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.