Friday, January 6, 2012
On Being Canadian and Wanting a Maternal Request C-section
Despite being cultural cousins, there are significant differences between Canadians and Americans. We have gun control. They have a constitutional right to bear arms. We have universal health care. They don't yet have unversal health care. We have highly trained and regulated midwives. They have the "Certified Professional Midwife"...which is a very different critter (see The Skeptical OB for more on this).
One significant difference that I failed to appreciate while I was awaiting Juno - is the significant difference between the Society of Obstetricians and Gynecologists of Canada(SOGC) and the American Congress of Obstetricians and Gynecologists (ACOG).
The Society of Obstetricians and Gynecologists of Canada (SOGC) has produced a Joint Policy Statement on Normal Childbirth - in December of 2008. In it there are some serious contradictions, on one hand "6. All pregnant and birthing women and their families should be able to make informed choices. All candidates for normal birth should be encourage to pursue it." and on the other hand "4. Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." and "5. A Caesarean section should not be offered to a pregnant woman when there is no obstetrical indication.". Also of interest is In short, the SOGC is supportive of informed choice, so long as that choice is "Normal Birth" wherever and whenever possible. It is clear that the SOGC is well aligned with the practice of midwifery in Canada.
Compare this with the American Congress of Obstetricians and Gynecologists who put out their stance on maternal request c-section in December 2007 and reaffirmed it in 2010. The ACOG recommends that "1. Cesarean delivery on maternal request should not be performed before gestational age of 39 weeks has been accurately determined unless there is documentation of lung maturity. 2. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. & 3. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta and gravid hysterectomy increase with each cesarean delivery." Overall, the ACOG is reasonably supportive of maternal request c-sections, provided some very reasonable conditions are met. I might argue that the unavailability of effective pain management (ie. lack of epidural access) might be considered a legitimate reason to request an elective c-section, given that unmanaged pain during labour likely predisposes a woman to post-natal PTSD.
I should note that I had heard of Canadian women successfully planning c-sections, IN CANADA, without medical indication before - I therefore thought that surely if one was clear in her request, consistent in her wishes, that this was something I too could secure. All I needed to do was ask to be referred to a doctor who was open to maternal request c-section and ask to be referred to an OB who would agree (after providing information on the relative risks and benefits) to perform the procedure. I did that, it didn't happen.
So if I were in those shoes again - a Canadian nullipara, informed on the risks and benefits of elective c-section vs. vaginal birth and intent on planning an elective c-section; knowing what I know now about the stark difference in stance between the ACOG and the SOGC; I would have bit the financial bullet and would have given birth in the USA. It is also pretty clear to me right now, that if I want #2 to be born via elective cesarean at term, I might stand a much better chance of achieving that goal south of the border.
Alternatively, if I were an American worried about the intervention happy ACOG, perhaps I would go North - in pusuit of 'normal birth'.