Friday, January 27, 2012

The Attack on CDMR in Canada

The other day I wrote about Ontario's plans to make moms pay for c-sections that were "medically unneccessary". The proposed plan is frought with difficulties and opens the door to some very disturbing changes to health care - which if successful other provinces in their own quests to reign in budgets would be sure to follow suit.

Let me begin with saying getting access to a maternal request c-section in Canada is already very difficult. A woman must make her request known to her doctor, her doctor must then refer her to an OBGYN, the OBGYN must then be receptive to the request, and then after all of that she must actually secure time in an OR - which if the hospital shares its OR with all the other areas of the hospital - might be practically impossible. And unlike other 'elective' surgeries - babies do not wait forever to be born. As a result, true maternal choice (in the absence of hard or soft medical indications) of how she delivers her baby is already unjustifiably thwarted many times, unless the stars align. Add to this the fact that as soon as you mention you prefer a c-section to deliver your child people look at you as though you have antlers. And now add to this the cost.

The difficulty in accessing CDMR in Canada already causes some women to forego having children, because they don't believe they have a right to ask for a c-section. For some women, the lack of access to CDMR forces women to birth vaginally when they do not want to - as a result they may suffer severe anxiety, and be at an increased risk PTSD and PPD. It causes other women to leave the country to give birth.

Secondly, who determines what is a "medically unneccessary" c-section. Many might argue that most repeat c-sections are "medically unneccessary" - after all VBAC is successful more than half the time. What about other 'soft-indications' for c-sections, you know the things that don't rule out a vaginal birth but certainly make it more risky? A history of crohn's disease or IBS? A narrow pelvis? A large baby? Tokophobia? I mean if a woman chooses vaginal birth aware of the risks she's facing, it is one thing, but if she has no choice or must pay for her choice? How is this promoting quality care? Will the woman know before she gives birth, whether or not her c-section is covered, or might she receive a letter in the mail from some bureaucrat that says based on the evidence you have a greater than 50 percent chance of having a 'successful' vaginal birth, so if you wish to proceed with your c-section it will be $x. Will the woman be on the hook for the full cost of the c-section - or just the difference between the cost of an elective c-section and the expected cost of a planned vaginal birth? Will the government be unjustly enriched by this move?

I am also quite appalled at the public sentiment on this issue as expressed in the comments section of the news articles on this story. Overwhelmingly, the public seems to support the idea that if a woman wants a c-section in the absence of medical indications (aside from being pregnant) that she should have to pay for it. The public is not giving birth to that woman's baby - she is. It is her body, she has to live with the results of her choice on how to birth that baby.

Is a public health system based on what the general public finds acceptable what we really want in this country? Think about that long and hard, and think about what might next be on the chopping block or delisted (epidurals? care for lifestyle induced afflictions? aggressive treatment choices for cancer?) Do you really want your care decisions based on what some bureaucrat has determined is 'neccessary' or 'most efficient'- or do you want to be able to decide based on your own assessment of risks and benefits in consultation with your doctor - to choose what's best for you?


  1. But the public is helping to offset the cost.

  2. and certain aggressive treatment choices for cancer are already not covered.

  3. Anonymous,
    The public is offseting the costs for all sorts of things that you could argue shouldn't be covered by public funds. What about abortions for women who don't use contraception? What about prolonged NICU stays for babies born to drug addicts? What about NICU stays for babies born asphyxiated at home? Either we support people choices or we do not. If caesarean section was significantly more risky, the counter-argument would be easier. The fact is, they are not significantly riskier if done at or near 39 weeks, for women planning families of three or less. I agree with mrs. W