In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. (...) Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging. (shrink)

Much of the discourse in the bioethics literature on what is often called “cesarean delivery on maternal request” has focused on balancing respect for patient autonomy with attention to the short- and long-term risks of this procedure to maternal and neonatal well-being. And while there has been some analysis of the social and economic costs inherent in performing cesareans, much of the clinical and ethical analysis has concluded that, given the degree of risk to the mother and neonate (...) from a primary or single repeat cesarean delivery, there is sufficient justification for pregnant women to request and obtain this procedure from obstetricians willing to meet such requests. However, these same analyses often caution that physicians should not offer these elective cesareans to all women, but only to those who initiate the request. This paper analyzes recommendations that do not promote universal access to these procedures and concludes that such a policy is ethically unjustifiable, as it treats women who do not inquire about such procedures differently. Depriving appropriate candidates—for example, healthy women who are good surgical candidates and desire only one or two children—of information about elective cesarean delivery is a form of undue influence on women's decision-making. (shrink)

The American Journal of Bioethics, Volume 12, Issue 7, Page 1-2, July 2012.

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. (...) Reproductive autonomy is at stake since a technological imperative undermines patients’ ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates. (shrink)

In this article I explore partial ectogenesis through the lens of choice in childbirth, framing it as a mode of delivery. In doing so, I refocus discussion about partial ectogenesis, ensuring that this centers upon the autonomy and rights of the birthing person—as the procedure required to facilitate external gestation will be performed upon their body. By drawing a critical comparison between “delivery by partial ectogenesis” and request cesarean sections, I argue that delivery by partial ectogenesis (...) ought to be available on the basis of the pregnant person’s request alone. (shrink)

ABSTRACT In recent years, the medical establishment has been speaking in favor of women's autonomy in childbirth by advocating cesarean delivery on maternal request (CDMR). This paper offers to look at the ethical dimension of CDMR through a feminist critique of the medicalization of childbirth and its influence on present‐day medical ethics. I claim that the medicalization of childbirth reflects a sexist bias with regard to conceptions of the body and needs to be used with caution when applied (...) to women's reproductive health. I then use this perspective to critically analyze the position of the American College of Obstetricians and Gynecologists (ACOG) on the ethics of decision‐making in patient‐choice surgery. I claim that informed consent cannot be meaningfully exercised unless women are made aware of the sexist underpinnings of the medical model of childbirth and its influence on the ethical reasoning of the American College of Obstetricians and Gynecologists. I also express concern about the effects of normalizing patient‐choice cesarean sections on the choices available to pregnant women using as examples the institutional rules on mandatory cesarean sections for women with a previous cesarean delivery or breech presentation. I conclude with a call for more research into the real cost of convenience in CDMR, particularly as our increasingly strained publicly funded healthcare system would greatly benefit from the de‐medicalization of normal body functions rather than an increased dependence on costly surgical technology. (shrink)

Definition of the problem. During the last few years obstetricians have become concerned over an increasing rate of cesarean sections, especially an increasing rate of ”section on demand” for non-medical, but personal reasons of pregnant women. For physicians this is a question of risks and benefits for both mother and child. On the other hand, there is the duty to respect women’s autonomy. Arguments. Pregnant women are healthy and the act of giving birth to a child is a physiological (...) one. Thus, the indication has to be proved carefully for surgical intervention instead of vaginal delivery. Cesarean section for non-medical reasons may be helpful for women with an extreme fear of vaginal delivery or previous traumatic experiences. On the other hand the possibility for pregnant women to choose their preferred mode of delivery is combined with the question, whether cesarean section on demand fulfils their demand for a self-determined delivery. Conclusion. With a mode of delivery oriented to the person instead of to the method, self-determination can be realized. Cesarean Section on demand can achieve this in some individual cases. However women’s own ability, activity, and involvement in giving birth to a child may be a stronger manifestation of self-determination. (shrink)

We present the case of a 36-year-old woman who has experienced three lost pregnancies; during the most recent loss, a full term pregnancy, she almost died from complications of placental abruption. She is now completing the 34th week of gestation and is experiencing symptoms similar to those under which she lost the previous pregnancy. Despite a lack of specific medical indications, the patient and her husband firmly but politely request that the attending obstetrician/perinatologist perform an immediate cesarean section in (...) order to alleviate the couple’s anxiety about possibly never having a family. Discussing the case are an experienced perinatologist, a neonatologist, a regional perinatal center coordinator, and a clinical ethicist. (shrink)

Interest in home birth appears to be growing among American women, and most obstetricians can expect to encounter patients who are considering home birth. In 2011, the American College of Obstetricians and Gynecologists (ACOG) issued an opinion statement intended to guide obstetricians in responding to such patients.In this article, I examine the ACOG statement in light of the historical and contemporary clinical realities surrounding home birth in the United States, an examination guided in part by my own experiences as an (...) obstetrician in home-birth-friendly and homebirth-unfriendly medical milieus. Comparison with other guidelines indicates that ACOG treats home birth as an ethical exception: comparable evidence leads to strikingly different recommendations in the case of home birth and the case of trial of labor following a prior cesarean; and ACOG treats other controversial issues that involve similar ethical questions quite differently.By casting the provision of information as not just the primary but the sole ethical responsibility of the obstetrician, ACOG statement obviates obstetricians’ responsibilities to provide appropriate clinical care and to make the safest possible clinical environment for those mothers who choose home birth and for their newborns. What, on its face, seems to be a statement of respect for women’s autonomy, implicitly authorizes behaviors that unethically restrain truly autonomous choices. Obstetricians need not attend home births, I argue. Our ethical duties do, however, oblige us (1) to refer clients to skilled clinicians who will attend home birth, (2) to continue respectful antenatal care for those women choosing home birth, (3) to provide appropriate consultation to home birth attendants, and (4) to ensure that transfers of care are smooth and nonpunitive. (shrink)

Definition of the problem: The rapid pace of medical progress has drawn renewed attention to the various possible ways of treating dead or brain-dead pregnant women since the 1980's. The discussion today revolves around medical, social, legal and economic aspects. The historical areas of conflict which surrounded deliveries carried out on dead mothers (usually by means of a Sectio in mortua, nowadays known as a perimortem Caesarean section) and their significance in today's debate are, for the most part, regarded as (...) being of little relevance.Arguments: The history of the Sectio in mortua was, for a long time, influenced by the difficulty in establishing whether the mother and foetus were actually dead, by the degree of autonomy of the foetus in the womb, by religious issues, by the lack of acceptance among the people because of their irrational fears concerning the operation and by legal regulations and constraints especially in relation to operations carried out on the dying. Each of these areas shows remarkable parallels to the present-day medical and ethical discussion.Conclusion: The value of such considerations does not lie in the uncritical application of experience gained in the past, but rather in a growing awareness of the wide spectrum of parameters and in a deeper understanding of the various possible approaches to a given situation. The tradition in the Western world of carrying out a delivery on a dead mother, in spite of the conflict of interests between the mother and the foetus, is of particular importance. In practice, the many non-medical factors should be taken more into consideration, with special emphasis being placed on the informed consent of the relatives. (shrink)

Deborah is a thirty-three-year-old who presented to labor and delivery at thirty-seven weeks gestation with complaints of contractions. Upon arrival, she explained that her fetus, Nathan, had been diagnosed with a “lethal” condition by her primary obstetrician. At twenty-two weeks gestation, an amniocentesis confirmed trisomy 13, a chromosomal abnormality leading to miscarriage or stillbirth in nearly one-half of affected pregnancies. During the admission process, Deborah voices the worry that due to Nathan's brain and heart structure, vaginal delivery could (...) be traumatic and cause him to suffer. Deborah wishes for him to have as painless and as dignified a death as possible; cesarean section, she feels, will achieve this. Yet with her history of three prior vaginal deliveries, normally progressing labor, and poor fetal prognosis that is unlikely to improve with cesarean delivery, there is no maternal or fetal indication for a cesarean section. Should the obstetrician proceed with a cesarean delivery despite knowing that it would expose the mother to surgical risks with little or no corresponding fetal or neonatal benefit? (shrink)

Over the last several years, as cesarean deliveries have grown increasingly common, there has been a great deal of public and professional interest in the phenomenon of women 'choosing' to deliver by cesarean section in the absence of any specific medical indication. The issue has sparked intense conversation, as it raises questions about the nature of autonomy in birth. Whereas mainstream bioethical discourse is used to associating autonomy with having a large array of choices, this conception of autonomy (...) does not seem adequate to capture concerns and intuitions that have a strong grip outside this discourse. An empirical and conceptual exploration of how delivery decisions ought to be negotiated must be guided by a rich understanding of women's agency and its placement within a complicated set of cultural meanings and pressures surrounding birth. It is too early to be 'for' or 'against' women's access to cesarean delivery in the absence of traditional medical indications – and indeed, a simple pro- or con- position is never going to do justice to the subtlety of the issue. The right question is not whether women ought to be allowed to choose their delivery approach but, rather, taking the value of women's autonomy in decision-making around birth as a given, what sorts of guidelines, practices, and social conditions will best promote and protect women's full inclusion in a safe and positive birth process. (shrink)

Background: Obstetric labor and childbirth are mostly regarded as a physiological process, whereas social, cultural, psychological and transcendental aspects have received less attention. Labor support has been suggested to promote labor progress. The aim of this study was to investigate whether continuous labor support by a midwife promotes labor progress and vaginal delivery.Material and Methods: A randomized controlled study at a university hospital in Sweden in 2015–17. Primiparous women with singleton pregnancy and spontaneous labor onset were randomized to continuous (...) support or standard care during delivery. The primary outcome was the duration of active labor. Secondary outcomes were delivery mode, women's need of labor analgesia and satisfaction with delivery, maternal cortisol levels, and neonatal morbidity.Results: Continuous support was followed by shorter active labor 11.0 ± 5.7 h compared to 13.7 ± 3.9 h with standard care. Women in the continuous support group tended to have lower cortisol levels and low cortisol during the first and second stages of labor were correlated with shorter active labor. Continuous support was followed by spontaneous delivery in 73%, instrumental delivery in 24% and emergency cesarean section in 3% in contrast to standard care which was followed by spontaneous delivery in 62%, instrumental delivery in 24% and cesarean in 14%. The continuous support group received combined analgesic methods more often. Women's satisfaction with delivery and neonatal morbidity were comparable.Conclusion: Continuous labor support was followed by shorter active labor compared to standard care. Women with continuous support had a high rate of vaginal delivery and tended to have lower cortisol levels during all stages of active labor reflecting a lower stress level. Low cortisol was correlated to shorter active labor. Based on these results, we recommend continuous labor support for all primiparous women during active labor. (shrink)

The diffusion of medical technology is largely determined by the marketplace demands supported by national and historical contexts. Using the cases of cesarean delivery and newborn intensive care in the United States, this article presents the argument that the interaction of four factors accounts for the rapid diffusion of untested technologies. These factors are economic expansion in an unrestricted market, the vulnerability of the patient population, a social disposition towards emergency medicine, and the vested interest of medical specialists.

In this article, we discuss decision making during labor and delivery, specifically focusing on decision making around offering women a trial of labor after cesarean section. Many have discussed how humans are notoriously bad at assessing risks and how we often distort the nature of various risks surrounding childbirth. We will build on this discussion by showing that physicians make decisions around TOLAC not only based on distortions of risk, but also based on personal values rather than medical (...) data. As a result of this, we will further suggest that the party who is best epistemically situated to make decisions about TOLAC is the woman herself. (shrink)

In 1987, a young woman named Angela Carder, pregnant and dying from cancer, was ordered by a court of law to undergo a cesarean delivery against her and her family’s wishes. She and her baby both died. Three years later, an appeals court took an extraordinary stand: it vacated the order that ended their lives and upheld pregnant women’s rights to informed consent and bodily integrity. The “unkindest cut of all,”1 it seemed, had been condemned by the courts.2 (...) Yet shortly before the twenty-year anniversary of this landmark case, the same rights were stripped from another young pregnant woman. In January of this year, oral arguments were heard in the case of Samantha Burton. She had been twenty-five weeks .. (shrink)

Cesarean sections are one of the most commonly performed surgical operations worldwide. Though evidence suggests that non-medically indicated cesarean sections raise the health risks for mothers and their babies and result in increased costs of health care compared with vaginal deliveries, reports are common that the frequency of performance of this surgical procedure is far above WHO recommendations. Of special concern has been the current increase of cesarean delivery rates in some Latin American countries. Here we (...) focus on Monterrey, Mexico, a city that has one of the highest rates of cesarean deliveries in the world. We explore aspects that relate to the practice of cesarean section that might shed light on determining why Monterrey has become the capital of cesarean sections. (shrink)

Childbearing is an increasingly complicated matter, which has evolved significantly over the past several decades. Treatment options for infertility have expanded. Prenatal testing and treatment have led to an evolution in obstetrical decision-making, wherein the risks and benefits to the fetus and future child are better understood and more strongly considered in medical management of the pregnant woman. Obstetrics appears to be increasingly interventional; one in three babies in the United States is now born by cesarean section. Neonatal intensive (...) care has markedly improved outcomes for premature babies. A pregnant woman may now be presented with many options— obstetrician or midwife, home or hospital delivery, choices among prenatal testing and monitoring, early induction of labor, cesarean delivery. Health care professionals face similar decisions with regard to what they recommend and the boundaries of safe and responsible care they should make available. Preterm Babies, Fetal Patients, and Childbearing Choices, by John D. Lantos and Diane S. Lauderdale, provides an excellent overview of the available information relevant to these questions. (shrink)

In the United States, clinical interventions such as epidurals, intravenous infusions, oxytocin, and intrauterine pressure catheters are used almost routinely in births in the hospital setting, despite evidence that the overutilization of such interventions likely plays a key role in increasing the need for cesarean section (CS). In 2010, according to the U.S. Centers for Disease Control and Prevention, approximately 32.8 percent of births in the U.S. were by CS. The U.S. National Institutes of Health has reported that CS (...) increases avoidable maternal and neonatal morbidity and mortality. To increase understanding of what might motivate the overuse of CS in the U.S., we investigated the factors that influenced women’s decision making around childbirth, because women’s conscious and unconscious choices about giving birth could influence whether they would choose or allow delivery by CS.In this article, we report findings about women’s decisions related to place of birth—at home or in a hospital. We found that choosing a place of birth was significant in how women in our study attempted to mitigate their perceptions of the risks of childbirth for themselves and their infant. Concern for the safety of the infant was a central, driving factor in the decisions women made about giving birth, and this concern heightened their perceptions of the risks of childbirth. Heightened perceptions of risk about the safety of the fetus during childbirth were found to affect women’s ability to accurately assess the risk of using clinical interventions such as the time of admission, epidural anesthesia, oxytocin, or cesarean birth, which has important implications for clinical practice, prenatal education, perinatal research, medical decision making, and informed consent. (shrink)

Domestic violence is one of the most common forms of violence against women. Domestic violence during pregnancy is associated with adverse perinatal and maternal outcomes. We aimed to assess whether domestic violence was associated with mode of delivery, low birthweight and preterm birth in two sites in Nepal. In this prospective cohort study we consecutively recruited 2004 pregnant women during antenatal care at two hospitals between June 2015 and September 2016. The Abuse Assessment Screen was used to assess fear (...) and violence. Having ever experienced either fear or violence was defined as any domestic violence. Obstetric outcomes were obtained from hospital records for 1381 women, selecting singleton pregnancies only. Mode of delivery was assessed as birth by cesarean section or not. A birthweight of less than 2500 g was defined as low birthweight and preterm birth as birth before completion of 37 weeks gestation. Descriptive and multiple logistic regression analyses were performed to assess associations. Twenty percent of the women reported any domestic violence. Among all 1381 women, 37.6% gave birth by cesarean section. Of those women who delivered by cesarean section, 84.7% had an emergency cesarean section. Less than 10% of the babies were born prematurely and 13.5% were born with low birthweight. We found no significant association between exposure to any domestic violence during pregnancy and risk of a low birthweight baby or birth by cesarean section. However, having experienced both violence and fear was significantly associated with giving birth to a preterm infant [aOR 2.33 ]. Domestic violence is common in Nepal. This is a potential risk factor for severe morbidity and mortality in newborns. We found that the risk of having a preterm baby was higher for pregnant women who experienced both fear and violence. This should be recognized by the health sector. In this study, no significant differences were found in the rate of cesarean section nor low birthweight for women who had experienced any domestic violence compared to those who did not. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Day I Touched JesusJeffery L. DealShe deserved better. They all do.I met her early on a morning that promised to be hot and wet, as Sudan tended to be at that time of year. Hot all the time. Hot and wet in the summers. I touched her for the briefest of moments, felt her leg move against my hand and caught a fleeting glimpse of a foot that (...) was barely the size of my fingertip. I was there because a missionary asked me to come, told me stories of conditions in Sudan and convinced me that I could save lives. He was right.Her twin brother was born eight hours earlier, sometime around midnight. The birth attendants managed the delivery as well as anyone could in the same situation. The last time I had attempted to manage such a problem delivery was almost twenty years earlier when I had been a Navy Lieutenant fresh out of my surgical internship on temporary assignment to a Marine Corps battle group in the Philippines. On that deployment, a corpsman brought me to a grass hut where a woman who looked barely more than a child herself labored against a breach delivery. I spent the day examining her while her family brought me things to eat that I do not believe should be eaten. After six hours of no progress, I radioed for a helicopter to take her to Clark Air Force base where they had operating rooms and obstetricians. In South Sudan, we had no such resources.My oldest daughter, a premed student at the time who had worked with me in Sudan on other occasions, sat in the corner with her classmates and watched as I put my hand inside the mother. She was of the Dinka ethnic group and was a large, robust woman who sweated profusely and occasionally caught her breath, but otherwise seemed unmoved by her contractions. Fluids gushed over my gloved hand and the students gasped. I felt the baby's leg retract slightly as if she resented my intrusion.I could not get past the baby's hip—she was wedged tightly in the uterus. I had some medicines that were used to hasten delivery and, not really knowing if it was the right thing to do, I gave the mother some through her IV. Still I could not dislodge the child. I told the students and birth attendants that we would give her one hour while I rounded on the other patients in our remote and poorly equipped clinic. If she did not deliver by that time we would take her to a facility run by a Catholic relief agency several hours drive from us—a drive that due to war, weather, or mechanical problems we could not always complete.I saw the rest of the patients in a hurry while browsing through all of the medical texts and the few books we kept at the clinic. This child's only hope of surviving was for her mother to have a cesarean section, and as quickly as possible. After determining that none of our other patients were in imminent danger, we loaded the mother, the first-born twin, and the grandmother into our vehicle for the long ride. One of the medical students, who at the time of this writing was completing her residency in obstetrics and gynecology, asked me if I shouldn't pray for the woman while we drove. I felt guilty for not praying out loud without being prompted, so I reached back and placed my hand on the mother's abdomen and prayed while I drove. I felt a slight movement. It could have been the rough road or the mother shifting, but I believe to this [End Page 81] day that I felt the child move. I would not feel her again. I drove as fast as the rough, bomb-cratered dirt road allowed.Mother and unborn child were doing well when we finally arrived three hours later. I knew the facility and many of the workers so I drove past the guard and directly to the obstetrics ward. Two nurses rushed out to meet us with... (shrink)

I was a second-year neonatal-perinatal fellow in a meeting between other members of the neonatal intensive care team and parents who had just received devastating news about their planned-for and highly desired baby, born after what had been an uncomplicated pregnancy. At home, a little sister was waiting to meet her new brother. These conversations are never easy, but this one I found particularly disturbing. John had been born at term via emergency cesarean section after his mother, Muriel, had (...) come for a routine obstetrical visit and reported decreased fetal movement. The obstetrician had detected a very slow fetal heart rate and sent Muriel to the hospital for emergent delivery. John was born floppy, with no respiratory effort. He was resuscitated, but a heart rate was not detected until fifteen minutes after birth. Not until several months later did I discover what had troubled me so much in this family meeting. (shrink)

Feminists have highlighted various ways in which medicalized childbirth is connected to violence. For example, the literature is replete with examples of court-ordered Cesarean sections, intimidation in the delivery room, women diagnosed with post-traumatic stress disorder as a result of their childbirth experiences. The most common approach to the accusations about the connections between medicalized childbirth and violence has been to investigate the degree to which the evidence bears out their accuracy. In this essay, the author takes a (...) different course; instead of trying to confirm or refute reports of violence in childbirth, she posits that understanding the ways in which violence is connected to medicalized childbirth requires us to note the existence of another form of violence that has not been recognized or discussed up to this point – metaphysical violence. The primary focus of this essay is to define that other form of violence as well as to suggest places where the routine practices of medicalized childbirth perpetuate it and possible ways to resist it. (shrink)

IntroductionElements mark the reality of reading the female body in symbolic constructions and social symbols in the exercise of their reproductive health. The study aims to identify elements that characterize the female condition while analyzing the reproductive health of Brazilian and French women.Materials and MethodsA qualitative, multicenter, international study was conducted in Brazil and in France between 2016 and 2019. Data were produced through the use of semi-structured scripts. Focus group discussions and individual interviews were conducted with women who gave (...) birth, hetero-female couples who lived the experience of gestation and birth of a baby, and professionals of maternal and childcare services or members of the associations concerned with the health of mothers and babies. It was guided by the theoretical-methodological framework of institutional analysis in line with the French Institutional Socioclinics.ResultsSexual and reproductive health in the realities researched in Brazil and France are sometimes close and sometimes far apart. In what involves the Brazilian health system, abortion is criminalized and often performed illegally. Furthermore, pregnancy, childbirth, and the postpartum period are highly medicalized. In addition, childbirth is not assured as an experience for a woman and her family. This aspect is confirmed by high numbers of cesarean sections performed or by maternal and infant mortality indicators. The French health system prioritizes vaginal deliveries and seems to assure more autonomy to women, but at the same time, it is worn out by the logic of profit, the efficiency of actions, and the rationalization of practices. In association with these, there are other intrinsic elements in the functioning of the institution that delineates the format of each country: notion of women's rights, violence against women, and discussion regarding the oppression markers of race, gender, sexuality, and social class.ConclusionsBoth countries reveal aspects related to the social role of women's bodies. The established logic reflects in the decision to have children, motherhood, women's autonomy over their own bodies, and in the core values linked to the termination of pregnancy and the professional practices developed in prenatal care, childbirth, and postpartum. (shrink)

PurposeThe relation between fear of childbirth and gestational age is inconclusive, and self-reported need for help regarding this fear has never been investigated. This study aimed to determine the prevalence and course of FoC according to gestational age, to identify risk factors for the development of FoC, the influence of this fear on preferred mode of delivery, and self-reported need for help.MethodsNulliparous pregnant women of all gestational ages completed an online survey. The study consisted of a cross-sectional and a (...) longitudinal analysis. Women who completed the survey in the first or second trimester were approached again in their third trimester. The Wijma Delivery Expectancy Questionnaire Version A was used with a cut-off score ≥ 85 to define presence of fear of childbirth. Questionnaires indexing social support, anxiety, symptoms of depression, preferred mode of delivery, and self-reported need for help were included.ResultsIn total, 364 women were enrolled at T0, and 118 out of 184 eligible women were included in the longitudinal analysis. Point prevalence of FoC at T0 was 18.4% with no significant difference between trimesters. In the longitudinal sample, the prevalence of FoC decreased from 18.6% to 11.0%, p = 0.004. Although mean scores for FoC decreased significantly, p < 0.001, scores increased in 41 women. The presence of FoC was associated with elevated anxiety, less family support, prenatal care of the obstetrician by choice, preference for a cesarean section, and for pain relief. Women with FoC were more likely to actively seek for help compared to women without FoC.ConclusionWhile FoC is common in each trimester, prevalence decreases over the course of pregnancy. Women with FoC are often actively seeking for help, suggesting that this fear should be addressed better, and help should be offered accordingly. (shrink)

As a result of the COVID-19 global pandemic, paramedics in the UK face unprecedented challenges in the care of acutely unwell patients and their family members. This article will describe and discuss a new ethical dilemma faced by clinicians in the out-of-hospital environment during this time, namely the delivery of bad news to family members who are required to remain at home and self-isolate while the critically unwell patient is transported to hospital. I will discuss some failings of current (...) practice and reflect on some of the ethical and practical challenges confronting paramedics in these circumstances. I conclude by making three recommendations: first, that dedicated pastoral outreach teams ought to be set up during pandemics to assist family members of patients transported to hospital; second, I offer a framework for how bad news can be delivered during a lockdown in a less damaging way; and finally, that a new model of bad news delivery more suited for unplanned, time-pressured care should be developed. (shrink)

In this article, I will argue that the delivery of healthcare could be an act of resistance, that is, day‐to‐day, routine and perhaps mundane acts, undertaken in the course of the delivery of health services, which for many could also be considered otherwise routine care. I first consider how resistance has been conceptualised. How we understand resistance will determine if we believe healthcare could be conceptualised this way. I will show how resistance has been applied to day‐to‐day struggles (...) elsewhere and argue that it can clearly encompass open, collective dissent and more subtle, day‐to‐day action that does not necessarily make clear political demands. I go on to introduce some examples, where the delivery of health services could be conceptualised as resistance. While I advocate for a broad understanding of resistance, clearly not every act could be considered resistance; I will consider some points of tension and contention in utilising resistance to describe the delivery of health services, in particular discussing the issue of intent and opposition as they relate to resistance. Finally, while I hope that I make a convincing case, one final issue remains, namely, why turn to resistance at all, when many of the examples that I provide could be labelled using concepts that are more widely utilised. I will offer some general reflections on this point, speaking to the benefits and potential of resistance. (shrink)

In the discipline of practical theology, one finds a long history of linking the name of the field to diaconiology, in which you find the Greek word diaconia, directly translated as 'service'. For good and scientific reasons, the field changed its name to practical theology in some Faculties of Theology but that does not take away the fact that this field of research is still very much engaged in the broad area of 'service of all kinds'. The purpose of this (...) article was to do a descriptive investigation into the problems and challenges of service delivery in the suburb of Belhar (Cape Town), specifically looking at the role of leadership during a (new) time of struggle. As part of the normative task, the researcher took a closer look at the Belhar Confession as a prophetic stance in this regard. In an ironic twist, we see in these events the struggle between the real and the ideal that is typical of many places in the country facing problems with service delivery. The Church often thinks it knows what the world wants from it - inspiration, 'leadership,' clear teaching. But surely what the world is most hungry for is the simple knowledge that healing is possible - not by forgetting or minimizing outrages and sufferings but by sheer, obstinate, costly commitment to work with the grain of grace. (Rowan Williams, Archbishop of Canterbury, in Lapsley 2012:i). (shrink)

This simulating book gathers five lectures that ask questions of the broadest general intellectual interest: What is religion? Do other peoples have the same emotional states as we do? Why do humans make use of body imagery? In Circumstantial Deliveries, Rodney Needham shows that the comparative study of societies may furnish the answers. Circumstantial Deliveries challenges the methodology and substance of many conventional ideas about human nature and calls for more radical and comparative analyses. For instance, the author discredits the (...) notion that to primitive peoples the colors red, white, and black symbolize blood, semen, and feces, respectively, arguing that an extensive comparative study of primitive societies discovered no such relationship. These essays sound a common theme: "If a deeper appreciation of the value of life can be had from reading Crime and Punishment, or if a more acute assessment of the springs of action can be acquired from Hamlet, then in principle it should be conceded that like benefits may be derived from a sympathetic observation of other men engaged in their daily affairs.". (shrink)

The radical transformations caused by the rapid development of information and communication technologies in the mid-1990s prompted the transition to the knowledge society which identified the key role of knowledge as the most important and valuable capital of organizations and had a decisive impact on the development of corporate training. In our study, we aimed to analyze the training methods used in American companies in the knowledge society, particularly, their feasibility, features, benefits and possible limitations. The results of our study (...) show that, at present, e-learning is considerably more widely used in American companies than instructor-led classroom training. Most organizations use blended learning which implies the combination of e-learning methods and instructor-led learning methods. A powerful stimulus for the wide implementation of e-learning methods was produced by the COVID-19 pandemic when the use of educational technologies made it possible for the companies not only to continue training and development of their employees but also to implement tactical and strategic practices which will have long-term implications for the future of the training industry. The most widely used e-learning methods in American companies are virtual classroom/webcast, online or computer-based methods, social learning, augmented reality, virtual reality, and artificial intelligence. In spite of certain limitations of e-learning methods, they have a number of important benefits which allow companies to expand access to training, save costs, increase adaptability and flexibility of learning programs, etc., and thus satisfy their needs in qualified employees. (shrink)

James Walsh and Moira McQueen accurately conclude that the early delivery of anencephalic fetuses is morally acceptable, but the reasoning they use to reach that conclusion is flawed. First, the principle of double effect does not require a weighing of good and evil, but rather seeks a sufficient reason for tolerating the physical evil indirectly intended. Second, the principle of double effect requires a clear distinction between physical and moral causality. Third, the Catholic moral tradition will not admit direct (...) and intended killing of the innocent. Rather, early delivery of anencephalic fetuses is permissible because of the pathology associated with delivery of anencephalic fetuses at full term. Thus, the early delivery of an anencephalic infant is acceptable if the purpose of the moral act is avoiding a pathological condition on the part of the mother. (shrink)

The Alexandra District Ambulance Service is the only volunteer-based ambulance service in Victoria, Australia. It provides an opportunity to reflect on the ethical issues surrounding the delivery of ambulance service by volunteers, and its impact on the community.

필자는 본 논문을 통해 서구 형이상학이 제시하는 몸의 위상을 분석한 뒤 새로운 몸 개념을 통해 기존의 몸의 도식의 전복 가능성을 고찰해 보고자 한다. 데카르트에 의해 수립된 몸의 도식은 몸-자동기계(body-mecanic)와 의식조정-자동기계라는 이중의 층위로 분절화되어 있는데 우리는 논증을 통해 이것을 비판적으로 분석하도록 할 것이다. 기존의 몸 도식이 ‘메카닉(mecanic)’이라는 정합적이고 기능주의적인 유기체 논리에서 벗어나지 못하고 있다는 점에 주목하여, 필자는 들뢰즈와 가따리의 “기관 없는 신체(Corps sans organes)” 개념의 프리즘을 통해 “장기-몸(intestins-corps)”이라는 새로운 몸 개념을 제시하고자 한다. 장기-몸(intestins-corps)은 일련의 정합적이고 유기체적인 질서로부터 적출되어 나와 카오스적인 에너지로 (...) 들끓으며 이질적 요소들과의 무한연접으로 열려있는, 새로운 차원의 몸이다. 이러한 장기-몸의 봉기를 가장 잘 나타내주는 사태는 다름 아닌 극한고통이 도래하는 출산이라고 본다. 필자는 출산이 어떤 의미에서 ‘장기-몸’이 실질적으로 가동되는 상태인지를 지젝의 논의의 분석을 통해 심도 있게 고찰할 것이다. 또한 출산을 거친 자들이 상징질서로 편입되지 않고 금기를 깨고 되돌아오는, 살아있는 망자(the living dead)임을 지젝의 논의로부터 분석해 보겠다. 이로서 출산과 같은 극한고통의 체험이 갖는 카오스적 파괴의 힘이 어떤 측면에서 상징적 질서에 균열을 가할 수 있는지도 발터 벤야민의 ‘신적 폭력’ 개념을 착안해 고찰할 것이다. (shrink)

Hydroxycamptothecin is a potent antineoplastic agent that has shown efficacy against multiple tumor lines in vitro. eww140918dxn This is the first study to investigate the release, distribution, and efficacy of hydroxycamptothecin which was incorporated into the biodegradable polymer Polylactic Acid (PLA), and implant into brain directly. In vitro release curve generated showed that a large initial release occurred over the first three days and was followed by a steady, but considerably slower rate of release over the next 25 days. After (...) implanting the discs into 40 male SD rats, the animals were followed up to 28 days, where the concentration in brain tissue was far higher than that in peripheral blood at the each of the eight time-points evaluated, and it was also within the therapeutic range for C6 cells tested in vitro. The in vivoefficacy of the discs was evaluated with rats inoculated intracranially with C6 glioma and treated with hydroxycamptothecin polymer compared to intravenous as well as intratumoral injections; the median survival is 21.1, 13.9, 14.9 days, respectively. Given these data, we conclude that the biodegradable polymer PLA releases hydroxycamptothecin, producing tumoricidal levels in brain tissues and prolonging survival in a rat glioma model. (shrink)

Partially because of the high cost of developing and maintaining cold chains, systems needed to keep heat-labile vaccines under adequate refrigeration from their points of manufacture to their administration in the field, the Joint WHO/FAO Expert Committee on Zoonoses (i.e., the approximately four fifths of all described human infections that people share with other vertebrate animals) recommended in 1982 operation of common cold chains by health and veterinary services in rural areas. Following this recommendation, a 1984 pilot level initiative in (...) medical-veterinary intersectoral cooperation should be regarded as a practical way to deliver human primary health care to currently neglected African pastoralists, and as a potential core program for development efforts overall within arid and semiarid areas of the African continent. (shrink)

In “Practical Knowledge of Language”, C.-h. Tsai criticizes the arguments in “Swimming and Speaking Spanish” (this issue, pp. 331–341), on the grounds that its account of knowledge of language as knowledge-how is mistaken. In its place, he proposes an alternative account in terms of Russell’s concept “knowledge-by-acquaintance”. In this paper, I show that this account succeeds neither in displacing the account in Swimming and Speaking Spanish nor in addressing Tsai’s main concern: solving the “delivery problem”.

This paper investigates how early career academics interpret and respond to institutional demands structured by projectification. Developing a ‘frame analytic’ approach, it explores projectification as a process constituted at the level of meaning-making. Building on 35 in-depth interviews with fixed-term scholars in political science and history, the findings show that respondents jointly referred to _competition_ and _delivery_ in order to make sense of their current situation. Forming what I call _the project frame_, these interpretive orientations were legitimized by various organizational (...) routines within the studied departments, feeding into a dominant regime of valuation and accumulation. However, while the content of the project frame is well-defined, attempts to align with it vary, indicating the importance of disciplines and academic age when navigating project-based careers. Furthermore, this way of framing academic work and careers provokes tensions and conflicts that junior scholars try to manage. To curb their competitive relationship and enable cooperation, respondents emphasized the outcome of project funding as ‘being lucky.’ They also drew on imagined futures to envision alternative scripts of success and worth. Both empirically and conceptually, the article contributes to an understanding of academic career-making as a kind of pragmatic problem-solving, centered on navigating multiple career pressures and individual aspirations. (shrink)

The number of cesarean sections performed globally has been consistently rising since the 1980s.1 The number of cesareans performed now greatly exceeds the number that experts predict are necessary.2 In Brazil, the world's "cesarean capital," over half of births are surgical. In the United States, approximately one third of babies are delivered by cesarean, and in the United Kingdom around 26 percent of births are by cesarean.3 Cesarean section can be a life-saving intervention when vaginal (...) birth poses a risk to woman or fetus.4 However, some doctors believe that cesareans performed in the absence of an emergency carry substantial risks for limited or no benefit (Wagner 2000... (shrink)

Within a given culture – whether industrialized or more tradition oriented – essentially the same fundamental medical theories, practices, and pharmacopoeia tend to be applied to human and non-human sickness and patients. In modern industrialized societies, however, healthcare services are sharply divided between human and veterinary medicine. There is likewise a sharp division between practitioners in these two health sectors: medical doctors and veterinarians. Yet in non-Western, traditional or indigenous medical systems, the same practitioners often treat both humans and animals. (...) There is a growing body of literature that attests to the efficacy of traditional health practices and herbal medicines for the prevention and treatment of both human and livestock ailments.The authors argue for an intersectoral approach to human and veterinary health services in poor countries, especially those targeted to rural people with LIMITED access to modern health services. Extension of conventional medical and veterinary services is particularly difficult and costly in Third World countries where the necessary infrastructure (roads, clinics, labs, cold chains, etc.) is poorly developed and where much of the populace and their livestock reside in remote, rural areas, or where people may be nomadic or transhumant. Consideration should therefore be given to the joint delivery of human and livestock healthcare and related services, as well as to linking informal, ethnoveterinary practices and practitioners with more formalized systems of veterinary AND medical practice. Several advantages of such an approach are identified and explored. (shrink)

I hypothesize here that the ability of probiotics to synthesize neuroactive compounds provides a unifying microbial endocrinology‐based mechanism to explain the hitherto incompletely understood action of commensal microbiota that affect the host's gastrointestinal and psychological health. Once ingested, probiotics enter an interactive environment encompassing microbiological, immunological, and neurophysiological components. By utilizing a trans‐disciplinary framework known as microbial endocrinology, mechanisms that would otherwise not be considered become apparent since any candidate would need to be shared among all three components. The range (...) of neurochemicals produced by probiotics includes neurochemicals for which receptor‐based targets on immune and neuronal elements (intestinal and extra‐intestinal) have been well characterized. Production of neurochemicals by probiotics therefore allows for their consideration as delivery vehicles for neuroactive compounds. This unifying microbial endocrinology‐based hypothesis, which may facilitate the selection and design of probiotics for clinical use, also highlights the largely unrecognized role of neuroscience in understanding how microbes may influence health.Editor's suggested further reading in BioEssays Harvesting the biological potential of the human gut microbiome Abstract. (shrink)

This special issue of the Journal of Medicine and Philosophy focuses on unintended intrauterine death (UID) and preterm delivery (both phenomena that are commonly—and unhelpfully—referred to as “miscarriage,” “spontaneous abortion,” and “early pregnancy loss”). In this essay, I do two things. First, I outline contributors’ arguments. Most contributors directly respond to “inconsistency arguments,” which purport to show that abortion opponents are unjustified in their comparative treatment of abortion and UID. Contributors to this issue show that such arguments often rely (...) on a grossly oversimplified picture of abortion opponents’ views. Furthermore, contributions in this issue weigh in on issues regarding UID with theoretical import and therapeutic implication beyond the inconsistency argument debate. These papers can be mined for principles that better inform us about anembryonic pregnancies (i.e., nonviable pregnancies in which a gestational sac exists but no embryonic pole can be seen via transvaginal ultrasound), UID-prevention research, the law concerning UID (especially post-Dobbs), policies for handling embryonic remains, and moral psychology as it relates to UID, emotion, and empathy. In each case, conceptual philosophical analysis might bring about therapeutic benefits for those affected by UID. Philosophers, therefore, are in position not only to provide clarity—careful analysis and discussion of UID and related phenomena—but are also in position to genuinely help people affected by UID. (shrink)

This article proceeded from the assumption that the theme of service delivery in present-day South Africa could well be qualified by the notion of 'crisis', to the extent that this qualification, from a theological perspective and on the basis of comparative social analysis, well recalls the statements in such critical and profound theological documents as The Kairos Document and Evangelical Witness in South Africa on the 'crisis' in the latter years of apartheid. The further recognition that the theme of (...) service delivery constitutes an essentially new focus for practical-theological scholarship in South Africa led the author, who has a pertinent interest in the field of Christian diaconia, to thereupon go the full circle of practical-theological interpretation in developing such a focus. This was done by, firstly, attempting to develop a deeper contextual understanding of the problem of service delivery in the country on the basis of the prevailing debate on service delivery in South Africa, after which the ideas from conceptualisations of two different modes of diaconal practice within contexts of endemic poverty in the practical-theological literature were explored. The discussion concluded with a more pertinent consideration of the extent to which these two conceptualisations could be taken as providing direction in conceptualising a transformational diaconal response to the current service-delivery problem. (shrink)