Thursday, January 24, 2013

Systemic Barriers to Maternal Request Cesarean are Prevalent in Canada

It is difficult to be a cesarean by choice mom - most people do not understand your choice and may even think that you are nuts for wanting to choose a surgical process over a natural process. It is a choice that is stigmatized and even denigrated. It is a choice where it is still debated openly whether or not women should "have the right to choose" and the term "too posh to push" is still thrown around. Many moms have an uphill battle in Canada when they choose cesarean that extends far beyond what their friends and family may think of their choice though - there are prevalent systemic barriers that prevent many women from being able to exercise their legitimate right to choose cesarean.

Many primary care givers - family doctors and OBGyn's do not support maternal request cesarean. When women ask their doctors about it, few are receptive to the request. It is not uncommon to hear of women not being referred to an OBGyn (family physicians and midwives do not and can not perform cesareans) until their pregnancies are very advanced. When I was pregnant with my daughter, I did not get to even meet with an OBGyn until I was practically at term (referred at 32 weeks and saw the OBGyn at 36 weeks) - despite having made my desire for a cesarean known at my appointment to refer to a maternity doctor and at my first and subsequent prenatal appointments with my maternity doctor. Many women who request cesarean have anxiety about the delivery and that anxiety often is not resolved until they have confirmation from an OBGyn about the delivery plan. I found it very difficult to enjoy either of my pregnancies until I knew what the plan was regarding the delivery. Further, there tends to be significant waits to access OBGyn's and as a result it is not uncommon for a woman to wait 4 or more weeks after referral to be seen by an OBGyn.

Unfortunately, many OBGyns in Canada are also not supportive of maternal request cesarean and I do not know of many who openly offer this choice. Quite simply a woman cannot go to a phone book or even online and see that CDMR is one of the services offered by a particular OBGyn. Perhaps this is because the Society of Obstetricians and Gynaecologists of Canada does not currently support CDMR and has stated that “Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." As such, if a woman is referred late in her pregnancy to an OBGyn for the purposes of getting a cesarean, and the OBGyn she is referred to is not supportive of the request, by virtue of the time sensitive nature of pregnancy she may be unable to get a CDMR.

Then add hospital policies that might present additional challenges to women wanting maternal request cesareans. For example, at BC Children and Women's hospital - the home of the "Power to Push Campaign", women desiring maternal request cesarean are encouraged to undergo counselling at the "Best Birth Clinic" and the power to push website repeatedly reminds women that vaginal delivery is the "normal" method of childbirth. This makes women who wish to choose cesarean feel abnormal or wonder if they are in need of psychological services because they prefer surgical delivery for their children. At the time of my daughter's birth I was told by my OBGyn that an elective cesarean needed to be an "add to slate" procedure, that he could not give me a specific time and date for the surgery. What he failed to inform me, is that by not having a fixed time and day for the surgery meant that there was a very real risk the surgery quite simply would not happen at all, as it would have to compete with all the other "add to slate" surgeries and that unless he advocated and made the case that my cesarean should be a priority that it would get bumped until it was ultimately denied.

So what is the impact of these systemic barriers to maternal request cesareans? Many women who would prefer to deliver by way of cesarean cannot access timely medical care and ultimately are forced to deliver vaginally. The current system unjustifiably imposes risks on mothers who would choose cesarean - it imposes anxiety as a result of the delay in having an OBGyn "approve" the planned delivery, and it imposes increased risk that a planned elective pre-labour cesarean will need to be an urgent cesarean or emergent cesarean or may even be an unwanted vaginal delivery. At the most basic level, every pregnant woman is currently told by this system that she cannot submit to a generally safe medical procedure unless she meets criteria entirely unrelated to her own priorities and aspirations - this removal of decision making power threatens women in a physical sense and the indecision of knowing whether a maternal request cesarean will be granted inflicts emotional stress. Depriving women of their right to make medical decisions for themselves is a travesty and a grave injustice - one that I am battling to change.


  1. The Power to Push Campaign and Best Birth Clinic at BC Women's Hospital respects and agrees with you on the importance of a woman's right to an informed choice, as well as timely access to quality care. We strive to ensure women are well informed about all the care options, and encourage women to advocate for the birth that is best for them - which absolutely includes elective cesarean section.

    Many women appreciate the opportunity to discuss the risks and benefits of elective cesarean sections. The professional counselor at the Best Birth Clinic does not encourage women to reconsider their choice, but strives to ensure they are armed with accurate, up-to-date, evidence-based information on which to make their decisions. The clinic also gives women an opportunity to discuss their concerns about mode of delivery with an unbiased, supportive non-medical professional.

    In the evaluations of the elective cesarean counseling clinic, 50% of women reported that prior to their appointment they felt they needed more information in order to make their decision. Following the counseling, 77% of women continued to plan an elective cesarean birth. However, 95% of all women reported that the appointment was useful in helping them to make their decision. Of the women who attended the clinic who have already delivered their baby, 73% had the elective cesarean they planned, 20% had the vaginal birth they planned, and 7% had a cesarean during labour for their planned vaginal birth.

    We hope this information will help to clarify any misconceptions. The Power to Push Campaign respects the right of every woman to make an informed choice about how she will give birth.

  2. Thank-you for your comments here - I must admit that I am somewhat surprised to learn that the Power to Push is supportive of women advocating for elective cesarean sections if a woman determines that it is the birth that is best for them.

    I have been to the Power to Push website - and feel that it is incredibly biased - the name and information provided seems to come from a place that assumes a vaginal delivery is a good in and of itself and that there is a real push there for women to choose to plan vaginal deliveries and that the program seems really focussed on facilitating that choice.

    If the Power to Push is truly supportive of a woman's right to access the birth that best meets her individual needs - is it willing to work to increase access to elective cesarean? Is it willing to make the best birth clinic accessible on a self-referral basis - for all women regardless of the planned mode of delivery, after all many women planning vaginal deliveries might not have adequate information regarding their choice? Is it willing to keep a registrar of OBGYNs and hospitals that are supportive of maternal request cesarean and to provide that information to women who request it? Is it willing to revise it's website to provide women with statistical information regarding the risks of various birth options as well as the sources of that information? Would it be willing to offer support to a case on this issue - a case that would establish that a woman has the RIGHT to an elective cesarean at term in British Columbia? Is it willing to lobby to change the performance measures used to assess quality of maternity care in British Columbia (which include the rate of cesarean sections and VBACs)?

    It is easy to have misconceptions about the Power to Push Campaign when it evolved as a result of the Task Force on Cesarean which had an explicit goal of reducing the rate of Cesarean sections in British Columbia. From the perspective of a woman who would and did choose cesarean - the Power to Push Campaign seems anything but supportive of that perspective.

  3. The Power to Push Campaign was launched under a mandate from the BC Ministry of Health to address the rising cesarean rate. The aim of the program is to facilitate access to expanded birth options for women, not to restrict access to birth options. Over the last decade, access to choice of delivery for women who are carrying a breech baby or who have had a prior cesarean has been increasingly restricted to mandatory cesarean, which has been a large contributing factor to the rising cesarean rate. The aim of the Power to Push Campaign is to promote options for women in these situations who would prefer not to undergo mandatory cesarean.

    The Best Birth Clinic is currently available on a self-referral basis, and offers appointments to women who are interested in learning about their options for birth when the baby they are carrying is breech, if they are pregnant again after a prior cesarean, or if they are considering elective cesarean for non-medical reasons. Women are informed of the risks and benefits of all modes of delivery and make their own choice about how they would prefer to give birth.

    The Power to Push website does offer evidence-based information on the risks and benefits of both vaginal birth and cesarean section; this can be found in the information booklet on VBAC and repeat cesarean here: (, and on vaginal breech and planned cesarean birth here: ( Neither vaginal birth nor cesarean section are ever risk free; the choices women make regarding their planned mode of birth are always respected.

    While the BC Women’s Cesarean Task Force (which runs the Power to Push Campaign and Best Birth Clinic) does have the goal of reducing the cesarean section rate, this goal is being pursued through the reduction in the number of women who are forced to undergo cesarean through lack of access to their preferred choice of delivery, not by restricting women’s access to cesarean birth.