Wednesday, March 28, 2012

How is this in the interests of the health system?

Today a friend of mine posted on facebook about being sad to see the forced departure of one her friends and their families from the country. My friend's friend is a nurse - she works at a local hospital. Her husband is a University of Victoria Psychology Professor. They have two young children and moved to Canada from California in 2010.

They were planning on making their lives in Canada. They were planning on raising their kids here.

So why are they leaving? Are they criminals? Have they evaded their taxes? Why would this family be unwelcome in our country?

Apparently, because the toddler was diagnosed with Autism in 2010 - they are "ineligible for permanent residency as they're son's autism is likely to place a strain on the health care system." As a result, they will be leaving Canada in November and returning to the US.

How is this good policy? How is it that the loss of a nurse isn't considered an equal strain on the health care system? How is the loss of the taxes this family is likely to pay over their course of their lives here not also an equal strain on the health care system? How is punishing a toddler and his entire family for having a medical condition fair?

If the child's condition had remained undiagnosed until permanent residency had been established they would be allowed to stay - so how is it good policy to create an incentive for families who have recently arrived in our country to delay seeking treatment because it would jeopardize their chances of remaining in the country?

There are days when I'm less proud of being Canadian - when I'm less proud of our health care system. This is one of those days.

A clip of this story can be found here.

Tuesday, March 27, 2012

A Restoration Project

This is likely to be the baby of the family - between two half-grown stepkids and a desire to have a few years (and a few dollars left) after the kids are grown to enjoy life as adults, this is likely to be it. We won't be taking permanent measures, but I also can't see us further adding to our family. So this is likely the last time I will know pregnancy and birth.

Thankfully, since finding an OBGYN who thus far appears supportive of my plans regarding this child's entrance into the world - a great measure of piece of mind has been regained. I'm starting to ease into being an expectant mother again - I'm starting to think that this time it is likely to be different. I may even start to (now that the morning sickness has subsided) enjoy this pregnancy. So far, my OBGYN has done a remarkable job - he has been very transparent, understanding, and reassuring. I feel like I'm in good hands, I feel like my child is in good hands.

Going to a different health authority, going to a different doctor, planning to give birth in a different hospital -- all of it seems to be helping to alleviate the anxieties and fear and helping to restore the hope that it will be different this time.

Wednesday, March 21, 2012

Paying for Lifestyle Choices

Imagine a world where the public was only "on the hook" for the lowest cost, medically neccessary standard of care. That every Canadian was faced with the same challenge: to only access public health care that is medically neccessary, the lowest cost, and not the result of a "lifestyle choice" - and that the determination of these things was done retrospectively. That EVERYTHING else was paid for out-of-pocket or via private insurance.

Public health care costs would plummet. At the same time out-of-pocket expenses would sky rocket and the quality of life of many Canadians would suffer greatly.

The reality is that much of health care spending is the result of lifestyle decisions. The decision to smoke a pack or more of cigarettes a day. The decision to drink excessively. The decision to forego adequate amounts of exercise. The decision to eat inappropriately. The decision to have children in the first place. The decision to undergo surgical sterilization. The decision to partake in extreme sports. The decision not to wear a helmet. The decision not to adhere to the advice of your physician. The decision to undergo an abortion. The decision to do illicit drugs. Yet, the public health care system pays for these lifestyle decisions.

It is also true that most health care spending occurs in the final two years of life. A time when that spending has little impact on the quality or quantity of life that remains - arguably much of this spending is 'not medically neccessary' as it does little to improve the health status of the person receiving the service. The returns on this health spending tend to be be very marginal. Again, the public health care system pays for the heroic measures taken to stave off what in many cases is inevitable.

However, when it comes to treatment decisions for pregnancy - there is a vocal outcry of wasting health resources by allowing women to exercise legitimate decisions about how their children are delivered. There is a refrain "The public should not pay for THIS lifestyle choice." I should note that THIS lifestyle choice might prevent the need for reconstructive surgery later. THIS lifestyle choice might prevent a life-long disability. THIS lifestyle choice impacts on a woman's sense of self-determination. THIS lifestyle choice might prevent an emergency c-section. THIS lifestyle choice, and the availability of it very well might make the difference between a woman choosing to have ANY children or none at all. Yet, THIS lifestyle choice is somehow open to public opinion as to whether or not it should be paid for. THIS lifestyle choice is NOT on par with a tummy tuck - and is far less costly than the health impacts of many other publicly supported lifestyle decisions.

Is this because only women give birth and have to deal with consequences of doing so?

Health care sustainability and spending is a very real dilemma - however, looking to 'save healthcare' by restricting choice in maternity care (access to epidurals, c-sections and other interventions) is misguided at best. This is especially true in light of evidence that suggests that an elective c-section at term might be cost-competitive with a planned vaginal birth, particularly when all costs of planned vaginal birth (emergency c-sections, damage to the pelvic floor, severe birth traumas) are taken into account.

Friday, March 16, 2012


Today I read the tale of JenniferG - today is the 8th anniversary of her daughter's death. Reading the story of her daughter's, Emily Hope's, birth and death - brought tears to my eyes.

I make no bones about never wanting to have to have experienced a vaginal birth in the first place - I was perfectly okay with idea that I would never know what a contraction would be like, that I would never know if *I could* have a vaginal birth. I had no desire to "see what my body could do". I had my reasons for wanting an elective c-section with my first pregnancy. A whole raft of reasons - but I never really examined what was likely a very primary motivation for lobbying for an elective c-section in the first place - the minimization of the risk of a truly catastrophic outcome for my child.

My number one priority after having worried about whether or not I'd ever get pregnant in the first place (Juno was a vasectomy reversal baby) was that after 9 months of pregnancy, I'd bring home a healthy baby.

I was perfectly okay trading an increased risk of transient tachynpea of the newborn (read short-term respiratory problem, perhaps a couple days in a NICU), an increased risk that my child could be nicked during delivery, an increased risk of infection, an increased risk of a lengthier recovery, an increased risk of placenta problems in a later pregnancy (note: I have always planned on a family size of at least 1 and not more than 2), if it meant that my child that I was already carrying would have a much lower risk of lifetime disability or death. I was terrified during labour and delivery - terrified that things would go sideways, and that my child would pay the ultimate price of a vaginal delivery - particularly, after I had chosen to avoid a vaginal delivery.

I know that birth injuries and death as a result of the normal birth process are exceedingly rare. However, I also know that they happen. I also knew I didn't want my child to be that unlucky 1 in 2,000. I babysat a kid with mild to moderate cerebral palsy when I was a teen - a red-headed smiley boy with two brothers. There was something truly tragic to knowing that he wouldn't have to struggle with his disabilities if only his birth had gone differently. I also have an uncle who is disabled as a result of a traumatic forceps delivery. I'm sure their mothers would have happily traded a four-to-five inch cesarean scar and a slightly longer recovery if it meant that their children would have the same opportunities as their siblings. What mother wouldn't?

What mother wouldn't trade a "normal birth" for a much higher chance of a "normal life"?

Thursday, March 15, 2012

Choosing Cesarean: A Natural Birth Plan, by: Dr. Magnus Murphy and Pauline McDonagh Hull

I recently bought the book, Choosing Cesarean: A Natural Birth Plan by Dr. Magnus Murphy and Pauline Hull, and while I have had an opportunity to read the book in its entirety - from the overview I have had of the book, I am left with the following impression:

"Choosing Cesarean: A Natural Birthplan is the definitive guide to surgical birth and gives a succint overview of the most recent research in this area. It is a refreshing approach that presents the information a woman who is considering delivering by elective cesarean section needs to know in order to make an informed choice."

I should also mention that there is a discussion forum moderated by Dr. Murphy that readers here may also find useful in discussing issues related to maternal request cesarean section.

Interview with Dr. Magnus Murphy on Choosing Cesarean on CTV Morning News

Please find this link to an interview with Dr. Magnus Murphy on Choosing Cesarean.

The first step in fixing a problem, is recognizing that there's a problem to be fixed

And the first step in recognizing that there's a problem to be fixed, is measuring it effectively.

I would love to blog about how exceedingly rare it is for women to have traumatic birth experiences in British Columbia in recent years. I would love to have the ability to proudly proclaim that my case was some sort of bizarre and rare exception, and that there is no evidence of a current and continuing problem in the care received by women who are giving birth in British Columbia.

I would also love to blog about where in British Columbia women are least likely to have bad experiences or about which providers and hospitals are rated the most highly as providing quality care. I would love to be able to blog about the kind of objective statistics that would truly help women avoid having a birth experience that is traumatic to them.

I can blog about some statistical sources of information on birth in BC, but for the most part what is available says little about the things that really matter. There is the "What Mothers Say: The Canadian Maternity Experiences Survey" (the most recent of which is 2005/06), which indicates that about 12 percent of women in British Columbia had a somewhat or very negative experience of labour and birth, and a further 12-13 percent had a neither negative or positive experience of labour and birth. However, there is no sub-provincial break down of data, nor is there a provincial breakdown for satisfaction by type of care provider, nor for specific aspects of interaction with health care providers during entire pregnancy, labour and birth, and immediate postpartum period. The maternal experiences survey also has some interesting information on the use of pain management techniques and their effectiveness - in it, it is reported that about 36 percent of women in BC who have a vaginal birth or attempt a vaginal birth have an epidural. This compares to a Canadian average that is nearly 60 percent. However, there is no sub-provincial break down of the use of epidurals, nor is there any information on the availability of different pain management techniques. Further sources of statistical information on birth in British Columbia, include the BC Vital Statistics Agency annual report and the Perinatal Services of BC website and the Canadian Institute for Health Information. Again there are some serious gaps in the kinds of questions that can be answered by these data sources.

So for the most part, I am left blogging about anecdotes - my own personal story about what happend to me when I gave birth in 2010, about the birth stories that result in legal action or media reports and my own personal opinions. While anecdotes are meaningful and poingnant, rarely are they a measure of the size or extent of a problem. All an anecdote is, is evidence that something happend once to somebody - and a sample size of 1 is simply inadequate to draw broad conclusions from. Further, a personal opinion, is just that, one person's thoughts on an issue which must be put into the context of who that person is and their own knowledge and experiences.

I'd love to be blogging about the issues and problems and successes of maternity care in BC from a position of adequate data on the subject. But as of 2012, adequate data on the subject doesn't exist. There's evidence of problems, but just what kind of problems and where and to what degree, is surprisingly scant. Unfortunately, I don't think that the problems that exist will be fixed until they are identified and adequately measured and identification and adequate measurement seem like rather distant goals.

Monday, March 12, 2012

Measuring Mom's Well-being

I read a very interesting article today from the New Yorker by Atwul Gawande entitled "The Score" - it focussed a lot on the history of childbirth and the contribution of obstetrics to reducing maternal and infant mortality and morbidity. Specifically, it highlighted the work of an anesthesiologist named Apgar, who had devised the Apgar score. The Apgar score is a measure our of 10 taken at almost every birth at both one minute and five minutes. It gives two points if a baby is pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two for a heart rate over a hundred. A baby with an Apgar of 10 is in good shape - perfect condition. A baby with an Apgar less than 4 is limp, and blue.

It revolutionized infant mortality. All of a sudden there was an immediate concrete measure of how well a baby was doing and a drive to improve that measure.

It is an example of a performance measure that performs well - in that its use enhances the outcomes that are desired.

There are many reasons why this measure is a shining example of what good measurement looks like. It's simple and provides instant feedback on the health status of the infant. Furthermore, it's responsive to the actions of the care providers.

So what would a similar score look like for mom? It might measure how closely moms expectation of birth matched her experience. It might measure her level of pain experienced during and after birth. It might measure the degree of tearing and the adequacy of repair. It might take into account post-birth infection rates. It might also measure adverse events (hemorrhage, shock, etc.). I'm sure maternity care providers, anaesthesiologists, and mothers all would have ideas on what a good composite MomStat would look like...the time for it has come.

Thursday, March 8, 2012

It's International Women's Day

Today is international women's day - a day to reflect on the lives and status of women across the world. A day to think about how the lives and status of women could be improved. A day to actually do something to change the lives and status of women for the better.

Reflect. Think. Do.

It doesn't matter if it is a big thing or a small thing - just do one thing that improves the life and status of women.

Write a blog post.
Tell the women in your life how they have made a difference.
Correct a stereotype.
Dispel a myth.
Raise awareness of an issue of importance to women.
Stand against discrimination.
Be there for a woman in need.
Call-out misogyny for what it is.
Support a woman's right to make legitimate choices.
Applaud those women who have been doing the hard work of making the lives of women better the 364 other days of the year.

Just one thing. Despite it being 2012, there is still a long way to go before the lives and status of women are improved to a point where there is no longer a need for an "International Women's Day". There are still people out who believe that because a person is a woman that she is somehow less. Less entitled to personal autonomy, health care, economic independence, freedom from violance. Less able to be a full member of society. Despite it being 2012, women are still terminated from their employment because they chose to be mothers. Despite it being 2012, women are still struggling to find childcare. Despite it being 2012, women are still defending legitimate choices about whether or not they have children, how they give birth to them, how they feed them and whether or not they stay home with them or rejoin the workforce.

It's time to move forward.
Do one thing.
One small thing.

Wednesday, March 7, 2012

Week 12 Looms - Hopefully the Morning Sickness will Soon Pass

Morning sickness is some kind of misnomer - maybe "mourning" sickness would be a better moniker, as it certainly is a sickness that causes some grief and I certainly am mourning the me that used to be able to enjoy eating.

It's also a misnomer, at least for me, as my pregnancy related nausea and vomitting strikes mostly in the evening between 5pm and 8pm. Right now, I'm entering into my 5th week of such pleasantness - and in the last 5 weeks, I can count on my fingers the number of nights where I haven't been praying to the porcelain gods for some kind of mercy - and on most of those nights its been a conscious battle to refrain from spewing. It really is remarkable that I've managed to gain any weight so far during this pregnancy (up one pound) given how little I've been able to actually consume.

I am somewhat relieved to know that as I enter week 12 of this pregnancy that the feeling of general quesiness and light headedness is likely to soon be behind me. I look forward to that happy second trimester when food regains its appeal, but before I resemble some kind of large animal.

In other news, Mr. W and I have decided to purchase the home we have been renting from our landlord. It effectively increases our monthly living expenses by a rather hefty sum (so there will be some budget cutbacks in the W household) - but in the long run is likely to be a decision that we will be happy to have made. I have no illusion of the house as an "investment", I am a bit of a pessimist when it comes to the Canadian housing market (by every metric we are worse than the US at its peak) - but feel that we have gotten a good enough "deal" to mitigate some of the correction that is likely to come, and in 10 years when the mortgage comes for renewal will likely have paid off enough that it is extremely unlikely that we'd be underwater at that point. Everyone has to live somewhere - and there is always a cost to that, regardless of whether one rents or buys.

Monday, March 5, 2012

The Micro-management of the Canadian Healthcare System

As part of what I do to pay the bills - I recently attended a conference that was all about how healthcare is funded and looked at a variety of different funding mechanisms including pay for performance and other funding structures.

I was struck by a variety things:
a) How incredibly complex some of the funding mechanisms were.
b) The intense focus on procedures, hospitals and providers of care.
c) The complete lack of focus on patients and outcomes.

The conference left me feeling as though the health care system has truly lost its way and has been micro-managed into losing its true sense of purpose (to serve patients and improve the health status of the population) and into a state of perpetual crisis (Waitlists! Affordability! Overcrowded ERs! Care delayed and denied!).

I can't help but be reminded of a child of a domineering parent who is over-scheduled and berated by a constant stream of demands - all of which on there own seem reasonable but combine to form some untenable and unhealthy state of being that undermine the true goals of childhood (to grow to be a functioning, independent adult who is a meaningful contributor to society).

I am also reminded of a business that has completely lost touch with its customers, what they want and need and has completely focussed on producing as much product as cheaply as possible - regardless of the demand for that product.

It's time for a massive shift - we need to refocus on what really matters in health care (health outcomes - most of which are very dependent on what the patient does or does not do) and to get back in touch with the 'customers' of the health care system. We need to better understand what they want and need and we need to start involving them more in the decisions that are made.

Furthermore, I don't think such a shift would neccessarily result in more costs - as the Nuka model of care demonstrates...