¿Vulneración del derecho a decidir entre parto natural o cesárea?: Análisis de la Sentencia 233/2023, 22 de febrero Juzgado de lo Contencioso Administrativo número 5 de Las Palmas de Gran Canaria / [Violation of the right to decide between natural birth or cesarean section?: Analysis of Sentence 233/2023, February 22, Contentious Administrative Court number 5 of Las Palmas de Gran Canaria]

A través del presente comentario se analiza la Sentencia del Juzgado de lo Contencioso Administrativo número 5 de Las Palmas de Gran Canaria, de 22 de febrero de 2023, ECLI:ES:JCA:2023:1039; en la que se condena al Servicio Canario de Salud a indemnizar a una mujer con un millón de euros por vulnerar su derecho a decidir entre parto natural o cesárea e imponer un parto gemelar natural prolongado hasta 17 horas que tuvo como consecuencia una lesión cerebral irreversible. (AU)

Through this commentary, the Judgment of the Administrative Court number 5 of Las Palmas de Gran Canaria, dated February 22, 2023, ECLI:ES:JCA:2023:1039, is analyzed. In this judgment, the Canarian Health Service is condemned to compensate a woman with one million euros for violating her right to choose between natural childbirth or cesarean section, and imposing a prolonged natural twin birth lasting up to 17 hours, which resulted in irreversible brain damage. (AU)

Lei da cesárea: sentidos produzidos na mídia e no cotidiano dos serviços de saúde / Cesarean law: meanings produced in the media and in the daily life of health services

Há mais de 20 anos iniciativas governamentais e movimentos sociais brasileiros, embasados em evidências científicas, vêm construindo propostas que visam a mudar o modelo de atenção obstétrica do país. Na contramão desse processo, que vinha alterando paulatinamente as formas e os indicadores de nascimento no Brasil, em 23 de agosto de 2019 o estado de São Paulo promulgou a Lei nº 17.137, cujo projeto tramitou em regime de urgência na Assembleia Legislativa. Conhecida como a Lei da Cesárea, a nova ordem legal garantia às gestantes, em todo território paulista, a opção pela cesariana a partir da trigésima nona semana de gravidez, mesmo sem indicação. Em julho de 2020 a lei foi declarada inconstitucional pelo Tribunal de Justiça de São Paulo, e em agosto de 2021 o Superior Tribunal Federal a julgou constitucional. O presente projeto analisou os discursos e os sentidos produzidos sobre a Lei da Cesárea no jornal Folha de S.Paulo, bem como seus desdobramentos no cotidiano dos serviços de assistência ao parto, ancorando-se no quadro teórico-metodológico das práticas discursivas e produção de sentidos no cotidiano. Este trabalho possibilitou compreender que a Lei da Cesárea foi resultado de uma articulação de grupos que negam as evidências científicas. Ficou evidente que a nova normativa, não discutida nem pactuada, gerou inseguranças e o enfraquecimento de toda a rede de atenção ao parto e nascimento.

For more than 20 years, Brazilian government initiatives and social movements, based on scientific evidence, have been building proposals that aim to change the obstetric model of care across the country. However, opposite to this process, which was gradually changing the forms and indicators of childbirth in Brazil, on August 23, 2019, the state of São Paulo enacted Law No. 17.137 whose project was processed as a matter of urgency in the Legislative Assembly. It is known as the Caesarean section Law, the new legal order guaranteed pregnant women throughout the territory of São Paulo, the option for cesarean section from the thirty-ninth week of pregnancy, even without indication. In July 2020 the law was declared unconstitutional by the São Paulo Court of Justice, and in August 2021 the Superior Federal Court ruled it constitutional. The present project analyzed the discourses and the meanings produced about the Cesarean Law in the Folha de S.Paulo newspaper, as well as its deployment in the daily routine of childbirth care services, anchored in the theoretical-methodological framework of discursive practices and production of senses in everyday life. This work made it possible to understand that the Cesarean Law was the result of an articulation of groups that deny scientific evidence. It was evident that the new regulations were not discussed or agreed upon, generated insecurities and weakened the entire delivery and birth care network.

A national measure to reduce primary cesarean rates in Turkey.

Purpose: To examine the influence of the "Physician Unit Performance Coefficient" (PUPC) regulation, taken into force by the TR Ministry of Health in January 2013 in our country, based on the cesarean rates in our clinic.Methods: The pregnant women who gave birth at the Diyarbakir Maternity and Pediatrics Hospital within a period of three years before the PUPC has been taken into force and the pregnant women who have birth within a period of three years after January 2013, when the regulation has been taken into force, have been divided into two groups as Group 1 and Group 2, respectively. Comparisons have been made between the two groups with respect to primary cesarean, total cesarean, neonatal mortality, and maternal mortality rates.Results: From the 125,816 pregnant women who gave birth between February 2010 and January 2016, 58,856 (46.7%) are included in Group 1 and the remaining 66,960 (53.3%) are in Group 2. The total Cesarean Rate is 27% in Group 2 and 24.8% in Group 1. The primary Cesarean Rate is 11.3% in Group 2 and 13.5% in Group 1. The neonatal mortality rate is 7.81‰ in Group 2 and 10‰ in Group 1. The differences in the total cesarean rates, primary cesarean rates and neonatal mortality rates have been found statistically significant. Maternal mortality rates have been found to be 5.1 in 100,000 in Group one and 4.48 in 100,000 in Group 2 and the difference between the two groups has not been found as statistically significant.Conclusions: A meaningful reduction has been achieved in the primary cesarean rates without increasing maternal and neonatal mortality rates after the PUPC, implemented by the TR Ministry of Health, has been taken into force.

Defensive caesarean section: A reality and a recommended health care improvement for Romanian obstetrics.

RATIONALE: Defensive caesarean section (CS) has become one of the most common medical procedure worldwide. Additionally, performing CS in accordance with the patient's choice is an appropriate professional practice. AIMS AND OBJECTIVE: This paper reports a prospective, observational, multicenter study to quantify the use of this type of practice that is performed by obstetricians to avoid medico-legal complaints and decrease the frequency of malpractice litigations. METHODS: We interviewed 73 obstetricians from three distinct units of obstetrics and gynaecology, to assess their opinion regarding defensive caesarean delivery and caesarean delivery performed upon maternal request. We conducted an opinion-based survey using questionnaires based on nine, close-ended questions. RESULTS: Out of 73 respondents, 51 (69.9%) stated that they perform defensive CS; 63 (86.3%) declared that their choice of birth delivery is influenced by the risk of being accused of malpractice; 60 (82.2%) indicated that it is normal for the patient to be able to decide on the type of delivery; and 63 (86.3%) declared that they consult their patients regarding their delivery preferences. We found statistically significant differences between the respondents who declare that they perform defensive CS (69.9%) and those who said that they are influenced by the risk of malpractice when they choose the method of delivery for their patients (86.3%) (P < .001; McNemar Test). CONCLUSIONS: The results of our study indicate that defensive caesarean section is a widespread practice among obstetrics practitioners in Romania.

[Women's experience with cesareans in Uruguay: the woman's right to be accompanied by a person of her choice and difficulties with enforcement]. / Experiencia de mujeres con cesárea en Uruguay: el derecho a estar acompañada por una persona de su elección y las dificultades en su cumplimiento.

The article aims to analyze how women are accompanied by a trusted person during cesareans, as guaranteed under Law 17,386 on "accompanying persons during labor and childbirth", enacted in Uruguay in 2001. The findings are part of a larger study on the experience and meaning of cesareans for Uruguayan women. An exploratory, descriptive qualitative methodology was used for this purpose. The technique involved in-depth interviews with 31 women whose cesareans were performed in their first pregnancy in the city and greater metropolitan area of Montevideo. Based on the findings, the conclusion is that having a trusted accompanying person during labor and childbirth is experienced by women as a factor for emotional protection given the anxieties generated by a major surgery like a cesarean. Nevertheless, for the women interviewed in the study, "being accompanied" was not a continuous process, but characterized by a series of separations, both from the accompanying persons and from their children, causing anxiety, anguish, ambivalent feelings towards the newborn infant, and difficulties in mother-infant bonding, especially in the immediate postpartum.

El objetivo de este artículo es analizar el acompañamiento durante la cesárea, por parte de una persona de confianza de la mujer, consagrado por la Ley nº 17.386 de "acompañamiento en el parto", aprobada en Uruguay en el año 2001. Los resultados forman parte de una investigación mayor sobre la vivencia y el significado de la cesárea para las mujeres que pasaron por esta experiencia. Para ello se optó por una metodología cualitativa de carácter exploratorio y descriptivo. La técnica utilizada fue la entrevista en profundidad, realizada a un total de 31 mujeres, cuyas cesáreas tuvieron lugar en su primera gestación, en Montevideo y área metropolitana (Uruguay). De los resultados obtenidos, se concluye que el acompañamiento en el proceso de trabajo de parto y nacimiento es vivido por las mujeres como un factor de protección emocional ante las ansiedades que genera la experiencia de una cirugía mayor como es la cesárea. Sin embargo, para las mujeres entrevistadas, el "acompañamiento" más que continuo se caracterizó por una serie de separaciones, tanto de sus acompañantes, como de sus hijos/as, lo cual provocó ansiedad, angustia, sentimientos de ambivalencia ante el recién nacido, dificultades en el establecimiento del vínculo materno-filial, sobre todo en el puerperio inmediato.

O objetivo deste artigo é analisar o acompanhamento durante a cesariana, por parte de uma pessoa de confiança da mulher, consignado pela Lei nº 17.386 de "parto assistido", adotada no Uruguai no ano de 2001. Os resultados fazem parte de uma pesquisa maior sobre a experiência e o significado da cesariana para as mulheres que passaram por esta experiência. Para esse fim, foi escolhida uma metodologia qualitativa de caráter exploratório e descritivo. A técnica utilizada foi a entrevista en profundidade, realizada em um total de 31 mulheres, cujas cesarianas tiveram lugar na sua primeira gestação, em Montevidéu e área metropolitana (Uruguai). A partir dos resultados obtidos, concluiu-se que o acompanhamento no processo de trabalho de parto e nascimento é experimentado pelas mulheres como um fator de proteção emocional ante as ansiedades que geram a experiência de uma cirurgia maior como a cesariana. No entanto, para as mulheres entrevistadas, o "acompanhamento" ao invés de continuo foi caracterizado por uma série de separações, tanto de seus acompanhantes, como de seus filhos/as, o qual provocou ansiedade, aflição, sentimentos de ambivalência em relação ao recém-nascido, dificuldades no estabelecimento do vínculo materno, especialmente no puerpério imediato.

Early Elective Delivery Disparities between Non-Hispanic Black and White Women after Statewide Policy Implementation.

BACKGROUND: In 2011, Oregon implemented a policy that reduced the state's rate of early (before 39 weeks' gestation) elective (without medical need) births. OBJECTIVE: This analysis measured differential policy effects by race, examining whether Oregon's policy was associated with changes in non-Hispanic Black-White disparities in early elective cesarean and labor induction. METHODS: We used Oregon birth certificate data, defining prepolicy (2008-2010) and postpolicy (2012-2014) periods, including non-Hispanic Black and White women who gave birth during these periods (n = 121,272). We used longitudinal spline models to assess policy impacts by race and probability models to measure policy-associated changes in Black-White disparities. RESULTS: We found that the prepolicy Black-White differences in early elective cesarean (6.1% vs. 4.3%) were eliminated after policy implementation (2.8% vs. 2.5%); adjusted models show decreases in the odds of elective early cesarean among Black women after the policy change (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-1.00; p = .050) and among White women (adjusted odds ratio, 0.79; 95% confidence interval, 0.67-0.93; p = .006). Adjusted probability models indicated that policy implementation resulted in a 1.75-percentage point narrowing (p = .011) in the Black-White disparity in early elective cesarean. Early elective induction also decreased, from 4.9% and 4.7% for non-Hispanic Black and non-Hispanic White women to 3.8% and 2.5%, respectively; the policy was not associated with a statistically significant change in disparities. CONCLUSIONS: A statewide policy reduced racial disparities in early elective cesarean, but not early elective induction. Attention to differential policy effects by race may reveal changes in disparities, even when that is not the intended focus of the policy.

Medical Malpractice Liability Exposure and OB/GYN Physician Delivery Decisions.

OBJECTIVE: This study examines the effect of physician medical malpractice liability exposure on primary Cesarean and vaginal births after Cesarean (VBACs). DATA SOURCES/STUDY SETTING: Secondary data on hospital births from Florida Hospital Inpatient File, physician characteristics from American Medical Association Physician Masterfile, and physician malpractice claim history from Florida Office of Insurance Regulation. STUDY DESIGN: Our study estimates the effects of physician malpractice liability exposure on Cesareans and VBACs using panel data and a multivariate, fixed effects model. DATA COLLECTION: We merge three secondary data sources based on unique physician license numbers between 1994 and 2010. PRINCIPAL FINDINGS: We find no evidence that the first malpractice claim affects primary Cesarean deliveries. We find, however, that the first malpractice claim decreases the likelihood of a VBAC (conditional on a prior Cesarean delivery) by 1.2-1.9 percentage points (approximately 10 percent relative to mean VBAC incidence). This finding is robust to focusing on obstetrics-related malpractice claims, as well as to considering different malpractice claims (first report, first severe report, and first lawsuit). CONCLUSIONS: Given the increase in both primary and repeat Cesarean deliveries, our results suggest that physician malpractice liability exposure is responsible for a relatively small share of the VBAC decrease.

Experiencia de mujeres con cesárea en Uruguay: el derecho a estar acompañada por una persona de su elección y las dificultades en su cumplimiento / Women's experience with cesareans in Uruguay: the woman's right to be accompanied by a person of her choice and difficulties with enforcement / Experiência de mulheres com cesariana no Uruguai: o direito a estar acompanhada por uma pessoa de sua confiança e as dificuldades no seu cumprimento

El objetivo de este artículo es analizar el acompañamiento durante la cesárea, por parte de una persona de confianza de la mujer, consagrado por la Ley nº 17.386 de "acompañamiento en el parto", aprobada en Uruguay en el año 2001. Los resultados forman parte de una investigación mayor sobre la vivencia y el significado de la cesárea para las mujeres que pasaron por esta experiencia. Para ello se optó por una metodología cualitativa de carácter exploratorio y descriptivo. La técnica utilizada fue la entrevista en profundidad, realizada a un total de 31 mujeres, cuyas cesáreas tuvieron lugar en su primera gestación, en Montevideo y área metropolitana (Uruguay). De los resultados obtenidos, se concluye que el acompañamiento en el proceso de trabajo de parto y nacimiento es vivido por las mujeres como un factor de protección emocional ante las ansiedades que genera la experiencia de una cirugía mayor como es la cesárea. Sin embargo, para las mujeres entrevistadas, el "acompañamiento" más que continuo se caracterizó por una serie de separaciones, tanto de sus acompañantes, como de sus hijos/as, lo cual provocó ansiedad, angustia, sentimientos de ambivalencia ante el recién nacido, dificultades en el establecimiento del vínculo materno-filial, sobre todo en el puerperio inmediato.

The article aims to analyze how women are accompanied by a trusted person during cesareans, as guaranteed under Law 17,386 on "accompanying persons during labor and childbirth", enacted in Uruguay in 2001. The findings are part of a larger study on the experience and meaning of cesareans for Uruguayan women. An exploratory, descriptive qualitative methodology was used for this purpose. The technique involved in-depth interviews with 31 women whose cesareans were performed in their first pregnancy in the city and greater metropolitan area of Montevideo. Based on the findings, the conclusion is that having a trusted accompanying person during labor and childbirth is experienced by women as a factor for emotional protection given the anxieties generated by a major surgery like a cesarean. Nevertheless, for the women interviewed in the study, "being accompanied" was not a continuous process, but characterized by a series of separations, both from the accompanying persons and from their children, causing anxiety, anguish, ambivalent feelings towards the newborn infant, and difficulties in mother-infant bonding, especially in the immediate postpartum.

O objetivo deste artigo é analisar o acompanhamento durante a cesariana, por parte de uma pessoa de confiança da mulher, consignado pela Lei nº 17.386 de "parto assistido", adotada no Uruguai no ano de 2001. Os resultados fazem parte de uma pesquisa maior sobre a experiência e o significado da cesariana para as mulheres que passaram por esta experiência. Para esse fim, foi escolhida uma metodologia qualitativa de caráter exploratório e descritivo. A técnica utilizada foi a entrevista en profundidade, realizada em um total de 31 mulheres, cujas cesarianas tiveram lugar na sua primeira gestação, em Montevidéu e área metropolitana (Uruguai). A partir dos resultados obtidos, concluiu-se que o acompanhamento no processo de trabalho de parto e nascimento é experimentado pelas mulheres como um fator de proteção emocional ante as ansiedades que geram a experiência de uma cirurgia maior como a cesariana. No entanto, para as mulheres entrevistadas, o "acompanhamento" ao invés de continuo foi caracterizado por uma série de separações, tanto de seus acompanhantes, como de seus filhos/as, o qual provocou ansiedade, aflição, sentimentos de ambivalência em relação ao recém-nascido, dificuldades no estabelecimento do vínculo materno, especialmente no puerpério imediato.

Legal Briefing: Unwanted Cesareans and Obstetric Violence.

A capacitated pregnant woman has a nearly unqualified right to refuse a cesarean section. Her right to say "no" takes precedence over clinicians' preferences and even over clinicians' concerns about fetal health. Leading medical societies, human rights organizations, and appellate courts have all endorsed this principle. Nevertheless, clinicians continue to limit reproductive liberty by forcing and coercing women to have unwanted cesareans. This "Legal Briefing" reviews recent court cases involving this type of obstetric violence. I have organized these court cases into the following six categories: 1. Epidemic of Unwanted Cesareans 2. Court-Ordered Cesareans 3. Physician-Coerced Cesareans 4. Physician-Ordered Cesareans 5. Cesareans for Incapacitated Patients 6. Cesareans for Patients in a Vegetative State or Who Are Brain Dead.

Oregon's Hard-Stop Policy Limiting Elective Early-Term Deliveries: Association With Obstetric Procedure Use and Health Outcomes.

OBJECTIVE: To evaluate the association of Oregon's hard-stop policy limiting early elective deliveries (before 39 weeks of gestation) and the rate of elective early-term inductions and cesarean deliveries and associated maternal-neonatal outcomes. METHODS: This was a population-based retrospective cohort study of Oregon births between 2008 and 2013 using vital statistics data and multivariable logistic regression models. Our exposure was the Oregon hard-stop policy, defined as the time periods prepolicy (2008-2010) and postpolicy (2012-2013). We included all term or postterm, cephalic, nonanomalous, singleton deliveries (N=181,034 births). Our primary outcomes were induction of labor and cesarean delivery at 37 or 38 weeks of gestation without a documented indication on the birth certificate (ie, elective early term delivery). Secondary outcomes included neonatal intensive care unit admission, stillbirth, macrosomia, chorioamnionitis, and neonatal death. RESULTS: The rate of elective inductions before 39 weeks of gestation declined from 4.0% in the prepolicy period to 2.5% during the postpolicy period (P<.001); a similar decline was observed for elective early-term cesarean deliveries (from 3.4% to 2.1%; P<.001). There was no change in neonatal intensive care unit admission, stillbirth, or assisted ventilation prepolicy and postpolicy, but chorioamnionitis did increase (from 1.2% to 2.2%, P<.001; adjusted odds ratio 1.94, 95% confidence interval 1.80-2.09). CONCLUSIONS: Oregon's statewide policy to limit elective early-term delivery was associated with a reduction in elective early-term deliveries, but no improvement in maternal or neonatal outcomes.

Responding to refusal of recommended cesarean section: Promoting good parenting.

Consideration of what a "good parent" would do in controversial perinatal cases has been largely absent from to ethics literature. This article argues when a cesarean section is required to prevent death or serious disability for a fetus, the pregnant woman has an ethical (although not legal) obligation to undergo that procedure even when she has concerns or conflicting commitments. Further, a clinician may be justified in using persuasive counseling when there is grave harm at stake that the patient has a moral obligation to prevent. This conclusion is tested by exploring its implications in several other analogous controversial contexts.

Caesarean delivery: conflicting interests.

Within the maternal-fetal relationship, interests may sometimes diverge. In this paper, a pregnant woman's refusal to undergo a caesarean delivery, which was recommended both to save the life of the fetus and to minimize risks to her, is described. The legal aspects involved in the conflict between maternal autonomy and fetal well-being are analysed. The patient requested an abortion because of the poor condition of the fetus; however, according to Spanish legislation, the possibility of abortion was rejected as the pregnancy was in its 27th week. The woman still persisted in her refusal to accept a caesarian delivery. After the medical team sought guidance on the course to follow, the Duty Court authorized a caesarean delivery against the wishes of the patient. From a legal point of view, at stake were the freedom of the woman - expressed by the decision to reject a caesarean delivery - and the life of the unborn child. In clinical treatment, the interests of the fetus are generally aligned with those of the pregnant woman. When they are not, it is the pregnant woman's autonomy that should be respected, and coercion should form no part of treatment, contrary to the decision of this court.

Cesarean section on maternal request: should it be formally prohibited in Italy?

BACKGROUND: Cesarean section on maternal request (CSMR) could represent an avoidable quota of cesareans. In Italy, this is a topical problem of health-policy, involving ethical, juridical and medical issues. AIM AND METHODS: A 5-questions questionnaire to quantitatively assess the perspectives of medical, juridical and ethical issues of planned CSMR was administered to obstetricians and gynecologists, midwives, lawyers and pregnant women. It was assessed to what extent those issues matter on the final decision of planning a CSMR. RESULTS: Non-homogeneous answers of stakeholders suggest different perspectives about issues on CSMR. The juridical issue seems to have the greatest impact on the final decision. CONCLUSION: Planning a CSMR associates overall with juridical issues in each group of respondents. Therefore, an obstetrician and gynecologist is unable to counsel a patient on CSMR from a medical point of view. The most direct way for reducing cesareans in Italy could be the formal prohibition of CSMR.