Fetal Consequentialism and Maternal Mortality

By Nadia N. Sawicki

It is well known that maternal mortality rates in the United States are higher than in other countries in the developed world, and that many of these deaths are preventable. But a report published by NPR last week, just a few days before Mother’s Day, drew a direct link between these poor maternal outcomes and health care providers’ focus on fetal health. The report quotes Barbara Levy, vice president for health policy and advocacy at the American Congress of Obstetricians and Gynecologists, who said, “We worry a lot about vulnerable little babies, [but] we don’t pay enough attention to those things that can be catastrophic for women.” According to the authors of the NPR report, “newborns in the slightest danger are whisked off to neonatal intensive care units … staffed by highly trained specialists prepared for the worst,” while new mothers are instead monitored by nurses and physicians “who expect things to be fine and are often unprepared when they aren’t.”

These patterns are consistent with what Prof. Jamie Abrams calls “fetal consequentialism” – the premise that the birth of a healthy child outweighs any harm to the birthing mother. The increase in U.S. maternal mortality rates highlighted in the NPR report is certainly a product of such fetal consequentialism. So is the practice of obstetric violence, described in my previous posts, where health care providers dismiss birthing mothers’ informed requests for minimal intervention during labor and delivery in an effort to reduce the risk of fetal harm, even when that risk is minimal. Fetal consequentialism is likely driven not only by providers’ judgments of the relative liability risks for harms to fetuses versus harms to mothers, but also by conservative societal trends (evidenced by increasing anti-abortion legislation) that preference fetal interests over maternal interests.

The NPR report focused on pregnancy-related mortality caused by conditions – like preeclampsia, hemorrhaging, and infection – that often go unnoticed by providers who are focusing on the health of the neonate. The report did not, however, address the morbidity associated with many of the medical interventions that have become increasingly common during labor and delivery – including continuous electronic fetal monitoring, induction of labor, epidural analgesia, and Cesarean section for low-risk deliveries. Whether the routine use of such interventions actually improves outcomes for neonates is open for debate, but there is no question that these interventions increase risks to birthing mothers. The legal and ethical principles of informed consent require that women be informed of these risks, and that their informed choices about which medical treatments to accept be given the same respect as the choices made by patients who are not pregnant. If physicians are choosing to violate patients’ clearly established legal rights to autonomous medical decision-making in order to reduce an already small risk of fetal harm (in the obstetric violence cases I have researched, there is no certainty that fetal harm will occur in the absence of medical intervention, and physicians’ predictions of risk often turn out to be unfounded), fetal consequentialism has gone too far.

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