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Montgomery and informed consent: where are we now?

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2224 (Published 12 May 2017) Cite this as: BMJ 2017;357:j2224

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Re: Montgomery and informed consent: where are we now?

Interesting judgment and discussion about the ethics of not informing pregnant patients about facts that are relevant to them. Here in the Netherlands, I am hoping women (or their descendants) will start a few court cases about this, in particular because they were not informed antenatally about the option of a tubal ligation (TL) in case their deliveries became a caesarean section (CS), as FIGO advises to discuss long before term (1), and a study in the Netherlands shows most women with ≥1 children would desire (2). This can have serious consequences because without the TL there is of course much more risk of an unintended/ unwanted pregnancy (such women are regularly seen in abortion clinics, and are often particularly upset (2)). Risks related to pregnancy are larger for these if-given-the-option-would-have-chosen-a-TL-women compared to the risks in average pregnancies because of the uterine scar, because of possible recurrent complications related to the CS indication (e.g. diabetes, hypertension, >BMI) and because these women are on average older(3). On top of that, there are the costs and side effects (e.g. thrombosis on the pill especially in smokers when they get older) and anxieties related to contraception for the next 10-15 years. With leftover sutures from the uterine closure, the TL is gratis, unlike with clips or with hysteroscopic sterilisations later on: and at least as reliable (3). Moreover, a very likely benefit of TL, i.e. a significant reduction in subsequent ovarian carcinoma risk, is withheld ― bilateral total salpingectomy is probably most effective for this effect, and easily performed during a CS. These malignancies apparently often originate in the tubes and there is no good method (like with breast and cervix carcinoma) to detect with screening these neoplasms when still relatively harmless (3). Conversely, serious TL regret is of course a risk, but many gynaecologists, or their mentors, were trained at a time when regret was more likely: women were more easily coerced; under five mortality was higher; serious congenital abnormalities were easier missed antenatally; IVF was not so mainstream; and women were on average much younger when they delivered their ≥2 child. Indeed, regret is not so much related to parity but very significantly to age (3). One can’t help but wonder if one woman with regret who is offered free IVF is worse: ethically; from a medical-complications perspective; and in light of financial considerations, than say 10 unintended pregnancies.
In the Commonwealth countries, Brazil, Spain, Switzerland (reputed to have the lowest induced abortion rate in the world), and the USA, most women know very well that a TL during a CS for a soon-expected-to-be-complete family is a popular option. This TO option is more or less understood to be on the table antenatally. Many doctors in the Netherlands, France, Germany, Eastern Europe and Belgium think it is unwise, unethical or even financially disadvantageous for them to offer the TO option under the above circumstances and most women are not well-informed enough to demand it or to insist. There is also very subtle TO counter-propaganda by cat food producers, where it hurts most, see photo (3). Not giving the TO option also has serious consequences for, for example, Africa where the medical norms are often related to those in Europe, where there is often no guaranteed access to a repeat CSs let alone NIPT and where millions of women have an unmet need for contraception and save abortion. A few court cases in Europe might help. In sub-Saharan Africa uterine scars can carry a similar risk to landmines: they can “explode” even 10 years after the last CS (3). Who knows whether the medical services will be in that particular region adequate then?

(1) Dickens B. Female contraceptive sterilisation: International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women's Health. Int J Gynaecol Obstet 2011;115:88–9.
(2) Verkuyl DA, van Goor GM, Hanssen MJ, Miedema MT, Koppe M. The right to informed choice. A study and opinion poll of women who were or were not given the option of a sterilisation with their Caesarean Section. PLoS ONE 2011;6:e14776. doi:10.1371/journal.pone.0014776. PMID: 21445338 http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0014776
(3) Verkuyl DA. Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it. Contraception and Reproductive Medicine (2016) 1:23 DOI 10.1186/s40834-016-0034-1 (open access)

Competing interests: No competing interests

20 May 2017
Douwe A. Verkuyl
Obstetrician
CASA Clinics, Leiden, The Netherlands
Leinweberlaan 16, 3971KZ, Driebergen,The Netherlands