News Maternity and Birthing

Florida Hospital Demands Woman Undergo Forced C-Section

Jodi Jacobson

The hospital has threatened to perform cesarean surgery on Jennifer Goodall "with or without [her] consent."

In an action that appears to be increasingly commonplace, a Florida hospital has threatened to force a pregnant patient to undergo cesarean surgery against her will, or to report her to child welfare authorities for attempting to exercise her right to make the medical decisions she deems best for herself and her family.

Jennifer Goodall of Coral Gables was informed in a July 10 letter from the chief financial officer of Bayfront Health Port Charlotte that because she decided to attempt vaginal delivery before agreeing to cesarean surgery in her fourth pregnancy, her prenatal care providers intended to report her to the Department of Children and Family Services, seek a court order to perform surgery, and perform cesarean surgery on her “with or without [her] consent” if she came to the hospital.

A complaint on behalf of Goodall was filed in federal court last week by National Advocates for Pregnant Women (NAPW) and Florida attorney Patricia E. Kahn, seeking a temporary restraining order to prevent the hospital from carrying out its threats. Federal District Judge John E. Steele denied the request, stating in part that Goodall has no “right to compel a physician or medical facility to perform a medical procedure in the manner she wishes against their best medical judgment.”

Goodall is now 41 weeks pregnant and has told her lawyers she is terrified to enter a hospital. Given this and the weight of medical evidence in Goodall’s favor regarding the safety of the delivery she wanted to have, it is unclear whether the hospital or the courts are considering “best medical judgment” and in whose interest they are acting.

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Goodall delivered her three other children via c-section and now desires to undergo what is commonly known as vaginal birth after cesarean (VBAC). In decades past, VBAC was a common choice for women who had previously had c-sections, rising from roughly 5 percent of all deliveries after a cesarean in 1985 to roughly 28 percent by 1996. The rate of VBAC deliveries started to fall in the late ’90s, according to the American Congress of Obstetricians and Gynecologists, reaching 8.5 percent in 2006 due in part to “restrictions that some hospitals and insurers placed” on the procedure. In tandem with what some have noted as pressure on women to undergo cesareans, the rate of cesarean delivery overall in the United States simultaneously increased dramatically over the past four decades, from 5 percent to over 31 percent in 2007.

Medical and public health bodies have long criticized the high rate of cesarean sections in the United States. The World Health Organization points out that at the current rate of 30 percent of all deliveries, cesarean sections in the United States far exceed what should normally be between 5 to 10 percent of all deliveries. ACOG agrees. “The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” ACOG President Richard N. Waldman said in a statement. “[ACOG’s] VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.”

“The risks associated with a vaginal delivery are lower than the risks associated with a C-section overall, as long as you can deliver the baby at a facility equipped to handle a C-section in case of emergency,” Roger W. Harms, an obstetrician at the Mayo Clinic in Rochester, Minnesota, and medical editor-in-chief of MayoClinic.com, said in a statement. And the recovery time is faster. Undergoing a cesarean surgery for the fourth time carries a 1 in 8 chance of major complications. In short, VBAC deliveries are safer for both the pregnant person and the fetus and lead to fewer complications.

These facts did not escape Goodall, who said in a statement released by NAPW:

My decision to allow labor to proceed before consenting to a surgical intervention is based on years of research, careful consideration of the risks to me and my baby, and my family’s needs. All I want is to be able to go to the hospital when I’m in labor and have my medical decisions respected – and my decision is to proceed with a trial of labor and not have cesarean surgery unless some medical complication arises that makes cesarean surgery necessary for my or my baby’s health. Instead of respecting my wishes like they would for any other patient, my health care providers have made me fear for my safety and custody of my children. The people who are supposed to be caring for me and my baby have put me into an even more dangerous situation. I know I’m not the only one to go through this; I’m speaking out because pregnant women deserve better.

“I would definitely consent to surgery if there were any indication during labor that it is necessary,” Goodall added. “I am trying to make the decision that will be safest for both me and my baby, and give me the greatest chance at being able to heal quickly after my child is born so I can care for my newborn and my three other children.”

NAPW staff attorney Farah Diaz-Tello expressed disappointment in Judge Steele’s ruling. “The process of labor and delivery isn’t a procedure; our client is the one trying to avoid a compelled medical procedure. Deciding whether and when to consent to surgery is a constitutionally protected right,” she said in a statement. Diaz-Tello explained that every appellate court to rule on this issue on a full record has held that pregnant women retain their constitutional rights, including rights to medical decision-making and bodily integrity. “No woman should fear that because she’s pregnant, she can be threatened, coerced, or deprived of her constitutional rights,” she said.

But this is exactly what happened to Rinat Dray in Staten Island and to at least six other women in Florida, according to NAPW. “Florida is particularly bad for people giving birth,” Diaz-Tello told Rewire in an email. “We know of at least a half dozen other women who have had court orders or threats of legal action this against them, but the certainty with which hospitals have made these threats makes us think there are more we don’t know of.”

According to declarations of medical experts filed with the lawsuit, the hospital’s actions violate medical ethics. In a statement to NAPW, Mary Faith Marshall, director of the Center for Biomedical Ethics & Humanities at the University of Virginia School of Medicine, called the hospital’s actions “troubling.”

“Given the clear statements from ACOG’s Committee on Ethics and other professional groups that coerced or court-ordered medical procedures are not ethically justified, it is stunning that a hospital would threaten such an action,” she said.

Diaz-Tello acknowledged the hospital’s concerns about malpractice liability, but noted that there is no legal or ethical authority that supports managing liability concerns by forcibly performing unwanted surgery. “The Florida Supreme Court has said health care providers are protected from liability when they respect and follow the decisions of a competent and informed patient to delay or refuse a proposed treatment, even when there are risks involved,” she said in the NAPW statement. “Ms. Goodall has explicitly and carefully documented her informed decision to proceed with a trial of labor; there is no justification for forcing her, or any person, to have unwanted surgery to protect a hospital’s bottom line.”

News Politics

Anti-Choice Group Faces Fundraising Gap in ‘Topsy-Turvy Year’

Amy Littlefield

“I will tell you that this has been the toughest year we have faced since I’ve been executive director of National Right to Life—and I came here in 1984—for our political fundraising,” David O’Steen announced at the annual National Right to Life Convention Friday.

Less than two weeks after the Supreme Court dealt the anti-choice movement its most devastating blow in decades, one of the nation’s leading anti-choice groups gathered at an airport hotel in Virginia for its annual convention.

The 46th annual National Right to Life Convention arrived at what organizers acknowledged was an unusual political moment. Beyond the Supreme Court’s decision to strike down abortion restrictions in Texas, the anti-choice movement faces the likely nomination later this month of a Republican presidential candidate who once described himself as “very pro-choice.”

The mood felt lackluster as the three-day conference opened Thursday, amid signs many had opted not to trek to the hotel by Dulles airport, about an hour from Washington, D.C. With workshops ranging from “Pro-Life Concerns About Girl Scouts,” to “The Pro-Life Movement and Congress: 2016,” the conference seeks to educate anti-choice activists from across the United States.

While convention director Jacki Ragan said attendance numbers were about on par with past years, with between 1,000 and 1,100 registrants, the sessions were packed with empty chairs, and the highest number of audience members Rewire counted in any of the general sessions was 150. In the workshops, attendance ranged from as many as 50 people (at one especially popular panel featuring former abortion clinic workers) to as few as four.

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The attendance wasn’t the only sign of flagging enthusiasm.

“I will tell you that this has been the toughest year we have faced since I’ve been executive director of National Right to Life—and I came here in 1984—for our political fundraising,” National Right to Life Executive Director David O’Steen announced at Friday morning’s general session. “It’s been a topsy-turvy year. It’s been, for many people, a discouraging year. Many, many, many pro-life dollars, or dollars from people that would normally donate, were spent amongst 17 candidates in the Republican primary.”

O’Steen said the organization needed “$4 million that we do not have right now.”

When asked by Rewire to clarify details of the $4 million shortfall, O’Steen said, “You’re thinking this through more deeply than I have so far. Basically, the Right to Life movement, we will take the resources we have and we will use them as effectively as we can.”  

O’Steen said the organization wasn’t alone in its fundraising woes. “I think across many places, a lot of money was spent in these primaries,” he said. (An analysis by the Center for Public Integrity found presidential candidates and affiliated groups spent $1 billion on the presidential race through March alone, nearly two-thirds of it on the Republican primary. Anti-choice favorite Texas Sen. Ted Cruz (R) spent more than than $70 million, higher than any other Republican.)

The National Right to Life Board of Directors voted to back Cruz in the Republican presidential primaries back in April. It has not yet formally backed Donald Trump.

“I really don’t know if there will be a decision, what it will be,” National Right to Life Committee President Carol Tobias told Rewire. “Everything has [been] kind of crazy and up in the air this year, so we’re going to wait and kind of see everything that happens. It’s been a very unusual year all the way around.”

Some in the anti-choice movement have openly opposed Trump, including conservative pundit Guy Benson, who declared at Thursday’s opening session, “I’m not sure if we have someone who is actually pro-life in the presidential race.”

But many at the convention seemed ready to rally behind Trump, albeit half-heartedly. “Let’s put it this way: Some people don’t know whether they should even vote,” said the Rev. Frank Pavone, national director of Priests for Life. “Of course you should … the situation we have now is just a heightened version of what we face in any electoral choice, namely, you’re choosing between two people who, you know, you can have problems with both of them.”

Another issue on the minds of many attendees that received little mention throughout the conference was the Supreme Court’s recent ruling in Whole Woman’s Health v. Hellerstedt, which struck down provisions in Texas requiring abortion providers to have hospital admitting privileges and mandating clinics meet the standards of hospital-style surgery centers. The case did not challenge Texas’ 20-week abortion ban.

“We aren’t going to have any changes in our strategy,” Tobias told Rewire, outlining plans to continue to focus on provisions including 20-week bans and attempts to outlaw the common second-trimester abortion procedure of dilation and evacuation, which anti-choice advocates call “dismemberment” abortion.

But some conference attendees expressed skepticism about the lack of any new legal strategy.

“I haven’t heard any discussion at all yet about, in light of the recent Supreme Court decision, how that weighs in strategically, not just with this legislation, but all pro-life legislation in the future,” Sam Lee, of Campaign Life Missouri, said during a panel discussion on so-called dismemberment abortion. “There has not been that discussion this weekend and that’s probably one of my disappointments right now.”

The Supreme Court decision has highlighted differing strategies within the anti-choice community. Americans United for Life has pushed copycat provisions like the two that were struck down in Texas to require admitting privileges and surgery center standards under the guise of promoting women’s health. National Right to Life, on the other hand, says it’s focused on boilerplate legislation that “makes the baby visible,” in an attempt to appeal to Supreme Court Justice Anthony Kennedy, who cast a key vote to uphold a “partial-birth abortion” ban in 2007.

When asked by Rewire about the effect of the Texas Supreme Court case, James Bopp, general counsel for the National Right to Life Committee, appeared to criticize the AUL strategy in Texas. (Bopp is, among other things, the legal brain behind Citizens United, the Supreme Court decision that opened the floodgates for corporate spending on elections.)

“This case was somewhat extreme, in the sense that there were 40 abortion clinics—now this is just corresponding in time, not causation, this is a correlation—there were 40 abortion clinics and after the law, there were six,” Bopp said. “That’s kind of extreme.”

Speaking to an audience of about ten people during a workshop on campaign finance, Bopp said groups seeking to restrict abortion would need to work harder to solidify their evidence. “People will realize … as you pass things that you’re going to have to prove this in court so you better get your evidence together and get ready to present it, rather than just assuming that you don’t have to do that which was the assumption in Texas,” he said. “They changed that standard. It changed. So you’ve gotta prove it. Well, we’ll get ready to prove it.”

Commentary Abortion

Looking Beyond ‘Whole Woman’s Health’: Challenges Remain in Dozens of States

Thomas M. Gellhaus MD

Even if we are able to celebrate a favorable outcome in the case Monday, the battle for reproductive health will continue in dozens of states across the country.

Read more of our coverage of Whole Woman’s Health v. Hellerstedt here.

Reproductive health physicians are nervously awaiting the Supreme Court’s decision in Whole Woman’s Health v. Hellerstedt this week. Rightly so: the outcome of this case will dramatically affect the ability to access safe, legal abortions in Texas, and could extend to other states with restrictions that are similar to HB 2, the law at the heart of the case.

But we also recognize that even if we are able to celebrate a favorable outcome in the case, the battle for reproductive health will continue in dozens of states across the country.

The two provisions of HB 2 before the Court are presented by supporters as improvements to abortion safety and protective of women. But the reality is quite contrary to this. For one thing, abortion is already one of the safest medical procedures; women do not need to be “protected” by politicians.

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For another, the requirements imposed by the lawmandating that abortion providers have admitting privileges at a local hospital and forcing abortion facilities to meet ambulatory surgical center (ASC) standards—do not directly or indirectly have a positive affect on the care provided before, during, or after abortion.

In practice, these targeted regulation of abortion providers (TRAP) requirements only restrict access to abortion. Few clinics have the resources needed to make the costly (and medically unnecessary) updates needed for ASC standards, and physicians can be refused hospital admitting privileges for a wide range of reasons unrelated to the quality of care that they provide.

Instead of improving care, TRAP law restrictions cause clinics to close, and prevent qualified, trained, experienced, dedicated health professionals from providing abortions to patients who need them. Fewer abortion providers means that some will have to wait much longer for their abortions, delaying care until later in pregnancy when the risk of complications—although still small—is increased.

TRAP laws also make abortion completely inaccessible for some women. The reasons can be complicated, involving factors such as geographical limitations, prohibitive cost of travel, and inability to obtain child care or take additional time off work. Regardless of the cause, the result is the same: Abortion restrictions force some women to carry their pregnancies to term, actually exposing them to greater risks associated with pregnancy and childbirth.

Not surprisingly, these laws disproportionately affect low-income women, only heightening the disparities that they already face day-to-day.

Even as our eyes are turned toward the Supreme Court, we must remember that Texans are not the only ones facing restrictions on their ability to access abortion care. Similar TRAP laws have been passed in other states, and in some cases, their implementation will depend on the outcome of Whole Woman’s Health. In addition, lawmakers have adopted a variety of creative approaches to limit abortion access.

In Indiana, state legislators passed a bill that would ban abortion for specific reasons; that law is awaiting judicial review. In Utah, a new law forces doctors to provide anesthesia to the fetus in an abortion performed after 20 weeks, despite there being no medical method for doing so and despite robust evidence that at that stage in development, a fetus does not feel pain. In Kansas and Oklahoma, state lawmakers banned physicians from using the preferred procedure for second-trimester abortion, subjecting women to less-than-standard methods; despite these laws currently being enjoined, five other states have followed suit.

None of these attacks are grounded in medicine, none of them are supported by the American College of Obstetricians and Gynecologists (ACOG) or the American Medical Association, and unfortunately, none of them would be struck down by a favorable decision from the Supreme Court. Even if access is restored in parts of Texas, advocates cannot rest on our laurels.

OB-GYNs do not have to be abortion providers in order to see the significant effect that an unintended pregnancy can have on overall health and well-being. We do not have to provide abortions ourselves in order to recognize that access to abortion is essential for the patients whom we provide care for every day.

As an OB-GYN and the president of ACOG, I remain hopeful and optimistic that we will see access to abortion restored and protected nationwide. But I urge reproductive health advocates to remain vigilant as state politicians continue to strip away access to care.