Thursday, December 6, 2012

Targeting the Wrong Cesareans

It sometimes seems like a week does not go by without someone, somewhere bemoaning the high rate of cesarean births in developed countries. British Columbia was at one point so concerned with its reputation for having the second highest rate of cesarean sections in Canada that it struck up a Cesarean Task Force and has even put together two campaigns to address the issue - The Power to Push and Optimal Birth BC. Personally, I am not a huge fan of either. The main reason I am not an admirer of these campaigns is because of the emphasis on process rather than outcome. I care about healthy mothers and healthy babies - and I believe that the way an individual mother gets there is very individual - for some mothers planning and achieving a cesarean is just going to be a better path, for other mothers planning a vaginal birth is just going to be a better path - even knowing it has a risk to result in an emergent cesarean or operative vaginal delivery.

I am not opposed to strategies that seek to lower the rate of unwanted and unnecessary cesareans - women who neither want nor need cesareans, should not be needlessly subjected to them. For that reason I am thrilled that women in British Columbia who desire a vaginal birth and have been informed of the risks and benefits of planning a vaginal birth and the risks and benefits of cesarean birth in their individual circumstance and would choose a vaginal birth have access and support even if they have had a prior cesarean or their baby is breech. Being able to plan a vaginal birth after cesarean or a vaginal breech birth, in the safest circumstance possible (in a hospital with trained staff and resources available) is a great thing and reduces the potential for such circumstances to result in death or significant disability to either mother or child. In other parts of North America, women have difficulty accessing the care they need to plan a vaginal birth after a cesarean (VBAC) or a vaginal birth with a breech baby - and as a result many choose to birth unassisted, do not seek assistance with delivery until they are pushing, or choose home birth with an under-qualified birth attendant and lack of access to appropriate resources. These women are exposed to risks to both themselves and their children that could be mitigated if they can find a care provider and a hospital to accommodate them. For some of those women - avoidable death and disability results.

However, selling the idea that a vaginal delivery should be achieved whenever possible - is damaging to women and their children. This is what the "Power to Push" campaign does - it encourages women to pursue a VBAC, it encourages women to attempt a trial of labour with a breech baby under certain circumstances, it encourages the use of external cephalic versions (ECV), and it discourages maternal request cesareans. Rather than providing women with unbiased information regarding their birth options and the risks and benefits associated with those options and letting women decide what is best for them and their families in their individual circumstances - it pushes the idea that vaginal delivery is best - and that a cesarean is sub-optimal. Furthermore, it does this by targeting a group of women for whom cesarean delivery is more likely to be a better choice and targeting the safest and cheapest cesareans - scheduled cesareans. As a result, it is likely that it might succeed in reducing the rate of cesareans - but at the cost of increasing the share of cesareans that are unplanned or emergent, and potentially increasing the numbers of mothers or babies that are injured, disabled or die.

Further, I am disappointed at a system that fails to support all pregnant women - including those who would choose cesarean delivery or even epidural anesthesia and focus on the ultimate goal of maternity care - healthy mothers and healthy children. It's great that women desiring risky vaginal deliveries are supported to do so in the safest environment possible - however, it's a travesty that those seeking planned cesareans are not given the same support. CDMR in British Columbia continues to be difficult to access with women having difficulty finding care providers and facilities to support their informed request for cesarean delivery. It's time we had a maternity care system that didn't try to sell women on a particular mode of delivery - but rather supported a patient-centred model of shared decision making based on the best available evidence that supported the full spectrum of pregnant women to make the decisions and have access to the care they need for both mother and baby to be happy and healthy.

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