In most of the literature on choosing an elective cesarean, the avoidance of labour pain is considered to be an inadequate reason to choose to have an elective cesarean section. It certainly wasn't THE reason I was lobbying for an elective cesarean during my last pregnancy - after all I had no idea what the pain of labour and delivery would be like. I had people assume that it was the reason for my choice, with my own step-mother-in-law greeting the news of our birth plan with "oh honey, just get the epidural". I'd typically responded with "my choice isn't just about the pain of childbirth.". In truth, the first time around, I anticipated that choosing cesarean wouldn't mean less pain overall, just different pain. I was anticipating trading the pain of labour and birth for the longer recovery and a longer duration of pain. I anticipated a qualitatively different kind of pain that on the whole would be roughly equivalent.
The thing is, I never imagined a circumstance in a major urban area in Canada where access to effective pain management (ie. an epidural) would be a problem. I had no reason to believe at that point in time that I would not have access to an epidural should I have decided to proceed with a vaginal birth.
Now, knowing what I know - I feel very differently about this. I think that the avoidance of being in a situation where the pain is not in control and is extreme, is a valid and reasonable reason to elect for a cesarean. It shouldn't be the only reason - but it certainly ranks a heck of lot higher this time around than it did the last time around. If the health system cannot guarantee access to effective pain management when it is known to be available, why should it expect women to just chance it with a natural delivery? If spontaneous labour comes with a risk of unmanaged and insufficiently mitigated pain that is off-the-scales, why should we expect women to willingly submit to that?
Why is pain in childbirth considered to be 'okay' - when pain in any other medical arena is seen to be something that should be managed and mitigated?
I believe part of the reason I found giving birth to my first child was traumatic (apart from a complete violation of my right to determine what happens to my body) - was the insufficiently mitigated pain I experienced during the process.
If access to effective pain relief (epidurals) during labour and delivery was guaranteed to occur on demand, then it likely isn't a valid reason to elect for a c-section. In the absence of that situation - I personally, think its very logical for a woman to choose a cesarean - particularly now that I know what I know about access to epidurals during labour in most of British Columbia.
Showing posts with label elective c-section. Show all posts
Showing posts with label elective c-section. Show all posts
Monday, April 2, 2012
Wednesday, March 21, 2012
Paying for Lifestyle Choices
Imagine a world where the public was only "on the hook" for the lowest cost, medically neccessary standard of care. That every Canadian was faced with the same challenge: to only access public health care that is medically neccessary, the lowest cost, and not the result of a "lifestyle choice" - and that the determination of these things was done retrospectively. That EVERYTHING else was paid for out-of-pocket or via private insurance.
Public health care costs would plummet. At the same time out-of-pocket expenses would sky rocket and the quality of life of many Canadians would suffer greatly.
The reality is that much of health care spending is the result of lifestyle decisions. The decision to smoke a pack or more of cigarettes a day. The decision to drink excessively. The decision to forego adequate amounts of exercise. The decision to eat inappropriately. The decision to have children in the first place. The decision to undergo surgical sterilization. The decision to partake in extreme sports. The decision not to wear a helmet. The decision not to adhere to the advice of your physician. The decision to undergo an abortion. The decision to do illicit drugs. Yet, the public health care system pays for these lifestyle decisions.
It is also true that most health care spending occurs in the final two years of life. A time when that spending has little impact on the quality or quantity of life that remains - arguably much of this spending is 'not medically neccessary' as it does little to improve the health status of the person receiving the service. The returns on this health spending tend to be be very marginal. Again, the public health care system pays for the heroic measures taken to stave off what in many cases is inevitable.
However, when it comes to treatment decisions for pregnancy - there is a vocal outcry of wasting health resources by allowing women to exercise legitimate decisions about how their children are delivered. There is a refrain "The public should not pay for THIS lifestyle choice." I should note that THIS lifestyle choice might prevent the need for reconstructive surgery later. THIS lifestyle choice might prevent a life-long disability. THIS lifestyle choice impacts on a woman's sense of self-determination. THIS lifestyle choice might prevent an emergency c-section. THIS lifestyle choice, and the availability of it very well might make the difference between a woman choosing to have ANY children or none at all. Yet, THIS lifestyle choice is somehow open to public opinion as to whether or not it should be paid for. THIS lifestyle choice is NOT on par with a tummy tuck - and is far less costly than the health impacts of many other publicly supported lifestyle decisions.
Is this because only women give birth and have to deal with consequences of doing so?
Health care sustainability and spending is a very real dilemma - however, looking to 'save healthcare' by restricting choice in maternity care (access to epidurals, c-sections and other interventions) is misguided at best. This is especially true in light of evidence that suggests that an elective c-section at term might be cost-competitive with a planned vaginal birth, particularly when all costs of planned vaginal birth (emergency c-sections, damage to the pelvic floor, severe birth traumas) are taken into account.
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.
Tuesday, January 31, 2012
Improving the Efficiency of Surgical Birth: Would it Make it Cost Competitive with Vaginal Birth?
One of the arguments against surgical birth - and specifically maternal request caesareans, particularly in health systems that are publicly funded - is that it imposes an unneccessary strain on the health care system. Being an economist (and more specifically one that practices in the field of health), I am quite intrigued by this argument and unable to take it at face value. The cost differences cited are frequently based on inappropriate assumptions, frequently the cost of all cesareans are lumped in together (both emergent and elective) and the cost of vaginal birth tends to exclude the cost of births that were planned vaginal but ultimately resulted in an emergent cesarean. There are many circumstances where the cost of the least expensive cesarean is far exceeded by the cost of the most expensive vaginal birth.
In a previous blog post I did a very back-of-the envelope calculation on the cost difference between planned vaginal delivery and planned caesarean delivery (I had to make some broad assumptions) - and estimated the difference to be less than $500. It is quite possible that the difference is even less than that.
This difference is not substantial. It actually is low enough that by improving the efficiency of surgical birth - that a planned cesarean might even be cost-neutral in comparison to a planned vaginal birth.
A couple of years ago, the province did a pilot project to reduce the backlog of patients waiting for hip and knee operations. It funded the "Centre for Surgical Innovation". The centre had 2 ORs and 38 inpatient beds. The ORs were specifically set up for hip and knee operations only - and completes 1600 of them a year. As a result of the surgical specialization of the facility, the centre was able to improve the OR time by 16 percent, and the length of stay per patient dropped 14 percent from 3.5 days to 3 days, and the cost per surgical case dropped 9.7 percent.
It is not hard to conceive that a similar approach applied to elective cesarean deliveries could yield vast improvements in the cost-efficiency of surgical delivery. If the cost of planned cesarean dropped by 10 percent - using the cost of a repeat c-section at $3410 as a proxy, $341 of the $471.55 difference in cost would be eliminated, leaving a cost difference of just $131.55.
Using data from C-section on request at 39 weeks: Impact on Shoulder Dystocia, Fetal Trauma, Neonatal Encephalopathy, and Intrauterine Fetal Demise. A Centre for Surgical Birth that did 2500 cesareans at 39 weeks per year would (compared to planned vaginal births) prevent approximately:
Between 1 and 12 brachial plexus injuries
8 cases of neonatal encephalopathy
5 Fetal still births
At an additional cost of $328,875 annualy over planned vaginal birth for these 2500 deliveries it would cost less than $65,775 to prevent 1 fetal still birth, less than $41,109 to prevent 1 case of neonatal encephalopathy, $54,812 to prevent on average 1 brachial plexus injury. As a composite (6 brachial plexus injuries, 8 neonatal encephalopathies, and 5 fetal still births) it would cost less than $17,310 to prevent one of these three events.
To put these numbers in perspective, it has been estimated that the cost of breast cancer screening is $13,200 and $28,000 per year of life saved. Assuming a baby who avoids a fetal still birth lives to be 75 years old, the cost per year of life saved of elective cesarean at 39 weeks is $877 per year of life saved. Even with the far more generour estimate of $500 difference between expected cost of planned cesarean and expected cost of planned vaginal birth, the cost per year of life saved would be $3,333.33.
I'm starting to think that elective cesarean at term might be a bargain in comparison to the costs of planned vaginal birth...
In a previous blog post I did a very back-of-the envelope calculation on the cost difference between planned vaginal delivery and planned caesarean delivery (I had to make some broad assumptions) - and estimated the difference to be less than $500. It is quite possible that the difference is even less than that.
This difference is not substantial. It actually is low enough that by improving the efficiency of surgical birth - that a planned cesarean might even be cost-neutral in comparison to a planned vaginal birth.
A couple of years ago, the province did a pilot project to reduce the backlog of patients waiting for hip and knee operations. It funded the "Centre for Surgical Innovation". The centre had 2 ORs and 38 inpatient beds. The ORs were specifically set up for hip and knee operations only - and completes 1600 of them a year. As a result of the surgical specialization of the facility, the centre was able to improve the OR time by 16 percent, and the length of stay per patient dropped 14 percent from 3.5 days to 3 days, and the cost per surgical case dropped 9.7 percent.
It is not hard to conceive that a similar approach applied to elective cesarean deliveries could yield vast improvements in the cost-efficiency of surgical delivery. If the cost of planned cesarean dropped by 10 percent - using the cost of a repeat c-section at $3410 as a proxy, $341 of the $471.55 difference in cost would be eliminated, leaving a cost difference of just $131.55.
Using data from C-section on request at 39 weeks: Impact on Shoulder Dystocia, Fetal Trauma, Neonatal Encephalopathy, and Intrauterine Fetal Demise. A Centre for Surgical Birth that did 2500 cesareans at 39 weeks per year would (compared to planned vaginal births) prevent approximately:
Between 1 and 12 brachial plexus injuries
8 cases of neonatal encephalopathy
5 Fetal still births
At an additional cost of $328,875 annualy over planned vaginal birth for these 2500 deliveries it would cost less than $65,775 to prevent 1 fetal still birth, less than $41,109 to prevent 1 case of neonatal encephalopathy, $54,812 to prevent on average 1 brachial plexus injury. As a composite (6 brachial plexus injuries, 8 neonatal encephalopathies, and 5 fetal still births) it would cost less than $17,310 to prevent one of these three events.
To put these numbers in perspective, it has been estimated that the cost of breast cancer screening is $13,200 and $28,000 per year of life saved. Assuming a baby who avoids a fetal still birth lives to be 75 years old, the cost per year of life saved of elective cesarean at 39 weeks is $877 per year of life saved. Even with the far more generour estimate of $500 difference between expected cost of planned cesarean and expected cost of planned vaginal birth, the cost per year of life saved would be $3,333.33.
I'm starting to think that elective cesarean at term might be a bargain in comparison to the costs of planned vaginal birth...
Thursday, January 26, 2012
Ontario Considers Covering Cesareans Only When "Medically Neccessary"
I am astounded and dumbfounded at news that the Ontario Ministry of
Health is considering delisting (not paying for) cesarean sections that are not "medically neccessary". It is a move that is at best short sighted, and at worst a blatent violation of pregnant women's charter rights.
Given that fewer than 1-2 percent of all women request a c-section to deliver their child and that the cost difference between planned vaginal delivery and planned cesarean delivery is debatable in the long run - this moves seems mean spirited. Putting women who do not want a vaginal delivery through a vaginal delivery is not quality care. It often has very tragic consequences, including PTSD and PPD.
I would strongly encourage the Ontario Ministry of Health to find other areas to curb costs - particularly as in Canada there is no private option to give birth.
Health is considering delisting (not paying for) cesarean sections that are not "medically neccessary". It is a move that is at best short sighted, and at worst a blatent violation of pregnant women's charter rights.
Given that fewer than 1-2 percent of all women request a c-section to deliver their child and that the cost difference between planned vaginal delivery and planned cesarean delivery is debatable in the long run - this moves seems mean spirited. Putting women who do not want a vaginal delivery through a vaginal delivery is not quality care. It often has very tragic consequences, including PTSD and PPD.
I would strongly encourage the Ontario Ministry of Health to find other areas to curb costs - particularly as in Canada there is no private option to give birth.
Thursday, November 10, 2011
A Clear Destination for the Canadian Maternity System
Often times it feels as though when it comes to maternity care in Canada - the system is being pulled in all directions without any true sense of destination.
There are those who would like to see the role of intervention limited (Dr. Klein, Ricki Lake, Ina May Gaskin, NCB advocates, etc.) as they see intervention as being costly and frequently unneccessary. They perceive the benefits of ready access to drugs and epidurals in labour as being outweighed by the risks of longer second stages of labour, increased risk of instrumental deliveries, increased risk of resuscitation. They may argue that medicalized birth is expensive birth, that on a whole does not yield better outcomes for low risk women than medicalized birth with it's "cascade of interventions". The claim is that women have been giving birth for thousands of years, our bodies are made to birth, and that there is no valid reason for c-section rates to exceed 15 percent. They also bemoan the impact that interventionist birth may have on breastfeeding. Birth to them is something that needs to "be reclaimed as a natural process". Home-birth and unassisted birth is viewed as a reasonable and inherently 'safe' option by many in this group.
On the flip side, is a small minority that has only recently found it's voice (Dr. Amy Tutuer, Mrs. Pauline McDonough-Hull, Mrs. Eckler, etc.) who argue that the medicalization of birth is a good thing that prevents morbidity and mortality and unneccessary pain and suffering. For the most part these women (as they are mostly women) argue for 'informed consent' and unbiased information as it pertains to birth. They see the benefits of intervention as frequently outweighing the risks. Birth is seen by this group as a biological process that has inherent risks and those risks can and should be proactively managed. C-section on demand is seen by many in this group as reasonable and a comparably 'safe' option.
There is no universal 'right' way to birth a child, just as there is no universal 'right' way to parent a child. To believe that there is, is the hight of sanctimommyness.
As such, there can be only one clear destination that would allow both viewpoints and all viewpoints in-between to exist and that is:
"A system that seeks to achieve the best health outcomes for moms and babies based on respect, informed consent, and the best available evidence."
There are those who would like to see the role of intervention limited (Dr. Klein, Ricki Lake, Ina May Gaskin, NCB advocates, etc.) as they see intervention as being costly and frequently unneccessary. They perceive the benefits of ready access to drugs and epidurals in labour as being outweighed by the risks of longer second stages of labour, increased risk of instrumental deliveries, increased risk of resuscitation. They may argue that medicalized birth is expensive birth, that on a whole does not yield better outcomes for low risk women than medicalized birth with it's "cascade of interventions". The claim is that women have been giving birth for thousands of years, our bodies are made to birth, and that there is no valid reason for c-section rates to exceed 15 percent. They also bemoan the impact that interventionist birth may have on breastfeeding. Birth to them is something that needs to "be reclaimed as a natural process". Home-birth and unassisted birth is viewed as a reasonable and inherently 'safe' option by many in this group.
On the flip side, is a small minority that has only recently found it's voice (Dr. Amy Tutuer, Mrs. Pauline McDonough-Hull, Mrs. Eckler, etc.) who argue that the medicalization of birth is a good thing that prevents morbidity and mortality and unneccessary pain and suffering. For the most part these women (as they are mostly women) argue for 'informed consent' and unbiased information as it pertains to birth. They see the benefits of intervention as frequently outweighing the risks. Birth is seen by this group as a biological process that has inherent risks and those risks can and should be proactively managed. C-section on demand is seen by many in this group as reasonable and a comparably 'safe' option.
There is no universal 'right' way to birth a child, just as there is no universal 'right' way to parent a child. To believe that there is, is the hight of sanctimommyness.
As such, there can be only one clear destination that would allow both viewpoints and all viewpoints in-between to exist and that is:
"A system that seeks to achieve the best health outcomes for moms and babies based on respect, informed consent, and the best available evidence."
Monday, November 7, 2011
The Serious Side of Funny
I'm hoping those of you who read my blog will appreciate my sometimes off sense of humour. In a semi-departure from the serious, I came accross this thought-provoking video featuring the "Completely Honest OBGyn".
A couple, obviously expecting their first are meeting with their OBGyn. They confess to him their desire for a "natural birth", the OBGyn then tells them how such an event would likely 'go down'. At the end he asks "So when can I schedule you for a c-section - does 3 or 4 work?" And the couple agrees that 3 is good.
My first thought was "where was that OBGyn when I had my first?".
My second thought was "some of that honesty about birth could be really refreshing."
My third thought was "this couple's experience is not at all unlike women who try to access elective c-sections when the prevailing culture is to attempt a natural birth".
I could entirely re-write the script and it would reflect the experience of many women who attempt to get the birth they want (c-section), only to be talked into something else entirely (natural) without any deference to the reasons behind the request in the first place. It could even be written in the delivery room itself as a woman is denied her request for an epidural.
The video highlights why many women self-select to the care provider who they feel will align most closely with their own philosophies on childbirth. Women who are highly desirous of a 'natural experience' tend to select care providers who are most likely to facilitate that experience (a midwife), meanwhile, women who are open to (or may even desire) a medicalized birth tend to choose a traditional medical provider (an OBGyn or MD). (I note that this is pure speculation, I have no actual survey data or study data to back up this hypothesis - but it makes sense to me so I'm going to run with it).
This video also highlights the information that women may be missing out on depending on which care provider they select. Those care providers most supportive of 'natural birth' tend to minimize the downsides to it and accentuate the upsides, meanwhile, those most supportive of 'medicalized birth' might share a similar bias in the other direction. (Again, this is mere speculation as I have no hard data to support this theory). As result of that kind of bias and self-selection, I can imagine the sort of trauma that might be inflicted should expectations not match up with experience (yet another theory without data, but again, I'm going to run with it).
Of course, if it was an example of what care in maternity SHOULD be like it wouldn't be funny at all...the really, really funny part (actually more sad now that I think of it) is - that the video might actually be a fairly accurate protrayal of what maternity care is like for many women. That needs to change.
A couple, obviously expecting their first are meeting with their OBGyn. They confess to him their desire for a "natural birth", the OBGyn then tells them how such an event would likely 'go down'. At the end he asks "So when can I schedule you for a c-section - does 3 or 4 work?" And the couple agrees that 3 is good.
My first thought was "where was that OBGyn when I had my first?".
My second thought was "some of that honesty about birth could be really refreshing."
My third thought was "this couple's experience is not at all unlike women who try to access elective c-sections when the prevailing culture is to attempt a natural birth".
I could entirely re-write the script and it would reflect the experience of many women who attempt to get the birth they want (c-section), only to be talked into something else entirely (natural) without any deference to the reasons behind the request in the first place. It could even be written in the delivery room itself as a woman is denied her request for an epidural.
The video highlights why many women self-select to the care provider who they feel will align most closely with their own philosophies on childbirth. Women who are highly desirous of a 'natural experience' tend to select care providers who are most likely to facilitate that experience (a midwife), meanwhile, women who are open to (or may even desire) a medicalized birth tend to choose a traditional medical provider (an OBGyn or MD). (I note that this is pure speculation, I have no actual survey data or study data to back up this hypothesis - but it makes sense to me so I'm going to run with it).
This video also highlights the information that women may be missing out on depending on which care provider they select. Those care providers most supportive of 'natural birth' tend to minimize the downsides to it and accentuate the upsides, meanwhile, those most supportive of 'medicalized birth' might share a similar bias in the other direction. (Again, this is mere speculation as I have no hard data to support this theory). As result of that kind of bias and self-selection, I can imagine the sort of trauma that might be inflicted should expectations not match up with experience (yet another theory without data, but again, I'm going to run with it).
Of course, if it was an example of what care in maternity SHOULD be like it wouldn't be funny at all...the really, really funny part (actually more sad now that I think of it) is - that the video might actually be a fairly accurate protrayal of what maternity care is like for many women. That needs to change.
Saturday, November 5, 2011
I'm not a Feminist, I'm a Humanist
I never took a "Women's Studies" course in university - actually the whole idea of there being a "Women's Studies" department somewhat baffled me at the time. It seemed to me to be a bit odd, that there would be a Women's Studies department but no Men's Studies department. Of course anybody actually enrolled in Women's Studies would say that a Men's Studies department would be completely unnecessary because all the rest of everything was done from a male dominated perspective.
I rarely gave a thought to the idea of feminism, beyond the idea that women were mentally on par with men and just as capable as human beings in terms of what they could do with their lives. In fact, it has only been recently that I've been labelled a feminist and that my feminist leanings had clouded my critical thinking abilities. This in reference to my stance on elective c-sections in the absence of a traditional medical indication for one. It seems that the area of birth is the last frontier of misogyny, and even more odd is that much of the criticism is levelled at women by other women.
Go to any media article on the topic of elective c-section and you will find a litany of misguided and abusive commentary with respect to the topic. The idea that somebody else should restrict how a woman does or does not approach a medical condition (birth) is still very alive and well in Canada today.
Is it not clear that when it comes to medical decisions with regard to a medical condition that the decision about how to treat or not treat that condition should rest with an informed patient and their medical caregiver? After all is it not that particular patient who must live with the consequences of their decisions? Is the patient not entitled to informed consent, and security of the person, and respectful care?
Never before in my life, have I thought so critically about something, as I have thought about birth. In part, because never before in my life have I had to defend an opinion as vigorously as I have had to defend my opinions on birth, and in defence of that position, I have had to do an extensive amount of research.
The only funny thing is, that my opinion on birth really boils down to a very simple idea, "That a patient and her medical caregiver have the right to decide on the best course of action for that individual patient with respect to that patients particular medical condition." As a result of this idea, it is clear that I would defend a woman's informed right to choose a natural birth as rigorously as a woman's informed right to choose a c-section. To me this really doesn't seem like such a contentious proposition, what is ridiculous is that it is a contentious proposition.
Further, such a position doesn't make me a feminist, it makes me a humanist.
I rarely gave a thought to the idea of feminism, beyond the idea that women were mentally on par with men and just as capable as human beings in terms of what they could do with their lives. In fact, it has only been recently that I've been labelled a feminist and that my feminist leanings had clouded my critical thinking abilities. This in reference to my stance on elective c-sections in the absence of a traditional medical indication for one. It seems that the area of birth is the last frontier of misogyny, and even more odd is that much of the criticism is levelled at women by other women.
Go to any media article on the topic of elective c-section and you will find a litany of misguided and abusive commentary with respect to the topic. The idea that somebody else should restrict how a woman does or does not approach a medical condition (birth) is still very alive and well in Canada today.
Is it not clear that when it comes to medical decisions with regard to a medical condition that the decision about how to treat or not treat that condition should rest with an informed patient and their medical caregiver? After all is it not that particular patient who must live with the consequences of their decisions? Is the patient not entitled to informed consent, and security of the person, and respectful care?
Never before in my life, have I thought so critically about something, as I have thought about birth. In part, because never before in my life have I had to defend an opinion as vigorously as I have had to defend my opinions on birth, and in defence of that position, I have had to do an extensive amount of research.
The only funny thing is, that my opinion on birth really boils down to a very simple idea, "That a patient and her medical caregiver have the right to decide on the best course of action for that individual patient with respect to that patients particular medical condition." As a result of this idea, it is clear that I would defend a woman's informed right to choose a natural birth as rigorously as a woman's informed right to choose a c-section. To me this really doesn't seem like such a contentious proposition, what is ridiculous is that it is a contentious proposition.
Further, such a position doesn't make me a feminist, it makes me a humanist.
Monday, October 24, 2011
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.
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.
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
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
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.
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.
Monday, September 19, 2011
Thinking about round two...
I am not even pregnant with bean 2...and yet I'm thinking about the inevitable end to that pregnancy. The birth end. And when I think about that end, I still get angry about the end to the first birth (aside from the healthy baby).
I so very deeply want a different ending this time (aside from the healthy baby, that can stay the same).
I don't want to labour in such extreme pain, knowing that its completely unneccessary. I don't want to feel as though I don't matter and that I don't have a choice, when I know that I do. I also don't want to have the fear that if shit goes sideways - as it can and does in birth that the right people who know how to do the right thing at the right time won't be there. I don't want to experience the changes that go along with pushing a baby out the way 'nature intended'. I researched my options last time (not that it did a fuck load of good) and I came to the reasonable answer for myself - one that had on a whole comparable risks and that I felt would yield the best outcome. I did everything I could to get what I thought would lead to the best outcome for myself and my child, and I didn't get it. The baby waited, I waited, and the system failed us.
How do I avoid going down the same road again? How do I guarantee an anaesthesiologist will be there? When it comes to birth in Canada - there is no private option...so what's an informed elective c-section desiring girl to do?
I so very deeply want a different ending this time (aside from the healthy baby, that can stay the same).
I don't want to labour in such extreme pain, knowing that its completely unneccessary. I don't want to feel as though I don't matter and that I don't have a choice, when I know that I do. I also don't want to have the fear that if shit goes sideways - as it can and does in birth that the right people who know how to do the right thing at the right time won't be there. I don't want to experience the changes that go along with pushing a baby out the way 'nature intended'. I researched my options last time (not that it did a fuck load of good) and I came to the reasonable answer for myself - one that had on a whole comparable risks and that I felt would yield the best outcome. I did everything I could to get what I thought would lead to the best outcome for myself and my child, and I didn't get it. The baby waited, I waited, and the system failed us.
How do I avoid going down the same road again? How do I guarantee an anaesthesiologist will be there? When it comes to birth in Canada - there is no private option...so what's an informed elective c-section desiring girl to do?
Friday, September 9, 2011
What we don't know...
I am in the 'real world' a health economist, who makes a living by supplying information to decision makers about the health care system. I work for the organization that has the responsibility for ensuring that quality, appropriate, cost effective and timely health services are available to all British Columbians. Granted, it's a hefty mandate and there are real and significant challenges to meeting it - an aging population, the rising incidence of chronic disease, technological advancement, human resource limitations, and funding limitations.
Having experienced an aspect of the health care system in BC - I am troubled. From my perspective the system 'failed' to delivery quality, appropriate, cost-effective and timely health services. What's worse, is that I know that from the system's perspective there is no way for the system to know that it has failed because it does not collect the kind of information it would need to in order to come to that conclusion. My experience does not 'show up' statistically...and that is problematic - because if my experience does not matter (in a statistical sense) then all of the women who have a similar experience also don't matter (in a statistical sense). Worse - how do we get to a better system that actually delivers what it is supposed to (quality, appropriate, cost-effective and timely health services) if we are not brave enough to collect the information that would actually enable an accurate and meaningful assessment of system performance?
So what do we not know, that we need to know (with respect to maternity care)?
1. We need to know how many women actually deliver their babies in the way that they and their doctors or care providers planned to deliver their babies.
2. We need to know how many women actually receive elective c-sections on the date that they planned to receive the c-sections.
3. We need to know if women are satisfied with the care they recieved - and if they aren't we need to know why.
4. We need to know how many women want to recieve epidural anaesthesia, how long they wait, and if they can't get it, we need to know why.
5. We need better information on rates of post partum depression (PPD) and post-natal post-traumatic stress disorder (PN PTSD).
6. We need better information on delays to accessing c-sections when they are deemed neccessary - near misses and the reasons for them need to be known.
What we know right now, what show's up statistically - just isn't good enough...
Having experienced an aspect of the health care system in BC - I am troubled. From my perspective the system 'failed' to delivery quality, appropriate, cost-effective and timely health services. What's worse, is that I know that from the system's perspective there is no way for the system to know that it has failed because it does not collect the kind of information it would need to in order to come to that conclusion. My experience does not 'show up' statistically...and that is problematic - because if my experience does not matter (in a statistical sense) then all of the women who have a similar experience also don't matter (in a statistical sense). Worse - how do we get to a better system that actually delivers what it is supposed to (quality, appropriate, cost-effective and timely health services) if we are not brave enough to collect the information that would actually enable an accurate and meaningful assessment of system performance?
So what do we not know, that we need to know (with respect to maternity care)?
1. We need to know how many women actually deliver their babies in the way that they and their doctors or care providers planned to deliver their babies.
2. We need to know how many women actually receive elective c-sections on the date that they planned to receive the c-sections.
3. We need to know if women are satisfied with the care they recieved - and if they aren't we need to know why.
4. We need to know how many women want to recieve epidural anaesthesia, how long they wait, and if they can't get it, we need to know why.
5. We need better information on rates of post partum depression (PPD) and post-natal post-traumatic stress disorder (PN PTSD).
6. We need better information on delays to accessing c-sections when they are deemed neccessary - near misses and the reasons for them need to be known.
What we know right now, what show's up statistically - just isn't good enough...
Monday, August 30, 2010
Juno has arrived
Well, I am no longer awaiting Juno, she has arrived, not in the way I lobbied for - elective cesarean at 39 weeks, but rather on her own without an epidural, after 5 hours of labour. She is a healthy baby who I love being a mom for...and my dissatisfaction with her birth is strictly limited to her birth and not the outcome. I have a healthy baby, but realistically I would have had a healthy baby either way. I am disappointed that the health system failed us, she waited until the surgery date, even the day after, but we got bumped and when she decided to come on her own, there was no anesthesiologist available due to other emergent surgeries. I'm coping with the aftermath, but also struggling with the need to continue to defend my original choice, even after it didn't materialize. I get no end of well meaning people telling me that it was for the best that I didn't get the csection. To that I say bullshit.
So what have been the consequences of having my autonomy completely disregarded and being subjected to a vaginal birth that I did not want?
1. I do not reflect upon her birth with happiness, rather I find such reflection stressful, my jaw tightens and I find it difficult not to get tearful. I associate it with being unprepared, being in immense pain, being out of control, and fear that things might go sideways that there might be long-lasting repercussions.
2. A sense of loss. Loss of autonomy, loss of experience, loss of the way I was.
3. Uncertainty around wanting a subsequent child - before this I thought I'd want two kids, now I'm not sure.
4. A sense of being let down by my care providers and the system.
Having experienced a vaginal birth, and having experienced open abdominal surgery, in hindsight I truly wish I would have been able to achieve the birth I had wanted. I wish my child would have been born in the calm environment of a surgical theatre, I wish I hadn't had to feel her passing through me - changing me in ways I didn't want to be changed, I wish I had felt in control of what was happening, I wish I had felt prepared for what would occur. I wish I could have stood on the other side of the experience, proud of the choice I made and it's consequences - but instead I stand on the other side somewhat alone as a woman who wanted the opposite of a natural birth who got a natural birth (fentanyl and gas do little for the pain of labour and delivery).
I love that I have a healthy daughter - however, I am not as well off as I would have been had I been able to achieve the birth I wanted.
So what have been the consequences of having my autonomy completely disregarded and being subjected to a vaginal birth that I did not want?
1. I do not reflect upon her birth with happiness, rather I find such reflection stressful, my jaw tightens and I find it difficult not to get tearful. I associate it with being unprepared, being in immense pain, being out of control, and fear that things might go sideways that there might be long-lasting repercussions.
2. A sense of loss. Loss of autonomy, loss of experience, loss of the way I was.
3. Uncertainty around wanting a subsequent child - before this I thought I'd want two kids, now I'm not sure.
4. A sense of being let down by my care providers and the system.
Having experienced a vaginal birth, and having experienced open abdominal surgery, in hindsight I truly wish I would have been able to achieve the birth I had wanted. I wish my child would have been born in the calm environment of a surgical theatre, I wish I hadn't had to feel her passing through me - changing me in ways I didn't want to be changed, I wish I had felt in control of what was happening, I wish I had felt prepared for what would occur. I wish I could have stood on the other side of the experience, proud of the choice I made and it's consequences - but instead I stand on the other side somewhat alone as a woman who wanted the opposite of a natural birth who got a natural birth (fentanyl and gas do little for the pain of labour and delivery).
I love that I have a healthy daughter - however, I am not as well off as I would have been had I been able to achieve the birth I wanted.
Thursday, June 10, 2010
35 weeks down - 5 to go
I now have a referral to an OBGYN and soon will know whether or not my request/desire for an elective-c will be respected or if I'll have to ask for another referral to another OBGYN. Although given the timelines (I'm now 35 weeks and 2 days and will be 36 weeks and 2 days when I meet with the OBGYN), I'm a little nervous.
The last prenatal went well - my weight was actually down a pound, which I guess means I haven't gained anything in the last 5 weeks - but overall I'm up 26 pounds from where I started and the doctor doesn't seem to worry. The baby is quite active and my energy levels have been good. Further, my blood sugars seem to be well controlled.
I've only got two more weeks of work to go...so soon that part of my life will be on pause although I would like to remain active in some capacity while on maternity leave.
Yesterday I bought the baby a long-sleeved onesie that says 'Bean' on it and next week the long awaited Bumbleride Indie will arrive into our home. It's hard to believe but this pregnancy is very nearly now done and soon our household will have one more person in it...
The last prenatal went well - my weight was actually down a pound, which I guess means I haven't gained anything in the last 5 weeks - but overall I'm up 26 pounds from where I started and the doctor doesn't seem to worry. The baby is quite active and my energy levels have been good. Further, my blood sugars seem to be well controlled.
I've only got two more weeks of work to go...so soon that part of my life will be on pause although I would like to remain active in some capacity while on maternity leave.
Yesterday I bought the baby a long-sleeved onesie that says 'Bean' on it and next week the long awaited Bumbleride Indie will arrive into our home. It's hard to believe but this pregnancy is very nearly now done and soon our household will have one more person in it...
Wednesday, May 26, 2010
33 Weeks down 7 (at most) to go...
The prenatal appointments are now every two weeks, had the last one yesterday and all was well. I'm up a pound over where I was 3 weeks ago at my last prenatal appointment (I had been up 10 pounds over the previous 2 months, and I'm up 25 pounds over the course of this pregnancy). Baby's heartrate was 145 and my blood pressure was 122/80 so all is good.
I got a referral to an OB/GYN and am waiting to hear back as to when that appointment will be. I will have to have all my reasons for an elective c-section gathered for that appointment, along with all of my supporting documentation...and then cross my fingers that the OB/GYN will be supportive of my request. For all those who think it's about being "Too Posh to Push", they really haven't looked into the issue and how complex it really is. There are risks either way. There is pain either way. There really is no perfect way to tell which way is best for any given woman or any given child before the event and all that remains is what would be best in retrospect.
In this context, is it really possible to make a truly informed decision? I mean, I do not know for certain what a planned vaginal delivery would yield for myself and my child, nor do I know for certain what a planned c-section would yield for myself and my child but it seems that there is greater certainty of experience, comparable risks for myself and less risk of truly adverse outcomes for my child with a planned c-section.
I got a referral to an OB/GYN and am waiting to hear back as to when that appointment will be. I will have to have all my reasons for an elective c-section gathered for that appointment, along with all of my supporting documentation...and then cross my fingers that the OB/GYN will be supportive of my request. For all those who think it's about being "Too Posh to Push", they really haven't looked into the issue and how complex it really is. There are risks either way. There is pain either way. There really is no perfect way to tell which way is best for any given woman or any given child before the event and all that remains is what would be best in retrospect.
In this context, is it really possible to make a truly informed decision? I mean, I do not know for certain what a planned vaginal delivery would yield for myself and my child, nor do I know for certain what a planned c-section would yield for myself and my child but it seems that there is greater certainty of experience, comparable risks for myself and less risk of truly adverse outcomes for my child with a planned c-section.
Thursday, May 13, 2010
Personal reasons why I want an elective c-section
For myself, personally, I am confident that an elective c-section at term is the decision that maximizes my overall welfare and that of my child given my preference for certainty of my birth experience (a very strong desire to avoid a long labour that results in a c-section anyways), an improved ability to prepare myself both mentally and physically for the birth of my child and a desire to avoid damage to my perineum and pelvic floor. This decision is in the context of planned fertility that includes potentially no more than one future birth and research that shows no statistically significant difference in maternal morbidity or mortality for a healthy nulliparous woman giving birth at term and lower risks for the infant (Dahlgren LS, von Dadelszen P, Christilaw J, et al. Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants. J Obstet Gynaecol Can 2009;31(9):808-17.). It is also in the context of the variability of birth experiences of my family and friends – I have friends who have had the fairy tale birth where recuperation is swift, I have also had friends who have had attempted vaginal births that have resulted in c-sections, those who have had elective c-sections for breech birth and those who have had difficult vaginal deliveries that required lengthy recuperations and subsequent surgeries. For myself, personally, I would feel disempowered and violated if I were told that my chosen method of birth (given an understanding of the risks and benefits involved) was not an option that was available to me. To be completely honest, at this point in time one of my greatest fears is that my request for an elective c-section at term (39 weeks or greater) will be denied and that I will be forced to undergo an experience that I do not desire with the potential to result in a birth experience that I would prefer to avoid.
Monday, May 10, 2010
The Many Reasons to Prefer an Elective C-Section
My mind still hasn't changed on this topic - I still want an elective c-section. I am hoping that this is an option and that my decision will be respected. My Dr. will be giving me a referral to an OBGYN at my next prenatal appointment (at 33 weeks). I hope that the OBGYN will be receptive, as frankly trying to find one who is when I'll be less than 7 weeks from my due date seems to be a daunting challenge. I want to avoid a vaginal birth as fiercely as many women want to avoid a c-section. The ironic thing is, that women who want vaginal births even in light of circumstances that are likely to merit elective c-sections (VBAC, breech) are likely to be more supported than the woman who wants a c-section in the absence of any medical reason.
So what do I perceive to be the advantages of an elective c-section:
1. Avoidance of pelvic floor damage and tearing.
2. Avoidance of going through an extensive labour and needing a c-section anyway.
3. Ability to mentally and physically prepare for the delivery.
4. Minimization of very adverse birth outcomes for my child.
5. Ability to organize support resources for my recovery.
6. Control over the experience.
7. Minimization of the risk of sexual dysfunction.
My understanding is that overall the risks (to the mom) of the two birth methods are relatively comparable, particularly in light of the fact that many planned vaginal births do not result in unassisted vaginal deliveries.
So what do I perceive to be the advantages of an elective c-section:
1. Avoidance of pelvic floor damage and tearing.
2. Avoidance of going through an extensive labour and needing a c-section anyway.
3. Ability to mentally and physically prepare for the delivery.
4. Minimization of very adverse birth outcomes for my child.
5. Ability to organize support resources for my recovery.
6. Control over the experience.
7. Minimization of the risk of sexual dysfunction.
My understanding is that overall the risks (to the mom) of the two birth methods are relatively comparable, particularly in light of the fact that many planned vaginal births do not result in unassisted vaginal deliveries.
Subscribe to:
Posts (Atom)