One of things that really, really perturbs me is the use of rates of VBACs and rates of c-sections as performance measures. I think that these measures might have been well-intentioned but are terribly flawed indicators of maternity care. In short I think that efforts to 'keep down the rate of c-sections', or 'increase the rate of VBACs' are bad policy, for a lot of very good reasons.
1. It places a value judgement on how birth occurs - in short by having a publicly stated goal to reduce the c-section rate or increase the rate of vaginal births after c-sections - it sends a message to moms. That message is "physiological birth is superior to surgical birth" - in short many women get the message that they have failed if they have a c-section or do not attempt/succeed with a VBAC. Birth no longer is about bringing home a healthy baby and a mom who is in the best physical and emotional health as possible - it becomes about how the birth occurred. It's time to realize that a c-section is not a failure and that a vaginal birth is not an accomplishment. A healthy mom and a healthy baby is an accomplishment - as is a process that facilitates that outcome and respects the emotional and physical needs of both mother and baby.
2. The unintended consequences of this focus might be really, really ugly. When the focus shifts to how birth occurs, inevitably there are trade-offs. The trade-off of having a low c-section rate might be an increase in the number of births that are assisted by forceps and vacuum. The trade-off of having a low c-section rate might be a decrease in the rate of inductions after 40 weeks and an increase in the number of still births. The trade-off of having a low c-section rate overall might be an increase in the number of emergent c-sections that occur when delivery with 30 or 20 minutes is critical to avoiding long-term disability. The trade-off of increasing VBACs might be an increase in uterine ruptures. The trade-off having a low c-section rate might mean more 3rd and 4th degree tears. The trade-off of a low c-section rate might be an increase in the rate of severe birth traumas. The trade-off might mean putting the process of how birth occurs ahead of the genuine desires and needs of the patient.
Are these trade-offs ones that we really want to make?
3. These are not indicators that tell us anything meaningful about the quality of care or appropriateness of the care received by maternity patients. By focussing on these measures, and actively seeking to reduce c-section rates or increase the rates of VBACs - we are not measuring what matters or moving closer to achieving the goal of maternity care that is actually better. Effort needs to be made to find the measures that really reflect good quality care and to report on those things.
It's time to quit focussing on reducing the cesarean rate or increasing the rate of VBACs - these measures and goals should be immediately scrapped. Yesterday wouldn't be soon in enough in my opinion.
Mothers and babies deserve better - they deserve quality care that places genuine outcomes that matter ahead of the specific mode of delivery.
Showing posts with label csection. Show all posts
Showing posts with label csection. Show all posts
Wednesday, April 4, 2012
Tuesday, February 14, 2012
Two Really Big Flaws to Cost Studies on C-Section versus Vaginal Birth
Everyone knows that vaginal birth is a lot less expensive than a surgical birth...and that women who are demanding c-sections for nothing more than convenience are drains on the social resources of the health care system.
What everyone doesn't know is that most of the cost studies that compare the costs of c-section to vaginal birth are fundamentally flawed - so much so that the cost difference between the two planned methods of birth might even be negligible.
Flaw 1: Prospective versus Retrospective
Imagine you are driving a car - now imagine that you have your car in drive but are looking exclusively in the rear view mirror, now apply your foot to the accelerator and drive on the basis of this rear view mirror information. This is using retrospective information to make prospective decisions.
Most cost studies that compare the costs of vaginal birth to the cost of surgical birth use this approach. After the outcome of the birth is known (surgical or vaginal) the cost of the birth is estimated and all of the costs of the successful vaginal births are averaged and all of the costs of the surgical births are averaged - if it's a 'good' cost study, the costs of unplanned or emergent surgical births might be seperated out from the costs of planned surgical births. When advocates for natural childbirth cite a figure for the cost-savings of avoiding c-sections they will often do some simple math whereby the average cost difference between a vaginal birth and a surgical birth is applied to the number of c-sections that are proposed to be avoided. Unfortunately this ignores the reality that many planned vaginal births end in urgent/emergent c-sections and as such there is likely to be a large difference between the expected cost of a planned vaginal birth and the actual cost of a vaginal birth.
Flaw 2: A Tunnel Vision Approach to Cost
The second flaw that is endemic to cost studies comparing c-section to vaginal birth is a type of tunnel vision on which costs are included in the comparison and which costs are excluded in the comparison. Typically most cost studies take a very narrow view on the costs of labour and delivery. It is the resources used by the mother and baby while in the hospital for the specific birth event. Once mom and baby are discharged the meter stops. As mode of delivery can have an ongoing impact on the use of health resources this is disingenous. So what kind of costs are currently being excluded in cost analyses on mode of delivery: 1. Cost of ongoing care for birth injuries, 2. Cost of reconstructive surgery, 3. Cost of incontinence supplies 4. Cost of psychological counselling, 5. Cost of litigation, 6. Cost of stillbirth, 7. Cost of pelvic floor injuries.
What everyone doesn't know is that most of the cost studies that compare the costs of c-section to vaginal birth are fundamentally flawed - so much so that the cost difference between the two planned methods of birth might even be negligible.
Flaw 1: Prospective versus Retrospective
Imagine you are driving a car - now imagine that you have your car in drive but are looking exclusively in the rear view mirror, now apply your foot to the accelerator and drive on the basis of this rear view mirror information. This is using retrospective information to make prospective decisions.
Most cost studies that compare the costs of vaginal birth to the cost of surgical birth use this approach. After the outcome of the birth is known (surgical or vaginal) the cost of the birth is estimated and all of the costs of the successful vaginal births are averaged and all of the costs of the surgical births are averaged - if it's a 'good' cost study, the costs of unplanned or emergent surgical births might be seperated out from the costs of planned surgical births. When advocates for natural childbirth cite a figure for the cost-savings of avoiding c-sections they will often do some simple math whereby the average cost difference between a vaginal birth and a surgical birth is applied to the number of c-sections that are proposed to be avoided. Unfortunately this ignores the reality that many planned vaginal births end in urgent/emergent c-sections and as such there is likely to be a large difference between the expected cost of a planned vaginal birth and the actual cost of a vaginal birth.
Flaw 2: A Tunnel Vision Approach to Cost
The second flaw that is endemic to cost studies comparing c-section to vaginal birth is a type of tunnel vision on which costs are included in the comparison and which costs are excluded in the comparison. Typically most cost studies take a very narrow view on the costs of labour and delivery. It is the resources used by the mother and baby while in the hospital for the specific birth event. Once mom and baby are discharged the meter stops. As mode of delivery can have an ongoing impact on the use of health resources this is disingenous. So what kind of costs are currently being excluded in cost analyses on mode of delivery: 1. Cost of ongoing care for birth injuries, 2. Cost of reconstructive surgery, 3. Cost of incontinence supplies 4. Cost of psychological counselling, 5. Cost of litigation, 6. Cost of stillbirth, 7. Cost of pelvic floor injuries.
Friday, October 28, 2011
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.
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.
Thursday, October 27, 2011
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?
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?
Friday, October 21, 2011
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.
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.
Wednesday, October 19, 2011
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
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?
Thursday, October 13, 2011
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
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!
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!
Tuesday, October 11, 2011
Does Morgentaler set a precedent for a woman's right to timely access to medical care?
More than 20 years ago on January 28, 1988, the Supreme Court of Canada handed down the decision in R. v. Morgentaler. Despite being a criminal case, the case examined a women's rights in the context of the Charter of Rights and Freedoms. The Morgentaler case found that the criminal legislation governing abortions in Canada was unconstitutional. The reasoning for the unconstitutionality of Canada's abortion laws was that it interfered with section 7 of the Charter which states that "Everyone has the right to life, liberty and security of the person and the right not to be deprieved thereof except in accordance with the princples of fundamental justice". Part of the reasoning for striking down Canada's abortion laws was the delay in obtaining therapeutic abortions that the was caused by the mandatory procedures for procuring an abortion at the time - the delay resulted in a higher probability of complications and greater risk which infringed upon a woman's section 7 charter right. (Judges Dicson and Lamer). Judges Beetz and Estey reasoned that section 7 of the Charter must include a right of access to medical treatment for a condition that represents a danger to life or health without fear of criminal sanction. Judge Wilson also agreed that the abortion laws were uncontitutional as it "takes a personal and private decision away from the woman and gives it to a committee which bases its decision on "criteria entirely unrelated to the pregnant woman's own priorities and aspirations." Judge Wilson also found that s.7 of the Charter should protect both the physical and psycological integrity of the individual and that section 251 was deeply flawed by subjecting women to considerable emotional stress and unnecessary physical risk and that putting woman's capacity to reproduce in the control of the state was a direct interference with the woman's physical person. (Note: Information on the Morgantaler case is from the University of Alberta's law website: http://www.law.ualberta.ca/centres/ccs/rulings/rvmorgentaler.php.
A woman who cannot procure an abortion in a timely way without fear of criminal sanctions, has been deprived of her right to life, liberty and security of the person. This is settled law.
Yet, in British Columbia women who are giving birth may have their access to medical intervention limited because of decisions made by the BC Government, the Health Authorities, the BCMA and BC Anaesthesiologist Society. Have these women been deprived of their section 7 charter rights?
I'll take my own personal experience as an example. I wished to procure a c-section without medical reason. My motivations were primarily psychological and included a desire to avoid an emergency c-section, desire to avoid damage to my pelvic floor, desire to avoid the pain of labour, desire to avoid serious harm to my child including the risk of brachial plexus injury, and cerebral palsy. I had throughly researched the issue, I was aware of the risks and benefits of both modes of delivery and I had made a choice. I found a care provider who was supportive of that choice and we booked a delivery date (July 9, 2010). Due to resource limitations (that the government and health authorities were well aware of) - I could not access timely medical care (a pre-labour c-section) and was for all intents and purposes - forced to give birth vaginally.
Similarly, access to epidurals is also constrained in BC.
Inability to access c-sections and epidurals in a timely way (39 weeks for elective, scheduled c-section, 2 hours for urgent c-sections, 30 minutes for emergency c-section and 2 hours for epidural) strikes me as a violation to a woman's section 7 rights, particularly when the only choice a woman has for giving birth is the public health system.
A woman who cannot procure an abortion in a timely way without fear of criminal sanctions, has been deprived of her right to life, liberty and security of the person. This is settled law.
Yet, in British Columbia women who are giving birth may have their access to medical intervention limited because of decisions made by the BC Government, the Health Authorities, the BCMA and BC Anaesthesiologist Society. Have these women been deprived of their section 7 charter rights?
I'll take my own personal experience as an example. I wished to procure a c-section without medical reason. My motivations were primarily psychological and included a desire to avoid an emergency c-section, desire to avoid damage to my pelvic floor, desire to avoid the pain of labour, desire to avoid serious harm to my child including the risk of brachial plexus injury, and cerebral palsy. I had throughly researched the issue, I was aware of the risks and benefits of both modes of delivery and I had made a choice. I found a care provider who was supportive of that choice and we booked a delivery date (July 9, 2010). Due to resource limitations (that the government and health authorities were well aware of) - I could not access timely medical care (a pre-labour c-section) and was for all intents and purposes - forced to give birth vaginally.
Similarly, access to epidurals is also constrained in BC.
Inability to access c-sections and epidurals in a timely way (39 weeks for elective, scheduled c-section, 2 hours for urgent c-sections, 30 minutes for emergency c-section and 2 hours for epidural) strikes me as a violation to a woman's section 7 rights, particularly when the only choice a woman has for giving birth is the public health system.
Friday, September 30, 2011
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.
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.
Tuesday, September 27, 2011
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.
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.
Monday, September 26, 2011
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"??.
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"??.
Thursday, September 22, 2011
Are women who fear childbirth given a fair deal by the health system?
The Globe and Mail today published that women who fear child birth were more likely to have c-sections (both elective and emergency) compared to those who do not fear birth.
What I found remarkable were the comments after the story. In particular there is a stark contrast between those from women who 'get' the fear of childbirth, and those who are hard core natural birth advocates. Those who get it would never denigrate the choice of a woman to opt for an elective c-section (or a natural birth if that is what she desires). Meanwhile the natural birth advocates are hellbent on enforcing their views on other women and would actively ban informed choice.
What I found remarkable were the comments after the story. In particular there is a stark contrast between those from women who 'get' the fear of childbirth, and those who are hard core natural birth advocates. Those who get it would never denigrate the choice of a woman to opt for an elective c-section (or a natural birth if that is what she desires). Meanwhile the natural birth advocates are hellbent on enforcing their views on other women and would actively ban informed choice.
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