Awaiting Juno

CDMR is a Women's Rights Issue

2013-05-21T20:29:00.000-07:00

Maternal request cesarean is a women's rights issue - every bit as much as abortion or participation in the paid labour force, or the right to vote or own property. At its very core, it about a woman's right to self determination - her right to choose what to do with her own body, her right to decide which risks she is willing to accept and which risks she refuses. It is about a woman's right to be treated the same as any other patient - and not differently because she is a maternity patient. Both access to choice and recourse for unreasonable denial of choice is needed. I look forward to the day when I will know that a similar experience is extremely unlikely to happen to another woman - and while that day is closer now than it was three years ago, there is still a ways to go.

It is frustrating knowing that planning a homebirth in British Columbia, even a home birth after a previous cesarean is far easier than planning an elective cesarean. Finding a care provider who is willing to facilitate a maternal request cesarean is difficult as they do not generally advertise that they are willing to facilitate a woman's desire for one - and many family physicians, midwives and OBGYN's do not support maternal choice cesarean. This is despite rather clear evidence that a planned cesarean at 39 or greater weeks poses some health and safety advantages for the child and may be comparably safe for the mother as a planned vaginal delivery. Personally, I believe that planned maternal request cesarean at 39 weeks' is a far less risky proposition than planned home birth and a far, far less risky proposition than planned home birth after a previous cesarean.

If it is a matter of cost - I would think that there are some very strange economics at work. A single preventable brain injury or death would make the cost difference between planned home birth and planned cesarean disappear many times over. Even a preventable pelvic floor injury that results in some incontinence nearly obliterates the cost difference. Further - home birth does not eliminate the need for hospital resources to be available as many home births (upwards of 40 percent in first time mothers) result in a transfer to hospital. In deed, planned cesareans could be cost competitive with planned vaginal deliveries as the ability to plan resource availability is improved.

At the end of the day - I cannot see how one choice (planned home birth, and planned home birth after cesarean) is widely supported in British Columbia, and another choice - maternal request cesarean - generates a kind of loathing usually reserved for pregnant women who choose to light up publicly while swilling Manhattens and Martinis.

What if??

2013-04-11T10:26:00.000-07:00

Occasionally I will read about a woman who is planning on having a cesarean for the birth of her child, such as Ms. Magee. She's done her research. She knows the risks and benefits of cesarean and vaginal delivery, and is prepared to put up with the static of choosing cesarean. It is her body and her choice.

However, because of my experience with my daughter's birth, and hearing of other women who planned on having a cesarean but ultimately did not - I find myself asking the question "What if?". It is all well and good to know what you want and to pursue it and women should expect to have their choices regarding childbirth respected to the degree possible. But what if the cesarean does not happen, then what?

That is the situation I found myself in after my daughter's birth.

That is the situation I worried about throughout my pregnancy with my son.

When I was pregnant with my daughter - I thought the risk of not delivering by cesarean was fairly small - I knew about 10 percent of women did not make it to their scheduled surgery date, but I also knew that few first time mothers had exceedingly short labours, and that the hospital I was delivering at was a tertiary care facility. I believed that if the hospital could provide emergent cesareans for those who needed them within a half hour, that surely if I did go into labour that I would be able to get a cesarean within two hours, and that it would be extremely unlikely that as a first time mother my labour would be less than two hours. In short, I thought the risk of enduring a labour and vaginal delivery, in the circumstance I was in, was vanishingly small - small enough that I discounted the possibility nearly entirely.

What I did not account for, and should not have needed to account for - was the possibility that the hospital and/or my doctors would fail to actually and reasonably facilitate and respect the choice that had been made. I believed that I might get bumped for more urgent cases, but when the chips were down, if I should happen to actually go into labour - I believed I would be an urgent case and would have my care facilitated (possibly bumping others). I believed that my ability to determine what happened with my own body would be respected to the degree possible. I fully trusted, that the system, while not perfect - would be "good enough" - and completely disillusioned when it proved otherwise.

So now I know what if, what if a chosen cesarean does not happen and a woman endures a vaginal delivery she does not want. I know that when it happened to me - I felt violated; I felt isolated; I felt betrayed; I feared the worse; I felt disempowered; I felt traumatized; I questioned my desire for a subsequent child; and, when I was pregnant with my second child I was anxious; I still worry about the longer run impacts to my pelvic floor and psychological health; I am both angry and numb; and I struggle with the experience and the large chasm between what should have been and what is. I know the answer to the question "what if?" - and know that the answer to that question is often not, "The woman will have a vaginal delivery like the billions of women before her, will likely have a healthy child, and get over it so it really is not a big deal to force her to have a vaginal delivery she does not want."

Forcing women who do not want to have vaginal deliveries, when cesarean is an acceptable and available alternative, to have vaginal deliveries - is a big deal, it is wrong, it needs to be addressed and stopped. Further, women need to be confident that their care providers and the facilities they go to give birth will actually and reasonably facilitate and respect the choices that they have made.

Oh, ACOG - Say it ain't so

2013-03-24T22:58:00.002-07:00

On facebook in the Cesarean by Choice Awareness Network group there's been a lot of discussion about the American College of Obstetrics and Gynaecologists committee opinion on cesarean delivery on maternal request. I am fairly disappointed at the new committee opinion, one that seems to take a step closer to the stance taken by the Canadian Society of Obstetricians and Gynaecologists - it does not condemn or disallow maternal request cesarean, but makes it quite clear that its members should recommend vaginal delivery in circumstances where there are no medical indications for a cesarean delivery. Which is fairly different from the stance that a physician is ethically justified in performing a maternal request cesarean if he or she believes it is in the interest of his or her patient. In many ways it is no different than the kind of approach taken to mothers who for whatever reason determine that their needs are better met by formula feeding - they are repeatedly told that "Breast is Best" and made to feel no end of guilt for needing or wanting to use formula to feed their children. ACOG has decided to tell women that Vaginas are meant for birthing children, and if you want a cesarean we might do it, but only after you are reminded that a "vaginal birth is best". Many women who are requesting a cesarean already face barriers in finding a physician who will accommodate their needs, to add the feeling that what they are asking for is something "against medical advice" - seems above and beyond what women who are requesting cesarean need.

What women who are asking for cesarean need are physicians who listen to their request, provide them with the risks and benefits of planned cesarean delivery and the risks and benefits of planned vaginal delivery, answer whatever questions they have about their treatment options AND ultimately respect, and facilitate the decision they make regarding the planned delivery of their child. They do not need to have someone else's ideology about childbirth imposed on them. What women who are choosing cesarean need is better information on their choice (much of the information that is currently available is not about "maternal choice" cesarean, but rather about cesareans that are performed as a result of medical indications for cesarean). What women who are choosing cesarean need is the confidence that their choice will be respected, even if their OB doesn't happen to be on-call when they go into labour.

Nothing is more empowering than having the confidence that you have the right to decide what to do with your own body - and nothing is more disempowering than feeling as though you do not have the right to decide what to do with your own body. Perhaps it is time that the ACOG, the SOGC, the mayor of New York and anybody else who feels that women should not have a choice about how their child is born or fed is reminded that - it is the woman's body, let her be free to decide what to do (or not do) with it.

The Beliefs of Canadian Maternity Care Providers - Who to choose when your choice is cesarean?

2013-03-14T23:03:00.000-07:00

The Canadian Journal of Midwifery Research and Practice published a study entitled "Midwives' Belief in Normal Birth: The Canadian Survey of Maternity Care Providers' Attitudes Toward Labour and Birth", by McNiven, et al. in Volume 10, Number 2, Summer 2011. The paper examines the results of a survey conducted in 2007.

It should be noted that midwives generally believed that a vaginal birth was a more empowering experience than a cesarean birth, that those who deliver by cesarean miss an important life experience, did not believe that cesarean prevented urinary incontinence or sexual dysfunction, agreed that there should be an organized pre-cesarean section peer review of all cesarean sections to reduce the cesarean rate, and agreed that all cesareans should be subject to a peer review to reduce the cesarean rate. Further, midwives are most likely to believe that childbirth can be considered normal prospectively, that childbirth doesn't usually require medical intervention, to prefer natural methods of pain relief, and that home birth is as safe as or safer than hospital birth. Personally, I did not find my vaginal birth to be more empowering than my cesarean birth (quite the opposite), and in terms of life experiences, frankly, I wish I would have missed out on the "life experience" of vaginal birth. That being said, I always believed that having a midwife as a prenatal care provider would be a poor fit personally, and the results of this survey seem to confirm that belief.

However, midwives have a tendency to portray themselves as some kind of guardians of patient autonomy. So what did the midwives of this survey think about a woman's right to choose cesareans?

More than half (58.6 percent) did not believe a woman had a right to choose a cesarean in the absence of a medical indication. Slightly fewer than one in five (18.5 percent) believed in a woman's right to choose cesarean.

What was surprising is that the view regarding cesarean sections was largely consistent with the views held by both Registered Nurses and Family Physicians who provided prenatal care with 60.4 percent and 60.8 percent of those providers disagreeing with a woman's right to choose a cesarean even in the absence of medical indications.

With regards to the right to choose cesarean, obstetricians were the most likely to agree that a woman has a right to choose a cesarean with 42.3 percent agreeing a woman has a right to a cesarean and 15.3 percent taking a neutral position.

I find it somewhat disconcerting, that the right to choose a cesarean in Canada among those providing prenatal care is so widely disagreed with (but particularly among midwives, RN's and family physicians). It seems trite to me that a patient has the right to decide what is done with their body (among the available options, after considering the advice of care providers) - the fact that it is not trite in prenatal care in Canada is disturbing.

Hopefully the memo that was sent regarding patient autonomy more than 25 years ago in the Morgentaler case will soon be received by the majority of those providing prenatal care in Canada.

Birth Trauma and Productivity

2013-03-07T10:05:00.002-08:00

Looking back at the year that I was back at work between maternity leaves - I hate to admit that I was not as productive as I could have been. Beyond juggling a child and work - I was also juggling a considerable psychological burden - as much as I may have wanted to focus on work, I found myself distracted. I was distracted by what had happened. I was distracted by my subsequent pregnancy and what was going to happen. I also found myself trying to deal with a degree of cognitive dissonance between what I do, and what I had experienced. I was able to get what needed to be done, done and managed to accommodate the travel back and forth to Vancouver to access care - but there was a considerable hidden cost to my birth trauma. My productivity was damaged.

The loss of productivity as a result of birth trauma is a cost that is largely hidden and difficult to quantify. Some women forego the paid labour force entirely as the demands that result from the birth trauma are too great to accommodate paid work. Other women, like myself, manage to accommodate their birth traumas and their careers, but are less productive than they would be otherwise. In both cases, there are no statistics that even attempt to get at the presence of this phenomenon or the degree of impact it has. Perhaps some of the differences that persist between men and women in the paid labour force can be attributed to the impact birth trauma has on women. After all if your coping but not thriving, you will not be promoted.

Still I must consider myself lucky. The work I do could accommodate the psychological burden I was carrying. I had four-walls and a door. I did not need to interact with the public or others on a daily basis. I could do what I needed to do (usually write a blog post on what I was thinking) to allow myself to focus enough on the work at hand. I could work longer days to accommodate days off for travel. I had an understanding supervisor. Indeed, I was lucky - and under different circumstances - arguably under most other circumstances, it probably would have been likely that my career could have been collateral damage to what had happened.

I am thankful that my son's birth went well - and I am hopeful that by the time I return to work from this maternity leave, I will not be carrying the same psychological burden and that my ability to work to capacity will be restored. Still, I can't help but wonder - in the absence of what happened, would I have been a better economist and mother?

200th Post

2013-03-05T11:52:00.000-08:00

When I started this blog, I was pregnant with my daughter. A first time mother-to-be, who really had no idea what was about to happen. When I started this blog, I was worried about finding a doctor who would support my request for a cesarean, I was confident that I would find one or do what needed to be done to have a planned cesarean delivery - but I really did not imagine that after finding a doctor who agreed that I would be in a position where I would be delivering my child by the very way that I had sought to avoid. When I started this blog, I anticipated that it would remain just another mommy blog - a place where I would have written about the cesarean birth of my daughter and then quickly moved on to the one-hundred-and-one different things that happen as a baby becomes a toddler, a big sister, a child. I did not imagine that it would remain focussed on maternal request cesarean, maternity care and birth trauma. I did not imagine that it would become one of the main ways that I would process my experience. I did not imagine that it would help other women. I did not imagine that it would have the kind of impact it has had. I did not imagine that it would even be read much at all.

So two-hundred posts later, I cannot help but look back on the last few years (most of the posts have been within the last year and a half) - and be somewhat pleased with the work that has been done. And in the ways that this blog has exceeded my expectations - I look forward to seeing what work will be done - as it still seems clear, that there is still much work yet to be done.

Thank-you.

The Power of Numbers - the Math of Maternity Care

2013-02-27T14:53:00.000-08:00

When I am working, I spend most of my time immersed in numbers and thinking about indicators that can be used to measure health and the health care system. As a result, I am acutely aware of the power of numbers and the importance of understanding what numbers are available, how the numbers used are calculated, what the numbers include or exclude, and what it might mean when the numbers change over time. As a result, I read statistics and particularly health statistics, with a different lens. Specifically, I am much more critical of the numbers I see - as I know that the story being told by the numbers depends critically on the numbers used and how they are being interpreted. I have become particularly aware and interested in the numbers used (and not used) to tell the story of maternity care, particularly in the news media. The thing is numbers have power, and by focussing on the wrong numbers or interpreting the numbers in the wrong way - there may be unintended negative consequences for women and their babies. Currently, the most commonly used statistics in the news media with respect maternity care are: infant mortality, cesarean section rates, and cost estimates - and, sadly these numbers and they way they are used are telling a story which may be leading many women, care providers, and health administrators astray.

Infant mortality is the number of babies who die from birth to one year of age relative to all babies who are born alive. As a result improvements in the rate of accidental death or access to paediatric care - perhaps as a result of better car safety, sleep safety or better health insurance coverage - will lower the rate of infant mortality. While fewer very young children dying is a very good thing, saying it is the result of better maternity care is a bit of a stretch. Unfortunately, many media reports make that stretch and equate infant mortality rates with maternity care.

With respect to cesarean section rates - little quality information can be gained by looking at the headline rate (number of c/sections as a share of all births). This is because nothing is known about how many of those cesareans are planned cesareans, how many are emergent cesareans, how many are maternal choice, how many have complications, how many are traumatic, or how many avoid much more severe complications that would have occurred in the absence of a cesarean. Given a choice between a third or fourth degree tear, an instrumental delivery, or an oxygen deprived baby - most moms are better off and would likely choose a cesarean section. Further, the cesarean section rate is not risk adjusted, and as such it is nearly impossible to say whether or not any specific rate is too high or too low without knowing the characteristics of the population being served - is it older? are the mothers of a healthy weight? are there other co-morbidities (heart problems, kidney problems, diabetes, etc.)? When the relative risks of cesarean are reported on, both emergent and planned cesareans are frequently lumped together and as a result the risks of an emergent cesarean are underestimated while the risks of an elective cesarean are overestimated. Lastly, the only thing the cesarean section rate tells us is how many cesareans were performed, the supply of cesareans, but it tells us nothing about how many cesareans should have been performed, the demand for cesareans.

Finally, the cost estimates that are available are at best flawed in that the costs included are only the immediate costs (those that occur within 30 days of the birth), and the costs of cesarean lump together emergent and elective surgeries and as a result do not reflect the costs associated with planned mode of birth. From an economics perspective, spending money on birth (including spending money on cesareans or other interventions) might be a good investment if it avoids other costs in the long run, such as those costs involved in coping with a damaged pelvic floor, birth trauma, or a birth injury.

There are better statistics that already exist - like the perinatal mortality rate. There are also better statistics that could exist - like the rate of unmet need (ie. epidurals requested but not given), the rate of adverse mental health outcomes, and patient reported outcome measures. Numbers are powerful, unfortunately it is quite possible that when it comes to maternity care, the focus is on the wrong numbers.

Are the common practices with respect to Maternal Request Cesarean negligent?

2013-02-14T11:54:00.000-08:00

I have been wondering if the common practices that are applied by many physicians in Canada and in many Canadian hospitals with respect to maternal request cesarean are negligent and unreasonably frustrate the rights of women to make medical decisions for themselves.

In my own case with respect to the birth of my daughter (and I do not believe this is uncommon), my maternity doctor did not refer me until I was 32 weeks pregnant. This might be common practice with respect to elective cesareans in general, but I would argue that it is negligent when it comes to maternal request cesareans. This is because under most circumstances an elective cesarean has an underlying medical need and as a result there is little doubt that the doctor who is receiving the patient will agree to undertake the procedure. In contrast - many doctors will not agree to perform a maternal request cesarean - just as many doctors will not agree to perform an abortion - and that is their prerogative (frankly, having a doctor who disagrees with treatment is probably not a good thing anyways). This may lead to the need to see more than one doctor to request the cesarean. Further, many mothers who are requesting cesareans are doing so because of anxiety over the prospect of a vaginal birth - and often that anxiety is not resolved until there is some certainty that the desired mode of birth will be realized. As such, the doctor who is referring the patient needs to be reasonably confident that the doctor that the patient is being referred to will agree to the request or at the very least it would appear prudent for the physician to refer as soon as the request is made and facilitate shared care of the maternal request cesarean patient with an OBGyn. To do otherwise seems to have a high risk of frustrating the patient's ability to direct her own medical care.

Also with respect to my birth of my daughter, it has been alleged that Vancouver Island Health Authority had no OR booking schedule for elective cesarean deliveries and as a result my case was necessarily added to the OR Slate. Failing to provide a fixed time and date leaves elective cesarean patients particularly vulnerable as they are competing with other emergent cases on the open slate. As a result, it is fairly predictable that an elective cesarean patient (unless she's in labour) is likely to be bumped by more urgent cases. This unreasonably frustrates the woman's right to choose a pre-labour cesarean - particularly in large hospitals with a high volume of emergent cases that arise. I would argue that it is negligent and discriminatory to provide for other elective surgeries on the regular slate but not elective cesarean deliveries. It is plain and obvious that a woman at 39 weeks' gestation is at high risk of going into labour, and that subjecting her to uncertain access to an OR puts her at risk of having her medical decision frustrated. Why should patients who choose tubal ligations, adult circumcisions, bladder suspensions, or any number of other elective surgeries be allowed a spot on the regular OR slate, but women in need of elective cesareans be denied space on the regular OR slate? This is particularly true when a delay in access to OR resources may result in that woman being deprived of exercising her right to make a medical decision for herself with regards to how her child is to be delivered. It is obvious that patients in need of elective cesarean deliveries deserve to have more certain access to OR resources as their conditions are arguably more time sensitive than many other elective surgeries. Again, I do not think that it is uncommon practice for hospitals to deny space on a regular OR slate to elective cesarean patients - even though it is plainly obvious that the practice of doing so poses unnecessary risks.

Women who choose cesarean section deserve to have their medical wishes respected and practices that unreasonably frustrate their ability to exercise their autonomy with respect to the delivery of their child should end. If the woman is going to need an OBGyn eventually - what purpose does delayed referral serve? If the woman is going to need OR resources for the delivery of her child - again what purpose does denying space on the regular OR slate serve? The only logical purpose these practices serve is to prevent women from obtaining the medical care they desire in a timely way - and there's something that's wrong with that.

Failing Mothers - Maternal Request Cesarean in Canada

2013-02-08T10:02:00.000-08:00

A while ago, a mom-to-be contacted me asking if I knew an OBGYN in her area (Hamilton, Ontario) who would agree to a maternal request cesarean. I asked the grapevine, and managed to wrangle a name - and with high hopes I hoped that this mother would be able to get what she needed when she needed it. I recently got an update from that mother - and my heart sank. She went into labour the day before she was to meet with the OBGYN (she was 36 weeks pregnant) the doctor on call did not support her request and she ultimately delivered her son vaginally. His respiration was depressed, he needed to spend some time in the NICU, he had some broken blood vessels and blood pooled between his skull and his scalp, he needed a blood transfusion and has been on morphine and the mother had some tearing that required stitches.

Her story - is illustrative of the many problems that persist with respect to maternal requests cesareans in Canada. Finding an OB supportive of the request, and hoping that if you do go into labour the OB on-call will be supportive of your request is a risky proposition. You may go from OB to OB (or have you primary maternity care physician neglect to refer you until late in your pregnancy) with each having a wait of several weeks for an appointment (how is that quality care???), or you may go into labour and have someone who disagrees with your choice and withhold the care that is needed, when it is needed. Or you may find a supportive OB but run head-long into a hospital policy that makes acquiring your delivery all but impossible.

It's a situation that must be addressed - all these mothers want is to be counseled on the risks and benefits of their treatment options (planned cesarean delivery and planned vaginal delivery) - and to be free to choose the treatment that best meets their needs and to expect that whatever choice they make will be respected and facilitated to the degree possible. They are asking not to be unfairly deprived of their personal autonomy without good cause - seems perfectly reasonable to me.

There are doctors and hospitals in Canada that do accomodate the needs of these mothers - but the difficulty is that it is difficult to know which doctors and hospitals they are when the time comes.

As I do get requests from time to time from mothers looking to have their needs met (I currently know of a woman who isn't even pregnant yet who wants to find a supportive doctor in Ottawa) - if you are an OBGYN who provides maternal request cesarean or your hospital has an accomodative policy (fixed OR date and time for MRCS and assurance that CS will be accessible if it is wanted should the woman go into labour before her scheduled date/time) - email me at qualitycareforbcmothers@gmail.com - as I'd like nothing more than to be able to help moms find the care they need when they need it.

Thank-you in advance.

Improving Maternal Health and Wellbeing: Measuring what Matters

2013-02-02T15:08:00.002-08:00

I love the story of the APGAR score and am moved how such a simple composite measure could improve the outcomes of babies by helping care providers focus on what matters. The story of APGAR demonstrates the power of good measurement.

Right now, British Columbia uses two measures - the rate of cesarean sections and the rate of attempted vaginal births after cesarean (VBAC) as performance measures for maternity care where good performance is considered to be a reduction in cesarean rates and an increase in the number of attempted vaginal births after cesarean. The use of these statistics as performance measures provides an incentive for hospitals and care providers to deny access to cesarean sections, sends a not-so-subtle message that vaginal birth is a good thing in and of itself, fails to adjust for risk, and has little or no relationship to what might be considered quality care. The problem is these measures place too much emphasis on process and not enough on outcome and may be undermining the health and well-being of women and their babies - in short driving the system towards providing care based on an ideology (natural/vaginal childbirth) and failing to provide patient centred care.

To highlight what I mean - my first birth would count positively in the measures used - it avoided a cesarean that would have otherwise been done. My second birth would count negatively in the measures used - it contributed to the cesarean section rate at the hospital I delivered. In terms of outcomes though, the second birth was by far, "the better birth" - at least from my perspective. Similarly, a vaginal birth that results in the use of forceps and yields extensive tearing and a brain damaged baby is still "good" by these measures, but a cesarean that results in a healthy baby and no post-operative complications is "bad" by these measures. Even a birth that results in a ruptured uterus and a permanently disabled baby is "good" but a repeat cesarean is "bad". These "performance measures" have the potential to drive truly Orwellian care - and should be abandoned in favour of measures that are capable of actually reflecting "good births" and "bad births" and driving care that is most likely to result in "good births".

I do not think it would be terribly difficult to come up with a better composite guage of whether or not a birth was a "good" birth - or at the very least measures that do not result in the provision of care that is not in the interests of the patient being cared for. Perhaps a composite measure that considers treatment plan compared to treatment outcome, APGAR scores, physical damage and psychological damage - would assist far more in the goal of providing care that results in "good births" than the silliness of measuring cesarean and VBAC rates. Is mom and baby healthy? Is mom happy? - those are the two questions that deserve to be answered, not how was baby delivered?

Systemic Barriers to Maternal Request Cesarean are Prevalent in Canada

2013-01-24T11:09:00.000-08:00

It is difficult to be a cesarean by choice mom - most people do not understand your choice and may even think that you are nuts for wanting to choose a surgical process over a natural process. It is a choice that is stigmatized and even denigrated. It is a choice where it is still debated openly whether or not women should "have the right to choose" and the term "too posh to push" is still thrown around. Many moms have an uphill battle in Canada when they choose cesarean that extends far beyond what their friends and family may think of their choice though - there are prevalent systemic barriers that prevent many women from being able to exercise their legitimate right to choose cesarean.

Many primary care givers - family doctors and OBGyn's do not support maternal request cesarean. When women ask their doctors about it, few are receptive to the request. It is not uncommon to hear of women not being referred to an OBGyn (family physicians and midwives do not and can not perform cesareans) until their pregnancies are very advanced. When I was pregnant with my daughter, I did not get to even meet with an OBGyn until I was practically at term (referred at 32 weeks and saw the OBGyn at 36 weeks) - despite having made my desire for a cesarean known at my appointment to refer to a maternity doctor and at my first and subsequent prenatal appointments with my maternity doctor. Many women who request cesarean have anxiety about the delivery and that anxiety often is not resolved until they have confirmation from an OBGyn about the delivery plan. I found it very difficult to enjoy either of my pregnancies until I knew what the plan was regarding the delivery. Further, there tends to be significant waits to access OBGyn's and as a result it is not uncommon for a woman to wait 4 or more weeks after referral to be seen by an OBGyn.

Unfortunately, many OBGyns in Canada are also not supportive of maternal request cesarean and I do not know of many who openly offer this choice. Quite simply a woman cannot go to a phone book or even online and see that CDMR is one of the services offered by a particular OBGyn. Perhaps this is because the Society of Obstetricians and Gynaecologists of Canada does not currently support CDMR and has stated that “Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." As such, if a woman is referred late in her pregnancy to an OBGyn for the purposes of getting a cesarean, and the OBGyn she is referred to is not supportive of the request, by virtue of the time sensitive nature of pregnancy she may be unable to get a CDMR.

Then add hospital policies that might present additional challenges to women wanting maternal request cesareans. For example, at BC Children and Women's hospital - the home of the "Power to Push Campaign", women desiring maternal request cesarean are encouraged to undergo counselling at the "Best Birth Clinic" and the power to push website repeatedly reminds women that vaginal delivery is the "normal" method of childbirth. This makes women who wish to choose cesarean feel abnormal or wonder if they are in need of psychological services because they prefer surgical delivery for their children. At the time of my daughter's birth I was told by my OBGyn that an elective cesarean needed to be an "add to slate" procedure, that he could not give me a specific time and date for the surgery. What he failed to inform me, is that by not having a fixed time and day for the surgery meant that there was a very real risk the surgery quite simply would not happen at all, as it would have to compete with all the other "add to slate" surgeries and that unless he advocated and made the case that my cesarean should be a priority that it would get bumped until it was ultimately denied.

So what is the impact of these systemic barriers to maternal request cesareans? Many women who would prefer to deliver by way of cesarean cannot access timely medical care and ultimately are forced to deliver vaginally. The current system unjustifiably imposes risks on mothers who would choose cesarean - it imposes anxiety as a result of the delay in having an OBGyn "approve" the planned delivery, and it imposes increased risk that a planned elective pre-labour cesarean will need to be an urgent cesarean or emergent cesarean or may even be an unwanted vaginal delivery. At the most basic level, every pregnant woman is currently told by this system that she cannot submit to a generally safe medical procedure unless she meets criteria entirely unrelated to her own priorities and aspirations - this removal of decision making power threatens women in a physical sense and the indecision of knowing whether a maternal request cesarean will be granted inflicts emotional stress. Depriving women of their right to make medical decisions for themselves is a travesty and a grave injustice - one that I am battling to change.

Timely Access to Medical Care - Lawsuits and the Blame Game

2013-01-16T15:03:00.002-08:00

There's a lawsuit that has been launched by Dr. Day alleging that the government has failed to provide timely access to medical care and in doing so has violated patient's charter rights to security of the person. The government has submitted in its statement of defence that it is not responsible and that it is the doctor's who failed to provide their patients with timely access.

Back when I had my daughter - I was told that by my doctors that they could not access the resources. My doctors told me that the OR was not available, that my case had been bumped by other more urgent surgeries. Then when I wrote the patient care quality office a year later to find out more about what had happened - the response I received back clearly indicated that it was not that the resources were unavailable, but rather that my doctors had failed to facilitate access to them when they were available.

As a result, I was left not knowing what happened - my doctors had said the resources were unavailable and the health authority had said that they were available. Either my doctors were lying and had committed a malpractice or the health authority/hospital was lying and had failed to ensure adequate resources were available when they were needed.

In the Day case, as in my own - it is clear that the doctors are pointing their fingers squarely at the system (the health authorities and the government) - only to find the government pointing squarely back at the doctors. Unfortunately, this leaves patients in a difficult position - in order to get accountability for being unable to get timely medical care, they must sue both the system (government/health authorities) and their own doctors.

It is a very daunting prospect - but given the realities of health care in Canada - do patients have any other choice?

Under what circumstances should women be able to "Choose Cesarean"?

2013-01-12T13:41:00.000-08:00

In the years since I first considered having a child and the relative risks and benefits of different modes of delivery for my particular situation, I have read a lot of material on the subject - both in the mainstream media and in the scientific literature. There continues to be an active debate on the subject. There continues to be a relative paucity of research that is "on all fours". There continues to be judgement and a persistent derogation of women who elect cesarean delivery. There continues to be uncertainty regarding a woman's "right" to choose cesarean. There continues to be a lack of awareness and respect, support and empathy. There continues to be tremendous barriers to exercising the choice of cesarean delivery, including difficulties in finding supportive health care providers and unreasonable and obscure hospital policies and practices.

That being said, tremendous headway has been made in those years. The commentary that news articles and related forums attract is becoming less vitriolic and more respectful of the choice. The National Institute of Clinical Excellence in the UK confirmed in November 2011 a British woman's right to elect cesarean on the NHS. Pauline Hull and Magnus Murphy published their revolutionary book "Choosing Cesarean". There is now a Cesarean by Choice group on Facebook. A lawsuit in Canada has been filed with hopes that it might formally recognize the right of women to make this medical decision and confirm that a failure to provide reasonable access is a reprehensible violation of patient autonomy - and may constitute a form of malpractice for which hospitals and/or doctors can be held liable.

So under what circumstances should women be able to choose cesarean? Under the exact same circumstances that women or men are able to direct any medical care - that is, after they have been provided with enough information on the available treatment options for their particular medical condition and the risks and benefits associated with those options (they have met the requirements of informed consent). Further, they should expect timely access to the care that has been chosen - otherwise the right to direct one's own medical care is rendered void - after all what good is the ability to choose treatment, if time makes that treatment choice meaningless?

Forging Ahead While Looking Behind

2013-01-11T12:06:00.002-08:00

My son's birth proved to me that birth could be an enjoyable, relatively pain free experience that affirms a woman of her ability to make medical decisions and to expect those decisions to be respected. For that I am thankful. He is healthy, I am healthy, I do not dwell on his birth and when I think about it or see pictures from it my emotional response is positive.

However, because I have been working on the litigation associated with my daughter's birth - I have been thinking about what happened then, a lot. Even when I am not wanting to. To say that it is emotionally difficult work is putting it mildly. Reading my medical file. Reading the statements of defense. Thinking about it all. The only thing positive about my daughter's birth - is my daughter. I survived the experience, I did the best I could at the time and it was enough (my daughter is fine) but it is abundantly clear that what happened did not need to happen and that my doctor's and the hospital failed me and failed my daughter.

It is trite to say that in preparing for birth, a mother should prepare not only for the birth experience that she wants, but also for the birth experience she doesn't want. I did not do antenatal classes - but I did educate myself on vaginal delivery (which was part of the reason why I wanted to avoid it), and when it was clear I did not have a choice in the matter, I did as best I could and for my daughter's sake it was enough. We survived.

And yet, in terms of coping with what happened - I still find myself, at times, overwhelmed. I cannot help but think that if what happened was truly neccessary - that if there was no way it could have been avoided, I could accept what happened (as awful as it was) as the price of admission to motherhood. However, now knowing more about what happened and what did not happen - I know that what happened was clearly not neccessary - it could have been avoided (easily). It does not make coping with what happened easier - rather it generates a profound need for accountability and justice.

Surviving the Days Before the Elective Cesarean Date

2013-01-05T11:40:00.000-08:00

I chose cesarean because I was uncomfortable with the realities of planned vaginal delivery. I was uncomfortable with the idea of needing an emergent cesarean. I was uncomfortable with the idea of tearing. I was uncomfortable with how much pain might be involved with a vaginal delivery. I was uncomfortable with the uncertainty of the impact on my sex life. I was uncomfortable with the risk of permanent neurological damage to my child. I was uncomfortable with the idea of defecating in front of others. I was uncomfortable with the risk of urinary or fecal incontinence. I could not find peace planning a vaginal delivery - the ugliness of vaginal delivery at its worst (and even a wide range was enter than worst) was a possibility that I wanted to completely preclude even if meant giving up the chance for a vaginal delivery at its best. This was true when I was pregnant with my daughter, and more true when I was pregnant with my son.

As such, there was considerable anxiety (particularly when I was pregnant with my son) about not making it to the elective cesarean date. So how did I cope and survive those final weeks of pregnancy and what can a woman do to make that last stretch of pregnancy a little less anxiety ridden?

1. Work with a therapist. I was working with a psychologist throughout my second pregnancy and think that it helped in finding coping strategies that worked for me in my particular situation.

2. Talk to your OBGYN about your risk of going into labour and what the plan is should that happen - discuss whether or not an urgent cesarean is likely to be available if you should go into labour prior to your cesarean date. Your doctor is the person who is most informed about your particular pregnancy and your particular plans with regard to that pregnancy and is likely in the best position to advise you accordingly. If at all possible, try to arrange for the earliest safe date possible to minimize the risk of going into labour spontaneously (generally speaking this is at 39 weeks gestation - but should be discussed with your own care provider to determine what is best in your particular situation).

3. Find an appropriate activity to distract yourself and that you find enjoyable.

4. Do not over exert yourself and keep well hydrated and well nourished.

5. Avoid anxiety provoking situations. I found myself avoiding social situations in my final weeks of pregnancy.

6. Relocate if neccessary to be near to where accessing care is planned - this is particularly true if where you plan on having your baby is significantly far from where you live.

7. Arrange for the care of older children, pets, help for after the delivery, meals, etcetera.

8. Reassure yourself that even if things do not go as planned, that your primary concern is for the health of yourself and your child, and that regardless of how things unfold you will find a way to deal with it and will deal with whatever situations arise as best you can - and that is all you can do, and it will be enough because it has to be enough.

The best thing about the pregnancy with my son was his safe arrival and knowing that the worry about that arrival was behind me and that the time had come for me to enjoy my son and all the happy days that lay ahead.

Luckier Than I Appreciated

2012-12-31T10:11:00.000-08:00

I've been reading my medical file with respect to my daughter's birth - and knowing what I know now, my doctors and the hospital are lucky that a worse outcome is not part of the litigation - and I am lucky (fingers crossed) to have what appears to be a neurologically normal toddler.

One of my greatest fears about vaginal childbirth, is the potential for it to result in lifelong neurological disability. Not everyone gets through vaginal childbirth unscathed - some are left with lasting physical and mental disabilities. I understand that it is rare for such things to happen, but the reality is that someone is that one in a thousand person. I have personally known people who did not make it through birth unscathed. It was one of the reasons I was choosing cesarean for the birth of my daughter. I was happy to trade some increased risks for a decreased risk of that particular outcome.

So when I read the following in my medical record - I was taken aback, because the outcome I feared the most was much closer to becoming reality than I had thought.

My daughter had a tight nuchal cord (it could not be reduced over her head), had no spontaneous respiration for the first minute of her life, cord blood gases were ordered with the notation of gases 7.0, bicarb 17 and BE -15.

I'm a little more thankful for my daughter and a little more livid at what happened.

Mrs. W's Comment Policy

2012-12-28T10:54:00.002-08:00

Readers should know that I have a very liberal comment policy - basically unless it is spam, I do not delete. Readers should also know that I do not take responsibility for the comments that are made (they are the responsibility of those making them), as such I cannot vouch for the credibility of the comments made. It is up to the reader to assess the credibility and accuracy of the information they are reading (I will note that if I am making a factual claim in my blog, I will cite the source of the claim and would think that when a commentator makes a factual claim, they too should cite the source if they are wanting anyone else who reads it to give any weight to it).

I've taken this policy because maternal request cesarean is controversial and while I have decided it is an appropriate way for me to give birth, I will not assume that it is a good choice for all women - and that they should hear both sides of the debate and make such decisions for themselves in conjunction with their health care providers (people who are licensed and appropriately trained to provide medical advice in specific circumstances). I have an interest in women making decisions that are best for themselves in their own personal circumstances - and as such will not prevent women (or others) from reading or providing opposing views and opinions, even on my own blog. As such, I do not personally agree with or approve of all of the comments that have been made on this blog - some are perfect illustrations of the prevailing ignorance, misconceptions and misinformation that persists when it comes to maternal request cesarean and birth in general.

I love comments when they are left by readers and appreciate the purpose that having a comment section provides - I love the good, but also appreciate the bad and sometimes downright ugly ones too (and will admit that I love when I am not the only one to counter the bad or ugly comments that are left from time to time). The comments section has proven to be one of the most rewarding aspects to blogging - so please continue to leave them!

Hindsight is 20/20

2012-12-20T10:56:00.000-08:00

Somewhere between my doctors and the hospital and health authority involved in my daughter's birth, we slipped through the cracks. I have looked back on what happened countless times, and have come to the conclusion the it should not have been that way, that it was not my fault that it was that way, and that it should not happen again.

I get that maternal request cesarean is controversial and that while there are many doctors who will accede to a woman's request, there are many that won't. I also get that some hospital policies are more accommodative than others. I get that health care resources are limited. However, there is an obligation to respect bodily autonomy and ensure that access to medical care is available in timely fashion.

I believe women who wish to plan a cesarean delivery (or an epidural assisted vaginal delivery for that matter) after being informed of the risks and benefits of cesareans AND the risks and benefits of vaginal delivery should be able to do so. These women should be able to make their plans without fear that their birth plan will be frustrated and that they will be subjected to a vaginal delivery (or an unmedicated delivery) against their clear wishes and without medical cause. Just as women who desire a unmedicated vaginal delivery need to be able to plan and to know the limitations and conditions of their plan, women who desire cesareans or epidurals need to be able to plan and know the conditions and limitations of their plan.

So, with the benefit of hindsight, what do I think should have or could have been done differently to prevent what happened to me?

1. I think my maternity doctor should have ordered an ultrasound at the earliest possible date to establish a more certain EDD. I estimated my due date to be July 13 - I had been keeping track of my cycles and was using an ovulation prediction kit. Yet my care provider decided it was prudent to use a due date based on a 28 day cycle and set it to July 17 - which while consistent with later ultrasounds that I had, it should be noted that when it comes to ultrasound they become less accurate at dating as a pregnancy progresses. I believe a EDD of July 13 would have also been consistent with those later ultrasounds and should have been used.

2. I think an earlier referral to an OBGYN would have been prudent. Waiting to refer until I was late in my pregnancy meant that despite my clearly stated desire to deliver by way of cesarean, that there was a risk that the OBGYN would decline to perform the procedure and that insufficient time would remain to make alternate plans. Further, anxiety about being able to access my desired delivery mode caused undue anxiety during the pregnancy. Shared care is not necessarily a bad model, but for women who are planning cesarean delivery, knowing that a GP or midwife cannot perform a cesarean, arrangements for the delivery are best made early on.

3. A fixed OR date and time. The OB involved in my care has claimed that there was a hospital policy in place that did not allow for maternal request cesareans to be scheduled and that as a result my case was added to the add board. At the time I really did not appreciate how much risk this introduced to my birth plan - I assumed that I would know the day of delivery, but not necessarily the time and when asked what I would like should I happen to go into labour prior to surgery - I indicated that I would still prefer a cesarean. In fact, I did not worry much when my surgery got bumped the first day, or even the second, as at the time I believed that if I did happen to go into labour that my case would then be considered urgent and would be completed without undue delay (ie. within 2 hours). I also believed that should I go into labour that an epidural would have been available to manage labour pain prior to delivery. I should have been warned that if I did go into labour that there was a chance that cesarean delivery would have an undue delay (in excess of two hours) and that an epidural may not be available. I believe if this policy was in place, the effect of the policy led to an inability to access timely medical care and resulted in a contravention of my charter rights.

4. Assessment for the risk of going into labour. From the time I was admitted to hospital until the time I went into labour I was not physically assessed. My case was bumped and bumped again without any physical assessments as to the likelihood that I would spontaneously go into labour. If an assessment had been done, it might have been found that labour was imminent and my case could have been managed accordingly.

5. Upon presenting to the nursing station with signs and symptoms of labour - my OBGYN should have been called immediately. According to the records - I presented at the nursing station at around 11:45. This was shortly after I noticed a second contraction after a first contraction 15 minutes prior and wiped bloody mucous when I went to the washroom. According to the statement of defense submitted my OBGYN was not called until 130 - nearly 2 hours after I first presented to the nursing station.

6. I was told an OR and an anaesthesiologist was not available. I laboured under the belief that should things go sideways, and the knowledge that if things did go sideways, that my child or myself could suffer serious adverse consequences. I was not told that there was a back-up on-call anaesthesiologist in the event of life or limb emergencies - and that he/she would be available within 15-30 minutes if needed. I was terrified.

7. Staff and doctors should be trained to respect and support all pregnant mothers. Pregnant mothers have a diverse array of values and beliefs with respect to birth and not all pregnant mothers desire a vaginal birth without epidural pain relief. I was told by nursing staff "my body was made to do this", and that "if I wanted a maternal request cesarean, I should have gone to Brazil", and to "direct my screams into pushing". From an on-call OB I saw regarding complications after the birth that he "was happy the c-section did not occur" - although he immediately apologized when I responded that I was not happy the c-section did not occur, the words still hurt. Women choosing cesarean or epidural pain relief are not well supported - the deserve (and should be entitled to) timely access to these desired medical resources - especially when they have indicated well in advance of their deliveries that they would like access to these things.

The sad thing is that maternal request cesarean was available in British Columbia - it was even available on the island at the time I had my daughter. There are doctors and hospitals that will accommodate women who choose to deliver by way of cesarean - who will schedule a date and time for delivery. The sad thing is, that what happened to me did not need to happen. I would have been both willing and able to travel to access care if that was what was needed. I clearly communicated my preferences early in my pregnancy and throughout my pregnancy. I did my part.

Somewhere, somehow, the system and my doctors failed us - and for that, there must be some accountability and retribution for the wrong that was done. Further, measures need to be taken to ensure the same wrong is not done again, and again, and again. Access to timely medical care during labour and delivery should not be uncertain - and that includes access to cesarean delivery and epidural anesthesia on maternal request.

Connecticut.

2012-12-15T11:35:00.002-08:00

I was busy most of yesterday and after I dropped the girl off at daycare, I spent my day working on a variety of things - and was away from the internet and television. When I was finally done, I checked in on Facebook and my heart sank. Connecticut. How? Why? There is no sense to be made of it.

I cried.

Parents had dropped their children off at school that morning. Teachers went to work. All were no doubt confident that at the end of the day, after recess and lunch and math and reading and playtime that they would go home. Home to their parents, to their spouses. Home to suppers and baths and bedtime. Home to the mundane things that as parents and spouses we take for granted.

Twenty children did not go home yesterday.

Six spouses, brothers or sisters, mothers or fathers - did not go home yesterday.

We take it for granted that our schools and workplaces are safe places where students go to learn and teachers go to teach.

Yesterday proved that it only takes one to shatter that delicate presumption - one man, with access to efficient weapons of destruction can perpetrate an act so violent, so beyond the pale, on victims so innocent.

I hugged my children a little closer yesterday. I tolerated the chores of motherhood, with a little more gratitude that my mundane life was intact. And I thought about how important it is to better understand what has happened - how important it is to ensure that the risk of such things happening is minimized.

What happened in Connecticut yesterday should never happen again - it did not need to happen, and it does not need to happen again. It is time to look at the tragedy with a critical eye and determine what needs to be done - what might be necessary to restore faith that when parents send their kids to school and spouses to work that they will come home home at night.

It's time to look at what needs to be done so that schools do not need to be the equivalent of high-security prisons in order to provide safe places to learn and work. Maybe better gun control is part of the answer. Maybe better mental health resources and access to those resources (regardless of income or health insurance status) are needed. Maybe schools need to be a little more secure and extra vigilance is needed with respect to those who teach and learn there. Maybe communities need to pull together a little more to know each other a little better so that maybe a future gunman never gets to the point of donning a bullet-proof vest, arming himself with assault riffles, and perpetrating the kind of violence that should be impossible to perpetrate on dozens of innocent victims. Maybe taxes need to be a little higher to pay for the things that need to be done to ensure what happened never happens again.

It's time to focus on what matters - ensuring that parents can take for granted the mundane chores of parenthood matters, ensuring that students can go to school to learn and never have to worry about not going home matters, ensuring that when teachers go to work they can focus on helping children learn matters, ensuring that there is access to mental health resources matters, the families of the twenty children and six innocent adults who lost their lives on Friday matter - access to assault rifles does not.

I hope insult to injury is not added to this utterly tragic circumstance - I hope that America takes the opportunity to understand better what happened and the circumstances that made it possible in the first place and does what needs to be done.

Targeting the Wrong Cesareans

2012-12-06T10:32:00.002-08:00

It sometimes seems like a week does not go by without someone, somewhere bemoaning the high rate of cesarean births in developed countries. British Columbia was at one point so concerned with its reputation for having the second highest rate of cesarean sections in Canada that it struck up a Cesarean Task Force and has even put together two campaigns to address the issue - The Power to Push and Optimal Birth BC. Personally, I am not a huge fan of either. The main reason I am not an admirer of these campaigns is because of the emphasis on process rather than outcome. I care about healthy mothers and healthy babies - and I believe that the way an individual mother gets there is very individual - for some mothers planning and achieving a cesarean is just going to be a better path, for other mothers planning a vaginal birth is just going to be a better path - even knowing it has a risk to result in an emergent cesarean or operative vaginal delivery.

I am not opposed to strategies that seek to lower the rate of unwanted and unnecessary cesareans - women who neither want nor need cesareans, should not be needlessly subjected to them. For that reason I am thrilled that women in British Columbia who desire a vaginal birth and have been informed of the risks and benefits of planning a vaginal birth and the risks and benefits of cesarean birth in their individual circumstance and would choose a vaginal birth have access and support even if they have had a prior cesarean or their baby is breech. Being able to plan a vaginal birth after cesarean or a vaginal breech birth, in the safest circumstance possible (in a hospital with trained staff and resources available) is a great thing and reduces the potential for such circumstances to result in death or significant disability to either mother or child. In other parts of North America, women have difficulty accessing the care they need to plan a vaginal birth after a cesarean (VBAC) or a vaginal birth with a breech baby - and as a result many choose to birth unassisted, do not seek assistance with delivery until they are pushing, or choose home birth with an under-qualified birth attendant and lack of access to appropriate resources. These women are exposed to risks to both themselves and their children that could be mitigated if they can find a care provider and a hospital to accommodate them. For some of those women - avoidable death and disability results.

However, selling the idea that a vaginal delivery should be achieved whenever possible - is damaging to women and their children. This is what the "Power to Push" campaign does - it encourages women to pursue a VBAC, it encourages women to attempt a trial of labour with a breech baby under certain circumstances, it encourages the use of external cephalic versions (ECV), and it discourages maternal request cesareans. Rather than providing women with unbiased information regarding their birth options and the risks and benefits associated with those options and letting women decide what is best for them and their families in their individual circumstances - it pushes the idea that vaginal delivery is best - and that a cesarean is sub-optimal. Furthermore, it does this by targeting a group of women for whom cesarean delivery is more likely to be a better choice and targeting the safest and cheapest cesareans - scheduled cesareans. As a result, it is likely that it might succeed in reducing the rate of cesareans - but at the cost of increasing the share of cesareans that are unplanned or emergent, and potentially increasing the numbers of mothers or babies that are injured, disabled or die.

Further, I am disappointed at a system that fails to support all pregnant women - including those who would choose cesarean delivery or even epidural anesthesia and focus on the ultimate goal of maternity care - healthy mothers and healthy children. It's great that women desiring risky vaginal deliveries are supported to do so in the safest environment possible - however, it's a travesty that those seeking planned cesareans are not given the same support. CDMR in British Columbia continues to be difficult to access with women having difficulty finding care providers and facilities to support their informed request for cesarean delivery. It's time we had a maternity care system that didn't try to sell women on a particular mode of delivery - but rather supported a patient-centred model of shared decision making based on the best available evidence that supported the full spectrum of pregnant women to make the decisions and have access to the care they need for both mother and baby to be happy and healthy.

Meet Mrs. W - She isn't who you might think she is...

2012-11-29T14:21:00.004-08:00

The other week - an anonymous someone - made the following comment on my blog:

AnonymousNovember 14, 2012 11:41 PM You strike me as one of the type of upper class white person who feels entitled to anything she pleases. This sort of arrogant mindset does not serve you well, it only makes you come across as snooty and reprehensible. Not everything should be accessible simply because you want it. This is a product of the over-consumption way of living that is not healthy nor admirable. It's not anyone else's problem that you have issues with squeezing a baby out of your vagina. It's not anyone else's responsibility to make sure this doesn't happen. It's YOUR responsibility to mature a bit and realize not everything in life is convenient, clean and pain-free. And it's nobody's job to make it that way.

They revealed their assumptions about me - and in doing so, demonstrated what the stereotype is of a woman who wants to avoid delivering her child vaginally and requests a cesarean. It's not a pretty picture. Entitled. Arrogant. Snooty. Reprehensible. Over-consumptive. Self-centred. Immature.

Such vitriol - no wonder this person wished to remain anonymous, it is easy to hate a stereotype and even easier when you can choose to remain nameless and faceless yourself.

So who am I really - and how does it compare to the woman this person thinks I am?

I am 33 years old. I'm caucasian. The second born child of three to two high-school drop-outs - a farmer and a waitress at the time of my birth. I was baptized Anglican. My parents divorced when I was 6 - after the farm failed in the wake of early eighties interest rates. My father graduated from college when I was nine. I went to Catholic school from grades 2 through 7. My father remarried when I was seven - and separated again by the time I was nine. I was bullied in grade school. I was confirmed Catholic. I elected to live at my father's house when I was thirteen. My mom graduated university when I was fifteen. I taught Anglican Sunday school and volunteered at the local hospital in high school. I graduated when I was seventeen. I moved out on my own and started at the University of Victoria when I was nearly eighteen. I worked full-time for most of my undergraduate studies - as a waitress at a family restaurant, as a cashier at Tim Horton's, as a hostess at Japanese Village, as a copy editor for the student newspaper, as a telephone surveyor. I graduated with an undergraduate degree in Economics and Sociology and more than $18,000 in student debt. I then worked as an employment standards officer and started graduate studies in Economics. My mother remarried when I was twenty-two. I was a teacher's assistant during graduate school. I did work terms with the Ministry of Forests and Tourism British Columbia. I worked as a labour relations officer with the federal government for a year. I graduated with my Masters Degree when I was twenty four. I then did economics consulting for a year, at which time I was offered an economist position with the Vital Statistics Agency. After a year with the Vital Statistics Agency my position was transferred to the Ministry of Health. I met my husband shortly before my 28th birthday - at which time his children were 9 and 5. We married shortly after my 30th birthday. His vasectomy was reversed shortly after the wedding. I lost my grand-mother, aunt and uncle to a drunk driver the summer after I married my husband. Our daughter was conceived in the fall. I became a mother at the age of 31 and again to my son this past September.

So who am I? I am a devoted daughter, sister, step-sister, wife, step-mother, mother, and aunt who has worked hard to get where she is. I am a devoted friend. I am educated. I am an economist. I am principled. I am confident. I am independent. I am open-minded. I am responsible. I am articulate. I am thoughtful. I am hard-working. I am respectful. I refuse to be bullied. I am determined to be the kind of woman and mother that I would want my daughter to be - and to do my part to make her world a better place.

So to Anonymous - I say the following, "I know who I am, I am not ashamed, I will not be disempowered and abused - I am not the stereotype you think I am - and it's rather telling that you make such assumptions to begin with."

A Silk Purse from a Sow's Ear

2012-11-24T15:31:00.001-08:00

I am still angry about the circumstances of my daughter's birth - and I do not think that I will ever find that set of circumstances acceptable. Not for myself. Not for my friends. Not for my sister. Not for my daughter. Not for any woman living in British Columbia or Canada today or in the future. Women deserve better, their children deserve better. Not for any patient.

I am not angry that my daughter was born healthy - I am thankful for that every day. Motherhood has been a tremendous blessing - and has given me tremendous amounts of joy and wonder as I watch my children grow. Indeed, having a healthy child was my primary goal during my pregnancy - and one of the reasons I had elected for a cesarean delivery: to reduce the risk of truly adverse and life-long health consequences such as severe disability or death.

I am angry that the care I reasonably expected and was entitled to receive was withheld. I am angry at an ideology that seems to be driving the system further, and further away from quality, evidence-based, patient-centred care. I am angry that I was lied to. I am angry that I was abandoned. I am angry that the experience was terrifying and painful and physically and psychologically damaging and left me feeling utterly violated. I am angry that the circumstance was entirely unnecessary. I am angry that there exists people out there that find such circumstances acceptable. I am angry that what I experienced was likely the result of either negligence or willful disregard.

It's okay to be angry about those things - actually, I would be more worried if I wasn't angry about those things as it would likely mean that I had given up and thought that such things just did not matter. Indeed what happened was on its face, a Sow's Ear.

However, that sow's ear has supplied the material for, what someday might indeed be a silk purse. If my daughter's birth had unfolded as my son's birth did two years later - I likely wouldn't be sitting here writing this blog post. I would not have spent the last two years thinking about what quality maternity care really looks like, about what really matters and about what is poorly understood. I would not have become acquainted with an entire community of women who want better - for themselves, for their sisters, for their friends, for their daughters - an entire community of women (and some men) who believe strongly in informed consent and patient-centred, evidence-based care. I would not be pursuing a lawsuit (there would be no need to) - that might result in a precedent that other women can depend on - or at the very least will likely send the message that lying to a woman and subjecting her to a treatment that she did not consent to without cause is actionable, even if that woman was pregnant at the time.

What happened was awful (I'll happily concede it was not the worse that could have happened) - but what has happened since has made a difference and will continue to make a difference, hopefully for the better. After all, shouldn't it be the goal of every mother that her daughter should have a better go of it when it's her turn - and that's why I'm not done. Not yet - there's still a long way to go before I'll look at the situation that exists and think that it's the silk purse that it can be.

Fear of childbirth: An unjustifiable barrier to motherhood for some

2012-11-19T15:00:00.003-08:00

Imagine for a moment your worst fear.

Imagine your deepest desire.

Now imagine being told that in order to fulfill one of your deepest desires, you must subject yourself to your worst fear.

Now imagine knowing that there is a way to fulfill your deepest desire without subjecting yourself to your worst fear - that subjecting yourself to your worse fear is completely unnecessary, that you can achieve your deepest desire some other way.

Now imagine being told that it doesn't matter that it is completely unnecessary for you to be subjected to your worst fear, that it doesn't matter that there is a perfectly acceptable alternative for you to achieve your deepest desires, that you *must* do what you do not want to do or forego your deepest desire.

This is what it is like for women who desperately want to be biological mothers but desperately want to avoid vaginal childbirth. For many of them, they know a safe, effective method of childbirth exists (elective cesarean) - but they are told that their bodies are "made to birth", that if they do not wish to do it as 'nature intended' that they should forego motherhood or adopt, that cesareans should only be reserved for those with a physical *need* for the procedure, that they are being hysterical.

Unlike some fears (ie. of clowns or non-poisonous spiders or non-venomous snakes) which may be completely irrational - the fear of vaginal childbirth has some rational basis. There is a real risk of perineal tears. There is a real risk of pelvic floor damage. There is a real risk of birth injuries including hypoxic ischemic encephalopathy (HIE), and brachial plexus injuries. There is a risk that an emergent cesarean delivery may not be available or timely. There is the risk of extreme pain. Indeed, from my perspective, a fear of vaginal childbirth is wholly rational.

Further, it is not like the alternative delivery method (cesarean) available to these women is grossly expensive or inordinately dangerous compared to the conventional delivery method (vaginal birth).

So why is it that so many people think that offering women who fear vaginal birth the choice of either subjecting themselves to a vaginal birth that they do not want, or foregoing biological motherhood is anything less than cruel? And why is it that when these women are subjected to the process that they fear (perhaps without notice) that anyone is surprised that they are at a high-risk to develop PTSD as a result?

This is why it is critically important for maternal request cesarean to be unquestioningly available - because it is cruel for it not to be an option when it is an acceptable choice to meet something as basic as the desire to be a mother or to have more children. And before you ridicule some other moms choice to deliver by way of cesarean, maybe take a moment to imagine what it would be like if you were told you had to subject yourself (unnecessarily) to your worst fear in order to meet a basic desire.

The Flawed Assumption of Cost-effective Natural Birth

2012-11-16T10:12:00.001-08:00

I'm an economist by training - but more than that, I am a health economist by profession. I understand (probably better than most) the concepts of scarcity, risk, cost, expected cost and cost effectiveness. I also understand the challenges that are facing our health care system - both today and going into the future.

Perhaps that is why I am particularly perturbed when time and time again I hear that reducing the number of cesareans would save the health system money and in particular how reducing the number of maternal request cesareans would save the health system money. On it's face it seems to be such a no-brainer, after all how could an expensive surgery (cesarean birth) compete with the free birthing procedure that nature gave us (unmedicated vaginal birth)?

Of course not using health system resources is cheaper (on its face) than using the health system.

Have a heart attack and die where you stand: $0 health expenditures, alternatively have a heart attack and go to the hospital, get a coronary artery bypass and go on to live another decade or two: A whole lot more than $0 health expenditures. Develop cancer and let the disease progress as nature intended: $0 health expenditures, alternatively going to your doctor, get diagnosed (likely via some screening program), get chemotherapy/radiation therapy, and either cure the cancer or buy some additional time: A whole lot more than $0 health expenditures.

Yet there is no widespread calls for natural heart attack therapy or natural cancer care. Anyone who stood on the corner saying that people should put the needs of the health care system ahead of their own needs - would be told to apply their 'natural therapies' to themselves and to stuff it.

The natural childbirth movement is standing on the corner and shouting (rather loudly) that women should forego medical care during birth because it will save the system money. What's worse is that government seems to be encouraging them to shout even louder.

The assumption that is behind this is that intervening in birth does not buy better health outcomes. Either that or, because the better health outcomes accrue to women and their children, they simply aren't "worth it". I would hope that it is the former rather than the latter driving the "save the health system money by avoiding cesareans" mantra.

Unfortunately this assumption is flawed and very likely, very wrong.

Intervening in birth by providing pain relief or access to surgical delivery for those who want or need it does buy better health outcomes and may even save the health system money over the longer term.

Those who choose cesarean are doing so for a wide variety of reasons. They are doing it so that they may avoid the risk of an emergent cesarean. They are doing it to avoid the risk of a perineal tears. They are doing it to avoid a pelvic floor injury. They are doing it to reduce the risk of developing urinary or fecal incontinence. They are doing it to reduce the risk of severe disability or death to their unborn child. They are doing it to better arrange the support resources they need during and after the birth. They are doing it to avoid the risk of having a traumatic experience. They are doing it to reduce the risk of developing PTSD or PDD. They are doing it to protect their sex lives. They are doing it to avoid the risk of severe, uncontrolled pain.

Chances are they are doing it for several reasons and in all circumstances they are doing it because the benefits of choosing to intervene exceed the costs and/or risks of not intervening at an individual level.

I would even be so bold as to argue - that the government would do well to spend MORE on maternity than it does now as the expenditures on maternity are likely to buy more than expenditures in other areas of care. Those served by maternity services tend to be young and as such any gains in health outcomes are likely to accrue over many years. A single case of cerebral palsy that is averted could save the health care system millions of dollars in costs of future care. Avoiding a pelvic floor injury that requires subsequent repair, would likely save thousands. Avoiding a case of PTSD or PDD, again would result in significant savings.

Further, it is unclear whether or not maternal request cesarean is even significantly more expensive than planned vaginal delivery to begin with. A study entitled "Cesarean delivery on demand: What will it cost?" in the American Journal of Obstetrics and Gynaecology Volume 188, Issue 6, pp. 1418-1423 found that the average cost difference between women who attempted a vaginal delivery and those who had an elective cesarean was just 0.2% in favour of vaginal delivery. Hardly a cost savings to deprive women of their treatment of choice - which is perhaps why many US health insurers (arguably even more keen to save money to boost profits than Canadian medicare) now cover elective cesarean section.

So why don't we start with the assumption that healthcare providers and mothers who choose cesareans are doing so in their own best interests and that they are no more "milking the system" than those with cancer or cardiac problems are "milking the system"? And maybe, just maybe we ought to look at the real economics of birth choice - the answers might be very surprising indeed.

Is CDMR a societal and professional failure?

2012-11-12T14:52:00.000-08:00

In this month's edition of Lamaze's journal Birth - Dr. Michael C. Klein will publish an article entitled "Cesarean Section on Maternal Request: A Societal and Professional Failure and Symptom of a Much Larger Problem".

I wish that this article would focus on the professional and societal failure associated with maternal request cesarean and the much larger problem. However, knowing Dr. Klein as a staunch natural childbirth advocate who is ideological in his belief that medical intervention should play a minimal role in birth; I know that this article will disparage the choice that some women make to deliver by way of cesarean as being driven by misinformation and fear and will completely fail to address the much larger problem.

I would argue that the rates of maternal request cesarean are indeed driven by misinformation and fear. In short, I believe the risks and negative impacts of vaginal delivery are understated and the risks and negative impacts of an elective cesarean delivery are overstated. Further, I believe that the advantages of vaginal delivery are systematically inflated, while those of cesarean delivery are systematically discounted. I believe that the fear of surgery drives many women to avoid it - even when a surgical delivery would have resulted in a better outcome for either mother or child than a vaginal delivery. I also believe fear and misinformation drive a lot of women to forego epidural pain relief. Yes, fear and misinformation are a big problem when it comes to birth - and likely result in lower rates of maternal request cesarean and use of epidural pain relief than would be 'ideal' as many women who would have a much better birth experience by having an elective cesarean or using epidural pain relief forego doing so based on misinformation and fear.

I also believe that the situation around maternal request cesarean is a symptom of a much larger problem. That problem is that not all women are supported when it comes to the choices that they need to make during pregnancy, labour and delivery. That the information given to women regarding pregnancy, labour and delivery is heavily biased. That many women have difficulty finding a provider and a care facility that will be supportive and respectful of a mother's requests for cesarean delivery and in many cases even access to epidural pain relief. That many other women seem to think that it is okay to criticize the informed choices some women make to deliver by way of cesarean or use epidural pain relief.

I will also agree with Dr. Klein that the system of maternity care, particularly in British Columbia, is in dire need of reform - all pregnant women need to be supported and empowered to meet their own needs with unbiased information and access to medical care including access to surgical delivery and epidural anesthesia on request. All pregnant women need to know what their choices are, the risks and benefits of those choices and to have the right to informed consent. Further, all pregnant women need to know that their choices will be respected and confident that just because they are pregnant does not mean that they lose the right to decide what is done with their body.