title: Refusal of treatment in obstetrics - A maternal-fetal conflict.
abstract: OBJECTIVE
  Clinical studies about the necessity of standard obstetric interventions raise questions, making refusal by pregnant women of treatment a legitimate choice. The present study was aimed at characterising patients refusing medical treatment during pregnancy and delivery, and to examine whether refusal of treatment in obstetrics is associated with adverse perinatal outcome.
  
  
  METHODS
  A population-based study, comparing patients who refused (1898) and did not refuse (164,064) medical intervention during pregnancy and delivery, was conducted. Deliveries occurred between the years 1988 and 2002 in a tertiary medical centre.
  
  
  RESULTS
  Patients refusing medical intervention tended to be older (30.5 +/- 5.0 vs. 28.4 +/- 5.9, p < 0.001) and of higher parity (above parity 5: 52.5% vs. 32.4%; parity 1: 10.2% vs. 20.0%; p < 0.001) than the controls. Parturients refusing medical treatment experienced significantly higher rates of adverse perinatal outcome including low Apgar scores (less than 7, in 1 and 5 min: 12.4% vs. 4.4%, p < 0.001 and 1.9% vs. 0.6%, p < 0.001, respectively). Moreover, higher rates of perinatal mortality in general and intra-partum death, in particular, were documented among women refusing medical treatment (3.3% vs. 1.5%, p < 0.001; 0.8% vs. 0.1%, p < 0.001). When using a multiple logistic regression model of risk factors for perinatal mortality, refuse of treatment was an independent risk factor for perinatal mortality (OR = 1.5; 95% CI = 1.1-2.0; p = 0.010).
  
  
  CONCLUSIONS
  Patients refusing a medically indicated intervention have higher rates of pregnancy- and labour- related complications. Refusal of treatment is an independent risk factor for perinatal mortality.
authors.affiliation: Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel. ohel@bgu.ac.il
authors.forename: Iris
authors.initials: I
authors.lastname: Ohel
authors.forename: Ohel
authors.initials: O
authors.lastname: Iris
authors.forename: Amalia
authors.initials: A
authors.lastname: Levy
authors.forename: Levy
authors.initials: L
authors.lastname: Amalia
authors.forename: Moshe
authors.initials: M
authors.lastname: Mazor
authors.forename: Mazor
authors.initials: M
authors.lastname: Moshe
authors.forename: Arnon
authors.initials: A
authors.lastname: Wiznitzer
authors.forename: Wiznitzer
authors.initials: W
authors.lastname: Arnon
authors.forename: Eyal
authors.initials: E
authors.lastname: Sheiner
authors.forename: Sheiner
authors.initials: S
authors.lastname: Eyal
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D002585:Cesarean Section / Q000523:psychology / Q000706:statistics & numerical data; D003220:Conflict, Psychological; D036861:Delivery, Obstetric / Q000379:methods / Q000401:mortality / Q000523:psychology* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008423:Maternal Age; D033261:Maternal-Fetal Relations / Q000523:psychology; D010298:Parity; D054238:Perinatal Mortality; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D012307:Risk Factors; D016312:Treatment Refusal / Q000523:psychology / Q000706:statistics & numerical data; D055815:Young Adult