- Email: [email protected]
Coercion in maternity care
Correspondence
3
UN Population Fund, International Confederation of Midwives, WHO. State of the world’s midwifery 2014. A universal pathway. A woman’s right to health. New York: UN Population Fund, 2014. Akseer N, Salahi AS, Hossain SM, et al. Achieving maternal and child health gains in Afghanistan: a countdown to 2015 country case study. Lancet Glob Health 2016; 4: e395–413.
Coercion in maternity care I read with interest the Maternal Health Series published in The Lancet. I was pleased to see that the over-medicalisation of TMTS (too much too soon) was recognised by Miller and colleagues (Sept 15, 2016).1 I would like to add to this by highlighting the issue of women being coerced into unwanted interventions during childbirth. The capacity to consent to or refuse medical interventions is defined by law, and a woman’s capacity to consent to procedures does not change just because she is pregnant. However, often the medical profession does not respect this, and treats women merely as carriers for the fetus. I know of several women who have been advised to undergo surgical birth intervention in the interest of their unborn child, which after consideration, they declined. Although none lacked capacity to consent to treatment, and were fully aware of the risks of declining treatment, they were later coerced into accepting surgery, in some cases by the threat of removal of their child after birth. Caesarean section is a major surgical procedure, and at the point it is undertaken, the fetus is not independent and does not have legal status. Consent forms for this procedure describe risks of hysterectomy, paralysis, and death. It is not unreasonable that a person, who perhaps is a single parent to several young children, decides not to take on these risks to herself in order to prevent possible harm to an unborn fetus. I know other women who have been left with life long and life-changing www.thelancet.com Vol 388 September 24, 2016
medical problems as a result of birth interventions. I am not suggesting that these interventions should not be available, and understand that all childbirth options carry risks, but women must be fully informed of the risks and benefits and uncertainties surrounding these, and then allowed to make a decision free of coercion. Doctors must respect the decision of a capacitous patient to refuse treatment, and this should not change just because that patient happens to be pregnant. I declare no competing interests.
Catherine Quarini [email protected] The Lancet Psychiatry, London EC2Y 5AS, UK 1
Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016; published online Sept 15. http://dx.doi.org/10.1016/S01406736(16)31472-6.
Sport and the city: midtown madness Physical inactivity might lead to excess cardiovascular and cancer mortality, whereas compliance with the WHO-recommended moderate and vigorous physical activity (MPVA) of 150 min per week as part of a healthy lifestyle could reduce that risk. One could argue that this is largely a matter of public education, but if people can be convinced, do they have sufficient opportunities to act accordingly? James Sallis and colleagues1 (May 28, p 2207) showed that the design of the urban environment has an important effect on physical activity levels of residents. They reported that physical activity of participants living in the most activity-friendly neighbourhoods was up to 29% greater than that of individuals in the least activity-friendly neighbourhoods, although this increased level of activity is still not enough to meet the WHO requirements.
If we succeed in improving people’s willingness to adapt their lifestyles, including meeting the 150 min per week MPVA target, and if sufficient urban activity-friendly areas are created, another issue influencing the net effects on health and mortality remains: air quality. In a recent Editorial in The Lancet2 the consequences and actions of the effects of air pollution on health in Britain were summarised. The hazard of air pollution, most importantly particulate matter, involves increases in both cardiovascular-associated and cancer-associated morbidity and mortality. 3,4 The hazard is highest in urban areas. Thus, if people increase sporting activity in these activity-friendly areas, they are also more exposed to particulate matter as they inhale it. Few studies address this dilemma. Even just walking in a city centre and travelling on a diesel bus is associated with the highest exposure to particulate matter, with extreme peaks at crossings and traffic jams.5 So, it could be argued that if you want to do sports (especially endurance sports) in the city, they should be done in designated areas, preferably at night, where and when traffic density is low; alternatively, play chess, billiards, or darts inside provided it is in a non-smoking area, because these pastimes might prove healthier. Providing activity-friendly areas in cities is a step in the right direction. However, if we do not succeed in changing people’s lifestyles, it is no more than window dressing. Participating in sport in the city will not have the benefits hoped, if people continue driving cars instead of using public transport, bicycles, or their feet. Additionally, damage is done to those who do adapt their lifestyles and practise sports, because they inhale the polluted air and particulate matter produced by individuals who have not made changes. If people would be willing to at least use alternative fuel sources, or even better, to drive
Published Online September 15, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31639-7 For the 2016 Lancet Maternal Health Series see http://www. thelancet.com/series/maternalhealth-2016
Bloomberg/Contributor
2
1277
3
UN Population Fund, International Confederation of Midwives, WHO. State of the world’s midwifery 2014. A universal pathway. A woman’s right to health. New York: UN Population Fund, 2014. Akseer N, Salahi AS, Hossain SM, et al. Achieving maternal and child health gains in Afghanistan: a countdown to 2015 country case study. Lancet Glob Health 2016; 4: e395–413.
Coercion in maternity care I read with interest the Maternal Health Series published in The Lancet. I was pleased to see that the over-medicalisation of TMTS (too much too soon) was recognised by Miller and colleagues (Sept 15, 2016).1 I would like to add to this by highlighting the issue of women being coerced into unwanted interventions during childbirth. The capacity to consent to or refuse medical interventions is defined by law, and a woman’s capacity to consent to procedures does not change just because she is pregnant. However, often the medical profession does not respect this, and treats women merely as carriers for the fetus. I know of several women who have been advised to undergo surgical birth intervention in the interest of their unborn child, which after consideration, they declined. Although none lacked capacity to consent to treatment, and were fully aware of the risks of declining treatment, they were later coerced into accepting surgery, in some cases by the threat of removal of their child after birth. Caesarean section is a major surgical procedure, and at the point it is undertaken, the fetus is not independent and does not have legal status. Consent forms for this procedure describe risks of hysterectomy, paralysis, and death. It is not unreasonable that a person, who perhaps is a single parent to several young children, decides not to take on these risks to herself in order to prevent possible harm to an unborn fetus. I know other women who have been left with life long and life-changing www.thelancet.com Vol 388 September 24, 2016
medical problems as a result of birth interventions. I am not suggesting that these interventions should not be available, and understand that all childbirth options carry risks, but women must be fully informed of the risks and benefits and uncertainties surrounding these, and then allowed to make a decision free of coercion. Doctors must respect the decision of a capacitous patient to refuse treatment, and this should not change just because that patient happens to be pregnant. I declare no competing interests.
Catherine Quarini [email protected] The Lancet Psychiatry, London EC2Y 5AS, UK 1
Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016; published online Sept 15. http://dx.doi.org/10.1016/S01406736(16)31472-6.
Sport and the city: midtown madness Physical inactivity might lead to excess cardiovascular and cancer mortality, whereas compliance with the WHO-recommended moderate and vigorous physical activity (MPVA) of 150 min per week as part of a healthy lifestyle could reduce that risk. One could argue that this is largely a matter of public education, but if people can be convinced, do they have sufficient opportunities to act accordingly? James Sallis and colleagues1 (May 28, p 2207) showed that the design of the urban environment has an important effect on physical activity levels of residents. They reported that physical activity of participants living in the most activity-friendly neighbourhoods was up to 29% greater than that of individuals in the least activity-friendly neighbourhoods, although this increased level of activity is still not enough to meet the WHO requirements.
If we succeed in improving people’s willingness to adapt their lifestyles, including meeting the 150 min per week MPVA target, and if sufficient urban activity-friendly areas are created, another issue influencing the net effects on health and mortality remains: air quality. In a recent Editorial in The Lancet2 the consequences and actions of the effects of air pollution on health in Britain were summarised. The hazard of air pollution, most importantly particulate matter, involves increases in both cardiovascular-associated and cancer-associated morbidity and mortality. 3,4 The hazard is highest in urban areas. Thus, if people increase sporting activity in these activity-friendly areas, they are also more exposed to particulate matter as they inhale it. Few studies address this dilemma. Even just walking in a city centre and travelling on a diesel bus is associated with the highest exposure to particulate matter, with extreme peaks at crossings and traffic jams.5 So, it could be argued that if you want to do sports (especially endurance sports) in the city, they should be done in designated areas, preferably at night, where and when traffic density is low; alternatively, play chess, billiards, or darts inside provided it is in a non-smoking area, because these pastimes might prove healthier. Providing activity-friendly areas in cities is a step in the right direction. However, if we do not succeed in changing people’s lifestyles, it is no more than window dressing. Participating in sport in the city will not have the benefits hoped, if people continue driving cars instead of using public transport, bicycles, or their feet. Additionally, damage is done to those who do adapt their lifestyles and practise sports, because they inhale the polluted air and particulate matter produced by individuals who have not made changes. If people would be willing to at least use alternative fuel sources, or even better, to drive
Published Online September 15, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31639-7 For the 2016 Lancet Maternal Health Series see http://www. thelancet.com/series/maternalhealth-2016
Bloomberg/Contributor
2
1277