With a shrinking world and a mobile healthcare workforce, it is important for midwives to be aware of what happens elsewhere. In June 2014, the International Congress of Midwives (ICM) holds its 30th congress in Prague—coincidentally the location of a discussion previously covered in this column (Symon, 2012). Sharing knowledge and experience with midwives from other countries can be enlightening, and can help us to appreciate better what we have come to expect in this country.
The debate about caesarean section rates will be familiar to most readers, and many will have heard that the situation in Brazil is particularly acute. In 2004 the Ministry of Health estimated a rate of 41.8% (Zizza et al, 2011), but there are reports that it is much higher in many hospitals, especially in the private health sector, where the rate is often well in excess of 80% (Hopkins et al, 2014). Demand from women has been cited as one of the causes of such a high rate, but even if demand from women for this operation may exist, most will assume that the operation is not performed against a woman's wishes. A cornerstone of our understanding in this country is that a caesarean section—with very few exceptions—can only be performed with the woman's consent. In describing a rare example of a court-ordered caesarean in the UK earlier this year (Symon, 2014) I stressed that the decision had only been reached after careful consideration had concluded that the woman was not mentally competent. After discussion with the woman's family, the course of action was also believed objectively to be in her best interests.
The logic of the decision being in the woman's best interests has just been used in very different circumstances in Brazil. On 2 April 2014 it was reported that a woman was taken from her home in the middle of the night after a judicial order ruled that she must have a caesarean section (Mendes, 2014). Adelir Carmem Lemos de Góes had had two previous caesareans but wanted a vaginal birth in her third pregnancy. She had attended the hospital the previous day (at either 41 or 42 weeks; versions conflict) with lower abdominal pain. She was not in labour, but when faced with being told that she must have a caesarean section she signed herself out and went home to await spontaneous labour. Her intention was to have the baby in hospital.
It appears that the hospital sought a judicial order for a caesarean section claiming that their objective ‘was to preserve the health and integrity of mother and baby’. There were also claims that the baby was presenting by the breech. Reports suggest that at 01:48 hrs that night armed police arrived to take Adelir Carmem away by ambulance. They arrived at the hospital at 02:40 hrs where she went straight to the operating theatre. Her baby was born by caesarean section at 03:10 hrs (Mendes, 2014).
This story is shocking for several reasons. Quite apart from trying to imagine what it's like to have the police arrive in the middle of the night to take you for an operation, Adelir Carmem's autonomy was completely disregarded. The protections offered in the UK following the Re MB [1997] case are that a mentally competent woman can decide what happens to her body, irrespective of her reasoning (‘for religious reasons, other reasons, for irrational or rational reasons or for no reason at all’ (per Butler-Sloss LJ @ 437). There was no suggestion that Adelir Carmem was not mentally competent. Even assuming that the baby was ‘breech’, the fact that the mother is mentally competent means that the decision should be hers. The argument that this course of action was done partly to protect the baby's health and integrity does not hold legal water either: as in the UK, the baby has no legal rights in Brazil until it is born. A proposal to introduce fetal rights into Brazilian law in 2012 was withdrawn following protests.
Adelir Carmem's partner was not allowed to accompany her to the operating theatre despite, according to Mendes (2014), a 2005 federal law which obliges those working in the public health system to allow the presence of a companion to be present throughout labour, birth and the immediate postnatal period. The companion is nominated by the labouring woman. The hospital justified this stance because the father was ‘frantic… To guarantee the safety of the procedure, they opted to perform the cesarean section without the presence of the father’ Mendes (2014).
Gabriella Sallit, a constitutional lawyer commenting on the case stated that ‘It is a violation of constitutional principles, such as the right to have control over your own body and the right to privacy’. She drew two analogies to explain the principle: ‘Prostitution is not a crime, but exploiting prostitution is a crime. That is to say a human being can violate his or her own body. Attempting suicide is not a crime, but aiding suicide is. Why is that? Because the judicial system acknowledges the autonomy of a person over their own life and body. If we did not have this guarantee, we'd have an institutionalised dictatorship’ (Mendes, 2014). Some feminists in Brazil disagree that this autonomy is guaranteed, claiming that the doctrine of ‘materno-infantilism’ is alive and well. This is the term used to refer to how ‘women are infantilised, considered childish and in need of guardianship from health services instead of being treated as consenting adults (justifying the absence of informed choice)…’ (Diniz, 2012: 126).
Midwives may have some sympathy with the health care staff who presumably wanted to try and ensure a live mother and baby. Having had two caesarean sections already Adelir Carmem's situation was not ideal; she may also have been just over two weeks over her due date (there seems to have been some disagreement over dates), and if the baby was presenting by the breech this will also have increased the clinical risk level. Nevertheless, the central issue is the woman's autonomy: do we trust her to decide what to do with her body, or do we take this away from her? Adelir Carmem was not planning a home birth with no medical intervention; she planned to attempt a vaginal birth in hospital. Using the full might of the law to force her to have a caesarean section looks, from the outside, to be a misuse of power.
It is evident that women in some parts of the world cannot expect the same rights and protections that women in the UK might take for granted. Being aware of such differences can help us to appreciate hard-won rights in this country, but they also encourage us to offer support to those living in very different circumstances.