Maternal Choice Caesareans: Misunderstanding, Misinformation and Misogyny is Still Alive and Well in Canada

Recently, Jamie Komarnicki of the Calgary Herald wrote a news story about a doctor (Dr. Magnus Murphy) who is publicly advocating for women to be able to have the choice of caesarean. The story got a lot of play across the country and has been picked up by many other news papers, and has resulted in a number of radio interviews. Dr. Magnus Murphy, is a urogynecologist and a former obstetrician. He has seen first-hand the longer run effects that normal birth has on women and has spent a good part of his career surgically correcting those problems. That’s right, the big push to avoid surgery (c-sections) – often results in surgery months or years later for many women. Recently, Dr. Murphy teamed up with journalist and well-known caesarean advocate Pauline Hull and published what is the most comprehensive and compelling book on the subject to date, Choosing Caesarean, and despite its title, neither Dr. Murphy, nor Pauline Hull is about selling caesareans to everyone or out-rightly abandoning the way children have come into the world since the start of humanity. Rather, they see it as a reasonable treatment option that should be considered relative to the default of vaginal delivery – one that will be appropriate for some and inappropriate for others. They see it as a matter of informed consent and choice – and they also see women being denied an opportunity to make a choice that might be of clear benefit to themselves as individuals. They present clear evidence of the often generally unknown facts of these two delivery options.

It’s good that this information is getting out there and that the universal supremacy of normal birth is being questioned – it’s about time women were made more generally aware of the choice they are making, the risks and the benefits of both vaginal and caesarean delivery options. It’s about time the information given to women about birth didn’t just come from the Natural Childbirth Industry.

What’s sad is that the comments sections in response to the stories are invariably filled with misogynistic, misinformed and misguided sentiments about this subject. People seem more than willing to make other peoples’ bodies, their business. I will happily concede that everyone is entitled to an opinion on a subject, however, the opinions expressed on this subject are generally far from well-informed and many demonstrate a tremendous lack of logic or understanding of the issue. Everyone is an armchair OBGYN. Of the 14 comments made on the story when I looked, 9 were negative – ranging from benign misunderstanding to utterly misogynistic. Here is a small selection of some of the less enlightened comments on this particular news story that I’ve read – I’ve copied them verbatim, so any spelling or grammar errors are not my own:

Golden Years:

“I don’t think they should be elective – but whatever, that’s your choice I guess. If you do “elect” to have on though, you can darn well pay for it on your own. Not on my dime!!!”

Steve Q:

“Quack quack.”

Anon147951286:

“Personally, my opinion. .. A vaginal birth is "natural" our bodies were designed to give birth. C sections are not natural, in some circumstances women need the help of a c section due to complications of child birth. I do not think its right to have a doctor pushing his ideas on women telling us childbirth vaginally is not safe- women have given birth forever . I have given birth 2x and I and my children are healthy and fine. Firstly- pregnancy ruins your bladder, and if your bladder is not drained before pushing a child out that can also ruin it. Get the facts people. I'm not against a c section- but it is also a major surgery. If its because complications with a natural birth- fine. If not, why would we do otherwise?”

Anon916080527:

“I personally would not want a section unless it was an emergency. Women that have a normal vaginal deliver are out of the hospital in a day or two. The women with sections are dragging their IV poles around the recovery is much longer.”

Notnecessarily:

“I’m sure there’s a financial benefit...the health benefit...not sure that is a guarantee for either baby or mother.”

Schapdel:

“Women have been having babies for thousands and thousands of years before modern medicine and we’re over 6 billions on the planet. I think the natural way works fine thank you very much!”

Bill200:

“And tell me again about those ballooning health care costs? What the heck- let’s take what’s normally a low-risk, relatively short and natural procedure involving no surgical intervention, and turn it into a major surgical procedure that requires women stay in hospital for multiple days.

Are their complications from natural childbirth? Yes. The advocates for c-sections suggest the complications from emergency c-sections should not be compared to natural childbirths. Equally, the complications of planned c-sections should be compared to natural childbirth, rather than simply talking about the latter.

Anyone who advocates for this is probably either going to make money off it by performing c-sections, or wants her own choices to be viewed as “natural”. C-section doesn’t form the basis for a “natural birth plan”, notwithstanding their book title.”

Dostros:

“Breaking News....Big pharma company promotes taking expensive pills for whatever ails ya’!”

Toyota:

“If you can’t do the time, don’t do the crime. Honestly, women and their partners today need to get a grip on reality. If you want a c-section for reasons other than an emergency, you should look into a surrogate.”

So what should women who are more informed on this subject do?

They should support those who are brave enough to put themselves out there and advocate for fully informed choice about birth options. They should work to dispel some of the myths and misconceptions that are commonly held by also commenting on these stories. They should call out the stupidity, misogyny, and failure in logic for what it is. They should think critically about what is said, and question whether or not it is actually coming from somebody who knows what they are talking about. Lastly, they should talk with their own health care providers, they should review the legitimate evidence on the subject, and they should proudly make whatever decisions best serve their own needs and those of their children – and respect the decisions of others, even though they may be different from the ones they would make for themselves.

Respect is not just given, it is earned. So go out and earn it!

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.

Is the BOBB effect dangerous?

I believe that there is a BOBB effect...in much of what I've read in the birthing blogosphere, there is a common refrain:

"I watched the Business of Being Born and it was then that...." which is ended in one of five ways:

a) "I decided on a home birth."
b) "I decided to avoid the 'cascade of interventions'."
c) "that a midwife was the best care provider for me and my baby."
d) "that freebirthing might even be an option for future children."
e) "I wanted to puke at all the misinformation and NCB bullshit."

The thing is that responses A-C are what 90 percent of the responses to that particular documentary are. Response D is also fairly rare (I'd say maybe 1 percent of women) and Response E only occurs among those who are skeptical enough to look for more information on birth and its risks.

What is dangerous is that the BOBB effect might be causing higher-risk women to push for non-interventionist births even when a more "hands-on" approach is safer for themselves and their babies. This might not be such a big deal in Canada where the regulations around midwives and their qualifications are pretty tight - but it might be in places like the US where regulations are more lax. I also wonder if it causes women to actively eschew tests that might demonstrate that they are higher risk, for fear of losing their preferred birth experience.

If there is a BOBB effect at work - it's not good - as at the end of the day babies and moms might be making some bad decisions when it comes to accessing appropriate care. Those bad decisions might lead to something far worse than an "unneccessarian" - a preventable death or a life-long disability.

It's time for the "Beyond Reason: The Religion of Being Born" to be produced - the anti-BOBB is needed, now more than ever.

Focus on Quality Care and the Efficiency will Follow

In healthcare, there's much talk about the "sustainability of the system" - the system of providing health care services. There's a prevailing attitude that the health system is not sustainable. Typically, most of the conversation focuses on the cost of providing health services and how growth in those costs are what is not sustainable.

I frequently question the 'sustainability' of the Canadian health care system (and more usually as it exists in BC) - and I do not think it is sustainable, but not because of 'cost' aspects. Rather, I think its unsustainable because of the investments that haven't been made, the costs that have not been incurred and should be.

It is not sustainable to have health care providers who do not have the tools and resources to do their jobs and do them well.

It is not sustainable to have a health care system that delays and denies access to care that is deemed appropriate by health professionals and their patients.

It is not sustainable to focus on a narrow range of acute services and ignore a broad range of preventative care.

It is not sustainable to put 'cheap care' ahead of 'quality care'.

Lastly, when thinking about whether or not the system is 'sustainable', it is not sustainable to exclude patients from the conversation.

I sometimes think if there was a fundamental shift - away from 'cost consciousness' towards 'quality consciousness' that the healthcare system would move much more expeditiously towards a more efficient and effective system. It should be about delivering the best care and generating the best health outcomes in the way that makes the most sense.

But it seems for now we're stuck...but not sustainably so.

There Should be Middle Ground in Maternity Care

In Victoria, and indeed in most of Canada, there is no middle ground of Maternity Care. A woman can choose a hospital or a woman can choose home. In a hospital (at least in BC) you can be attended by a GP, a midwife or an Obstetrician. At home you can be attended by a midwife. At a hospital, the environment may be less than appealing - uncomfortable beds, lack of privacy, potential exposure to some germs. At home, the lack of immediate access to medical intervention may not be appealing - there is no way an epidural happens at home. At the hospital (at least in Victoria) there is no birthing tubs.

This in and of itself is not really a problem, except that it is. There are women who would probably choose a home birth but for the lack of access to medical care (they like the safety net and who knows maybe their a fan of the epidural option), on the flip side there are women who choose home births who would benefit from choosing a hospital birth instead (like the 16 percent who transfer to a hospital during a home birth).

The obstetric community needs to ask itself what it can do to make the services it offers more attractive to women who would benefit from it. At the same time the midwifery/homebirth community need to ask what they can do to make birth safer.

If it were up to me, I'd establish stand-alone Maternal Health and Education Centres. These would be full-service maternity care centres that would take the best of all care approaches. They would have more family friendly birthing rooms, birthing pools, dedicated obstetric anaesthesiology, dedicated obstetric OR. They would also provide prenatal and postnatal education services - in an unbiased way. They would be focused on meeting the needs (both physical and psychological) of mothers and their babies (up to age 1). They would be a resource and a one-stop place to get connected to the resources available.

Care would truly be integrated - and mothers and families would feel truly valued....

But its a bit of a pipe dream...after all if such a hybrid was so great - why doesn't it exist yet?

BC Government Cuts Public Health Nurse Visits to New Moms and Babies

In classic up is down fashion, the BC government recently announced that it was cutting public health nurse visits to new moms and babies - and redirecting the resources to poor moms under the age of 25. The things is, a new mom, is a new mom - and she, regardless of age or economic resources may greatly benefit from the public health visit. Many new moms (regardless of age or economic status) do not know what is 'normal' when it comes to babies, or 'normal' when it comes to their thoughts and feelings around the birth. As a result there are cases of post-partum depression, jaundice, feeding difficulties, etc. that may go undetected. This puts at risk the health and well-being of BC moms and babies.

I'm starting to think that this government has it out for mothers and babies...

Am I anti-'normal/natural' birth?

In general I would have to say that I am not anti-normal/natural birth.

I know that for myself, it's not an option that I like. It doesn't make me less of a mom. It doesn't make me a bad parent. It doesn't make me think that those who choose natural birth are somehow crazy for wanting that experience - nor do I think that those who enjoy that experience are 'weird'. Rather that given the information I know about myself, and information I know about birth - I prefer medicalized birth (ideally elective pre-labour c-section).

What I wish is that every woman was empowered with the information that she needed to make a choice that best meets her needs and the needs of her baby. This might be normal/natural birth, at a hospital or at a home - or it might be medicalized birth in a hospital.

I also wish that every woman was treated with respect - respect from her careproviders and respect from others about the decisions which are hers and hers alone to make.

So it's not about maternal choice c-sections, or maternal choice planned vaginal births. It's about maternal choice...and that choice should be fully informed and respected.

Quality care needs to be about meeting the needs of mothers and babies - healthy mom, healthy baby should be the goal and that includes physical as well as psychological health.

Dear Materniy Care Providers

Found this on Birthing Beautiful Ideas and thought it was worth reposting.


Dear Maternity Care Providers of the World:

On behalf of all women who are, or have been, or ever will be pregnant, I wish to make the following requests and pleas and clarifications.
I make these requests and pleas and clarifications to you not because I think that you are callous or unwise or deficient in your skills.  In fact, I don’t think you, on the whole, are any one thing at all.
You are not a homogenous group, and we are not a homogenous group, and we all come from places and perspectives that are radically unique and individual.
But still.
But still.
I make the following requests of you because, in addition to the quality prenatal care that we all deserve, regardless of our social and economic backgrounds, I also think that we pregnant women–we who have been pregnant, or who are pregnant, or who will be pregnant–deserve a special and robust sort of respect from our care providers.
And I think that too many of us are not receiving this respect.
Perhaps, you might argue, this is because we don’t know  how to properly engage with you.  Perhaps our own advocacy for ourselves and our babies seems disrespectful to you.
For sometimes we state our cases inelegantly.  We use medical terms incorrectly.  We print out pages upon pages of information gleaned from internet sources of varying repute.  We make requests that seem ridiculous or useless or even harmful to you.
And sometimes you find us to be annoying or petulant or curious or infuriating or stupid.
But what many of us really are is desperate.
We’re desperate to find a care provider who respects our autonomy, and not just theoretical respect for our theoretical autonomy but a real, earnest respect for the actual exercise of our autonomy.
We’re desperate to find a care provider to listens to us, and who responds to us without condescension.
We’re desperate to find a care provider who is willing to admit when they don’t know the answer to one of our questions.
We’re desperate to find a care provider who avoids exaggeration and coercion and manipulation in conversation with us.
We’re desperate to find a care provider who supports our active engagement in our pregnancy and birth.
And we’re desperate to find a care provider who simply sees us as persons.  Who treats us as persons.
Not as ticking time bombs.  Not as potential lawsuits.  Not as fetus carriers.  As persons.
And this is regardless of whether we want to give birth in a home or birth center or hospital.
Notably, to expect this from you–to want this, and even demand it from you–we know that we have responsibilities too.
We have a responsibility to treat you with the same courtesy that we expect from you.
We have a responsibility to research our options with care and discretion.
We too have a responsibility to appreciate the differences in your perspectives and values and practices.
We have a responsibility care for ourselves and our babies as best as we are able to (though please note that these abilities vary widely).
Yet despite how well or how badly we manage these responsibilities, we still have a right to your respect.
All your years of training–the blood, the sweat, the tears, the money spent on education, the hours sacrificed to your profession–give you extraordinary skills and abilities and knowledge, but they do not give you  the knowledge of what it’s like to be any one of us.
To inhabit our bodies, to know our bodies as we do, to have the exact and unique values and perspectives and preferences and commitments and plans and dedications that we have.
And all your years of experience do not give you infallibility, nor do they grant you the right to approach us with domination and paternalism instead of mutual respect and partnership.
So we ask you to grant us this respect.  To treat us as partners in our maternity care.
Even those of us who don’t yet have the skills or knowledge or resources to act on these rights.
For we all deserve it.
Every single one of us.
 
Sincerely,
A pregnant woman, who also wants and deserves this respect from you.

*image credit seanmcgrath on flickr
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Pushing for Better Access to Maternity Care in BC

BC Children's and Women's hospital continues to be the only level 3 hospital in BC with Dedicated Obstetric Anaesthesiology to provide anesthesia services to women who are in labour and delivery. Royal Columbian, Surrey Memorial, and Victoria General Hospital are also level 3 hospitals. Both the government and the health authorities have known (or ought to have known) that failing to have anesthesiologists to meet the needs of pregnant and labouring women would result in delayed and denied access to epidurals, delayed and denied access to elective c-sections, delayed access to urgent c-sections and delayed access to emergency c-sections.

As a result of these delays and denials women have been harmed. Those who had their access to epidurals unreasonably delayed have had to endure unneccessary labour pain. Those who have had their access to epidurals denied have faced unneccessary labour pain and have faced the risk of general anesthesia in the event of an urgent or emergent c-section, the risk of inadequate pain management in the event of an instrumental delivery, and an increased risk of their child needing to be resuscitated due to exposure to intrapartum narcotics. Those who have had elective c-sections delayed have faced increased risk including the increased risk of going into labour prior to the c-section and an increased risk of an unwanted vaginal delivery, and for those who did go into labour awaiting their elective c-section they endured unneccessary labour pain and increased surgical risks. For those who had their c-sections denied, they endured an unwanted vaginal delivery, unneccessary labour pain, and all the sequalae and risks of vaginal delivery that would have been avoided if the planned c-section had taken place. For some their husbands and loved ones have had to watch as they suffered unneccessarily. For some they continue to experience increased levels of anxiety and may have PTSD and PDD as a result of their poor birth experiences. Some are hesitant to trust the health system and some are choosing to forego having additional children out of fear that the medical services that they need won't be there when they need them.

Thankfully for vast majority of these women who have been impacted there have been no long-run damage to their health or the health of their child, but unfortunately for some there have been disasterous consequences.

Women who have been impacted need to take a stand and demand better from their government and the health authorities. They need to write to the Patient Care Quality Offices of their respective health authorities. They need to write to their MLAs. They need to take a stand and say that it is wrong to unreasonably delay or deny access to epidurals and c-sections to women at level 3 hospitals. It is particularly wrong when women and their care providers have determined that access to these services are in the woman's and her infant's best medical interest (both physical and psychological).

Government needs to be held accountable for this apalling breach - or nothing will change.

Email me at qualitycareforbcmothers@gmail.com if you have been impacted by this issue and are interested in making a difference in BC.

The Disservice of Biased Information

I skipped out on the prenatal childbirth preparation classes - not to say that I didn't prepare myself for childbirth, I did - but I focussed my attention and education on surgical childbirth, as that was what I had planned on doing. I skimmed the other stuff (I went to the meet the doctor night at the hospital) - but mostly found that it confirmed what I did not want to do - give birth the 'normal' way. One of the reasons I opted out was that I perceived that I would be a poor fit in the traditional class - the maternal request c-section mom - no doubt I'd be singled out and potential ridiculed for my choice. I wasn't going to put myself in that position. This was a perception of bias (on my part) about the information that would be given in the class. Of the moms who did attend pre-natal class, they confirmed for me that indeed there was a 'natural childbirth' bias in the information given. Thanks, but, no thanks.

Unfortunately this left me somewhat flat-footed when I was faced with no other choice but to give birth 'naturally'.

I don't think biased information is limited to the 'natural childbirth community', I think the medicalised birth also has some degree of bias and perhaps an over emphasis on the avoidance of risk at all costs.

My problem is that I don't think there's much of a middle ground, and as a result women are left trying to decipher the information they receive about childbirth. For some women, likely those with higher levels of information literacy, they can sift through the information and make decisions that work best for them. Unfortunately for many women, they are ill-equipped to sift through the information in a way that identifies the bias (and corrects for it) and may make decisions that are less than ideal for themselves and their babies.

Good decisions that meet the needs of women and their babies would allow women to determine what matters most to them and which course of action is most likely to result in the most satisfaction when the job of parenting begins. I think this is the underlying problem with birth plans and can explain the sometimes large gap between what women expect of childbirth (and after) and what women actually experience of childbirth (and after).

The other big problem with bias, is that it tends to generate a paradigm where there is only one right way to give birth or parent. It generates the "if I didn't do it this way, I'm a failure" feeling and provides fertile ground for the development of "sanctimommies" and that is also damaging. Every woman should be able to stand by her decisions and say with conviction "I looked at the information available, and I made the choice that works for me and my child" with pride and with knowledge that it's okay to make a decision that is different from somebody else's decision.

Bias in information is bad, informed choice is good - but good choices rely on good (unbiased) information - a difficult challenge for any pregnant or birthing woman or parent today.

Elective c-section at 39 weeks, could prevent some very unpleasant consequences of vaginal delivery

Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise.
Semin Perinatol. 2006; 30(5):276-87 (ISSN: 0146-0005)
Hankins GD; Clark SM; Munn MB
The University of Texas Medical Branch, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Galveston, TX 77555-0587, USA. ghankins@utmb.edu

PURPOSE: The purpose of this analysis was to determine the impact on specific forms of neonatal morbidity and mortality by allowing women to opt for delivery by elective cesarean section at 39 weeks of gestation (EGA). According to the National Vital Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational ages>or=39 weeks EGA. Estimating that over 4 million deliveries occur annually in the United States, this would yield approximately 3 million pregnancies wherein the woman may exercise her choice for either primary or repeat cesarean section at 39 weeks EGA or at the point when labor is established. METHODS: A search was conducted using Ovid Medline spanning the past 10 years using the following key words: fetal trauma, shoulder dystocia, brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal encephalopathy. Using this search technique, over 2100 articles were identified. The abstracts were reviewed and pertinent articles were chosen for further consideration. The identified articles and their applicable references were obtained for inclusion in this review. Preference was given to publications on or after the year 2000 with the exception of classical or sentinel articles, which were included without regard to year of publication. RESULTS: Four major categories of neonatal morbidity and mortality are discussed: Shoulder dystocia: Accepting that we do not have a successful method for the prediction or prevention of shoulder dystocia, the question becomes, "What is the chance that a baby will sustain a permanent brachial plexus injury at delivery?" Additionally, is there a significant protective effect of cesarean section in reducing the risk of such injury? Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a composite estimate of the risk of 0.15% for vaginal deliveries and applying it to the 3 million deliveries>or=39 weeks EGA, approximately 4500 cases of brachial plexus palsy would occur. If only 15% of these injuries were permanent, 675 permanent brachial plexus palsies would occur annually. If the risk of permanent injury is 1 in 10,000 as reported by Chauhan, 300 permanent brachial plexus palsies would occur annually in the United States. The range then for permanent brachial plexus injury that could be avoided with cesarean section on request would appear to vary between 1 in 5000 and 1 in 10,000 vaginal births. Fetal trauma: The incidence of significant birth trauma varies from 0.2 to 1 to 2 per 1000 births. The use of sequential instruments, for example, vacuum followed by forceps or vice versa, is specifically associated with an unacceptably high injury rate. Intrapartum-related neonatal deaths of vertex singleton fetuses with birthweights>2500 g from traumatic cranial or cervical spine injury secondary to vacuum- or forceps-assisted vaginal delivery are still occurring. Overall, the frequency of significant fetal injury is significantly greater with vaginal delivery, especially operative vaginal delivery, than with cesarean section for the nonlaboring woman at 39 weeks EGA or near term when early labor has been established. Neonatal encephalopathy: The prevalence of moderate to severe neonatal encephalopathy is 3.8/1000 term live births with a neonatal fatality rate of 9.1%. In 4% to 10% of cases, the etiology appears to be pure intrapartum hypoxia. Intrapartum hypoxia superimposed on antepartum risk factors may account for up to 25% of the moderate to severe encephalopathies, according to one cohort. A paradox in the data thus far is that infants born to nonlaboring women delivered by cesarean section had an 83% reduction in the occurrence of moderate or severe encephalopathy. Considering a prevalence of moderate or severe neonatal encephalopathy of 0.38% and applying it to the 3 million deliveries occurring at >or=39 weeks EGA in the United States annually, 11,400 cases of moderate to severe encephalopathy would occur. The rate of encephalopathy observed in infants delivered by cesarean section would yield approximately 1938 cases. This net difference in moderate to severe encephalopathy would represent 9462 cases annually in the United States that could be prevented with elective cesarean section. Although cesarean delivery may be protective for the development of neonatal encephalopathy, to date it has not proven to be protective of long-term neurologic injury in the form of cerebral palsy with or without mental retardation and/or seizure disorders. Intrauterine fetal demise: Copper reported that the rate of stillbirth is consistent from 23 to 40 weeks EGA with about 5% of all stillbirths occurring at each week of gestation. Yudkin reported a rate of 0.6 stillbirths per 1000 live births from 33 to 39 weeks EGA. After 39 weeks EGA, a significant increase in the stillbirth rate was reported (1.9 per 1000 live births). Fretts reported on fetal deaths per 1000 live births from 37 to 41 weeks of gestational age, showing that the rate progressively increased from 1.3 to 4.6 with each week of gestation. It can be estimated that delivery at 39 weeks EGA would prevent 2 fetal deaths per 1000 living fetuses. This would translate into the prevention of as many as 6000 intrauterine fetal demises in the United States annually-an impact that far exceeds any other strategy implemented for stillbirth reduction thus far. CONCLUSION: It is reasonable to inform the pregnant woman of the risk of each of the above categories, in addition to counseling her regarding the potential risks of a cesarean section for the current and any subsequent pregnancies. The clinician's role should be to provide the best evidence-based counseling possible to the pregnant woman and to respect her autonomy and decision-making capabilities when considering route of delivery.

Major Subject Heading(s) Minor Subject Heading(s)
Birth Injuries [epidemiology] [prevention & control]
Brachial Plexus Neuropathies [prevention & control]
Brain Diseases [etiology] [prevention & control]
Cesarean Section [trends]
Dystocia [etiology] [prevention & control]
Female
Fetal Death [epidemiology] [prevention & control]
Fetal Diseases [epidemiology] [prevention & control]
Fetal Hypoxia [prevention & control]
Gestational Age
Humans
Infant, Newborn
Patient Participation
Pregnancy
Stillbirth [epidemiology]
Surgical Procedures, Elective
United States [epidemiology]


PreMedline Identifier: 17011400

Inadequate Resources to Support Maternal Choice in Birth in BC is Unreasonable

The numbers of women who give birth in British Columbia have been fairly stable with the rate per 1,000 population being aroun 10 since 1999 (ranging from a high of 10.4 in 1999 to a low of 9.69 in 2005 - source BC Vital Statistics Agency 2009 annual report). As such, the demand for services related to childbirth and pregnancy should be fairly well known. Further, many women make decisions regarding the birth of their children well in advance of labour - choices about whether or not to have an epidural and in some cases about how to deliver their child (ie. planned c-sections). As such, when women go to give birth and cannot access epidurals and c-sections in a timely way, is it really excusable to blame a lack of resources?

Is the 'Power to Push' campaign dangerous?

In BC there is a well known campaign that is called the Power to Push, and while at first glance it appears to support woman's choices in childbirth, it is decidedly "Pushy" about pushing natural child birth. This is particularly true of it's facebook page.

I have several concerns about the campaign. First, it's intended purpose is to 'push' down the Caesarean section rate in BC. Second, when discussing birth options, very few statistics are given about the relative risks of the options. Third, the benefits of medical intervention are downplayed. Fourth, the risks of natural birth are downplayed.

In short I think the campaign is irresponsible and I'm somewhat concerned that a major hospital (BC Children and Women's - the only hospital in BC with dedicated obstetric anaesthesiology) would support such a biased campaign.

Women need to be empowered to make decisions regarding birth - decisions that are safe and informed. Further, women need access to the services that support those decisions. Failing to provide unbiased and complete information (like real statistics on the risks and benefits) is irresponsible and dangerous.

Why doing something is important

Nothing I do now can change the past experience I have had of childbirth, it will always be what it was. However, knowing that what it was and what it should have been are two very different things, remaining silent about it sends the message that somehow that is okay. Burrying it in the past will not help me move forward. What happend was wrong on many different levels. Knowing that I am not alone in my experience of being unable to access appropriate care, makes it more wrong not less...

Which is why I am finding that doing something about it is helpful. It is why speaking out, is important. It is why talking to other moms matters - because mothers matter and they deserve better. I hope that what I do today will reduce the chance of the same wrong continuing to be done. I want my daughter to get the care that she deserves when she decides (if she decides) to be a mom.

I can't change the past - but I might be able to change the future, but only if I refuse to be silent. What happened to me was wrong, if it happens to my daughter and I could have prevented that in some way - then I will have truly failed.

Letter Sent to VIHA's Patient Care Quality Office

Today I sent the following to the Patient Care Quality Office of the Vancouver Island Health Authority:

Dear Vancouver Island Health Authority, Patient Care Quality Office;

I write more than a year after I gave birth on July 11, 2010 - because I feel that the care I received failed to meet an acceptable standard.

I was supposed to give birth by way of a scheduled c-section on July 9, 2010. I recieved the call from the hospital, fasted accordingly and arrived as directed and waited. As I was a gestational diabetic, the lack of food eventually caused my blood sugar to drop into a hypoglycemic range and a glucose drip was started. We continued to wait. Surgery did not happen that day and I spent the night in the hospital hoping it would happen the next day. Again we fasted and waited, and again surgery did not happen and again I prepared to spend another night in the hospital - with the promise that surgery would occur first thing the next morning. Unfortunately, I went into labour at quarter to midnight, at which point I was informed that there was no anaesthesiologist available. There was no access to an epidural. My daughter was born vaginally at 4:42 am and needed to be resuscitated. I sustained 2nd degree tears and experience a minor degree of stress urinary incontinance. My labour was terrifying and painful. To this day I have difficulty reflecting upon the experience without feeling stress and anxiety. My autonomy as a woman was violated that day as I was subjected to a natural vaginal delivery, despite having planned for an elective pre-labour c-section.

I am apalled at the level of care I received and am further apalled that VIHA was aware or should have been aware that reducing the level of anaesthesia access to labouring women would result in access to c-sections and epidurals being unreasonably delayed or denied.

Sincerely,
Mrs.W

The Cost of Cheap Healthcare

Before I was a mom, I would have never believed that a woman living in Canada, in an urban centre, in the 2000's would be denied an informed choice about where and how to give birth. In my pre-mom naivete I believed that birth plans carried weight and were a critical element of quality, patient-centred care. I knew that birth had all kinds of twists and turns - that often those planning vaginal birth had a need for c-section or found the pain of labour too great and needed pain medications. However, I believed (wrongly!) that such flexibility was reserved for the exceptional circumstance. I mistakenly thought that the phenomenon of waitlists and care rationing was absent from maternity care - after all it seems absurd that such things would apply in this area of care. As anyone with any experience with babies knows - babies do not wait! Further, the care needs of pregnant woman are known largely in advance - there are a good 7 to 8 months of advance notice...

I certainly did not just show up at the hospital one day and say - I'd like my c-section now please. Rather from the first prenatal appointment, I let it be known that that was my preferred method of birth.

The decision to inadequately resource labour and delivery services has undoubtedly saved the system money - but at what cost? Would I be sitting here more than 15 months after the event still thinking about it, if I had gotten the care that was appropriate in a timely way? Would I be so trepiditous about venturing towards having another baby? How many other women in BC feel as I do?

Forcing women to endure the pain of childbirth against their will when there is medical technology available that is on a whole, safe, to alleviate the pain of childbirth seems really misogynistic and antiquated. Doing so to save money, is just cheap!

Legal Issues: The Right to Timely Access to Medical Care and the Right to Choose Treatment

In British Columbia, many women who are in labour and delivery do not have access to timely medical care and effectively cannot choose treatment because reasonable resources (dedicated obstetric anaesthesiology in level 3 hospitals) are not available. Is this a violation of their charter rights and should government be held accountable for the resulting psychological and physical harm?

Section 7 of the Canadian Charter of Rights and Freedoms states that:

7. Everyone has the right to life, liberty and security of the person and the right not to be deprived therof except in accordance with the principles of fundamental justice.

External Review into Infant Death Released

The Vancouver Island Health Authority (VIHA) has released its external review into the death of an infant at Victoria General Hospital in August 2011. That review concluded that a c-section was provided within guidelines (20 minutes after being ordered).

It really is an interesting read and gives the depiction of an ongoing situation of sub-optimal maternal and fetal care in Victoria, particularly since the provision of anesthesia services to the labour and delivery ward was reduced as of May 31, 2010. VIHA has also released its response to the recommendations.

The problem I have is that the review indicates that there have been past concerns - these concerns were identified both prospectively (Failure Modes and Effects Analysis) as well as retrospectively (the Qmentum accreditation process also identified and recommended an immediate remediation of the problem). Those reports happend in 2010 - and yet it took a baby death in August 2011 to spark an external review that basically recommends what has already been recommended. I'm not left with a lot of confidence that anything will change.

Is it time for a 'counter-revolution' in Birth?

There's another voice in the birth debate that has been squelched in the last couple of decades by those who view a 100% natural birth experience as being superior to the medical alternatives. There's a bias in childbirth education classes. There's a bias on the web. It's not a scientific bias - despite what Ina M. Gaskin and Rikki Lake might have you believe. Worse - it harms women and babies by restricting their choices and leading them to make decisions that wind up making them (and their babies) worse off. It makes women who do not subscribe to their beliefs feel as though they've failed in mothering or parenting.

The voice of the 'Natural Child Birth' (NCB) movement is exceptionally loud - they have their figureheads and their documentaries ("The Business of Being Born").

The counter-voice is quiet and must be sought out - it exists but it seems less charged. Where is the anti-NCB documentary "Beyond Reason: The Religion of Being Born"??.