**18. Interventions for severe congenital malformation of the foetus**

A woman carrying a severely malformed foetus has the ethical right of having the pregnancy terminated. In situations where termination of pregnancy is not considered as a management option, for example for legal, religious or other personal reasons, prenatal diagnostic procedures for severe foetal congenital malformations should be preceded by counseling of the woman on the possible findings and ascertaining from her the extent of the findings to be disclosed to her. Pregnancy termination on the basis of the sex of the foetus is un-ethical. In multiple pregnancies involving normal and malformed foetuses prime consideration should be given to survival of the normal foetuses provided the mother's life is not at risk. Where the couple disagrees on the management option in severe foetal malformations, the view of the woman should take precedence over that of spouse. The medical team has the ethical responsibility to encourage the parents, in the case of severe foetal malformation, to seek a second opinion, should they not be satisfied with the medical advice given to them. The decision on the termination of pregnancy for congenital malformation should be made by the parents free from coercion, financial inducement or demographic considerations whether from government or other bodies. Medical practitioner should seek appropriate consent to confirm and appropriately document the nature and extent of foetal malformation following termination and furthermore appropriately inform and counsel parents.

#### **19. Caesaeran section for non-medical reason**

Worldwide there has been and increasing incidence in the rate of caesarean section attributable to medical, legal, financial, social and psychological factors. Oftentimes physicians are confronted with request for caesarean section for personal reasons such as the convenience of the patient. Caesarean deliveries are associated with higher risks than vaginal deliveries. Furthermore complications, costs and duration of hospital stay are more following caesarean deliveries compared to vaginal deliveries. It is ethically wrong for medical practitioners to perform caesarean section for indications that are not medical. The health practitioners are therefore obligated to inform adequately and counsel woman against requests for caesarean section for non-medical reasons.

Bioethics in Obstetrics 311

Vertical transmission of HIV to an infant is averted when breast feeding is avoided. In societies where affordable alternative infant feeding methods are available it is unethical to allow an HIV positive mother to breast feed her infant. In low socio- economically developed societies where infant feeding formula may not be affordable or may be prepared under unhygienic condition with risk of infection to the infant, or in societies with strong cultural ties to breast feeding, it is ethically justified to allow breast feeding provided the countries' protocol for the reduction of the infectivity of the breast milk and increasing its safety to the infant is adhered to. Gamete donation for Assisted Reproduction requires informed consent and screening for HIV. Only donors with sero-negative HIV status are

World health organization (WHO) has estimated in a 2007 report that 536, 000 maternal deaths occur annually the world over from causes related to pregnancy and childbirth (WHO, 2007). As high as 99% of these deaths occur in developing countries (WHO, 2001). Maternal and Perinatal mortality statistics are the most important measure of safe motherhood, and their reduction has been recognized in the 5th and 4th component respectively, of the United Nations

Maternal mortality can occur from direct medical causes – obstetrics haemorrhage, sepsis, complications of unsafe abortion, hypertensive disorders in pregnancy and obstructed labour; from indirect medical causes – factors pre –existing or co –existing with pregnancy e:g cardiac diseases and gender based violence; and from non –medical factors – underlying social-cultural, legal, religious, and economic factors, reproductive health factors, health systems and health services factors and delays to access to emergency obstetrics care (Fatusi

Most causes of maternal deaths are preventable, such deaths therefore represents a violation of ethical principles and human right of the woman – a situation more marked in the developing countries, lack of access to family planning, abortion services, good antenatal care, delivery by skilled birth attendant, emergency obstetrics care, good neonatal care and postnatal services – all constitute a violation of woman's ethical principles of respect for persons, beneficence, non – maleficence, and justice which may occur both at microethical or macroethical level. Physicians have an ethical responsibility to protect the sexual and reproductive rights of women in other to promote their rights to life, information and education, to decide on whether and when to get married and found a family, to healthcare and protection, to benefit of scientific progress and to be free from

Physicians also have an important role to play in publicity and campaign towards the development of policies and programs that will strengthen the health systems and health service to promote safe motherhood and reduce maternal mortality to the barest minimum. Governments should work in partnership with non – governmental organizations and communities to provide good roads, acceptable and affordable maternal health services with good health facilities equipped and manned by skilled birth attendants adequately trained

Millennium Development Goals (UNDP, 2003; UNO, 2003).

and Ijadunola, 2003; WHO, 1994; Maine and Wray, 1984).

medical

allowed to donate gamete.

**22. Safe motherhood** 

ill treatment and torture.

on emergency obstetrics care.

#### **20. Management of pregnancy related to sudden unexpected maternal death**

When a pregnant woman is certified dead or is in the danger of imminent death from circulatory or respiratory failure, the life of the foetus is severely endangered and urgent intervention becomes necessary. It is important to maintain the circulation and respiration of the woman while waiting for an urgent decision on the foetus. Pertinent issues requiring considerations includes, the viability, and probable health status of the foetus, any wishes expressed by the mother as well as any views expressed by her family members especially her partner. The management options include immediate caesarean delivery if the foetus is alive and matured, co-ordinating effects to maintain the vital functions of the woman to allow the preterm foetus to mature provided that the informed consent of the woman's partner or family has been obtained, and the deceased had not wished otherwise, and outright discontinuation of support for the respiratory and circulatory function of the woman if the foetus is dead or the two former conditions are not wished by the involved parties. If support for the vital organs of the woman cannot be maintained immediate caesarean section is recommended.

#### **21. HIV infection in pregnancy**

HIV infection is a global pandemic. 2008 estimate has if that approximately 33.4 million people worldwide are living with HIV including 2.1 million children under 15years of age (UNAIDS, 2009; WHO, 2009). HIV prevalence rate ranges from as low as less than 0.1% in countries such as Bangladesh, Croatia, and Egypt to as high as 24.8%, and 25.9% in Botswana and Swaziland respectively (UNAIDS, 2010). HIV infection has profound psychological and social implications to the victim, her partner, family, the health worker, and the society at large. Vertical transmission of the infection during pregnancy and breast feeding is the most common source of infant and childhood infection. The disease which runs a chronic course has varying degrees of morbidity and is characterized by social stigmatization of the patient, with discrimination in the work place and societal activities. HIV disease has ethical challenges. The respect for the privacy and confidentiality of the HIV infected person conflict with the need to protect the partner, the health workers and other members of the public that may be placed at risk by virtue of their contact with the infected person. Ethical concerns on the privacy and confidentiality of the infected HIV patient however should be weighed against the need to prevent the disease from getting to epidemic proportions through providing information to the public on the morbidity and mortality statistics of the disease, mandatory screening for antenatal patient, and disclosure of HIV status of patients to partner, health workers and other vulnerable persons. The responsibility of the physician therefore includes the provision of individual counseling, care and treatment for the HIV infected persons and advocacy to the public towards the protection of the patient from stigma and discrimination. The ethical responsibility of the physician to protect persons at risk of being infected by an HIV patient requires proper counseling of the patient together with enough information to enlist the consent for testing, and disclosure to such persons. For example, the partner and the health worker, where informed consent for disclosure is not obtained in spite of adequate counseling of the patient, and the risk of transmission of the disease is high, the physician can after due consultation with relevant bodies such as, the institution's ethical committee, decide to override the patients autonomy of confidentiality.

**20. Management of pregnancy related to sudden unexpected maternal death**  When a pregnant woman is certified dead or is in the danger of imminent death from circulatory or respiratory failure, the life of the foetus is severely endangered and urgent intervention becomes necessary. It is important to maintain the circulation and respiration of the woman while waiting for an urgent decision on the foetus. Pertinent issues requiring considerations includes, the viability, and probable health status of the foetus, any wishes expressed by the mother as well as any views expressed by her family members especially her partner. The management options include immediate caesarean delivery if the foetus is alive and matured, co-ordinating effects to maintain the vital functions of the woman to allow the preterm foetus to mature provided that the informed consent of the woman's partner or family has been obtained, and the deceased had not wished otherwise, and outright discontinuation of support for the respiratory and circulatory function of the woman if the foetus is dead or the two former conditions are not wished by the involved parties. If support for the vital organs of the woman cannot be maintained immediate

HIV infection is a global pandemic. 2008 estimate has if that approximately 33.4 million people worldwide are living with HIV including 2.1 million children under 15years of age (UNAIDS, 2009; WHO, 2009). HIV prevalence rate ranges from as low as less than 0.1% in countries such as Bangladesh, Croatia, and Egypt to as high as 24.8%, and 25.9% in Botswana and Swaziland respectively (UNAIDS, 2010). HIV infection has profound psychological and social implications to the victim, her partner, family, the health worker, and the society at large. Vertical transmission of the infection during pregnancy and breast feeding is the most common source of infant and childhood infection. The disease which runs a chronic course has varying degrees of morbidity and is characterized by social stigmatization of the patient, with discrimination in the work place and societal activities. HIV disease has ethical challenges. The respect for the privacy and confidentiality of the HIV infected person conflict with the need to protect the partner, the health workers and other members of the public that may be placed at risk by virtue of their contact with the infected person. Ethical concerns on the privacy and confidentiality of the infected HIV patient however should be weighed against the need to prevent the disease from getting to epidemic proportions through providing information to the public on the morbidity and mortality statistics of the disease, mandatory screening for antenatal patient, and disclosure of HIV status of patients to partner, health workers and other vulnerable persons. The responsibility of the physician therefore includes the provision of individual counseling, care and treatment for the HIV infected persons and advocacy to the public towards the protection of the patient from stigma and discrimination. The ethical responsibility of the physician to protect persons at risk of being infected by an HIV patient requires proper counseling of the patient together with enough information to enlist the consent for testing, and disclosure to such persons. For example, the partner and the health worker, where informed consent for disclosure is not obtained in spite of adequate counseling of the patient, and the risk of transmission of the disease is high, the physician can after due consultation with relevant bodies such as, the institution's ethical committee, decide to

caesarean section is recommended.

**21. HIV infection in pregnancy** 

override the patients autonomy of confidentiality.

Vertical transmission of HIV to an infant is averted when breast feeding is avoided. In societies where affordable alternative infant feeding methods are available it is unethical to allow an HIV positive mother to breast feed her infant. In low socio- economically developed societies where infant feeding formula may not be affordable or may be prepared under unhygienic condition with risk of infection to the infant, or in societies with strong cultural ties to breast feeding, it is ethically justified to allow breast feeding provided the countries' protocol for the reduction of the infectivity of the breast milk and increasing its safety to the infant is adhered to. Gamete donation for Assisted Reproduction requires informed consent and screening for HIV. Only donors with sero-negative HIV status are allowed to donate gamete.
