Ethical Implications of Obstetric Care in Hungary: Results from the Mother-Centred Pregnancy Care Survey

Background: Informed consent plays an important role in clinical decision making. It is a basis of self determination in health care. In ideal situations health care professionals inform their patients about all relevant aspects of care and alternative care options, map the value system of the patients, and adjust the information process accordingly. Objectives: Our objective was to see the frequency of selected interventions (birth induction, caesarean section, episiotomy, forced supinal position during birth, and the consent process associated to these interventions. Methods: 1,257 women (with childbearing capacity) between the age of 18 and 45 with children under the age of 5 were surveyed online. Results: Caesarian section was done without permission in 10.2% of women. Labour was inducted in 22.2% of all deliveries and it was done without permission in 25.4% . Episiotomy was done in 39.9% of women having vaginal delivery in the Sample 2 group and in 72.2% of women having vaginal delivery in the Sample 1 (representative) group. Women undergoing episiotomy were not asked for consent in 62.0% in the Sample 1 group and in 57.1% in the Sample 2 group. Freedom to choose labour position for women having vaginal birth was restricted in 65.7% in the Sample 1 group and in 46% in the Sample 2 group. Discussion and Conclusions:We have found that the right of women to informed consent and best available treatment is frequently and seriously violated in obstetric practice in Hungary in the given period. These findings should serve as an important basis for improving the quality of maternity care

Epistemic Silences and Experiential Knowledge in Decisions After a First Cesarean: The case of a vaginal birth after cesarean calculator.

Evidence-based obstetrics can employ statistical models to justify greater use of cesareans, sometimes excluding experiential elements from informed decision making. Over the past decade, prenatal providers adopted a vaginal birth after cesarean (VBAC) calculator designed to support patients in making informed decisions about their births by estimating their probability for a VBAC. Among other factors, the calculator used race and ethnicity to make its estimate, assigning lower probabilities for a successful VBAC to Black and Hispanic patients. I analyze how a diverse group of women and their providers engaged with the VBAC calculator. Some providers used low calculator scores to remove a shared decision-making model by prescriptively counseling Black and Hispanic women who desired a VBAC into undergoing repeat cesareans. Consequently, women racialized by the calculator as Black or Hispanic used experiential knowledge to challenge the calculator's assessment of their supposed lesser ability to give birth vaginally

The MFMU VBAC Success Calculator: statistical prediction and race in an ethnography of obstetric thinking

In 2015 some 29.7 million women gave birth via cesarean, the majority of whom will subsequently give birth via repeat cesareans. The steep rise in surgical births might outpace the abilities of health systems to safely conduct the surgery, potentially reversing hard fought gains in reducing maternal mortality in low- and middle-income countries. The United States too has witnessed a sharp increase in cesarean use over the last 20 years, now accounting for 1 in 3 births, or 1.2 million per year. Even in California, the state that leads the nation in reducing avoidable maternal morbidity and mortality, 40% of the rise in maternal morbidity over the last 20 years can be explained by cesarean overuse, with Black women most seriously affected. After decades of advocating for universal facility-based childbirth, the global health community must now deal with the consequences of a sometimes necessary but often overused surgery. The U.S. cesarean rate is sustained by increases in primary cesareans and decreases in the number of women attempting a Vaginal Birth After Cesarean (VBAC). Down from a peak of 28% in the late 1990s, the VBAC rate is persistently low at 13%. After a first cesarean, most women in the U.S. continue to schedule an Elective Repeat Cesarean Delivery (ERCD). In a 2010 consensus statement the NIH found that several prediction models could accurately predict VBAC using varying combinations of individual risk factors. The rationale for the development of accurate VBAC prediction tools was to support clinicians in identifying those candidates with the highest chance for a successful VBAC. The VBAC rate might increase if only those candidates assessed to have the highest chance for success went on to attempt VBACs, on the assumption that a proportion of these women currently underwent repeat cesareans. One VBAC prediction tool rose to prominence in the United States: the Maternal-Fetal Medicine Units (MFMU) VBAC Success Calculator. The VBAC calculator predicted the probability for a successful VBAC by combining the indication for the prior cesarean with a woman’s age, Body Mass Index (BMI), and her race or ethnicity, categorized as White, Black, or Hispanic. All these factors were known at the first prenatal visit, allowing clinicians and women to make an early plan for the ultimate mode of birth. On average the VBAC calculator gave scores to Black and Hispanic women that were 5-15 points lower than White women with similar risk factors. The MFMU VBAC calculator was invented and widely disseminated without seeking input from those who were thought to most benefit from the tool, namely pregnant women and birthing individuals who have had a prior cesarean. The aims of this dissertation were two-fold. First, I critically evaluated the invention of the VBAC calculator, paying attention to scientific paths not taken and to the ways in which practices that sustained the calculator silenced alternative approaches to the uncertainty of planning a VBAC. Second, I assessed the impact of the VBAC calculator on the pregnancy and birth experiences of a diverse group of women with varying birth histories and racial/ethnic identifications. The methodological approach for the study was critical and ethnographic, including an 18-month immersion in scientific papers, blog posts, podcasts, visual artifacts, interviews, audio recordings of prenatal visits, and observations. In order to obtain the full range of engagements with this technology, I purposively selected 22 key informants as users and non-users of the calculator based on their research publications or public statements. In order to understand the practical applications of the calculator, I interviewed 17 providers (perinatologists, general obstetrician-gynecologists, and Certified Nurse Midwives or CNMs) who worked across 4 different institutions. I enrolled 27 pregnant and 4 postpartum women who spoke Spanish or English, were over 18-years old, and had at least one prior cesarean. Women had diverse birth histories and racial/ethnic identifications, whose calculated likelihood of successful VBAC ranged from 12% to 95%. Ultimately, 13 women went on to have VBACs, 10 had unplanned cesareans, and 8 had ERCDs. Qualitative data were analyzed thematically on multiple levels, using modified grounded theory. In Chapter 1, I argue that the VBAC calculator marginalized the diverse ways in which VBAC candidates approached risk and uncertainty. I present evidence from VBAC candidates whose experiences run counter to the calculator, including women who saw their pregnancies as an embodied and unfolding process rather than as a pre-ordained statistical fact. In Chapter 2, I directly address the racial dimensions and consequences of the calculator. I argue that the VBAC calculator automated the reproduction of racism by foreclosing the possibility that racism, not race, explained the differences in successful VBAC rates between White, Black, and Hispanic women. In Chapter 3, I examine how non-numeric elements influence the decision to attempt a VBAC or a repeat cesarean. That VBAC prediction models appear to be a globally ascendant approach to counseling should concern Global Health scholars. Under conditions of cesarean overuse, which is rapidly becoming most of the world, VBAC prediction models turn more prior cesareans into recurring indications, thus challenging Global Health efforts to safely reduce cesarean use. To date, the Global Health discussions around mistreatment of women in birth facilities has largely focused on measuring and describing experiences of mistreatment, violence, and abuse. In the mistreatment research literature, violations of autonomy are among the most common, and many recommend that women worldwide transition into the decision making role in order to fulfill their fundamental right to self-determination in childbirth. However, due to the ways that the VBAC calculator both engaged women as decision makers and reproduced racism in the process, the VBAC calculator complicates the notion that mistreatment, violence, and abuse during childbirth is adequately addressed through the concept of choice

A systematic review of person-centered care interventions to improve quality of facility-based delivery

Abstract Introduction We conducted a systematic review to summarize the global evidence on person-centered care (PCC) interventions in delivery facilities in order to: (1) map the PCC objectives of past interventions (2) to explore the impact of PCC objectives on PCC and clinical outcomes. Methods We developed a search strategy based on a current definition of PCC. We searched for English-language, peer-reviewed and original research articles in multiple databases from 1990 to 2016 and conducted hand searches of the Cochrane library and gray literature. We used systematic review methodology that enabled us to extract and synthesize quantitative and qualitative data. We categorized interventions according to their primary and secondary PCC objectives. We categorized outcomes into person-centered and clinical (labor and delivery, perinatal, maternal mental health). Results Our initial search strategy yielded 9378 abstracts; we conducted full-text reviews of 32 quantitative, 6 qualitative, 2 mixed-methods studies, and 7 systematic reviews (N = 47). Past interventions pursued these primary PCC objectives: autonomy, supportive care, social support, the health facility environment, and dignity. An intervention’s primary and secondary PCC objectives frequently did not align with the measured person-centered outcomes. Generally, PCC interventions either improved or made no difference to person-centered outcomes. There was no clear relationship between PCC objectives and clinical outcomes. Conclusions This systematic review presents a comprehensive analysis of facility-based delivery interventions using a current definition of person-centered care. Current definitions of PCC propose new domains of inquiry but may leave out previous domains

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator

ObjectiveTo describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors.MethodsWe invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts.ResultsAmong the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC.ConclusionOur findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling

In search of respect and continuity of care:Hungarian women's experiences with midwifery-led, community birth

Introduction: To describe and compare intervention rates and experiences of respectful care when Hungarian women opt to give birth in the community. Methods: We conducted a cross-sectional online survey (N = 1257) in 2014. We calculated descriptive statistics comparing obstetric procedure rates, respectful care indicators, and autonomy (MADM scale) across four models of care (public insurance; chosen doctor or chosen midwife in the public system; private midwife-led community birth). We used an intention-to-treat approach. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale). Findings: In the sample, 99 (7.8%) saw a community midwife for prenatal care. Those who planned community births had the lowest rates of cesarean at 9.1% (public: 30.4%; chosen doctor: 45.2%; chosen midwife 16.5%), induced labor at 7.1% (public: 23.1%; chosen doctor: 26.0%; chosen midwife: 19.4%), and episiotomy at 4.44% (public: 62.3%; chosen doctor: 66.2%; chosen midwife: 44.9%). Community birth clients reported the lowest rates of disrespectful care at 25.5% (public: 64.3%; chosen doctor: 44.3%; chosen midwife: 38.7%) and the highest average MADM score at 31.5 (public: 21.2; chosen doctor: 25.5; chosen midwife: 28.6). In regression analysis, community midwifery clients had significantly reduced odds of cesarean (0.35, 95% CI 0.16–0.79), induced labor (0.27, 95% CI 0.11–0.67), episiotomy (0.04, 95% CI 0.01–0.12), and disrespectful care (0.36, 95% CI 0.21–0.61), while also having significantly higher average MADM scores (5.71, 95% CI 4.08–7.36). Conclusions: Hungarian women who plan to give birth in the community have low obstetric procedure rates and report greater respect, in line with international data on the effects of place of birth and model of care on experiences of perinatal care.</p