Aust N Z J Obstet Gynaecol 2018; 58: 704–706

DOI: 10.1111/ajo.12919

CURRENT CONTROVERSIES IN OBSTETRICS AND GYNAECOLOGY - OPINION

Vaginal delivery: An argument against requiring

consent

Rodney W. Petersen

ANU Medical School, ANU College

of Health and Medicine, Canberra, Birth by vaginal delivery is an evolutionary process refined over millennia to cre-
Australian Capital Territory, Australia ate a sustainable and safe method of human reproduction. A key argument

Correspondence: A/Professor Rodney
W. Petersen, ANU Medical School,
ANU College of Health and Medicine,
Canberra, ACT 2600, Australia.
Email: rodneywpetersen@gmail.com
Conflict of Interest: The author reports
no conflicts of interest.
Received: 11 September 2018;
Accepted: 26 September 2018
against requiring consent for vaginal birth acknowledges that from an evolution-
ary point of view, vaginal delivery has successfully accompanied human develop-
ment and remains the natural and default form of human birth. Concern has
been raised by the Montgomery court case in the United Kingdom; however, the
ruling does not mean consent is required for normal birth. What it does reaffirm
is the need to engage patients in their care decisions when complications occur
in pregnancy and delivery. Effective communication, rather than a legalistic con-
sent pathway, is required for positive healthcare outcomes.

KEYWORDS
consent, vaginal delivery

‘That was excellently observed’, say I, when I read
a passage in an author, where his opinion agrees
with mine. When we differ, there I pronounce him to
be mistaken.
Jonathan Swift
Birth by vaginal delivery is an evolutionary process refined over
millennia to create a sustainable and safe method of human re-
production. It has been the delivery route of choice for humans for
200 000 years and, with over 7.6 billion humans on the planet, has
a track record of providing a safe, effective and efficient method of
delivery. The earliest drawn and carved records of humans include
dedicated works that celebrate human fertility and vaginal birth. By
example a stone carving from central Turkey of a seated female fig-
ure believed to be a fertility goddess giving birth vaginally is dated
to 6500 years B.C.E.1
Birth by caesarean section is a more recent development.
According to the US National Library of Medicine, the procedure
has occurred as a perimortem event in Hindu, Egyptian, Grecian,
Roman and Chinese cultures, when the mother was moribund or
dead and the procedure was performed primarily in an attempt
to save the child. The first written record of both mother and baby
surviving caesarean section was in Switzerland in 1500 C.E.2
A key argument against requiring consent for vaginal birth
acknowledges that from an evolutionary point of view, vaginal
delivery has successfully accompanied human development
and remains the natural and default form of human birth. In
contrast, caesarean section has evolved from perimortem and
life-­threatening complications and remains the exception to be
applied when pregnancy and birth are abnormal. There can be
no logical argument that consent is required for the normal pro-
cess of vaginal birth as there is no medical treatment per se. In
contrast, when pregnancy and birth are complicated, consent is
required to provide treatment outside of this normal process.
A person must not be subject to ‘medical… treatment
without his or her full, free and informed consent’.
Charter of Human Rights and Responsibilities Act
2006 (Vic).
Advocates of consent argue that vaginal birth requires consent
because there are ‘safe alternatives’ in the form of caesarean sec-
tion. For example, a review article on informed consent for vaginal
delivery supported this argument with little more than an opinion
that ‘…verbal discussion of risks without documentation may no lon-
ger be appropriate due to medical advancements and the litigious
health care climate’.3
If the rationale of ‘medical advancements’ were to be applied
universally, then it could be argued that consent is required for
other normal events that occur in our everyday lives such as

704wileyonlinelibrary.com/journal/anzjog
© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
R. W. Petersen
the carcinogenic impact of eating foods. After all, we have total
parenteral nutrition as a safe medical alternative to food. Using
this flawed logic but concentrating on fecundity, an argument
could be made that consent is required for the option of trying
to conceive through sexual intercourse. After all, in vitro fertilisa-
tion (IVF) offers an alternative, medical pathway for conception.
Relying on sex to conceive a child is risky business. Think of those
sexually transmitted diseases that might be avoided if human-
ity consented to IVF rather than sex. All those concerns around
dyspareunia, male and female sexual arousal and sexual injuries
could also be avoided if sex with intent of conception were re-
placed by IVF. A 2010 UK telephone interview study reported in
detail how one-­third of adults had experienced a ‘sexual injury’
with 5% requiring time off work. The list of injuries reported was
exhaustive.4 These adverse consequences and medicolegal risks
could have been avoided using IVF.
Therefore, if we argue that consent is required for natural pro-
cesses like vaginal birth because medical alternatives like caesar-
ean section exist, then surely we need to demand consent before
we participate in sex with intent of conception.
A further concern argued by pro-­consent advocates for vaginal
birth is the increasing concern about litigation. In particular, pro-
ponents often cite the 2015 case Montgomery v Lanarkshire in the
UK Supreme Court, arguing that this case provides a legal prece-
dent for the need for informed consent for a normal vaginal birth.
They claim this judgement means that a normal vaginal delivery
should be considered to be a procedure or treatment.5 However,
the case does not argue this at all. For a start, the case involves
a complicated pregnancy in a woman with type 1 diabetes with
a macrosomic baby. This pregnancy and delivery was not what
most health practitioners would consider to be normal but rather
somewhat complicated. So, quite correctly, the Montgomery rul-
ing argues that for a woman with a complicated pregnancy, birth
options should be discussed in detail to help her decide upon an
agreed management plan – quite a different concept entirely.
This case, while framed as a clash of values between patient
autonomy and medical paternalism, is in reality more about
the nuanced negotiation of information in the setting of patient
decision-­making. Patient-­centred care means patients take the
central role in treatment decisions in complex clinical situations.
They cannot take this central decision-­making role unless clini-
cians deliver information about risks relative to alternatives in a
way that they (the patient) can understand. This means discussion
on options and possible management plans. The Montgomery
ruling does not mean consent is required for normal birth; how-
ever, it does reaffirm the need to engage patients in their care
decisions when complications occur in pregnancy and delivery.6
Further argument against the litigation risk comes from a re-
view of litigation data which found that the vast majority of dis-
putes between patients and care providers (in this case doctors)
arose in relation to consent for surgical interventions. The authors
noted that ’Concerns about surgical risks not properly explained
appear to be the heartland of contemporary disputes between
705
patients and doctors over consent, at least in Australia. By con-
trast, other types of breakdowns in the consent process that have
attracted intense scholarly attention and debate (eg, failure to
canvass alternative treatments, patient competence) appear to be
infrequent triggers of formal disputes, and still others (eg, con-
sent to services rendered as part of research), however interest-
ing from an ethical perspective, are exotic in medicolegal fora.’7
The therapeutic relationship between patient and care provider
is already imbalanced and weighted toward the care provider’s
authority. The need for consent for a normal vaginal delivery may
aggravate this imbalance and intimidate some patients who feel re-
luctant to voice an opinion that might be seen to be different from
that of their health provider. Forcing consent onto a natural process
may harm the trust developed in a healthy care provider–patient
relationship. In contrast, explanations and discussions that focus on
what is important to the patient can enhance the therapeutic rela-
tionship. Every patient deserves a positive communication experi-
ence with their care provider, one that explores what is important
to the patient and involves active listening to concerns voiced by the
patient. Effective communication, rather than a legalistic consent
pathway, is required for positive healthcare outcomes. A recent
review of 69 published articles is affirmation of this view, conclud-
ing that poor communication increases the risk of various negative
outcomes – noncontinuity of care, compromise of patient safety,
patient dissatisfaction and inefficient use of resources.8
Another problem with focusing so much attention on consent
and risks, is that the benefits of vaginal birth are often neglected.
As already discussed, vaginal delivery is natural and carries evolu-
tionary benefit which should be seen as the default mode of deliv-
ery. This paper does not intend to hash out the risks of caesarean
section versus vaginal delivery, as both have their rightful place in
modern obstetrics. However, one argument raised by proponents
for consent for vaginal birth rests on the risks from vaginal deliv-
ery and the perceived safety of caesarean section. These propo-
nents usually ignore the benefits to the survival of humans that
have evolved with vaginal birth. Two clear evolutionary advan-
tages centre around breastfeeding and the newborn microbiome.
Women who deliver by planned caesarean section are signifi-
cantly less likely to initiate breastfeeding. Those who do breast-
feed do so for a shorter duration and experience significantly
higher rates of feeding and newborn difficulties in the immediate
postpartum period and for up to four months postpartum.9 These
results are even more marked in developing nations.10 Promoting
vaginal birth to women after a caesarean section also holds a
breastfeeding advantage. One large population study reported
that women who delivered vaginally after a prior caesarean sec-
tion were 47% more likely to initiate breastfeeding than women
delivered by elective repeat caesarean section.11 Breastfeeding
carries many evolutionary and health advantages for children.
The benefits of vaginal birth on the newborn microbiome
is a new and exciting area of research. Following vaginal birth,
babies are colonised with bacteria from the vagina. In contrast,
babies born by caesarean section are colonised by a diverse
706
mixture of bacteria including many pathogenic bacteria found
on the skin and in hospital settings such as Staphylococcus and
Acinetobacter.12 While babies born by caesarean section may
subsequently develop a normal microbiome, there is a body of
evidence that this delayed normal colonisation may play a role in
asthma, allergic diseases and gut health, and the development of
immune diversity.12 An increased risk of a number of childhood
diseases is now thought to be linked to the delayed acquisition
of the natural vaginal microbiome. By example, children born
by caesarean section are more likely to suffer from coeliac dis-
ease and be hospitalised for gastroenteritis.13 A meta-­analysis
reported a 19% increase in type 1 diabetes in children born by
lower segment caesarean section even after controlling for con-
founders.14 A more recent meta-­analysis of the long-­term risks
and benefits of caesarean section noted, as a primary outcome,
that caesarean section increased the risk of the development of
asthma in the child (odds ratio (OR) 1.21; CI 1.11–1.32).15
Another problem with taking a pure consent approach to
birth is the complexity caused by harm to future pregnancies. The
meta-­analysis of the long-­term risks and benefits of caesarean
section discussed above noted that it is associated with increased
future subfertility (OR 1.60; CI 1.45–1.76) and increased subse-
quent pregnancy risks such as placenta praevia (OR 1.74; CI 1.62–
1.87), placental abruption (OR 1.38; CI 1.27–1.49), uterine rupture
(OR 25.81; CI 10.96–60.76), hysterectomy (OR 3.85; CI 1.06–14.02),
ectopic pregnancy (OR 1.21; CI 1.04–1.40) and stillbirth (OR 1.27;
CI 1.15–1.40) as well as an association with increased adult-­onset
obesity (OR 1.34; CI 1.25–1.44) in the child.15
analysis15 clearly shows there are ben-
This same meta-­
efits to having a caesarean section with reduced risk of uri-
nary incontinence (OR 0.56; CI 0.47–0.66)) and reduced risk
of pelvic organ prolapse (OR 0.29; CI 0.17–0.51). Interestingly,
reduced faecal incontinence is an oft-­quoted benefit of cae-
sarean ­section; h
­ owever, this very large meta-­analysis found
no ­reduction in the risk of faecal incontinence in the mother
(OR 1.04; CI 0.73–1.48).  11. Regan J, Thompson A, DeFranco E. The influence of mode of
So, this then raises the question of where in a consent process
would the discussion of risk end? Would consent involve outing
all possible complications of immediate vaginal birth or caesar-
ean section, as well as medium and long-­term risks and benefits
to mother and child, and then immediate and long-­term bene-
fits and harm to a future pregnancy? The real risk of introducing
consent for normal birth is that we would swamp women with
statistics and forget to communicate. We would fail to provide a
patient-­centred pregnancy and birth experience.
In summary, health providers including medical practitioners
are in a privileged position to provide advice. Communication
builds trust, the more the better. Women have a reasonable ex-
pectation for information to be presented to them in a balanced
and unbiased manner as far as is practical. In general, women
No consent required for vaginal delivery
do not like going against medical advice and may find signing a
consent form to proceed with a process that is both inevitable
and natural, as unnecessarily stressful and confusing. It is dif-
ficult to understand why women who choose a natural, non-­
interventional, default pathway need to explain their decision to
a third party via consent. If we insist on consent for vaginal birth,
where will it end?
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