Friday, December 30, 2011

Ending the Loneliness of CDMR

There's a group of women, in Canada and in the US, who are poorly understood, often marginalized, and sometimes maligned. All they really want is the right to choose what happens with their own bodies. Most of them are highly educated and well informed. Most of them would fight for another woman's right to informed choice, even if that choice is different from her own. They understand that there is no one 'right' way to birth a child, and that birth, like most other life decisions is very contextual.

Yet, these women are labelled 'Too Posh to Push'. These women, if they are open about their choice, must continually defend it to others. Some achieve their plans. Others do not. For those who do not achieve their plan - it is a lonely place. There is no 'denied elective cesarean awareness network'. There are reams of classes, books and resources for those planning a vaginal birth, a home birth, and a 'natural' birth and plenty of support and sympathy for those who planned but did not achieve that vaginal birth plan. The same cannot be said for those who reject the notion that a vaginal delivery, or at the very least, a trial of labour, is the price of admission to motherhood. The resources are sparse in comparison.

There are a few bright lights, and they are making progress. Pauline Hull of the UK is an amazing resource. Her website and blog are both worthwhile reads. Ms. hull has been instrumental in the recent revisions to the NICE guidelines which give women the right to choose a cesarean delivery. Ms. Eckler is a Canadian journalist who has written about her choice. Dr. Magnus Murphy has co-written a book with Ms. Hull. The birth trauma organizations in both Canada and the UK are also supportive of the cause.

There is as of yet no, 'Cesarean by Choice Awareness Network of North America'....perhaps that is what really needs to change. We need a community and a voice of our own, and moreover, we need to be heard.

So as of today, I, Mrs. W, am venturing on a new project, "The Cesarean by Choice Awareness Network of North America"....details to follow, hopefully soon.

Wednesday, December 28, 2011

10 day (and counting) headache

My head hurts. More specifically the area immediately above my right eye (and sometimes behind my eye) hurts. Tylenol seems to assist, and yet the ache persists. The doctor evaluated my headache on day 3 - working diagnosis, Migraine, with instructions to go to the ER if it gets worse. I am now on day 10. It does not seem to be impacted by sound or light. It has given me a few hours of reprieve, only to return. It seems somewhat sinusy....

I am not a person who typically gets headaches. Never have I had one that has been so persistent, and so localized. I am not impressed...

Monday, December 26, 2011

What went wrong last time?

Last time, I, from my first prenatal appointment on, indicated that I wanted to deliver by prelabour elective c-section. Prospectively, I could not have known what would happen. It is not my fault, nor is it my daughter's. In hindsight there are things I might have done differently, but it is only with the help of hindsight that I know that these are important things...things that might have made a difference for me in my case.

#1. I would have/should have insisted on using my Expected Due Date (EDD). My expected due date was July 13, 2010. I had been keeping track of my cycles and had used ovulation prediction strips the month I got pregnant. My cycle is short, I knew when I ovulated. My doctor decided to base my EDD on my last menstrual period, and set the due date at July 17, 2010. I chose the date for the csection as soon as I could (July 9,2010). If my due date had been used, perhaps I could have chosen a date as soon as July 6, 2010.

#2. I would have asked for a referral or referred myself to a psychologist. This is not because I believe I was mentally unhealthy during my pregnancy, but rather, that perhaps having a psychologist give a prognosis on the impact a vaginal delivery would have on me, might have made the c-section more likely to happen. One of my reasons for wanting it was control, to eliminate uncertainty....there is some research that indicates that this may predispose a woman to problems if things do not unfold as planned.

#3. I would have insisted on a specific date/time, a 'hard appointment' for surgery. When My ObGyn said I would be an 'add to slate', the implications of that to me were unknown. I just thought it meant that I would know the day of delivery but not necessarily the time of delivery. I had no idea that it meant that my chosen method of delivery would be unlikely to materialize. My doctor certainly didn't tell me that it made the csection less likely to happen.

#4. If I could not have #3, I would have chosen a hospital with DOBA so that in the event that I went into labour while waiting, there would be a good chance an anesthesiologist would be available and that I'd still be able to get a urgent c-section and effective pain relief. I had the mistaken belief that a major tertiary hospital in BC would have the resources needed when needed. This may or may not have been the case.

#5. I would have done more research before deciding on a maternity care provider(s). My Dr.'s had excellent ratings and I was given no reason to think that they would not be supportive of my request. However, given it all to do again, I would have chosen different doctors...

#6. There's a good chance I would have gone elsewheres to have baby number 1.

Hindsight is great, it doesn't change the past but it improves the chance that I won't be forced to repeat it.

Thursday, December 22, 2011

Context Matters

If I take my experience out of context, it is not a bad experience. In fact it is an experience that many women strive for - an epidural free labour that is 5 hours start to finish, in a clean hospital, that results in a vaginal delivery with a few second degree tears and, ultimately, a healthy baby.

Millions of women the world over would trade their experience for mine, in a heart beat.

I've heard this before. It doesn't help.

Others may say, but its one day of your life. One day. Having a baby is like having a wedding - does it really matter if it doesn't go 'as expected'?, it's the marriage that matters, the years and months after the baby is born that matters.

I've heard this before. It also doesn't help.

Birth is a natural process, its best for mother and baby. Consider it a blessing that you didn't get the c-section, really, what happend was a "blessing in disguise", you should be thankful you didn't have to recuperate from surgery. Ask most women who have had a c-section and a vaginal birth, and most women will say they preferred their vaginal births.

I've also heard this before and, it is no solace.

These platitudes don't help because context matters.

I had a reasonable expectation that I was going to give birth by way of c-section. I had carefully weighed the pros and cons of my two delivery methods (c-section and vaginal) and I had made my choice. I clearly communicated that choice to my doctor, and I was led to believe that my doctor supported my choice. I had every reason to believe that I would avoid a vaginal delivery. If my doctor had told me otherwise, I could and would have made other plans. I spent 9 months defending my choice.

Then the day for surgery came...and I was led to believe that it was bad luck. There were more urgent cases, and that is why I got bumped. I was led to believe that there were pediatric appendectomies and quite simply that there were not the resources to provide me with my c-section when I went into labour. A vaginal delivery when you've prepared yourself for a c-section is terrifying in and of itself and knowing that things in birth sometimes go sideways, beleiving that there are not the resources there, should it actually go sideways is even more terrifying.

In the months that followed, I tried to cope with my experience. At first writing about it would cause me to be overwhelmed with the emotions. (I am now on most days able to write about it, as long as I don't think too much about it when I write). I asked for advice about how to get over a 'negative birth experience', I talked with other moms, I tried to bury it...but like a zombie it refused to die.

Then I read of other women, having their care delayed or denied at Victoria General Hospital - in February and again in August. And I questioned how unlucky I really was. The external review was done. I was convinced I was a victim of the dispute between the anesthesiologists/VIHA/BCMA/Ministry of Health feud. A casualty of a level 3 hospital not having dedicated obstetric anesthesiology (DOBA). I decided I needed to speak up about my own experience. I decided that I needed to work to change the system.

I started to blog again.

I wrote a letter to the editor of the Times Colonist.

I researched the potential to bring legal action, on a class basis, to bear on the issue. However, came to the conclusion that I could not be a representative plaintiff as by way of employment and marriage I was in a conflict of interest. For what its worth - there may be something to that aspect still.

I wrote the Patient Care Quality Office.

And then I found out, that my experience was entirely unneccessary. I could have had my treatment of choice - if only my doctor/hospital had facilitated it. If only I mattered enough to them, I would have got the care that I had sought. Apparently, I didn't matter enough. I was truly violated, not by some strange twist of fate, but either by negligence or intent. If this situation is not cruel and unusual, I don't know what is.

I know, that as a result, I need therapy. There's only so much that a person can be expected to handle on an emotional level - despite my better efforts.

There is still much work to be done to 'fix it'...if that is even possible.

Tuesday, December 20, 2011

Post-Partum Psychological Dystocia

During vaginal birth, occasionally the baby gets stuck and can't get out without some assistance. A change in position. The use of forceps or a vacuum. A broken clavicle. A change in delivery method. If the dystocia is managed appropriately, the baby and mother emerge relatively unscathed. If not, there are injuries that range from from mild to traumatic and debilitating.

I am happy that I have a healthy, thriving daughter. There was a time, from September 2010 to February 2011 when I was doing "okay" just not thinking about the experience - just basking in the new mommy joy...being thankful for every milestone reached, thankful to have a happy baby, thankful that life in general was good. I am very thankful (by whatever small miracle) that I do not associate my daughter's birth, with my daughter. It sounds absurd, but my daughter is seperate from the process which brought her into the world - she is not her birth, she is not responsible in any way for what happend.

And yet I'm stuck - I don't cope well whenever I reflect on what did happen. Sometimes when I read a news story about a mom denied pain relief in labour or having a c-section delayed or unable to access timely care, I find myself back there. In the delivery room. Terrified. Sometimes, ff the conversation turns to birth, and other moms are reflecting on their experiences - I am back there. In the delivery room. Terrified. Sometimes (often) when I turn my mind to the next baby, who is wanted but not yet conceived. I am back there. In the delivery room. Terrified.

Sometimes I'm just angry...and at others sad - in no small part because I know that it didn't have to happen.

It's been 17 months - the passage of time has done little to resolve the outstanding issues, and given what I know now - time alone is not the cure.

Friday, December 16, 2011

The PCQO Responds

A few months ago I wrote to the Patient Care Quality Office, wanting more information on my particular case. I believed that I didn't get my c-section because there were more urgent cases and I was bumped, and because when I went into labour there was no anaesthesiologist or OR available.

Today I received their response. I don't know what I was expecting.

I still believe that the lack of Dedicated Obstetric Anesthesiology in level 3 hospitals in this province is a problem. But it, according to VIHA's, Patient Care Quality Office, wasn't my problem between July 9 and 11th.

According to the PCQO:
-During the period of July 9 to July 11 there were times that the OR was not being used, and that my physician could have called in the back up anaesthetist.
-Throughout the period of July 9 to July 11, the back up anaesthetist was not called in for any cases during that time period.
-At the time my contractions started, the OR was not occupied and their was full surgical staffing available, however the OR did not receive a call from either my physician or the LDR to proceed with my c-section.

Let me make this clear, at the time it was confirmed I was in labour, my physician informed me that no anesthesiologist was available as the OR was occupied with 'pediatric appendectomies'.

In many ways this makes what happend in my case even more disgusting.

Wednesday, December 14, 2011

The BC Maternity Care Rant

I'm a bit livid right now. I'm livid with the anesthesiologists. I'm livid with the BC Medical Association. I'm livid with the BC Ministry of Health. The situation right now is an all out cluster f**k - the game playing has reached an obscene level, and in the middle of it are the patients. The mothers and the babies.

Yesterday the BC Government, announced funding for dedicated obstetric anesthesiology at Surrey Memorial, Royal Columbian and Victoria General Hospital. But don't break out the cigars just yet...this is not the birth of DOBA, at least not yet - I'm not sure if this will be yet another miscarriage or actually result in DOBA being a resource for pregnant mothers to rely on that will actually result in women having access to timely care (epidurals and c-sections) during labour and delivery.

So what is the cause of my cynicism? DOBA in BC has a long history - a history of being 'supported', but not actually realized. There has been a series of miscarriages. You see, the announcement yesterday is about 3 years too late. Why? Because, the government actually did try to get DOBA at these hospitals in 2009. What happend? Well not a single anesthesiologist applied to the positions. So as much as DOBA was then recognized to be a good thing that should be at all level 3 hospitals in BC, it did not come to be.

As a result - when I had my baby in July 2010, DOBA was not there. When Mrs. Frith had her baby in December 2010, DOBA was not there. When the baby in August was stillborn and sparked an external review, DOBA was not there.

So now, given the outright hostility between the BCMA, the Ministry of Health and the Anesthesiologists - I am in no way certain that DOBA will be in place anytime soon. I'll believe it when I see it, and in the interim - what about all the women who have been harmed between the time the government first realized that DOBA should be in all tertiary hospitals in BC and the time it actually becomes a reality?

There needs to be some accountability for the harm that has been caused - and right now there isn't...there needs to be some recognition of the pain and suffering that didn't need to happen, shouldn't have happend. If you've been harmed by the lack of DOBA in level 3 hospitals in BC, speak up - your voice deserves to be heard above the petty bickering!

Tuesday, December 13, 2011

The 2011/12 Labour Games in BC - Featuring Anesthesiologists

This issue seems to be moving so fast today as to make my head spin. I came across the following headline this afternoon:
B.C. Government's $2.5-million Surprise Announcement Called Game-Playing

The government apparently has tried to end the bitter dispute with anesthesiologists by offering $2.5 million for dedicated obstetric services at Victoria General Hospital, Royal Columbian Hospital and Surrey Memorial Hospital.

Unfortunately, it appears that the government decided that the deal hashed out with the BCMA did not need the involvement of the anesthesiologists. As a result, the anesthesiologists were not even aware of the pending announcement.

Consequently the move is seen as game-playing by the anesthesiologists.

I think there's merit to the game-playing accusation. The issue has been ongoing for years (since 2009/10 at least) and it does appear that this latest pronouncement is in response to pending job action. I also think the anesthesiologists have a right to be unhappy with the negotiating environment. The fact that what is ostensibly a union could negotiate the terms and conditions of employment without input from the individuals it claims to represent - is a bit disturbing. It is more disturbing when that same group has been begging for its own voice for years.

Unfortunately, I think this means that I'll have to hold off on the celebratory champagne - as I've got a gut feeling that as a result of the game playing by the BCMA and the government that it might be a while before DOBA becomes a reality. I feel the announcement, particularly the timing of it and the way the deal was reached, might well inflame the situation further. This is no olive branch.

The real losers of all this game playing of course, are the women, particularly those who want and need medical services (c-sections and epidurals) during labour and delivery and have those services delayed or denied as a result.

I hope I'm wrong, the women and patients of BC deserve better - they should not have to pay the very painful price in this dispute.

News on the Anesthesia Front in BC

This morning I woke up to the following headline:

Job action by B.C. anesthesiologists could delay, cancel medical procedures

It appears that the issues between the province, the BCMA and the anesthesiologists are no closer to being resolved. I wish I could say that I was somehow surprised by the headline, but I am not. Further, it makes me even more hesitant to plan a birth in BC - if I was not so keen on the idea before given past experience, I am really not so keen on it now.

What is really disturbing about the proposed job action, is that patients are the ones who will ultimately pay the price. People generally do not undergo surgery because its a fun thing to do, rather they do so because the benefits in the long-term outweigh the pain of recovery and the risks associated with the surgery. Waiting to be 'fixed' isn't fun, often its a time of anxiety, disability, pain and suffering. Having your surgery further delayed or even cancelled because of a labour dispute isn't fair -- and can leave patients feeling like the system lets them down.

Further, in a health care system such as Canada's, there is no outside option - you can get 'medically neccessary' services but you must get them through the public system. Some people might be 'lucky' enough to have the resources to arrange for their surgeries either in another province or out of country - but doing so is an adminstrative and logistical nightmare that can be quite costly.

This does not bode well for expectant mothers in BC who might need anesthesia services that could be considered 'optional'.

Friday, December 9, 2011

A Retrospective Reason for Wanting an Elective C-section

It has dawned on me that another reason for wanting a c-section with #1, would be to actually have a respected choice with #2. In Canada, and in British Columbia particularly, women who want to have vaginal births after c-sections (VBAC) are actually encouraged to do so. This is despite the relative risks of repeat c-sections compared to VBACs. It actually is a preformance indicator of the health care system, and those in the ministry of health (whoever they are who decide these things) actually want to see the number of women who attempt VBACs in BC increase. It's a bit mind-boggling (to me) in a province where only 1 hospital in BC currently has DOBA - but at any rate it is what it is.

I have a friend who is currently pregnant, and if she decided to go for a VBAC she would be free to do so. She is currently planning a RCS (repeat c-section) - but without a doubt, knows that the final decision of c-section or VBAC is hers and hers alone to make. I am somewhat envious of her freedom to choose at this point in time.

So I can add to the reasons for wanting an elective c-section: The Right to Choose Mode of Birth with subsequent births (all be it that vaginal births subsequent to a c-section do have higher risks).

Is DOBA in BC around the corner?

Last week, the anesthesiologists were given a 'final offer' in a pay dispute that has been ongoing for years. The dispute has impacted on the quality of care that mothers at Victoria General Hospital have been able to access during labour and delivery.

This week the anesthesiologists have offered $3 million of their own funding to help recruit staff to help high-risk pregnant mothers and their babies.

Unfortunately, unless offers become deals, the situation at Victoria General Hospital (and other level 3 hospitals in BC that do not have DOBA) is unlikely to change. So far the track record for resolving the problem is less than inspiring. Unless the offer made on December 1 is competitive with what is available in other provinces, I don't think its very likely that the anesthesiologists will accept it. Further, unless the BCMA and the Ministry of Health are willing to work with the anesthesiologists on their offer of $3 million to recruit maternity staff - it is unlikely to have any impact in practice.

I am watching this situation unfold, and am truly hoping for the best as patient care needs to be the priority in this province - too many moms and babies have already paid a rather dear price while the BCMA, BCAS, and Ministry of Health have squabbled.

Wednesday, December 7, 2011

The Justifications for a C-section This Time Around

My reasons for wanting a planned c-section at term with my first pregnancy were very rational. I was very well informed about my options, and had found an OB who I thought would respect my wishes. I was looking forward to meeting my baby in a calm environment and avoiding the physical changes that can be expected when a woman undergoes a normal vaginal delivery.

This next time around (which isn't even on the cervical horizon - so might not even happen), I cannot ignore that my body has been subjected to a normal vaginal delivery - no matter how unwanted it was. I cannot undo those physical changes, no matter how much I may want to. No more so than a woman who has undergone a c-section can undo the c-section. No obstetrician will ignore this fact either - and it's likely to make finding one to agree to my request for a planned cesarean harder than it was the first time.

In a second delivery, labour and delivery tends to be much faster (typically half as long as the first, which for me would be about 3 hours). Further the risk of emergency c-section is greatly reduced when the first pregnancy resulted in a spontaneous vaginal delivery. If I go into labour spontaneously (as I did last time), the risk of c-section is 2.3 percent, if I'm induced the risk is 7.5 percent (source: BC Perinatal Services Annual Report).

As such 2 of my reasons for electing c-section last time - avoiding a real and significant risk of emergency c-section and wanting to avoid the physical changes of a normal labour and delivery - aren't really valid this time around.

So what is there to gain by having a c-section this time around?

1. Avoidance of labour pain - given an expected labour that would be very short 2.5 to 3 hours, there's a good chance there might not be time for an epidural the second time around. Labour pain is hell on earth - before I suspected that it might be hell on earth, which is why I wanted to avoid it in the first place and now I know it is hell on earth.
2. Avoidance of further physical changes.
3. Avoidance of the experience of a second 'normal' birth.

And at what cost?
1. There's a good chance I won't find an obstetrician to agree to my request locally - as such I'm looking at travel expenses, and medical expenses. I should anticipate that acquiring a c-section this time around might be around $20,000.
2. Increased length of hospital stay and a longer recovery.
3. Increased risk of maternal morbidity and mortality.

From a physical standpoint - there's not a lot of justification in requesting a c-section this time around. Going through a c-section isn't going to reverse the physical changes that resulted from the first delivery and is unlikely to resolve any of the psychological issues. I know this.

And yet the idea of subjecting myself to another 'normal delivery' is deeply disturbing to me in part because I would be doing so because my right to choose was violated the first time I gave birth.

My situation logically sucks...

Tuesday, December 6, 2011

Medical Tourism: Elective C-Section Edition

So far my efforts looking into option #4 (arrange to have baby #2 outside of the province, and outside of the country) have not yielded a lot of success. I've contacted one Canadian based company that specializes in medical tourism in the US called Timely Medical Alternatives, and one German company called Erikson Medical.

Neither response was positive, but at least the response from Timely was polite and brief. "Thank-you for your inquiry. Unfortunately, we do not offer c-sections. I'm sorry that we cannot help you."

The German response...well I'm reminded of the Seinfield episode with the soup nazi - "No C-section for you!". I'll be honest it hasn't exactly provided the best start to my day.

The email from Erickson starts of nice enough:

Hello Mrs. W. - thank you for your request. we do not think that we can help you. In Germany c-sections are mainly favoured in cases of emergency.

Had the email ended there, it would have been negative but not insulting. Very much similar to the email from Timely. The email did not end there. Rather it continued...

Responsible doctors do not recommend planned c-sections. does this means that if I find a doctor that will respect my well-informed request for a c-section and my autonomy as a person, that that doctor is irresponsible? Of course the email does not end there either, it continues further:

A birth is a natural event and natural birth is the best way for the mother to bring her child to this world, and it is known that to go through birth is important for the further life of the child.

Hurricanes are natural events. Earthquakes are natural events. Forest fires are natural events. Heart attacks and kidney stones are again very natural events. Further, are all those babies - you know the roughly one in three who are born each year via c-section irreparably harmed as a result of their births?? I don't think so. What's important for the further life of the child is not the 'how' of its birth. Will the child have loving parents? A warm-dry place to sleep at night? Access to education? Good food to eat? Guidance and nurturing? Of course the email doesn't even stop there.

It is a fairytale that a c-section is more easy for the woman. The abdomen has to be cut through which means a scar you have for the rest of your life and which can cause problems, and a long period of recovering after the c-section during which you have pains, are not able to carry, while you have to take care of then two children.

It's a fairytale that a vaginal birth is more easy for the woman, it's not - at least not for all women. It particularly isn't easy for the woman who has absolutely no desire to experience natural childbirth. Many women have life-long issues associated with their vaginal births - for which they would happily trade a c-section scar. I, for one, would happily trade the memory of natural childbirth and its sequalae for the memory of an elective c-section and the scar. I am aware of the additional recovery associated with c-sections and am more than prepared to make arrangements for the care of myself and my children during that time of recovery. Of course the email doesn't even end there:

I know what I am talking about, I myself have three children, one of them with an emergency c-section. That was the worst birth.

Thanks for relating to me your personal experience of an emergency c-section. An emergency c-section is NOTHING like an elective c-section. And then it continues:

Of cause there are pains during the birth, but isn`t it also interesting to experience, what a body is able to do?

I've experienced what a body is able to do - not that I wanted to, but I did. Thanks, but no thanks...continuing:

And if you decide yourself to take an epidural (I had this one time) you do not feel anything and still you have the softer choice of a natural birth for you and the child.

Epidural or not - I would still be aware of the large object passing through my vagina, when I do not want a large object passing through my vagina. Didn't like the first time, won't like it next time. And since when is a vaginal birth the 'softer' choice for the child - has she seen the shape of some kids after they go through a 'natural' birth? ...there is yet more:

Another point of not recommending the planned c-section in Europe is the risk of a long flight in the state of high pregnancy. Do you want to come months earlier or do you want to risk a birth "above the clouds" with none professial medical help at all? This obviously is much too dangerous.

I get the logistics of planning a foreign birth. It is perhaps the one aspect to it that is a big detraction. If it was an option (which it doesn't appear that it is) - I would work with it. If that meant going to Europe several weeks before the baby and staying for a few works after, then that is what would be done. Still there's more:

So go into yourself and consider again. Of course it is beautiful to have a second child. And the second birth usually is much easier and shorter of time than the first one. Talk to your doctors and mention your fears, there are possibilities to release pains. Maybe you have a midwife who you appreciate and who can be with you and accompany your birth. And then plan your natural birth which really can be an overwhelming experience!
I wish you the very best!

I spend a lot of time 'into myself' - my decision is not about pain and there is no way I'd consider a natural birth. So it's very obvious that: "Dieses Baby wird nicht in Deutschland geboren werden!"

Friday, December 2, 2011

Measuring Access Delayed and Denied

I have anecdotal evidence that timely access to medical care during labour and delivery is sometimes delayed and sometimes denied in BC. I have news articles about these cases and I have the conversations that I have had with other moms. I have some evidence that access to some services is significantly lower in BC than in other parts of the country (for example, the use of epidurals in BC is 30 percent compared to 60 percent in the rest of the country).

I know a problem exists, what I have no real way of knowing is how big of a problem exists. Statistics on how long a person waits for a requested service are not kept. Statistics on requests for services that ultimately didn't happen are not kept. Statistics on services that are bumped by more urgent cases are not kept. As such, I don't know how many other moms in BC are like me - I know that I'm not alone in my experience, but I don't know exactly how not alone I am.

I fear that I am less alone than I should be - I fear that cases like mine, that should be a very rare exception, actually aren't. I fear that quality care is missing for many women. If access delayed and denied was measured, it might be a first step to recognizing that a problem exists, the magnitude of it and moving towards changing it so that patients have a better experience of care.

Thursday, December 1, 2011

Update on the financial implications of Options 3 and 4....

If the baby were born out-of-province but within Canada the birth of the baby would be covered by BC Health Insurance.

If the baby is born out-of-country there would be no financial coverage of the birth.

Can I find a hospital/OBGYN within Canada in which I would be confident that outcome and plans would be reasonably aligned?


Option 5: Forego Baby #2

My options suck. In order for me to really be at peace with the idea of baby #2, I need to know that I could schedule a c-section at term and that it would actually happen. Given a history of 'successful' vaginal birth, I know that asking for and getting a planned c-section in Canada is likely to be even harder than it was last time. It didn't happen last time - and I did almost everything to see that it would happen. If it did, then asking for a repeat c-section would be a walk in the park.

So maybe baby #2 isn't such a good idea. Maybe I should just not go there, let the past be in the past and focus on an only child future.

Wednesday, November 30, 2011

Evaluating Potential Exit Strategies

I need an exit strategy for baby #2 before it comes onto the cervical horizon. I need to KNOW that the care I need will be there when I need it. It's not good enough to have a c-section date at Victoria General Hospital, knowing what I now know about how those are treated at Victoria General Hospital. I could not access the care I needed, when I needed it, last time and I have no reason to believe it would be any different this time. Further, I think Mr. W needs to know that there's an exit strategy before he'll even really risk putting baby #2 on the cervical horizon.

So what are my options:

Option 1: Plan to Deliver at Victoria General Hospital

The only pro I can think of is that it's local. It has a NICU and is a level of 3 hospital. It does not have dedicated obstetric anesthesiology (DOBA). Access to epidurals is questionable, as is access to maternal request c-sections, particularly those without 'medical indication'. The thing is, if I didn't want medical intervention or the insurance that it would be there when I needed it - I would likely plan a home birth. Given my history with this particular facility, I really don't think its a realistic option. At least not one that gives me any piece of mind...

Option 2: Plan to deliver at an Alternate BC Facility

The only hospital that has dedicated obstetric anesthesiology in British Columbia is BC Children's and Women's hospital in Vancouver. I'd be fine planning a delivery there. The problem is that because I'm not likely to be a high-risk pregnancy, and do not live in Vancouver - I do not meet their eligibility requirements for delivering there. I suppose I could find a friend to let me use their address to pretend to be a Vancouverite - but I don't know if I can bring myself to such dishonesty - I shouldn't have to lie to access services. Delivering there is hypothetically feasible, but I find it a huge drawback that I would effectively have to lie to do so.

Option 3: Birth Within Canada but Outside of British Columbia

According to the Health Insurance BC(a.k.a. Medical Services Plan or MSP) it will pay for unexpected medical services anywhere in the world, provided that they are medically required, rendered by a licensed physician and normally insured by MSP. Reimbursement is in Canadian funds and does not exceed the amount payable had the same service been provided in BC. I also note that the maximum that BC will pay per day for in-patient hosptial care is $75. I don't think an elective c-section at term would be considered an "unexpected" medical service - the expected nature of it is exactly what I find appealing (among many other things). Further, given the obscenely low rates of reimbursement of in-patient hospital care (note, I don't think BC incurs such a low expence if care is provided IN BC) - it looks like it might be an expensive option even if it were covered. There would also be travel costs incurred. It is also obvious that the person providing my prenatal care will not be the same person who delivers the baby.

I have enquired to Health Insurance BC about the coverage available for an out-of-province birth.

Option 4: Birth Outside-of-BC and Outside-of-Canada

This option has high travel costs and suffers some of the difficulties with #2, except medical expenses are likely to be even higher. Further, it would bestow upon baby #2 second class Canadian citizenship, which means that my grandchild could risk statelessness if baby #2 also has his or her child outside of Canada in a jurisdiction that does not grant citizenship on the basis of country of birth. If I do birth baby #2 in a country that does grant citizenship on the basis of place of birth, that baby gets the advantage of additional citizenship. It is also obvious that the person providing my prenatal care will not be the same person who delivers the baby.

I have enquired to Health Insurance BC about the coverage available for an out-of-country birth.

That pretty much sums up my options. There is no private option in BC or in Canada for that matter when it comes to giving birth. I cannot pay to guarantee access to an elective c-section at term, or even guaranteed access to an epidural.

Sunday, November 27, 2011

Do Childbirth Preparation Classes Need to Be Redeveloped?

I did not attend childbirth preparation classes. Not to say I did not do an extensive amount of research and preparation prior to the arrival of Juno, I did, but did not feel that attending such classes would be of much benefit. In large part this was because I had chosen my mode of birth (csection) and that there were no classes geared towards maternal request csection moms, so I felt any such course would be of limited use to me and would just open my decision up for even more criticism. Further, of the inquiries I made to other parents about the usefulness of childbirth preparation classes - many parents seemed to indicate that they really weren't all that helpful, that the networking was useful but aside from that, there was little value.

I've come to the conclusion that perhaps its time for childbirth preparation courses to be redeveloped to reflect the current evidence on the topic, to balance the natural birth and pro-breastfeeding bias, to help women develop better (and more dynamic/useful) birth plans, to have more information on infant care and more information on the available local resources.

If I had felt that such a course would have provided me with truly useful information and an environment that would be supportive of individual choices that best meet the needs of specific mothers and babies, I likely would have attended.

Thursday, November 24, 2011

Cojocaru versus BC Children and Women's Hospital Goes to the Supreme Court of Canada

Giving birth has risks, giving birth after a previous c-section has additional risks. Vaginal birth after c-section (VBAC) carries with it a 1 in 200 risk of uterine rupture. What this means is that the baby is expelled into the mothers abdominal cavity during labour and deprived of oxygen. If a c-section cannot be performed immediately, there is a danger of permanent brain damage.

This is what happend during Eric Cojocaru's birth at BC Women and Children's hospital in 2001. According to the information in the original judgement and the appeal judgement (found at and ), Eric's mother, Monica, arrived in Canada pregnant and went to an OBGYN in Vancouver. Monica was told by her doctor in her home country that any future deliveries should be done by c-section. Monica told her OBGYN in Vancouver she wanted a c-section. The OBGYN offered Monica a VBAC indicating that it was successful in most cases (70 to 80 percent), and that the risk of uterine rupture was small. Monica, whose first language is not English, believed that she had to go through a trial of labour to get a c-section.

Monica's labour was induced when she was 10 days overdue by way of vaginal insertion of a prostaglandin gel. It is noted in the appeal judgement that the unchallenged evidence was that the Hospital had four operating rooms (“OR”s) but only one anaesthetist and one OR team on duty at any given time throughout the day that Mrs. Cojocaru was induced. Anticipating these conditions, the Hospital had scheduled no caesarean sections for the day, as it would have on a normal day. Rather, the operating room was taking only statim (urgent, emergency) caesarean sections. The undisputed evidence was that the waiting list that day for caesarean sections designated “urgent” was one to two hours long and that they were given priority. A bradycardia was detected at 6:18pm, Monica was assessed at 6:22pm and found to have signs of a partial tearing or rupture of the uterus, an attempt to attach a scalp electrode to the fetus was unsuccessful and a stat c-section was ordered. Monica arrived at the OR at 18:29, the c-section was started at 18:30 and Eric was deliveried at 18:41 (23 minutes after the initial bradycardia was detected). The evidence, unchallenged and uncontradicted, was that the only anaesthetist and OR team at the appellant Hospital were engaged between 18:00 and 18:30 in performing an emergency caesarean section; that the decision to call in a second anaesthetist was for the anaesthetist at the hospital to make; and that, had the on-duty anaesthetist called for them, it would have taken 20 to 30 minutes for a second anaesthetist and OR team to be assembled to perform an emergency caesarean section on Mrs. Cojocaru. It was found that the bradycardia detected at 6:18pm was caused by a uterine rupture and complete placental abruption. In order to avoid brain damage, a baby must be delivered within 10 to 15 minutes of a placental abruption (by 6:28pm and 6:33pm, which due to resource constraints would not have been possible). Eric Cojocaru suffers from a form of cerebral palsy and has many physical disabilities, as well as impairments to his ability to think, learn and develop social skills. The orginal judgement awarded the Cojocarus $4 million dollars and found that there was negligence in regards to "informed consent" and "malpractice".

The decision was reversed on appeal and will be heard by the Supreme Court of Canada.

I am struck that a woman, attempting a VBAC would be induced on a day when the hospital is short-staffed and at risk of being unable to provide timely access to medical care (a c-section within 10 to 15 minutes) should they be needed. There was only 4 ORs and 1 anesthetist on duty that day. A back up anesthetist would take 20 to 30 minutes to arrive. There was a 1 to 2 hour wait for urgent c-sections. How is it that a woman, who was at risk of a uterine rupture (1 in 200) was allowed to be induced and proceed to a Trial of Labour when, should she need a c-section the wait would likely exceed the 10 to 15 minute wait that would avoid brain damage? Does the hospital not have a responsiblity to ensure that such services are available if a known high-risk patient is labouring? Why wasn't a second anesthetist at the hospital on that day, given the prevailing conditions (a full high-risk ward, a 1-2 hour wait for urgent c-sections)? Was the risk of being unable to access timely medical care communicated with the patient at the time the induction was started? Under the circumstances should Monica have been offered a repeat c-section that day instead of a trial of labour?

I wish the Cojocarus the best under the circumstances, and hope that the Supreme Court of Canada will uphold the $4 million award of damages - it seems to me that the system failed to deliver quality care to the Cojocarus and that Eric's injuries were entirely preventable. I will be watching this case with interest.

Wednesday, November 23, 2011

The Need for Anti-Cynicates

I don't think I'm depressed - Angry, check - Cyncical, check - Depressed, nope not really. Angry and cynical...its a toxic mix for a girl who is typically easy going and optimistic. Unfortunately, I don't think there's anti-cynicates to cure me of the cyncicism...

I guess I'll just have to work with it.

On a side note - I've been actively researching options for baby #2. I really do not want to deliver at Victoria General Hospital again - not unless things change, which from the recent resignation of Dr. James Helliwell -does not look likely anytime soon. Call me crazy but I want to know that I will have access to anesthesia, it's not something I want to risk and in the absence of dedicated obstetric anaesthesia, I know exactly where on the priority list a maternal request c-section at Victoria General would be.

So where does that leave me...

Well there's choosing a mainland hospital - but neither Surrey Memorial nor Royal Columbian have dedicated OB anesthesia. So I may very well be faced with the same problem I had with VGH.

Only BC Children's and Women's hospital does have dedicated OB this would likely be my first choice. However, unless I am a "long-term patient" of the doctor/midwife who will deliver my baby at BC women's hospital, I am unlikely to meet the criteria which are found here:

It seems a little absurd, that the ONLY hospital in BC to have dedicated obstetric anesthesiology, is not available to ALL women in BC.


Catching up on the 'news'

Apparently while I was away - the following story hit the news:

B.C. Anesthesiologists’ Society president resigns because of 'corruption in the health care system'

By Cindy E. Harnett and Rob Shaw, timescolonist.comNovember 15, 2011

The president of the B.C. Anesthesiologists’ Society has resigned, claiming the health-care system is corrupt as a bitter dispute between the specialists and the B.C. government drags on.

Dr. James Helliwell, president of the society, quit Tuesday because of what he said, in a statement, is “corruption in the health care system.

“I am a firm believer in quality care and honest relationships,” said Helliwell, in his resignation letter. “I cannot believe the complacent acceptance of poor patient safety and severely rationed access to care which is endemic in B.C.’s health system.”

Last week, the B.C. government and the provincial medical association rejected a call for binding arbitration to resolve a labour dispute with anesthesiologists.

The Canadian Anesthesiologists’ Society released a letter to Premier Christy Clark last week that asked her government to consider mediation, and binding arbitration, to resolve “serious concerns for the safety and well-being of British Columbia patients.”

B.C. anesthesiologists are locked in a pay dispute with the government and the B.C. Medical Association because they say they have the highest workload but lowest compensation in Canada.

The dispute has manifested itself in a bitter public feud at Victoria General Hospital, where anesthesiologists have said the lack of a dedicated obstetric anesthesiology unit is leading to long wait times, poor service and dangerous conditions for pregnant mothers in need of emergency caesarean sections.

Dr. Helliwell writes in his resignation letter that if the government worked with the society, together they could have reduced surgical waiting lists, made better use of the billions in tax dollars spent on surgical care in B.C. and, most importantly, delivered better and timelier care to tens of thousands of suffering British Columbians.

“I've made repeated offers of consultation and co-operation, but they’ve been steadily rejected by [Health] Minister Mike de Jong and his officials,” Helliwell writes.

The B.C. Health Ministry said it has had over a dozen meetings with the society in the past three years, and many more meetings at the local health authority level to discuss their concerns.

As well, it’s committed up to $170 million in patient-focused funding in the coming years, the health ministry said.

Helliwell said his resignation will clear the way for a new leadership approach to force change.

“I am disgusted by the intransigence and denials of a provincial government which is defending the status quo at the expense of patients’ safety and quality of care,” Helliwell concluded.

The vacancy rate for anesthesiologists in B.C. has doubled in eight years to 25 per cent, the highest in Canada and well ahead of a 4.42 per cent national vacancy rate, according to an assessment by the national anesthesiologists society.

Dr. Rick Chisholm, national president, said last week: “I think someone is going to have to say that the three parties have got to sit down and resolve the problem and it may take mediation.”

But the idea was rejected by B.C.’s health ministry and the BCMA, which are both negotiating a new physician master agreement that will set rates for doctors and specialists, including anesthesiologists.

Health Minister Mike de Jong is in India and wasn’t available for comment Tuesday.

“Government remains completely committed to a fair negotiating process that serves the interests of physicians, the taxpayers and, most importantly, patients," the health ministry said in a statement, last week. "As to the call for binding arbitration, we have not yet exhausted all of the mechanisms provided under the physician master agreement regarding the B.C. Anesthesiologists' Society call for increased fees."

Currently there are six anesthesiologists vacancies advertised through HealthMatch B.C. while health authorities have an additional nine anesthesiologist vacancies posted, according to the health ministry.

Vacant positions are comprised of temporary and permanent jobs.

The ministry said the number of anesthesiologists in B.C. has increased by 31 per cent in the past 10 years — greater than the 21 per cent increase in ordinary physicians — leaving B.C. with one of the best supplies of anesthesiologists per capita in the country.

Saturday, November 19, 2011

Mojito Por Favor

I've been enjoying some sun, some sand, some nuptials, more sun, more sand and mojitos the last 5 days, as such posting has been sporatic, Imanticipate more regular posting upon my return to Northern climes November 22...

Friday, November 11, 2011

The Haunting of Mrs. W.

I never took the decision to request a csection lightly. I had my reasons for wanting one - I wanted to know with a fair degree of certainty what my experience would be like, I wanted to reduce the already small chance of a catastrophic outcome for my baby, I wanted to protect my pelvic floor, I wanted to avoid an emergency csection and the risks associated with that, and I wanted to keep the girly bits I had largely as they were - for they were mine and I was comfortable with them. I didn't particularly fear labour pain (although I certainly do now), as I could not conceive what labour pain was like. It was my body, my choice and I decided c-section.

I breathed a big sigh of relief when I secured a date for the surgery.

Then, I arrived and fasted and I got bumped....

No worries, it's not like I was in labour.

And then bumped again...oh well, I still wasn't in labour.....AND then I was....

The c-section didn't happen. An epidural didn't happen. Fentanyl and gas. 2nd degree tears. Upon birth, my daughter needed resuscitation and Narcan.

The experience haunts me to this day....

I could have handled surgery, I would have been over surgery by now. Instead every now and again it hits me like a steam engine. It's a terribly depressing thing to know that choice, particularly choice on a matter so personal is an illusion. I have no confidence I won't (if I decide to have another child), be there again.

But isn't it worth it, to have a healthy child?

I would give my life for my child....but it's disturbing to think that my autonomy as a person, my ability to say my body, my choice could be so readily violated - in the absence of any medical justification to be deprived of those services. It's revolting to know that such services exist, and that as a result of some sick game between the BCMA, the anesthetists, the ministry of health and VIHA, timely access to medical care was denied.

Thursday, November 10, 2011

The Sound of Crickets Chirping

There are days when I feel incredibly alone. Today is one of those days. There are not many women who plan an elective pre-labour c-section, make it to the surgery date at 39wks+1d, get bumped 2 days and then have an epidural free SVD.

I know I should not be mired in that day, but today I am, and it sucks.

I don't know when (or even if) I'll ever make peace with that day, if I'll ever get over the anger at the system.

A Clear Destination for the Canadian Maternity System

Often times it feels as though when it comes to maternity care in Canada - the system is being pulled in all directions without any true sense of destination.

There are those who would like to see the role of intervention limited (Dr. Klein, Ricki Lake, Ina May Gaskin, NCB advocates, etc.) as they see intervention as being costly and frequently unneccessary. They perceive the benefits of ready access to drugs and epidurals in labour as being outweighed by the risks of longer second stages of labour, increased risk of instrumental deliveries, increased risk of resuscitation. They may argue that medicalized birth is expensive birth, that on a whole does not yield better outcomes for low risk women than medicalized birth with it's "cascade of interventions". The claim is that women have been giving birth for thousands of years, our bodies are made to birth, and that there is no valid reason for c-section rates to exceed 15 percent. They also bemoan the impact that interventionist birth may have on breastfeeding. Birth to them is something that needs to "be reclaimed as a natural process". Home-birth and unassisted birth is viewed as a reasonable and inherently 'safe' option by many in this group.

On the flip side, is a small minority that has only recently found it's voice (Dr. Amy Tutuer, Mrs. Pauline McDonough-Hull, Mrs. Eckler, etc.) who argue that the medicalization of birth is a good thing that prevents morbidity and mortality and unneccessary pain and suffering. For the most part these women (as they are mostly women) argue for 'informed consent' and unbiased information as it pertains to birth. They see the benefits of intervention as frequently outweighing the risks. Birth is seen by this group as a biological process that has inherent risks and those risks can and should be proactively managed. C-section on demand is seen by many in this group as reasonable and a comparably 'safe' option.

There is no universal 'right' way to birth a child, just as there is no universal 'right' way to parent a child. To believe that there is, is the hight of sanctimommyness.

As such, there can be only one clear destination that would allow both viewpoints and all viewpoints in-between to exist and that is:

"A system that seeks to achieve the best health outcomes for moms and babies based on respect, informed consent, and the best available evidence."

Wednesday, November 9, 2011

What I want

I want to know that if I plan on an elective csection at 39 weeks gestation - I will get an elective csection at 39 weeks. Is that so much to ask?

It didn't happen last time. I have no reason to believe it will this time.

And this time isn't even 39 weeks away yet.

And that is why, I am in a less than stellar mood today.

Three Months...

Three months have passed since baby Ava was born still at Victoria General Hospital. Still there is no dedicated obstetric anaesthesiology at Victoria General Hospital, Royal Columbian Hospital or Surrey Memorial Hospital.

How many more months before women in BC giving birth in level 3 hospitals get access to appropriate resources during labour and delivery?

Tuesday, November 8, 2011

Why care about Dedicated Obstetric Anesthesiology in level 3 hospitals in BC?

I'm not an an anesthesiologist. I'm not a hospital administrator. I'm a mom, and by the time the situation changes in Victoria, I'll likely be done having my babies. I guess that also makes me a pessimist because baby number 2 isn't even conceived as of yet - so it reveals how confident I am that the situation will change anytime soon.

I will also say, that my biggest problem with a lack of dedicated obstetric anesthesiology at VGH, Royal Columbian and Surrey Memorial isn't even that it removes the ability of women to reasonably decide whether or not they'd like a surgical birth, or have access to epidural pain relief (although I do believe this is a big issue - that is wrong and should be addressed). These are major hospitals that handle a high volume of births every year and serve high risk mothers. And there is the true rub.

There's a false perception of safety at these hospitals. Women believe that when the cards are down, they'll be able to get the care they need when they need it. If I were a mom who had decided that I wanted to attempt a vaginal birth after c-section - could I be confident that if my uterus ruptured, I'd get access to an OR within the critical timeframe and be saved from the agony of having to bury or care for a severely disabled child who was much wanted? Is it reasonable to think that the anaesthesiologist who is handling other acute cases will be able to drop everything and tend to my needs? Will the back-up anesthesiologists actually be called, will he/she answer the call and provide the service?

It's sad and frustrating. The province claims to be bending over backwards on this and saying the anesthesiologists won't budge. The anesthesiologists claim that its the BCMA and the province who are at fault and not budging to bring their pay up to what colleagues in other provinces receive. The patients are in the middle paying the real price.

Monday, November 7, 2011

The Serious Side of Funny

I'm hoping those of you who read my blog will appreciate my sometimes off sense of humour. In a semi-departure from the serious, I came accross this thought-provoking video featuring the "Completely Honest OBGyn".

A couple, obviously expecting their first are meeting with their OBGyn. They confess to him their desire for a "natural birth", the OBGyn then tells them how such an event would likely 'go down'. At the end he asks "So when can I schedule you for a c-section - does 3 or 4 work?" And the couple agrees that 3 is good.

My first thought was "where was that OBGyn when I had my first?".

My second thought was "some of that honesty about birth could be really refreshing."

My third thought was "this couple's experience is not at all unlike women who try to access elective c-sections when the prevailing culture is to attempt a natural birth".

I could entirely re-write the script and it would reflect the experience of many women who attempt to get the birth they want (c-section), only to be talked into something else entirely (natural) without any deference to the reasons behind the request in the first place. It could even be written in the delivery room itself as a woman is denied her request for an epidural.

The video highlights why many women self-select to the care provider who they feel will align most closely with their own philosophies on childbirth. Women who are highly desirous of a 'natural experience' tend to select care providers who are most likely to facilitate that experience (a midwife), meanwhile, women who are open to (or may even desire) a medicalized birth tend to choose a traditional medical provider (an OBGyn or MD). (I note that this is pure speculation, I have no actual survey data or study data to back up this hypothesis - but it makes sense to me so I'm going to run with it).

This video also highlights the information that women may be missing out on depending on which care provider they select. Those care providers most supportive of 'natural birth' tend to minimize the downsides to it and accentuate the upsides, meanwhile, those most supportive of 'medicalized birth' might share a similar bias in the other direction. (Again, this is mere speculation as I have no hard data to support this theory). As result of that kind of bias and self-selection, I can imagine the sort of trauma that might be inflicted should expectations not match up with experience (yet another theory without data, but again, I'm going to run with it).

Of course, if it was an example of what care in maternity SHOULD be like it wouldn't be funny at all...the really, really funny part (actually more sad now that I think of it) is - that the video might actually be a fairly accurate protrayal of what maternity care is like for many women. That needs to change.

Post - Over at 10 Centimeters Blog Today

While I am somewhat skeptical of the Canadian research on homebirth (every other country in the world shows an increase in relative risk to homebirth) - I am very thankful for the relative strength of the Canadian system of midwifery (highly regulated with high levels of credentials - at least in BC) and am thankful for the good work of midwives in Canada providing quality care to pregnant women.

In the US, the situation is much different. My understanding is that CNMs (Certified Nurse Midwives) are similar to Canadian midwives, and are respected professionals who provide quality care to pregnant women - frequently providing that care in hospitals in collaboration with other professionals such as OBGYNs. However, many midwives who provide services to women who desire to birth at home in the US have little more than a post-high school certificate. This is concerning and dangerous. As such my comments on the HomeBirth Consensus Summit apply to the situation (as I understand it) in the US. My post on is as follows:

The Nine Statements of Consensus from the Home Birth Summit: Nine Times Nothing is Still Nothing

There are substantive and real issues confronting the home birth and obstetric communities in the United States. Having a summit could have moved things forward, fairly substantially, if they actually took the 9 pre-determined agreed upon consensus statements and used them as starting points, instead of accomplishments – because nothing is accomplished as a result of the statements made.

#1. We uphold the autonomy of all childbearing women…

Autonomy in the absence of complete and unbiased information is meaningless – there cannot be free informed choice when the information given to women on childbirth is incomplete or biased. A woman must be informed of the risks and benefits of the choice she is making if she is to be empowered to make the choice that best meets her needs and the needs of her child. If the autonomy of childbearing women is to be upheld, there must be a consensus on what the real facts of childbirth are, and a commitment to providing that information to women in an unbiased and accessible way.

#2. We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…

Again a really lovely idea, but, clearly there are substantial barriers to making this a reality in the current system. In order to collaborate, midwives and OBGYNs need to speak the same language. In order to collaborate, midwives and OBGYNs would need to hold each other in esteem and respect. In order to collaborate, they need to facilitate the work of one another. This means that when a woman who is at risk in labor is transferred to hospital for care, the hospital is prepared for her arrival before hand and the midwife is capable of giving full and appropriate information about the woman and her labor to the OBGYN upon arrival.

#3. We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…

Homebirth as it exists in the US today does not ameliorate disparities in access, delivery of care, or outcomes – it accentuates them.

Women in the US are far more at risk accessing the homebirth system than the hospital birth system. They are at risk of having a care provider who does not undertake standard and appropriate prenatal care (gestational diabetes testing, group B strep testing, weight and fundal height measurements, and pre-natal ultrasounds). They are at risk of having a provider who does not have adequate and appropriate education and experience. They and their babies are at greater risk of death or disability and they are at risk of having a provider who does not carry malpractice insurance and who would be held accountable to a lower standard of care in the event of death or disability.

There will continue to be disparities in access, delivery of care and outcomes and these seem unavoidable in the current context.

#4. All health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice…

This begs the question what is the appropriate standard? Furthermore, in the absence of legislation, what would be the consequence of failing to meet the standard?

#5. We believe that increased participation by consumers … is essential to improving maternity care…

Is this the facilitation of informed joint decision making during the care delivery process? If so, See number 1. Or, perhaps more meaningfully, will this mean that consumers would have a way of voicing their concerns and having those concerns heard in much the same way that hospital patients can have a formal review of the care they received?

#6. Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…

See #2.

#7. We are committed to improving the current medical liability system …

Another starting point – what medical liability system currently applies to homebirth midwives? Doesn’t a system need to be in place before it can be improved upon? Is there an insurer that would take on the risk in the current environment?

#8. We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….

So. Data is collected. MANA collects data. Does a $#!T load of good – unless you commit to releasing the data, it means nothing. Data existing does nothing without it being available to be analyzed, actually having it analyzed and releasing the results of that analysis. Furthermore, there needs to consensus on what data elements are critical and the definitions of those elements – this is essential if the data across birth settings are to be comparable and the data is to be transformed into meaningful information.

#9 We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies…

This seems at odds with valuing patient autonomy, particularly when not all pregnant women giving birth would choose physiologic birth if given complete information to make an informed choice. Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?

Saturday, November 5, 2011

I'm not a Feminist, I'm a Humanist

I never took a "Women's Studies" course in university - actually the whole idea of there being a "Women's Studies" department somewhat baffled me at the time. It seemed to me to be a bit odd, that there would be a Women's Studies department but no Men's Studies department. Of course anybody actually enrolled in Women's Studies would say that a Men's Studies department would be completely unnecessary because all the rest of everything was done from a male dominated perspective.

I rarely gave a thought to the idea of feminism, beyond the idea that women were mentally on par with men and just as capable as human beings in terms of what they could do with their lives. In fact, it has only been recently that I've been labelled a feminist and that my feminist leanings had clouded my critical thinking abilities. This in reference to my stance on elective c-sections in the absence of a traditional medical indication for one. It seems that the area of birth is the last frontier of misogyny, and even more odd is that much of the criticism is levelled at women by other women.

Go to any media article on the topic of elective c-section and you will find a litany of misguided and abusive commentary with respect to the topic. The idea that somebody else should restrict how a woman does or does not approach a medical condition (birth) is still very alive and well in Canada today.

Is it not clear that when it comes to medical decisions with regard to a medical condition that the decision about how to treat or not treat that condition should rest with an informed patient and their medical caregiver? After all is it not that particular patient who must live with the consequences of their decisions? Is the patient not entitled to informed consent, and security of the person, and respectful care?

Never before in my life, have I thought so critically about something, as I have thought about birth. In part, because never before in my life have I had to defend an opinion as vigorously as I have had to defend my opinions on birth, and in defence of that position, I have had to do an extensive amount of research.

The only funny thing is, that my opinion on birth really boils down to a very simple idea, "That a patient and her medical caregiver have the right to decide on the best course of action for that individual patient with respect to that patients particular medical condition." As a result of this idea, it is clear that I would defend a woman's informed right to choose a natural birth as rigorously as a woman's informed right to choose a c-section. To me this really doesn't seem like such a contentious proposition, what is ridiculous is that it is a contentious proposition.

Further, such a position doesn't make me a feminist, it makes me a humanist.

Friday, November 4, 2011

We Need More Krugmans in this World

One of the people who I greatly admire is Dr. Paul Krugman - he is an economist who has demonstrated a level of integrity and intellectual honesty that is rarely found. Furthermore, he's been brave enough to go beyond being an academic and has worked tirelessly to criticize bad public policy in a way that is widely accessible.

We need more Krugmans in this world. We need more people who really think about things, who can really identify problems and analyze them, and who are brave enough to voice their thoughts to the wider world. We need more thoughtful dissenters who refuse to go with the flow when evidence says that there's something wrong.

So when you see a Krugman - be thankful for the work that they do. It's not easy work, saying what doesn't want to be heard but needs to be said. They identify the problems and make solving those problems possible - and that work is immensely valuable and does affect change. Support the Krugman's you know, and encourage them. Without them our world would be a much lesser place.

Thursday, November 3, 2011

Dr. Roland Orfaly - "B.C.'s health care is failing mothers, babies"

On October 5, 2011 the following story was published in the Times Colonist.

B.C.'s health care is failing mothers, babies

An external review of the Aug. 9 newborn death at Victoria General Hospital is now complete. Expectant mothers on Vancouver Island deserve better than the care which is currently available. So do mothers elsewhere in B.C., where the same problems are also being ignored by the provincial government.

By Times Colonist (Victoria)October 5, 2011

An external review of the Aug. 9 newborn death at Victoria General Hospital is now complete. Expectant mothers on Vancouver Island deserve better than the care which is currently available. So do mothers elsewhere in B.C., where the same problems are also being ignored by the provincial government.

Released last week, the report is critical of unresolved safety issues in VIHA's maternal and fetal program, many of which were identified in a 2010 report by Accreditation Canada. Among other safety issues cited in both reports, at issue is whether anesthesiologists' staffing was up to standards and adequate to properly meet the needs of higher risk obstetrical patients.

The external report is very clear. "There is restricted availability of anesthesia services to support obstetric operative procedures [C-sections]. This is a significant risk issue for the VIHA, which should be addressed immediately."

The reviewers recommend that Victoria General Hospital "establish a dedicated obstetrical anesthesiology [DOBA] service."

However, the review, commissioned by VIHA, is dismissive about the 20minute delay experienced Aug. 9 between the time the obstetrician called for a C-section and when that C-section began.

This is at odds with a resolution proposed by Liberal MLA Dr. Moira Stillwell and approved by a Surrey Memorial Hospital advisory committee in 2009. The motion reads, "Obstetrical anesthesia services at Surrey Memorial Hospital should be available within a timeframe of 15 minutes, 24 hours per day, seven days per week to ensure safe patient care."

I'm not sure why the standard for what is safe for women in Surrey is different from the standard for women in Victoria.

What is equally newsworthy is the report's view on staffing. "The Department [of Anesthesiology] would have to recruit additional members to provide DOBA 24/7." And that is the problem. Both VIHA and the Health Ministry claimed in August that "there is no shortage of anesthesiologists at Victoria General Hospital."

By denying a shortage that is evident to everyone else, the government is exposing its true colours. It has no intention of providing the additional anesthesiologist resources needed to ensure the safety of mothers.

Between July and October 2009, the Health Ministry directly contacted over 3,000 anesthesiologists from across Canada in an attempt to recruit staff for a DOBA program. Not a single applicant replied. The external report recommends, "Priority should be given to candidates with specialized training in obstetric anesthesiology." There were no interested candidates, with or without that training.

Instead of admitting its failure, the government has been cynically playing politics with the issue ever since. While ignoring women in the rest of the province, they've tried to download blame for the failed provincial recruitment onto the Victoria Department of Anesthesia.

The DOBA "offer" made through VIHA was identical to what had already been offered by B.C. - and rejected - by anesthesiologists everywhere else in Canada. As VIHA had to admit in August, much of the funding for the "offer" originated from money that was already being paid for current services being provided, leaving little to help attract new anesthesiologists to Victoria.

Solutions are available. Eighteen months ago, B.C.'s anesthesiologists offered to dedicate some of their own funding to help attract more anesthesiologists to staff DOBA in Victoria and elsewhere in B.C. With government approval, DOBA would have been up and running by now. The Health Ministry rejected our offer.

Meanwhile, taxpayers would also be better off with DOBA. Over $12 million per year in operating room resources are wasted due to the lack of DOBA staffing. While the on-site anesthesiologist is attending to obstetrical patients, the OR and its staff come to a standstill waiting.

Gordon Campbell kept promising, "The right care, in the right place, at the right time." What happened to that promise?

Patients and taxpayers in B.C. deserve better.

Dr. Roland Orfaly is spokesman for the Coalition of B.C. Anesthesiologists for Change. He practices at Royal Columbian Hospital in New Westminster.

© (c) CanWest MediaWorks Publications Inc.

Lack of Anesthetists Made Women Suffer

A letter I wrote a while ago to the Times Colonist was published September 29, 2011 as a story. Here is the story:

Lack of anesthetists made women suffer

It seems patient-centred care in British Columbia means that patients are left in the middle of the mess of the health-care system.

By Times Colonist (Victoria)September 29, 2011

It seems patient-centred care in British Columbia means that patients are left in the middle of the mess of the health-care system.

The review of the August stillbirth at Victoria General Hospital found the reduction in access to anesthesiology since May 31, 2010, resulted in a decline in the quality of care experienced by maternity patients, as those patients are now dependent on the resources of the main operating room.

This has resulted in many scheduled C-sections being delayed, inadequate access to timely pain relief during labour and delivery and increased risks to both mothers and babies. These problems were identified in the Failure Modes and Effects Analysis in 2010 and when Qmentum completed its accreditation process in 2010.

Further, there were resignations and reports in the media about concerns over the quality of care for labour and delivery in Victoria, and in other tertiary level hospitals that do not have access to dedicated obstetric anesthesiology.

Despite this prior information on the risks and impacts of reduced access to anesthesiology for labour and delivery patients in level III hospitals (Victoria General, Surrey Memorial, and Royal Columbian), the health authorities, Health Ministry and anesthetists did not remedy the problem in a timely way. The only level III hospital with dedicated obstetric anesthesiology continues to be B.C. Children's Hospital in Vancouver.

The women who have given birth in these hospitals and have had scheduled C-sections delayed or denied and the women who have had epidurals delayed or denied have suffered immensely.

The ministry, the health authorities and anesthetists need to be accountable for the denial of access to quality, timely and medically necessary services.

Janice Williams


© (c) CanWest MediaWorks Publications Inc.

Wednesday, November 2, 2011

Zombie Statistics that Just Won't Die

A couple of years ago the WHO retracted their statement that c-section rates above 10-15 percent illustrated an excess use of the procedure. They retracted this statement in 2009 - because it was based on absolutely no real evidence. Yet in 2011 - this zombie statistic continues in it's undead form to haunt everywhere, all the time.

Targeting any particular rate of intervention or non-intervention is a fool's quest. Targeting a particular method of delivery is absurd. These targets put process ahead of outcome and do nothing to advance the health and well being of mothers and babies.

Want a meaningful target - how about lowering the rate of maternal mortality. Lowering infant mortality. Lowering rates of birth attributable disability. Improving maternal satisfaction. How about reducing the rate of post-partum depression. Maybe reducing the rate of post-traumatic stress disorder might be good too.

Shift the focus to OUTCOMES, real OUTCOMES and maybe, just maybe, things will get better for moms and babies.

Tuesday, November 1, 2011

Celebrating the Updated NICE Guidelines in the UK

I am thrilled that in the new NICE guidelines in the UK, women will be given the right to request an elective c-section for the delivery of their child. This is a hard fought victory for many women that has come after years of hard work.

It's a huge step forward because it recognizes that patient autonomy matters. That the right of women to decide how they birth their child matters. It signals that women and their health matters and that access to healthcare should not be limited because the patient is a woman and the condition is pregnancy. It says informed choice matters, and part of informed choice is being aware of the risks of 'natural' childbirth and being able to choose which risks to accept. Further, it signals that health care should be about quality care, and not just cheap care.

I'm particularly proud of the work done by Pauline McDonough-Hull in making the recent guidelines a reality. She has worked tirelessly on this issue for many years, and now something real to show for it. She is an inspiration.

Monday, October 31, 2011

Is the BOBB effect dangerous?

I believe that there is a BOBB much of what I've read in the birthing blogosphere, there is a common refrain:

"I watched the Business of Being Born and it was then that...." which is ended in one of five ways:

a) "I decided on a home birth."
b) "I decided to avoid the 'cascade of interventions'."
c) "that a midwife was the best care provider for me and my baby."
d) "that freebirthing might even be an option for future children."
e) "I wanted to puke at all the misinformation and NCB bullshit."

The thing is that responses A-C are what 90 percent of the responses to that particular documentary are. Response D is also fairly rare (I'd say maybe 1 percent of women) and Response E only occurs among those who are skeptical enough to look for more information on birth and its risks.

What is dangerous is that the BOBB effect might be causing higher-risk women to push for non-interventionist births even when a more "hands-on" approach is safer for themselves and their babies. This might not be such a big deal in Canada where the regulations around midwives and their qualifications are pretty tight - but it might be in places like the US where regulations are more lax. I also wonder if it causes women to actively eschew tests that might demonstrate that they are higher risk, for fear of losing their preferred birth experience.

If there is a BOBB effect at work - it's not good - as at the end of the day babies and moms might be making some bad decisions when it comes to accessing appropriate care. Those bad decisions might lead to something far worse than an "unneccessarian" - a preventable death or a life-long disability.

It's time for the "Beyond Reason: The Religion of Being Born" to be produced - the anti-BOBB is needed, now more than ever.

Sunday, October 30, 2011

The Perils of Mommy Group

I throughly enjoy my mommy group - we are all well-educated moms in our late twenties to mid-thirties with babies born within 2 months of each other. When we get together we talk about all sorts of thing....our husbands, our work (for those who went back to work), our kids and the joy of taming toddlers. All sorts of stuff. Last night, we had our "moms night out" it was quite enjoyable - we talked about saggy balls (apparently men in their geriatric years are also not immune to the effects of gravity), placenta consumption and other uses (for myself I just let it go the way of biohazardous waste or teaching material, although I had a very funny thought about a couple who are awaken in the middle of the night by raccoons fighting over a freshly "planted" placenta.....placenta is strewn everywhere in the morning....neighbors ask what it is....), work, the trials and tribulations of nap time/bed time/toddler discipline, mortgages...I am very happy to hear of the new pregnancy of one of my mommy friend. And then the conversation turned to birth.

I should have known better, I should have politely found an excuse to hurry home, but I didn't. And then I was there again, as the other women talked of all they did to speed up their labors and avoid the dreaded 'interventions'...I recall lying there hoping labour would stop or slow down, praying for a csection or at the very least an epidural...but more than anything praying that nothing would go sideways. My eyes glazed over and I starred at the red menu on the table....I tried to mentally absent myself from the conversation. It was hard to hear.... I think only one other mommy noticed my distress. My hand trembled as I reached for my water. Eventually the conversation ended and we departed, the drive home was difficult. My mind was still racing, my heart pounding. Upon my arrival home I poured myself two stiff cocktails to wind down from it.

Yep, I am nuts to consider #2....

Friday, October 28, 2011

Focus on Quality Care and the Efficiency will Follow

In healthcare, there's much talk about the "sustainability of the system" - the system of providing health care services. There's a prevailing attitude that the health system is not sustainable. Typically, most of the conversation focuses on the cost of providing health services and how growth in those costs are what is not sustainable.

I frequently question the 'sustainability' of the Canadian health care system (and more usually as it exists in BC) - and I do not think it is sustainable, but not because of 'cost' aspects. Rather, I think its unsustainable because of the investments that haven't been made, the costs that have not been incurred and should be.

It is not sustainable to have health care providers who do not have the tools and resources to do their jobs and do them well.

It is not sustainable to have a health care system that delays and denies access to care that is deemed appropriate by health professionals and their patients.

It is not sustainable to focus on a narrow range of acute services and ignore a broad range of preventative care.

It is not sustainable to put 'cheap care' ahead of 'quality care'.

Lastly, when thinking about whether or not the system is 'sustainable', it is not sustainable to exclude patients from the conversation.

I sometimes think if there was a fundamental shift - away from 'cost consciousness' towards 'quality consciousness' that the healthcare system would move much more expeditiously towards a more efficient and effective system. It should be about delivering the best care and generating the best health outcomes in the way that makes the most sense.

But it seems for now we're stuck...but not sustainably so.

Thursday, October 27, 2011

There Should be Middle Ground in Maternity Care

In Victoria, and indeed in most of Canada, there is no middle ground of Maternity Care. A woman can choose a hospital or a woman can choose home. In a hospital (at least in BC) you can be attended by a GP, a midwife or an Obstetrician. At home you can be attended by a midwife. At a hospital, the environment may be less than appealing - uncomfortable beds, lack of privacy, potential exposure to some germs. At home, the lack of immediate access to medical intervention may not be appealing - there is no way an epidural happens at home. At the hospital (at least in Victoria) there is no birthing tubs.

This in and of itself is not really a problem, except that it is. There are women who would probably choose a home birth but for the lack of access to medical care (they like the safety net and who knows maybe their a fan of the epidural option), on the flip side there are women who choose home births who would benefit from choosing a hospital birth instead (like the 16 percent who transfer to a hospital during a home birth).

The obstetric community needs to ask itself what it can do to make the services it offers more attractive to women who would benefit from it. At the same time the midwifery/homebirth community need to ask what they can do to make birth safer.

If it were up to me, I'd establish stand-alone Maternal Health and Education Centres. These would be full-service maternity care centres that would take the best of all care approaches. They would have more family friendly birthing rooms, birthing pools, dedicated obstetric anaesthesiology, dedicated obstetric OR. They would also provide prenatal and postnatal education services - in an unbiased way. They would be focused on meeting the needs (both physical and psychological) of mothers and their babies (up to age 1). They would be a resource and a one-stop place to get connected to the resources available.

Care would truly be integrated - and mothers and families would feel truly valued....

But its a bit of a pipe dream...after all if such a hybrid was so great - why doesn't it exist yet?

Wednesday, October 26, 2011

BC Government Cuts Public Health Nurse Visits to New Moms and Babies

In classic up is down fashion, the BC government recently announced that it was cutting public health nurse visits to new moms and babies - and redirecting the resources to poor moms under the age of 25. The things is, a new mom, is a new mom - and she, regardless of age or economic resources may greatly benefit from the public health visit. Many new moms (regardless of age or economic status) do not know what is 'normal' when it comes to babies, or 'normal' when it comes to their thoughts and feelings around the birth. As a result there are cases of post-partum depression, jaundice, feeding difficulties, etc. that may go undetected. This puts at risk the health and well-being of BC moms and babies.

I'm starting to think that this government has it out for mothers and babies...

Monday, October 24, 2011

Am I anti-'normal/natural' birth?

In general I would have to say that I am not anti-normal/natural birth.

I know that for myself, it's not an option that I like. It doesn't make me less of a mom. It doesn't make me a bad parent. It doesn't make me think that those who choose natural birth are somehow crazy for wanting that experience - nor do I think that those who enjoy that experience are 'weird'. Rather that given the information I know about myself, and information I know about birth - I prefer medicalized birth (ideally elective pre-labour c-section).

What I wish is that every woman was empowered with the information that she needed to make a choice that best meets her needs and the needs of her baby. This might be normal/natural birth, at a hospital or at a home - or it might be medicalized birth in a hospital.

I also wish that every woman was treated with respect - respect from her careproviders and respect from others about the decisions which are hers and hers alone to make.

So it's not about maternal choice c-sections, or maternal choice planned vaginal births. It's about maternal choice...and that choice should be fully informed and respected.

Quality care needs to be about meeting the needs of mothers and babies - healthy mom, healthy baby should be the goal and that includes physical as well as psychological health.

Sunday, October 23, 2011

Dear Materniy Care Providers

Found this on Birthing Beautiful Ideas and thought it was worth reposting.

Dear Maternity Care Providers of the World:

On behalf of all women who are, or have been, or ever will be pregnant, I wish to make the following requests and pleas and clarifications.
I make these requests and pleas and clarifications to you not because I think that you are callous or unwise or deficient in your skills.  In fact, I don’t think you, on the whole, are any one thing at all.
You are not a homogenous group, and we are not a homogenous group, and we all come from places and perspectives that are radically unique and individual.
But still.
But still.
I make the following requests of you because, in addition to the quality prenatal care that we all deserve, regardless of our social and economic backgrounds, I also think that we pregnant women–we who have been pregnant, or who are pregnant, or who will be pregnant–deserve a special and robust sort of respect from our care providers.
And I think that too many of us are not receiving this respect.
Perhaps, you might argue, this is because we don’t know  how to properly engage with you.  Perhaps our own advocacy for ourselves and our babies seems disrespectful to you.
For sometimes we state our cases inelegantly.  We use medical terms incorrectly.  We print out pages upon pages of information gleaned from internet sources of varying repute.  We make requests that seem ridiculous or useless or even harmful to you.
And sometimes you find us to be annoying or petulant or curious or infuriating or stupid.
But what many of us really are is desperate.
We’re desperate to find a care provider who respects our autonomy, and not just theoretical respect for our theoretical autonomy but a real, earnest respect for the actual exercise of our autonomy.
We’re desperate to find a care provider to listens to us, and who responds to us without condescension.
We’re desperate to find a care provider who is willing to admit when they don’t know the answer to one of our questions.
We’re desperate to find a care provider who avoids exaggeration and coercion and manipulation in conversation with us.
We’re desperate to find a care provider who supports our active engagement in our pregnancy and birth.
And we’re desperate to find a care provider who simply sees us as persons.  Who treats us as persons.
Not as ticking time bombs.  Not as potential lawsuits.  Not as fetus carriers.  As persons.
And this is regardless of whether we want to give birth in a home or birth center or hospital.
Notably, to expect this from you–to want this, and even demand it from you–we know that we have responsibilities too.
We have a responsibility to treat you with the same courtesy that we expect from you.
We have a responsibility to research our options with care and discretion.
We too have a responsibility to appreciate the differences in your perspectives and values and practices.
We have a responsibility care for ourselves and our babies as best as we are able to (though please note that these abilities vary widely).
Yet despite how well or how badly we manage these responsibilities, we still have a right to your respect.
All your years of training–the blood, the sweat, the tears, the money spent on education, the hours sacrificed to your profession–give you extraordinary skills and abilities and knowledge, but they do not give you  the knowledge of what it’s like to be any one of us.
To inhabit our bodies, to know our bodies as we do, to have the exact and unique values and perspectives and preferences and commitments and plans and dedications that we have.
And all your years of experience do not give you infallibility, nor do they grant you the right to approach us with domination and paternalism instead of mutual respect and partnership.
So we ask you to grant us this respect.  To treat us as partners in our maternity care.
Even those of us who don’t yet have the skills or knowledge or resources to act on these rights.
For we all deserve it.
Every single one of us.
A pregnant woman, who also wants and deserves this respect from you.

*image credit seanmcgrath on flickr
You might also like:
Bettering the Birth Experience: A Little Goes a Long Way
Informed Childbirth: Fear and Guilt, or Confidence and ...
Catching Babies Blog Series: Tolerating Risk in the U.S. ...

Friday, October 21, 2011

Pushing for Better Access to Maternity Care in BC

BC Children's and Women's hospital continues to be the only level 3 hospital in BC with Dedicated Obstetric Anaesthesiology to provide anesthesia services to women who are in labour and delivery. Royal Columbian, Surrey Memorial, and Victoria General Hospital are also level 3 hospitals. Both the government and the health authorities have known (or ought to have known) that failing to have anesthesiologists to meet the needs of pregnant and labouring women would result in delayed and denied access to epidurals, delayed and denied access to elective c-sections, delayed access to urgent c-sections and delayed access to emergency c-sections.

As a result of these delays and denials women have been harmed. Those who had their access to epidurals unreasonably delayed have had to endure unneccessary labour pain. Those who have had their access to epidurals denied have faced unneccessary labour pain and have faced the risk of general anesthesia in the event of an urgent or emergent c-section, the risk of inadequate pain management in the event of an instrumental delivery, and an increased risk of their child needing to be resuscitated due to exposure to intrapartum narcotics. Those who have had elective c-sections delayed have faced increased risk including the increased risk of going into labour prior to the c-section and an increased risk of an unwanted vaginal delivery, and for those who did go into labour awaiting their elective c-section they endured unneccessary labour pain and increased surgical risks. For those who had their c-sections denied, they endured an unwanted vaginal delivery, unneccessary labour pain, and all the sequalae and risks of vaginal delivery that would have been avoided if the planned c-section had taken place. For some their husbands and loved ones have had to watch as they suffered unneccessarily. For some they continue to experience increased levels of anxiety and may have PTSD and PDD as a result of their poor birth experiences. Some are hesitant to trust the health system and some are choosing to forego having additional children out of fear that the medical services that they need won't be there when they need them.

Thankfully for vast majority of these women who have been impacted there have been no long-run damage to their health or the health of their child, but unfortunately for some there have been disasterous consequences.

Women who have been impacted need to take a stand and demand better from their government and the health authorities. They need to write to the Patient Care Quality Offices of their respective health authorities. They need to write to their MLAs. They need to take a stand and say that it is wrong to unreasonably delay or deny access to epidurals and c-sections to women at level 3 hospitals. It is particularly wrong when women and their care providers have determined that access to these services are in the woman's and her infant's best medical interest (both physical and psychological).

Government needs to be held accountable for this apalling breach - or nothing will change.

Email me at if you have been impacted by this issue and are interested in making a difference in BC.