached to the hospital and one in the middle of nowhere plus the Consultant led labour ward where all the Doctors hang out. You can only get epidurals in the latter and since that’s where all the trials of labour for vbacs, all the inductions/augmentations and other high risk births take place, she’s been told she can’t access it (and it’s epidurals) unless she needs her labour augmenting/inducing.

          • Valerie

            I’m so sorry you are dealing with this. We as a society acknowledge that some people need to (or at least strongly prefer to) be heavily sedated or unconscious while having wisdom teeth extracted so as not to experience psychological distress, but for something so much more invasive, emotional, and potentially traumatic as giving birth, it’s not an option. It doesn’t seem right- yes, there are risks, but there are benefits, too. Also, plenty of dads and adoptive parents miss the birth of their kids, and they bond just fine. Fathers in the military, for example, or just from unexpectedly quick labors. I know at least one who missed the birth of his third child because he went to the cafeteria and then things progressed very quickly, and I’m sure he loves that kid as much as the other two. I hope you can get everybody to sign off on it so you have peace of mind.

          • Mattie

            I need sedation for any dental work that isn’t a check up. I have never been told that ‘natural’ dentistry is better, would help me bond with my teeth more or that it just hurts because I don’t trust my mouth enough.

          • Valerie

            Exactly- I was conscious, with only a local anesthetic when my wisdom teeth were born, and I have no bond with them.

            I’m wondering if people are required to be awake for any other “major abdominal surgery,” or if it’s just for CS.

          • Dr Kitty

            I feel for you.
            Have you considered a second opinion?

            It shouldn’t be this much of a fight for you and I’m sorry it has been.

            Maybe it is good that Northern Ireland is 40-odd years behind the rest of the U.K.
            One of my patients recently got an elective CS at 37 weeks due to anxiety and I personally assisted at a MRCS under GA (patient request) a few years ago. There doesn’t seem to be quite the same push for “normal birth” here.

            Is your psychiatrist willing to put in writing that being conscious during any future CS would be likely to have a severe, permanent effect on your mental health? That, plus a very clear informed consent ought to ease their minds about any medico-legal fall out of a GA gone wrong.

            Being very clear that you would consider litigation should you suffer further emotional trauma which could have been avoided by a GA…

            I wish I could make this better for you. It sucks to have that uncertainty hanging over you.

          • Erin

            They took it to “committee”. From what I can make out, it’s the new Peri-natal Psychiatrist (who I haven’t met) who is the biggest obstacle as she seems to think that not seeing my son being born, not being a part of his birth was the final straw which shoved me off the edge and that I’m just punishing myself. So apparently the answer to that is for them to “punish” me by making me choose between either attempting a vbac or forcing myself to be awake during a procedure that I’m terrified will trigger my PTSD and turn me into a raving lunatic again.

            The situation is not helped by the fact that I want baby to go to my husband as soon as they’re okay and then not to come to me until I ask for them once I’m awake and conscious in recovery. It seems that the usual plan is to re-unit Mother and Baby asap after a GA and one friend of mine who had a crash section under GA woke up in recovery with her baby on her and of course what I want isn’t baby friendly. Apparently trying to avoid the “childbirth” bit of childbirth is frowned upon regardless of the circumstances/reasons.

            What makes it even more frustrating is that the Consultant told me in a phone call after their meeting that the Anesthetist from my son’s arrival is on-board for a GA if that’s what I want on the day but his boss/ the psychiatrist and whole bunch of the OBs are not.

            So trying a whole new tack. I’m going to met said peri-natal psychiatrist and try and get her to change her mind. The Consultant is going to speak the other Maternity Hospital in our area which is further away but still close enough to get to (and is actually closer to family) to see if they see it any differently and the Psychiatrist I’m seeing from the Adult Mental Health team has re-referred me to therapy to see if I can separate how I feel about surgery/ORs/being unable to move/passive from the rape trauma.

            I hate feeling like such a pest but I’m so conflicted. Not helped by the fact that about six of my friends are pregnant and are planning water births, vbacs and “family centric” c-sections happily. Plus when it comes to advocating for myself I tend to be conflict averse (thanks Mum) so I’m scared that I could get pushed into doing something I’m really not happy with and end up back at “raving lunatic” again.

          • Dinolindor

            I just want to state unequivocally – you are NOT a pest to demand correct and compassionate care for yourself and family. Not in any way shape or form. The ones blockading you from these obvious solutions are the pests.

          • Tokyobelle

            This is only tangentially related to your current situation, but I had a scheduled/elective CS at 38 weeks, was “awake” in the sense that I wasn’t given GA, but a spinal, and yet, I still don’t remember a damn thing about the event. Friends and family joke that it was hilarious seeing me so out of it, but really, I have no memory of the event other than puking several times, and being rolled off the table and onto the gurney at the end. My husband has photos of me holding our son while I was being stitched up, and a video of me talking to him in the theater, so these things clearly happened, but I have no memory of them whatsoever.

            My point being, I did not see my son be born, and yet, we’re both absolutely fine. I still think he’s mine, and I’m not traumatized by the fact that I didn’t see him be “born”. Your choice and preferences are valid, they’re reasonable, and they’re perfectly safe. Please have the confidence to stand up for them and argue your position. I hope you get what you want.

      • fiftyfifty1

        It’s different in the US. You can show up in labor and refuse a CS (that part’s the same), but they don’t have to send a midwife out to your home.

        • Mattie

          Yeh, that’s fair, the ‘send a midwife’ out is not usual, they would encourage a person to come in to the hospital, but if someone flat out refuses and for example, calls an ambulance, the paramedics would also contact the midwife on call anyway

    • AirPlant

      Isn’t that the idea behind the idea of waiting and then coming in pushing? You simply do not give the medical staff the time to make any decision other than VBAC.

      • The Bofa on the Sofa

        What about “medical staff” vs “my doctor”?

        Of course the hospital will have to treat anyone who comes in with an emergency. But in that case, it should be treated like an emergency.

        • AirPlant

          No, there is no ethical way to force a specific doctor into a specific procedure, but most of the time you are not guaranteed your OB for the delivery anyway. You get whoever is there when you show up.
          .
          Your doctor can refuse care for a patient that says that they will attempt VBAC AMA, but they can’t do anything if the patient lies to them and then shows up pushing. Super unethical of the patient, but it is a legitimate way of forcing the doctor’s hand.

        • MaeveClifford

          I don’t think anyone is guaranteed a specific provider though. I went into labor a week or so before my due date, and I got a random ob I’d never met before. I would have liked “my doctor,” because she’s awesome, but she wasn’t on call. I don’t get to make her come in on her day off just because “autonomy.” Autonomy means you can choose from the options on the menu, not that you can force them to provide you with something that isn’t even offered.

          Seems to me if you really want a specific provider, you schedule an induction or elective c/s. I know homebirthers like to crow about having “their midwife” guaranteed, but I’ve read far too many stories of transfers, or midwives being busy/not answering their phone/not having reliable transportation, etc. to buy that for a second.

    • Angie Young-Le

      The doctor of course has a right to refuse to do a procedure. For example you can’t force a doctor to cut off a viable leg because you want it. That is not a violation of autonomy.

      That being said a person could go home, mangle their leg to the point of needing amputation and then return to the hospital. Now the doctor has no choice.

      It is manipulative and irresponsibly stupid, but technically people can do that to get what they want.

      • The Bofa on the Sofa

        The doctor of course has a right to refuse to do a procedure.

        The problem is, a VBACS isn’t really a “procedure,” is it?

        Which makes it even harder. Should the hospital be required to allow the patient to labor in a room despite refusing the appropriate medical care?

        • fiftyfifty1

          “The problem is, a VBACS isn’t really a “procedure,” is it?”

          Exactly. It’s the lack of a procedure. Patients do indeed have the right to show up in labor and refuse a CS. It’s obnoxious, but it is their right. They also have the right to sue the OB later if the baby is born damaged. They might not win, but they can try.

          • Daleth

            They also have the right to sue the OB later if the baby is born damaged. They might not win, but they can try.

            I sure hope they would lose, or even get the lawsuit dismissed on the grounds that the doctor explained the risks of VBAC, refused to plan one because medical guidelines preclude it (no 24/7 anesthesiologists or whatever reason), and yet you not only insisted on trying a VBAC, you insisted on doing it at a hospital that you’d already been told wasn’t equipped for it.

        • Angie Young-Le

          Even though its not surgery it is still a procedure.

          Definition of medical procedure: a series of steps for doing something; see also maneuver, method, operation, surgery, and technique.

          In this case I guess it would be considered a method.

          Ethically the hospital would have to give this person a room. I’m pretty sure hospitals are required to give emergency care. Sometimes that means not doing what the doctor recommends as medically necessary. Along the same lines as not giving someone a blood transfusion because it goes against their religion or someone signing a DNR. They aren’t going to toss that person out onto the street, even if that means the patient dies.

          • Charybdis

            Meant to reply to Bofa….

            It might come down to how far along in labor the mother is when she appears at the hospital. If she shows up in the ER, the hospital has to provide emergency care, especially if she is pregnant/in labor. She can then refuse any and all medical recommendations she does not want. Frustrating for the staff, because why did you show up if you weren’t intending on following any of the doctor’s recommendations, but there you are. Happens with DNR’s, Jehovah’s Witnesses,etc. I’m sure signing consent/declination forms will definitely be in order with each and every step along the way (I consent to fetal monitoring and the placement of a heplock, but I decline an epidural and a CS, even though my baby is breech or I want a VBAC,etc.).

            I would think there would be several opportunities to decline a CS throughout the labor, each one being documented and signed/initialed by the woman, because she might change her mind somewhere down the line.

            The other option I can think of is that they treat the mother, assess her condition and then transfer her to a larger hospital/one equipped to handle a VBAC. This happens with insurance conflicts, i.e. you are injured in a car wreck and are transported to the nearest hospital for emergency treatment. Treatment starts, but it is discovered that your insurance is not accepted at the hospital where you are. They will arrange a transfer after you are stabilized enough to make the trip.

          • Megan

            “The other option I can think of is that they treat the mother, assess her condition and then transfer her to a larger hospital/one equipped to handle a VBAC. This happens with insurance conflicts, i.e. you are injured in a car wreck and are transported to the nearest hospital for emergency treatment. Treatment starts, but it is discovered that your insurance is not accepted at the hospital where you are. They will arrange a transfer after you are stabilized enough to make the trip.”

            Yes, this is EMTALA. You must treat if they are unstable (imminent delivery would be considered not stable) but if she is stable, and delivery felt to not be close, you could transfer in that instance. Only problem is, if the delivery unexpectedly occurs during transport, I could see that possibly being a legal issue.

            Also, Dr. Amy did a guest post on this very issue on KevinMD:

          • Megan
        • Gatita

          I don’t know about should but they are required to do this. I know a doctor who had a patient refuse CS for a footling breech and he had to deliver the baby in the hospital. Baby ended up in NICU for six weeks but the parents were so pleased they wanted him to deliver their next baby but he refused to provide prenatal care.

          • Kelly

            That poor doctor. Not only did he have to deliver their baby knowing the consequences but they wanted him to do it again? Those parents are pure crazy. I also feed bad for that baby. Six weeks in the NICU is no small deal.

          • sdsures

            Good for the doctor. That poor kid.

        • Azuran

          I think that technically yes, a VBAC is some kind of procedure, since it’s the result of you having a medical procedure in the past that require different care if the future.
          Birth is a procedure, and birthing in a hospital is a medical procedure that come with the pros and con of every medical procedure.
          The only difference is that birth is going to happen eventually, you can’t stop it, so by default it will always end with (either failed or successful) vaginal birth unless you intervene.

          A doctor can refuse to plan a vbac with you if they don’t have the resources and expertise needed to safely do one. But if you show up in labor and refuse the c-section, they’ll have to help you give birth vaginally. So yes, they’ll have to put her in a room and help her.
          As a comparison point, I can’t make plans to have a vaginal birth at the medical clinic down the street. They don’t do births, so they would refuse me. But if I show up in their waiting room in active labour and refuse to transfer in an hospital, they are going to have to help me.

          Patient autonomy allows you to refuse recommended treatments or make a choice between a number of acceptable treatments. But it doesn’t allow you to chose treatments that have not been proposed or are not medically adequate or available.

    • fiftyfifty1

      “I sure as hell hope the ACOG does not expect that.”

      The ACOG does indeed expect that, as does the law.

      • The Bofa on the Sofa

        Be careful. I specifically said, “Could we show up at the hospital, refuse to leave and refuse a c-section and insist that she deliver the baby?”

        The hospital cannot refuse care, but it doesn’t have to be HER doing it. At best, it would be “the OB on duty” (which may be her, or may not be) or even “the ER doctor.”

        • Mattie

          Well of course you wouldn’t be able to force a specific doctor to provide care, however would the doctor not want to do it? Surely they have a better relationship with the pregnant person and know the medical history etc…

          • The Bofa on the Sofa

            Would you want to? A patient whom you have advised to do something else, and told them if they want to do it, they need to go somewhere else, shows up at you door, and expects you to do it anyway?

            It’s an adversarial patient. Who is volunteering for that?

          • Mattie

            I’d probably hope that I’d be able to encourage them to make an alternative decision. But yeh, I guess it’s not the easiest patient. It is super difficult to understand for me, cause UK = NHS and that means you don’t have ‘your own’ doctor or midwife (generally) you just get who is on shift

          • sdsures

            “How Doctors Die: Showing Others the Way”. Really good article, and it’s what Dr Kitty was talking about: http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?_r=0

        • fiftyfifty1

          You are right. You can’t insist on a specific doctor. It would be the doctor on call. In a smaller town that may very well always be the one OB however…

          • The Bofa on the Sofa

            So there is a limit to autonomy. Patients can’t always have it their way.

          • Dr Kitty

            Absolutely.
            You might *like* me to do CPR on your 97 year old mother with end stage dementia and lung cancer if she has a cardiac arrest, but I’m not going to on the basis it would be futile, undignified and not in her best interest.

          • Mattie

            Would you not be required to resuscitate unless there is a DNR/Directive in place not to? Personally I wouldn’t want resus to be performed in that instance but surely a discussion would have taken place prior to that happening

          • Dr Kitty

            Not in the UK, no.
            If I can make a medical decision that CPR is futile and not in someone’s best interest, I don’t have to resuscitate them if they arrest in front of me.

            Do bear in mind- I’m a Dr who has the power to write DNAR orders, and I’d be the one calling time on any resuscitation and certifying death. The same doesn’t necessarily apply to nursing home staff or paramedics who, not having the same skill set, are expected to attempt resuscitation unless a DNAR is in place.

            A DNAR merely puts in writing that everyone has agreed in advance not to resuscitate.

            A patient can make themselves DNAR, with or without medical agreement, but you cannot insist a Dr resuscitate you or your relative against their best clinical judgement.

            This is the problem, people think that discussions about DNAR are just that, discussions. They aren’t. They are about the medical team telling the family and patient why resuscitation is not appropriate and why they won’t be performing it.

            Typically, the very frail, very elderly and those with terminal illnesses are made DNAR on the basis of futility- you’re not going to get them back, and the trauma and indignity of a CPR attempt would rob them of a dignified and peaceful death surrounded by family. The family should be informed of this, but no, they can’t override it, despite what they may have been made to believe by the media.

          • Mattie

            Thank you SO much, that’s really interesting 🙂 definitely didn’t know this.

          • MI Dawn

            Interesting, because unless things have changed, MDs in the US can’t do that. Everyone is a full code unless the family has agreed on DNR or the patient comes in with a Living Will that specifies DNR situations.

            (I can recall doing a full code on a lady with severe dementia who hadn’t spoken in 7 years; family still wanted everything done for wife/mom/sister. She threw a PE 5 minutes after I did vitals on her. Didn’t make it, but we did a 1 hour code attempt anyway.)

          • Mattie

            I think my understanding of it came from watching a lot of US tv shows which explains why I was confused haha

          • Dr Kitty

            Things are different in the USA, I know that.

            I read Atul Gawande’s book about dying and was shocked when he talked about the kind of patients in US ICUs- the very frail elderly, people with dementia, people with terminal illnesses…

            You can spin it as NHS death panels if you want, but those patients rarely end up in ICUs in the UK, and I try to keep nursing home patients with severe dementia out of hospital if at all possible.

            If you are at the point where you are bed bound, without speech and you can’t swallow food without aspirating, I would argue it is better to die from aspiration pneumonia peacefully in your own bed with your family beside you than to die tube fed and ventilated in an ICU bed after an hour of unsuccessful CPR.

            Everyone dies.
            For those very frail people with dementia it is better to talk about how and where than when.

          • MI Dawn

            Personally, I like the NHS view better.

          • The Computer Ate My Nym

            I have my issues with some NHS policies, but this isn’t one of them. I am willing to do stupidly aggressive if the patient is asking me to and understands what they’re getting into. But I’m not ready to do the same because the family wants it for a patient who is too far gone to be able to object.

          • Dr Kitty

            I know…
            but it can get messy if secondary gain or guilt are the drivers.

            For example, one adult child living in the family home as parent’s carer, but the home would be sold and proceeds distributed between all children once parent dies. Obviously, that is a motivator for wanting the parent kept in hospital (so the child doesn’t actually have to nurse them) and alive as long as possible (so they don’t lose their house).

            Or children living hundreds of miles away who feel guilty they can’t do more, and want “everything possible done”.

            “Just because we can do something, doesn’t mean we should, the decision is mine and I cannot ethically agree to what you are suggesting because I think it would merely prolong suffering and cause indignity. Please do not ask me to compromise my professional ethics.”

            That approach has worked so far- and in more than one case family have come back to me and said that they were grateful for the peaceful death their relative was able to have.

          • The Computer Ate My Nym

            Medical futility is a reason for not performing CPR in the US, but if the family chooses to get cranky about it, the situation can be messier. Often, when there is a clearly medically futile case and a family insisting that “everything be done” the code is called rather quickly because it’s clear that what is being done is a waste of time and resources and not helping the patient in the least.

            I remember hearing about one case in medical school where a man with multiple strokes resulting in end stage dementia and contractures of his limbs was kept on aggressive care at the insistence of his family. Secondary gain on their part was suspected. The resident I talked to said she had to actually break the man’s arms to get them out of the way to be able to even perform CPR. I can not imagine how awful that must have been. Needless to say, the code was not successful.

          • sdsures

            Which book? He’s written a few.

          • Mattie

            Literally nobody is saying that they can? They are saying that they have the right to refuse any and all treatment.

          • The Bofa on the Sofa

            But it’s not just about refusing treatment. It’s forcing a procedure.

            This isn’t “I refuse to take chemotherapy and will go home and take herbs.” It’s “I won’t do chemo but will insist on being in the hospital while I eat herbs”

          • Angie Young-Le

            I thought you said it wasn’t a procedure 😛 (I’m just teasing you playfully, not attacking. Please don’t take it negatively)

          • The Bofa on the Sofa

            But that’s the question, and it is challenging. Even if it is baby catching, does that make it a procedure?

          • Mattie

            I do kind of see your point, but what the ACOG are saying is that refusal to provide any care because the person is refusing one thing is sort of coercive and not acceptable. Everyone has the right to say no to something, but that shouldn’t be used as a reason by the medical staff to provide all care.

          • The Bofa on the Sofa

            IIRC, the AAP also advises not to disenroll patients who don’t vaccinate, but many pede’s do it, and with great support.

            So they are using refusal to accept care as grounds to not provide any care.

            I don’t have a problem with that, personally, either.

          • Mattie

            That’s not really the same though, usually the parents would be told in advance (like when they register, or at the point where they refuse the vaccines) but if the kid needed emergency care they’d still be able to go to the hospital to access that. They can go to a different doctor or do something else. Also, refusing to accept non-vaccinated children protects others, refusing to help a labouring woman because she’s not listening to you is just kind of petty and could lead to harm for her.

            I guess the end point is if something awful happens in labour you have a better case (if the person sues) if you have evidence that you offered treatment and it was declined, than if you just sent the person away.

          • The Bofa on the Sofa

            That’s not really the same though, usually the parents would be told in advancet if the kid needed emergency care they’d still be able to go to the hospital to access that. They can go to a different doctor or do something else.

            But here they are still being told in advance that the doctor won’t do a VBACS, they can go to a different doctor. See my initial scenerio – that is exactly what our OB did. Said if you want a VBACS (i.e. refuse a c-section) you need to go to a different hospital because I won’t care for you.

          • Daleth

            if you want a VBACS (i.e. refuse a c-section) you need to go to a different hospital because I won’t care for you.

            If you want to PLAN a VBAC, you’ll need to find a different OB and give birth in a different hospital. But if you just show up at the ER in labor and refuse a c-section, you will get your VBAC, although it will be with whatever OB is on call when you arrive. You may not get a live baby, but you’ll get your VBAC.

          • Valerie

            The hospital cannot refuse care to a laboring woman because she has had a previous CS, and a hospital cannot refuse emergency care to a child because they have not been vaccinated. However, a doctor may refuse to support planned VBACs for insurance/staffing purposes (which is what it comes down to, in my understanding), and pediatricians can refuse to be the primary care physicians if the children are not vaccinated for the sake of other children in the practice (which is the primary reason). In either case, it is not “you are doing the less safe thing so I will refuse to treat you out of spite.”

          • Amy

            This. It’s all related to the EMTALA law. Originally, the law was put in place because some hospitals were refusing to treat patients in active emergency situations if insurance/income couldn’t be verified, often with tragic results. The law requires hospitals and hospital staff to treat patients who present at the emergency room or in active labor until the patient’s condition is stabilized. Agreeing to be the primary-care pediatrician or the OB for the duration of a pregnancy doesn’t fall under the act because there’s no emergency. Nor does demanding to be seen or treated by a particular doctor. The law, after all, is for emergencies.

          • Daleth

            I don’t have a problem with that, personally, either.

            I have the opposite of a problem with it. I actually chose my kids’ pediatrician from a pool of good, conveniently located ones based on the fact that their vaccination policy was “get vaccinated with all the recommended shots, on time, or get another pediatrician.”

          • Sarah

            I don’t, but it’s not quite the same because unvaccinated children are a threat to other patients at the practice. Which isn’t true of eg someone refusing induction against medical advice. I think being potentially contagious makes a difference in such scenarios.

          • AirPlant

            In the chemo analogy I feel like presiding over the AMA VBAC delivery would be more akin to treating the cancer patient for the complications of late stage cancer than presiding over the herbal treatment.
            .
            The woman in labor is a natural consequence of refusing the section, just like pain or broken bones or illness can be a natural consequence of cancer. In both cases you try to mitigate harm in spite of bad decisions.

          • Charybdis

            I wouldn’t think a hospital would allow that; there are probably a number of legal and safety issues involved with that scenario. The hospital is not a hotel, retreat or spa and I really don’t know if you could force them to do it your way. Again, probably for legal and safety reasons.

          • sdsures

            Yes, there are. My husband’s aunt died from her cancer, which was being treated by chemo in hospital, because at the time she was also consuming herbs which stopped the chemo from working.

          • Charybdis

            Uh, no. Medical care is not Burger King; you do not get to always have it your way. You certainly have the right to decline/refuse medical treatment/advice, because it is your body and your decision. You have been given the facts, pros and cons of the situation and have made your decision to deny/refuse care.

            You cannot insist that the medical staff cave to your demands because you are the patient and want things done your way. Usually there is some negotiation room depending on the situation, but ultimatums don’t generally work.

          • Amy

            The ACOG isn’t saying they can. It’s saying they can/should always have the right to REFUSE treatment.

            In a lot of crunchy circles, it’s popular to compare doctors to contractors, plumbers, mechanics and the like. A lot of “They work for YOU.” But even with that analogy, which they obviously mean to be insulting, the customer doesn’t always get her way. You can’t force a plumber to install a toilet in the middle of your kitchen or more toilets than your septic system can handle. You can’t force a mechanic to modify your car to the point where it will not be road-legal. You can’t force your contractor to violate building codes.

            But in all of those cases, if I have a contractor come to give me an estimate, I do retain the right to refuse service or decline to hire them to do the job they recommend. And that’s really all the ACOG is saying. But the BFHI doesn’t respect that pretty basic standard.

          • Sarah

            Which is why advocacy for pain relief on request in labour is more important than advocacy for home birth and intervention refusal. The latter is available to any woman who simply refuses anything else, the former obviously requires a clinician.

          • sdsures

            A hospital isn’t a spa.

    • Daleth

      Could we show up at the hospital, refuse to leave and refuse a c-section and insist that she deliver the baby?
      I sure as hell hope the ACOG does not expect that.

      You can’t insist on a particular doctor, but if you show up in labor and absolutely refuse a c-section no matter what, you’ll get your VBAC (assuming you don’t rupture, which would require immediate surgery). You’ll get it with whoever is on call. Ideally, but not always, you will also get a living, healthy baby.