Centring choice in birthing services; COVID-19 and maternal request caesarean sections

By Anna Nelson & Elizabeth Chloe Romanis

During the COVID-19 pandemic pregnant and birthing people saw significant changes to the services they were offered. From March 2020 substantial restrictions were introduced in an attempt to curb the spread of the virus, with some notable examples including bans on partners attending scans, limitations on the number of permitted birth partners and the suspension of homebirth services.  In our newly published paper in the JME, we consider the blanket ban on all Maternal Request Caesarean Sections (MRCS) that some NHS Trusts introduced as part of their response to the pandemic. While changes aimed at keeping birthing people, health care staff and newborns safe were (and remain) vital, we argue that imposing a blanket ban on MRCS is a disproportionate attack on the autonomy and welfare of birthing persons.

In our paper we assess the potential justifications for imposing a blanket ban on MRCS as part of the pandemic response and demonstrate that these are insufficiently convincing to render the resultant imposition upon the autonomy of the person giving birth legitimate. Ensuring that the choices that birthing people make about, and during, childbirth are respected is vital; failing to do so can have an incredibly harmful, lasting impact on wellbeing.  Though we recognise that in certain circumstances COVID-19 may have rendered it impossible to meet all requests for birth by caesarean section, decisions to deny any such request must take into account individual circumstances. A blanket ban is an insufficiently nuanced tool to apply in this circumstance, and the application of such a ban fails to strike an appropriate balance between pandemic response and broader protection of the autonomy and wellbeing of the birthing person.

In writing about the restrictions placed upon MRCS by some NHS Trusts, we noticed that the pandemic has crystallised some of the barriers and prejudices already faced by those who choose or wish to give birth by caesarean section.  Though not the primary focus of our paper, it is worth reflecting upon the way that issues associated with access to MRCS during the pandemic intersect with issues of access more broadly as this can help shape discussion moving forward.  Firstly, the application of a rigid blanket ban is indicative of a broader failure by some to understand that MRCS is a health decision when welfare is considered holistically. For some individuals, the opportunity to opt for caesarean is absolutely necessary in order to protect their physical or mental wellbeing, and failure to facilitate such a choice can have hugely negative and long-term implications.  Secondly, we believe that COVID-19 has served to underscore an interesting dichotomy increasingly present in the discourse about choice during childbirth; that there is an increasing medicalisation of childbirth, while at the same time there remains a reluctance to acknowledge the importance of facilitating access to MRCS (arguably, the most medicalised form of childbirth available) for those who desire it.

We believe that, in birthing services, the health of the birthing person must be viewed holistically and encompass both the physical and mental impacts of birth. Autonomy and welfare must be appropriately centred. The rights and dignity of the birthing person must remain central at all times, including during emergency circumstances; imposing a blanket ban on all MRCS, regardless of individual circumstances, fails achieve this. As the possibility of a second wave of COVID-19 continues to loom large, it is vital that we reflect on the policies which have been imposed and ensure that any future restrictions placed upon pregnant and birthing people strike the appropriate balance between the protection of their autonomy, rights and wellbeing and pandemic-related public health concerns.


Paper Title: Maternal Request Caesareans and COVID-19: the virus does not diminish the importance of choice in childbirth [OPEN ACCESS]

Authors: Elizabeth Chloe Romanis, Anna Nelson

Affiliations: ECR: Centre for Ethics and the Life Sciences at Durham Law School; AN: Centre for Social Ethics and Policy, University of Manchester

Competing Interests: The authors have no competing interests to declare.

Social media accounts: @ECRomanis @Anna_Nelson95


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