Who is best to assess maternal and fetal risk?

February 25, 2016 by Heather Zeiger report
Pregnancy test. Credit: public domain

(Medical Xpress)—At what point does fetal risk outweigh maternal autonomy? The recent findings that the Zika virus may cause birth defects have lead some governments in Latin American countries to recommend that women not get pregnant until the virus can be contained. The Centers for Disease Control and Prevention have recently recommended that pregnant women or women who could become pregnant should not drink alcohol. Additionally, the increase in babies born to women addicted to drugs has caused some U.S. areas to punish pregnant women who use illicit substances while pregnant.

Minkoff and Marshall explore when and if the state or doctors should intercede on behalf of the fetus by forcing a woman to undergo a recommended procedure or treatment. They evaluate the nature of and how risk is used to justify punishing a mother for decisions made before the baby is born. They contend that many decisions regarding when it is appropriate to limit a 's autonomy are based on subjective moral intuitions. They argue that it is ultimately up to the mother to make decisions in relation to the collective interest of her family. Their discussion and peer commentary responding to their paper appear in the recent issue of the American Journal of Bioethics.

Minkoff and Marshall begin their discussion by outlining the difference between absolute and relative risk and how relative risk can sometimes be used to justify preferences rather than assess actual risk thresholds. They use as examples a study on planned verses hospital births and a study of trial of labor after cesarean section (TOLAC). Reporting relative risk may involve saying a baby is twice as likely to die in a planned home birth as in the hospital, but absolute risk shows that the likelihood of a baby dying in a planned home birth is 1 in 1,000. The risk for both is low, but one is relatively higher than the other. TOLAC has a higher relative and absolute risk of infant mortality, but physicians are more likely to allow this than they are home births. The authors point out that a person's preconceived notions on a procedure may determine whether he or she considers the risk significant or not.

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recognize that any intervention to help the fetus will have implications for the woman's bodily health and, therefore, cannot be performed without her explicit informed consent. While parents have a special obligation to their children Minkoff and Marshall take the view that even though the fetus has an evolving moral status during a voluntary continued pregnancy, parents do not have the same obligations as they do to born children.

They contend that the issue is less about the duty of the parent and more about the conduct of the state. On what basis can the state enforce coercive interventions that conflict with the mother's autonomy? Their examples from past cases as well as a survey among obstetricians indicate that the decision is based on motivated reasoning stemming from evolutionary-based intuitions on the developing fetus. Difficulties and disagreements occur in cases where these moral intuitions seems to conflict.

They conclude that while there may appear to be a conflict in moral intuitions, there actually does not have to be conflicts. The pregnant woman should be able to make decisions in relation to the collective interests of the entire family because it is her "personal, fetal, and family interests [that] hang in the balance." In other words, she considers the consequences to fetus and to herself within the context of the family or community.

There were several peer commentaries that provided comment or critique on Minkoff and Marshall's paper. They included discussions on the moral status of the fetus, gender biases and expectations, the subjectivity of determining risk, relational autonomy, cultural views on risk and pregnancy, racial biases in coerced care, as well as risk and religious obligations to fast.

Explore further: Second pregnant woman diagnosed with Zika in Australia

More information: Howard Minkoff et al. Fetal Risks, Relative Risks, and Relatives' Risks, The American Journal of Bioethics (2016). DOI: 10.1080/15265161.2015.1120791

Several factors related to fetal risk render it more or less acceptable in justifying constraints on the behavior of pregnant women. Risk is an unavoidable part of pregnancy and childbirth, one that women must balance against other vital personal and family interests. Two particular issues relate to the fairness of claims that pregnant women are never entitled to put their fetuses at risk: relative risks and relatives' risks. The former have been used—often spuriously—to advance arguments against activities, such as home birth, that may incur risk; the latter implicate the nature of relationships in determining the acceptability of coercing or precluding activities. Motivated reasoning by clinicians and judges leads to inaccurate risk assessments, and judgments based on false claims to objectivity. Such judgments undermine the moral and legal standing of pregnant women and do not advance the interests of fetuses, pregnant women, families, or states.

Related Stories

Second pregnant woman diagnosed with Zika in Australia

February 12, 2016
A second pregnant woman has been diagnosed with the mosquito-borne Zika virus in Australia, officials said Friday, adding that the disease was acquired overseas and there was no public health risk.

Pregnant woman diagnosed with Zika in Australia

February 10, 2016
A pregnant woman has been diagnosed with the Zika virus in Australia, officials said Wednesday, adding that the disease was acquired overseas.

Millions of pregnant women put their babies at risk with alcohol: CDC

February 2, 2016
(HealthDay)—Drinking before and during pregnancy can cause lifelong physical, behavioral and mental problems for a child. Yet more than 3 million U.S. women risk exposing their baby to alcohol, federal health officials ...

Mexican woman with Zika gives birth to healthy child

February 20, 2016
A woman with a confirmed case of the Zika virus in the southern state of Chiapas gave birth to a "clinically healthy" baby boy, Mexico's health ministry said.

ACOG supports CDC's zika virus travel precautions

January 23, 2016
(HealthDay)—The American College of Obstetricians and Gynecologists (ACOG)—the largest organization representing obstetricians and gynecologists in the United States—said Thursday that it supports new guidelines aimed ...

Therapy to stop premature birth safe but ineffective, study finds

February 23, 2016
A therapy widely recommended in the UK, Europe and the US to stop babies from being born too soon is ineffective, research shows.

Recommended for you

Mice delivered by C-section gain more weight than those delivered naturally

October 11, 2017
Mice born by Caesarian section gained on average 33 percent more weight in the 15 weeks after weaning than mice born vaginally, with females gaining 70 percent more weight.

Study shows epidurals don't slow labor

October 10, 2017
Epidural analgesia - a mix of anesthetics and narcotics delivered by catheter placed close to the nerves of the spine - is the most effective method of labor pain relief. In widespread use since the 1970s, epidurals have ...

Progesterone does not prevent preterm birth or complications, says study

October 3, 2017
An increasingly popular hormonal "treatment" for pregnant women with a history of preterm birth does not work, a major new international study shows.

Study questions practice of placenta eating by new moms

September 29, 2017
(HealthDay)—You may have heard that some new mothers choose to eat their own placenta after childbirth. But there's no indication the trendy practice offers any health benefits, and some evidence it could prove dangerous, ...

Hope for couples suffering IVF miscarriage

September 20, 2017
Women who miscarry during their first full round of IVF are more likely to have a baby after further treatment than women who don't get pregnant at all.

Does mother's mental health affect pregnancy?

September 13, 2017
(HealthDay)—Three common mental health disorders—depression, panic disorder and generalized anxiety disorder—pose no serious threat to pregnant women or the health of their babies, a new study finds.


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.