Who has more rights: Unborn child or mother?
Elective C-sections cut HIV risk by half
In an unusual move, editors of the New England Journal of Medicine approved the early release of an article detailing research by the National Institute of Child Health and Human Development (NICHD) in Bethesda, MD. The NICHD indicates pre-labor cesarean sections in HIV-positive women can significantly reduce the risk of transmission of the HIV virus to the baby.
Although not scheduled for publication in the journal until April, editors said that the study’s findings were so compelling, they made the article available on their Web site (www.nejm.org) on Jan. 28.
"This finding can prevent needless suffering and loss of life," NICHD Director Duane Alexander, MD, advised in a National Institutes of Health news release regarding the study. "A C-section presents risks to the mother, so each case must be evaluated individually — but this fact is striking — C-sections cut mother-to-child HIV transmission by at least 50%." (See related story on findings of the NICHD study, p. 29.)
The finding also adds some urgency to the debate over balancing the rights of pregnant women with the health needs of their unborn children, and hospital ethics committees and administrators may soon find themselves facing these issues head-to-head, experts predict.
"This is perhaps a special case of all the other issues about maternal-fetal conflict," says Rosalind Elkman Ladd, a professor of medical ethics in the Department of Philosophy at Wheaton College in Norton, MA, and a member of two hospital ethics committees. "I think the question will be, if many doctors adopt this information, is whether it will be totally elective on the mother’s part or will there be some formal or informal effort at coercion."
Several states have already established regulatory measures that compel expectant mothers to take certain action on behalf of their fetuses, and it is not unrealistic to expect that some people may argue that HIV-positive women should be compelled to undergo cesareans if they become pregnant and choose to carry the child to term, Ladd adds.
"There is a very strong state interest in having healthy babies," she says. "Some may argue that it is within the right of the state to say, When you make the decision to carry the child to term, you have the obligation — and we are going to impose the obligation — to submit to a cesarean, even against your will, if it is felt that it is vital to the interests of the baby.’"
Aside from the ethical debate, most hospitals will have to consider issues of ensuring informed consent and advising physicians on the legal and ethical implications of the medical counseling they give their HIV-positive pregnant patients.
Ladd is aware of several instances when ethics committees were faced with an obstetrician who advised a C-section for medical reasons for a mother who refused to submit to the procedure.
"In a lot of cases you have physicians who are very focused on saving lives, saving these babies," she notes. "You have to clarify the issues for them. One, that they can’t perform a surgical procedure on an adult, competent person without her consent."
Ladd doubts that the issue of lack of informed consent will come up with any HIV cases.
"These are very competent individuals who are able to make these decisions," she adds. "You might have a case of someone who just had extremely unrealistic beliefs about how the virus was transmitted. You could make the argument that the person was out of touch with reality and incapable of making that decision for herself, but I don’t think that would be something that would happen often."
What physicians may tell their patients may be another issue that will come up. "What do you do in a case like this [where a patient is reluctant to have the procedure]?" questions Ladd. "How much pressure are you allowed to put on somebody? Could you go to a court for an order, the way you can in some other medical emergencies when people make decisions for their children?"
There is not much law in this area, Ladd adds, so ethics committees can only be aware of laws and regulations in their state and make the physicians aware of all of the options and obligations.
Although the research presented by the NICHD may be compelling, that does not necessarily mean it will change medical practice right away, says John Larsen, MD, professor and chairman of the department of OB/GYN at George Washington University Medical Center in Washington, DC.
"I don’t think the United States will suddenly change overnight and we will start sectioning everyone who is HIV-positive," he says. "There will be some serious discussions, and some women, certainly, will get C-sections. But, there remains the question of what are the associated risk factors that can be separated out into whether you are doing more harm or less harm?"
For example, Larsen notes, women who contracted HIV through intravenous drug use may have damage to their veins that make them poor surgical candidates. Among HIV-positive pregnant women are also a disproportionately high number of individuals who are noncompliant with drug therapy and likely to have a resistance and high viral load that might also preclude surgery, he adds.
Examining how many of these women were included in the studies evaluated by the meta-analysis will be of interest to many obstetricians, suggests Larsen. In addition, many experts are waiting for more information on the impact of long-term antiretroviral drugs on maternal-fetal transmission of the virus.
"All of this information [the use of new drugs and elective cesarean] is very cutting-edge," he states.
Previous European studies have indicated a possible benefit of elective cesarean and he has used this information when counseling patients, he says. "This will probably be more information, more news that people can work with."
Sources
For more information regarding maternal-fetal HIV transmission risk, contact:
• Rosalind Elkman Ladd, Wheaton College, Department of Philosophy, 25 E. Main St., Norton, MA 02766.
• John Larsen, MD, Department of OB/GYN, George Washington University Medical Center, Office of Public Relations, 1001 22nd St. NW, Suite 820, Washington, DC 20037.
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