Agoraphobic mum-to-be forced to go to hospital for the birth

[UppityPuppity]

Judge states she doesn’t have the capacity to decide to have a home birth.

Not enough information to form a view about the supposed risks, except that I am so sad for her and wish her and the baby well.

www.bbc.co.uk/news/uk-57108649

In the court case under discussion, both the woman's mother and her partner want her to have the baby in hospital, not at home.

I’ve been in that situation with a family member refusing lifesaving treatment due to a phobia (not agoraphobia). I wouldn’t wish it on my worst enemy. Although we persuaded/bullied them into it eventually it wrecked some family relationships beyond repair. I don’t know if they would have been judged to have capacity to refuse treatment if it went to court as thankfully it never got that far.

I think it was right in this case for the judge to take into account the risk of harm to the baby, if indeed they did, not because the baby is yet a person with human rights but because it would be enormously detrimental to the mother’s wellbeing if the child died or was seriously harmed because she felt unable to leave her home for the birth. That can’t be in her best interests. And that’s leaving aside the issue of whether there was direct medical risk to her. As others have said, these decisions are not taken lightly and we don’t know much at all about what happened.

Justawoman
I didn’t read the judgment linked to but the woman whose case is the subject of the Birthrights blog (which I linked to above) seemed to be about if a really serious situation arose during a birth already started at home and the issues of then getting the agoraphobic woman from home to hospital.

However the judgment here involving the 21 year old woman who is subject of this thread seems perhaps even more difficult to live with for that woman because it could be potentially several days that she has to be away from home before the baby comes, couldn’t it? Unless they’ve decided she will get a c-section?. The judge basically said that she should be taken on a specific date in advance of the due date to hospital and stay there until the baby is safely born.
I don’t understand how this represents taking a minimum intervention proportionate approach to her consent to treatment. If she potentially needs force to get her to hospital, how are they going to keep her in there safely and humanely and while respecting her rights, for what could be several days if she is desperate to get back home? It doesn’t bear thinking about. Will they just force her straight into c section? What if she didn’t want a c section? These are massive decisions being made for her.

I know the facts available to us are very limited but it doesn’t feel right that the young woman has been deemed to lack capacity to make decisions around the birth as a whole which is a very wide scope of decisions, possibly quite far in advance. How do they know that the lack of capacity they’ve determined will persist over this whole period covering the birth?

I’d hope that they will keep on repeatedly offering this young woman choices and assessing her capacity for however long she may be in hospital against her stated will, to see what aspects of her care that she can make competent decisions about. Clearly there aren’t easy answers in a case like this and we don’t have facts, but norms of consent and capacity do seem at odds with a judgment possibly some way in advance of a birth, (and reportedly because the judge wants to avoid a rushed decision ‘in the middle of the night’) which then means on the very wide set of deeply personal decisions around birth, and with potentially quite different longer term physical and mental consequences for her depending on what her preferences would be, a woman’s right to determine what happens to her body on major issues like having surgery or not is removed from her for what could be several (physically and emotional pivotal) days.

Our of interest, if someone had a partner or family member who had an illness which needed hospital treatment (medical professionals had facilitated scans and tests at home, but there was a good chance they would die if they didn't go in- small chance they might be fine) but they were agoraphobic, would they just say ah well, your choice, even thought that choice cannot be an informed one as their illness cloud's the ability to do so?

False analogy as Alfonso has pointed out.

@MissBarbary

Our of interest, if someone had a partner or family member who had an illness which needed hospital treatment (medical professionals had facilitated scans and tests at home, but there was a good chance they would die if they didn't go in- small chance they might be fine) but they were agoraphobic, would they just say ah well, your choice, even thought that choice cannot be an informed one as their illness cloud's the ability to do so?

False analogy as Alfonso has pointed out.

Why?

Caveat: not all the circumstances in this case have been made public ..

On the face of it, the judge stated that the risk of home birth are higher than being forced into hospital against this woman's will and possibly induced against medical necessity rather than allowing her to birth naturally in a safe place supported by professionals. All of the evidence we have about birthing would say that this is incorrect.

I know many birth supporters have expressed their willingness to reach out and help her. I hope she hears this support and is able to avail of it.

@ChateauMargaux

Caveat: not all the circumstances in this case have been made public ..

On the face of it, the judge stated that the risk of home birth are higher than being forced into hospital against this woman's will and possibly induced against medical necessity rather than allowing her to birth naturally in a safe place supported by professionals. All of the evidence we have about birthing would say that this is incorrect.

I know many birth supporters have expressed their willingness to reach out and help her. I hope she hears this support and is able to avail of it.

Precisely, we don't know the details. How would they get her to hospital whilst in labour if she does require medical care that can only be done in hospital?

This decision should be only about the woman, not considering the good of the baby

I don’t agree in this particular case. I’m all for abortions etc and women and only women should choose what happens to their body but this isn’t an unwanted child, this woman wants her baby and presumably would like a healthy baby as all mothers do. So why shouldn’t the baby matter when it’s clearly wanted and will be brought into the world?

On the face of it, the judge stated that the risk of home birth are higher than being forced into hospital against this woman's will and possibly induced against medical necessity rather than allowing her to birth naturally in a safe place supported by professionals. All of the evidence we have about birthing would say that this is incorrect

Sorry but that depends entirely on her health and the circumstances. Medical staff have carried out a risk assessment and a home birth is not appropriate here. Just because you have had one or your friends have doesn’t mean that it is appropriate for everyone. There have been home births where the baby has died or been severely disabled for instance.

How many women should be traumatised, coerced, receive unnecessary interventions, have birth injuries against their wishes to save one baby?

Is it that one babies life worth the suffering of 100 women, 500 women, 1000 women.. more...

Those sufferings impact own lives, their existing children, their future children, their wider families.. .. where do we draw the line.

@Pota2.. 'There have been home births where the baby has died or been severely disabled for instance.'

Babies also die and are severely disabled in hospital.

"Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician."

www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/

We do not know that medical staff have made an appropriate risk assessment based on the facts as presented.

Just today, I attended the post birth assessment (yes on a Sunday!) of a traumatised women and the senior OB on duty at the time said it was not an amber or a red decision but the woman is left with life long trauma because the decision on what happened was imposed upon her rather than the team taking the time to allow her to come to an evidence based decision.

*"Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician."

www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/*

This paper only looks at women who met the existing eligibility criteria for home-birth (and compares them with a matched group). It therefore selects out women who had risk factors for complications of labour and delivery.

(The eligibility criteria are found in Box 1 in the paper.)

The overall evidence base is, as you say, that home birth is as safe as hospital for low risk pregnancies, but there is no way of knowing whether this paper is relevant to this woman’s situation.

rather than the team taking the time to allow her to come to an evidence based decision.

What if the woman doesn't have capacity to make an evidence based decision? The bar for being deemed to not have capacity is high, its not just said on a whim.

@ChateauMargaux

How many women should be traumatised, coerced, receive unnecessary interventions, have birth injuries against their wishes to save one baby?

Would you prefer a baby carried to term should die or be seriously harmed?

@MissBarbary.. how many women should suffer so that one baby should live... its not an easy question...

If there is a 1 in 1,000 chance that my baby might die, compared to me making a choice to having the homebirth that means I give birth in the place that I feel safe, that is there are 999 chances in 1,000 that my baby will live and I get to feel safe therefore increasing my chances of a straightforward birth without interventions and without increased risk to me or the baby and an increased chance that my baby will be born to an unmedicated, unexhausted mother with neonatal instincts intact, facilitating natural feeding and overall reducing their risk of short and long term health impacts.. I would go for that.

Like I said at the very beginning. If she has a high risk pregnancy then sedating her, getting her to hosp for immediate CS, keeping her on morphine/ sedated until safe to go home (24 hours sometimes round here), and getting her home again would seem a good option.

In this case the judge talking about reasonable force to get her to hosp sounds all wrong. How much force is reasonable on a heavily pregnant woman who is terrified and struggling etc? That statement from the judge is awful.

We don't know much about the case obv.

If she's that scared and has been deemed to lack capacity. Then risk of suicide, trying to induce abortion has presumably been considered.

My daughter is agoraphobic and needed urgent medical care recently. I had to force her into the car and into the hospital. It was distressing but I didn't have a choice.

Although I've read many times that an agoraphobic mother will put up with extreme fear for their baby. I'm not sure if they can't see the baby then that would still be the case.

"Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician."

Yeah because they only let you have one if you are low risk. If you are high risk like this woman seems to be, they will advise against it and very few women will go against that advice.

[quote ChateauMargaux]@MissBarbary.. how many women should suffer so that one baby should live... its not an easy question...

If there is a 1 in 1,000 chance that my baby might die, compared to me making a choice to having the homebirth that means I give birth in the place that I feel safe, that is there are 999 chances in 1,000 that my baby will live and I get to feel safe therefore increasing my chances of a straightforward birth without interventions and without increased risk to me or the baby and an increased chance that my baby will be born to an unmedicated, unexhausted mother with neonatal instincts intact, facilitating natural feeding and overall reducing their risk of short and long term health impacts.. I would go for that.[/quote]
Why do you seem unable to grasp that she doesn’t have the mental capacity to make a decision? That’s why it’s been made for her. It’s exceptionally unusual for this to happen. It’s not like the courts intervene to protect unborn children all the time. Unborn children have no legal standing at all and the mother’s autonomy takes precedence. This is a rare situation where the mother cannot properly make a decision and therefore one has been made for her based on what is best for her (which actually includes consideration of what she would have wanted if she did have capacity). All the armchair obstetricians on here don’t have a clue.

As others have said, faith placed in professionals without question in cases like this revolving around their skill or experience in determining capacity to consent will sometimes be misplaced.

HCPs to a ‘significant’ extent don’t always know much about assessing patients around capacity and therefore making determinations around the patient’s ability to consent. This is according to academic research pointed to by Birthrights blog:
www.birthrights.org.uk/2021/04/07/blog-agoraphobia-and-mental-capacity-a-new-obstetric-intervention-case/

See pubmed.ncbi.nlm.nih.gov/32647042/
‘Mental capacity assessment: a descriptive, cross-sectional study of what doctors think, know and do.’ Journal of Medical Ethics, July 2020.

Abstract:

Background: The Mental Capacity Act (MCA) (2005) was enacted in 2007 in England and Wales, but the assessment of mental capacity still remains an area of professional concern. Doctors' compliance with legal and professional standards is inconsistent, but the reasons for poor compliance are not well understood. This preliminary study investigates doctors' experiences of and attitudes toward mental capacity assessment (MCAx).

Methods: This is a descriptive, cross-sectional study where a two-domain, study-specific structured questionnaire was developed, piloted and digitally disseminated to doctors at differing career stages employed in a large, multi-site National Health Service Trust in London over 4 months in 2018. Descriptive statistics and frequency tables adjusted for missing data were generated and secondary analysis was conducted.

Results: Participants (n=92) were predominantly UK trained (82%), female (58%) and between the ages of 30 and 44 years (45%). Less than half (45%) of the participants reported receiving formal MCAx training. Only one-third (32%) of the participants self-rated themselves as very competent (29%) or extremely competent (4%). Self-reported MCA confidence was significantly affected by career stage with Consultants with over 10 years of experience reporting lowest confidence (p=0.001).

Conclusions: This study describes significant variation in practice by doctors and low self-confidence in the practice of MCAx. These results raise concerns that MCAx continues to be inconsistently performed by doctors despite appropriate awareness of the law and professional guidance on best practice.

Maybe some doctors don’t have enough expertise on patients who lack capacity but they have a lot more expertise than the posters on here. Therefore I am more inclined to believe that they are probably right here and I also note that the woman’s family agrees with the doctors.
Some women need medical intervention to give birth and sometimes this is known from the outset. Few women with mental capacity would go ahead with a home birth when the doctors say this is not a good idea. The women who do opt for home births usually do so with support of their midwife and where complications are unlikely. That’s why outcomes are generally good. If you want to go back in time to when everyone gave birth at home, the stats aren’t as great.

It’s also worth pointing out that the doctors’ determination of her lack of capacity to make this decision was upheld by a judge.

I thought the ‘natural birth is always best, let’s get all women out of those nasty medicalised hospitals’ thing had died a death since the Telford and Wrekin scandal. Apparently not.