Ethics in reproductive health care: a midwifery perspective.

Knowledge and technologic advancements have created a myriad of new screening, diagnostic, and treatment options for women of reproductive age. These new options often raise ethical issues as the women, their health care professionals, and society adapt to the benefits while coping with the pressures and burdens these options create. Threats to accomplishing the good that midwifery strives to contribute to health care for the benefit of women are identified from the perspective of the midwife's instrumental and expressive roles. Suggestions are presented for resolving ethical dilemmas that may occur in the selection and implementation of health care options. A distinction is made between midwifery practice at the microlevel, which achieves the good through direct interaction with the woman, and the institutional macrolevel that promotes accomplishing the good in reproductive health care through policy developmental and management decisions.

PIP: This article considers ethical issues arising from new reproductive health options and the impact of these issues on the practice of midwifery in the US. The article defines the vision of "the good" held by midwives as a blend of the expression of caring rooted in nursing and the instrumentality of cure rooted in medicine, which is based on the belief that reproduction is normal and that interventions should be used for specific indications only. Next, the article discusses the implications for women and their families of 1) new care options, 2) new categories of patients, 3) the interrelatedness of women's choices, 4) the expectations of society, and 5) moral pluralism. After reviewing the implications of the erosion of traditional midwifery, the article considers the emerging discipline of bioethics as a possible means of resolving ethical dilemmas, the differences between the macro- and micro-levels of ethical engagement in the health care system, and the uniqueness of the patient in relation to reproductive health care. This is followed by a look at decision-making about screening and interventions arising from the devaluation of normal reproductive processes, about cost-related decisions, and about midwifery as a care option. Finally, it is proposed that the resolution of ethical dilemmas in midwifery practice depends upon seeking informed consent, resolving conflicts between respect for patient autonomy and beneficence, consulting institutional ethics committees, implementing a plan of care, and dealing with potential threats to patient autonomy.

The incidence of meconium-stained amniotic fluid from 1980 through 1986, by year and gestational age.

The annual incidence of meconium-stained amniotic fluid was analyzed for changes in a total obstetric sample of 45,115 singleton, vertex, liveborn infants over a 7-year study period. The incidence of meconium-stained amniotic fluid for the total obstetric population was calculated for each year of the study period. The sample was then stratified by estimated gestational age, and the incidence of meconium-stained amniotic fluid was calculated for each gestational age group. The incidence of meconium-stained amniotic fluid increased 40.9% over the study period, from 18.8% in 1980 to 26.5% in 1986 (P less than .001). This increase was found to be in a consistent linear trend (P less than .05). The incidence of meconium-stained amniotic fluid was also found to increase significantly in a linear trend as gestational age of the fetus increased. These findings lend support to both the maturational theory and the stress theory of meconium passage in utero.

Pregnancy-related mortality in New York City, 1980 to 1984: causes of death and associated risk factors.

To identify causes and risk factors for pregnancy-related mortality in New York City, we analyzed 224 pregnancy-related deaths that occurred from 1980 to 1984. The leading causes of death were ectopic pregnancy complications, embolism, intrapartum cardiac arrest, and hypertension. Mortality ratios were determined by comparing the characteristics of the women whose death was pregnancy-related with those of women who had survived delivery of a live infant in New York City during the same period. Black and Hispanic women had mortality ratios that were respectively 4.2 and 2.0 times higher than those for white, non-Hispanic women. In comparison with women aged 20 to 24, those older than 30 were more than twice as likely to die from pregnancy-related causes, and those older than 40 were five times as likely to do so. Other factors that were associated with an increased risk of pregnancy-related mortality included 9 to 11 years of education, lack of private medical insurance, more than five previous pregnancies, and fewer than five prenatal visits. This study suggests that changes in current maternal-health and family-planning services will be required to achieve further reductions in preventable pregnancy-related mortality.

Comparison of urinary transforming growth factor-alpha in women with disseminated breast cancer and healthy control women.

In an effort to explore the use of polypeptide growth factors as potential markers for cancer detection, we have identified the presence of transforming growth factor-alpha (TGF-alpha) in pooled urine of patients with metastatic breast cancer by a commercial radioimmunoassay (RIA) based on a rabbit antiserum raised to the C-terminal 17aa synthetic fragment of rat TGF-alpha. This TGF-alpha RIA detected both high molecular weight (HMW) and low molecular weight (LMW) forms of TGF-alpha in the conditioned media of a breast cancer cell line (MDA-MB-231) and in the urine of healthy women and those with breast cancer. The ratio of HMW to LMW species of TGF-alpha by RIA after Bio-Gel P-100 chromatography was approximately equal in pooled urine samples from both healthy women and those with breast cancer, and in the conditioned media from the cell line MDA-MB-231. Using established procedures for concentrating urinary proteins from 24-h urine samples by adsorption onto methyl-bonded microparticulate silica and selective elution by acetonitrile, TGF-alpha RIA results from women with disseminated breast carcinoma were compared with those of healthy pre- and post-menopausal control women. Analysis indicated a median TGF-alpha value of 981 ng/g urinary creatinine for urine samples from cancer patients (range 608 to 1737) and 642 ng/g creatinine (range 417 to 941) for control urine samples. Although the difference was statistically significant (p less than 0.05), urinary TGF-alpha detection with this assay method appears to have limited usefulness as a diagnostic marker for metastatic human adenocarcinoma of the breast.(ABSTRACT TRUNCATED AT 250 WORDS)