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

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

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

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

Golden Years:

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

Steve Q:

“Quack quack.”

Anon147951286:

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

Anon916080527:

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

Notnecessarily:

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

Schapdel:

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

Bill200:

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

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

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

Dostros:

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

Toyota:

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

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

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

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

Cojocaru versus BC Children and Women's Hospital Goes to the Supreme Court of Canada

Giving birth has risks, giving birth after a previous c-section has additional risks. Vaginal birth after c-section (VBAC) carries with it a 1 in 200 risk of uterine rupture. What this means is that the baby is expelled into the mothers abdominal cavity during labour and deprived of oxygen. If a c-section cannot be performed immediately, there is a danger of permanent brain damage.

This is what happend during Eric Cojocaru's birth at BC Women and Children's hospital in 2001. According to the information in the original judgement and the appeal judgement (found at http://canlii.ca/t/2336k and http://canlii.ca/t/fl1nt ), Eric's mother, Monica, arrived in Canada pregnant and went to an OBGYN in Vancouver. Monica was told by her doctor in her home country that any future deliveries should be done by c-section. Monica told her OBGYN in Vancouver she wanted a c-section. The OBGYN offered Monica a VBAC indicating that it was successful in most cases (70 to 80 percent), and that the risk of uterine rupture was small. Monica, whose first language is not English, believed that she had to go through a trial of labour to get a c-section.

Monica's labour was induced when she was 10 days overdue by way of vaginal insertion of a prostaglandin gel. It is noted in the appeal judgement that the unchallenged evidence was that the Hospital had four operating rooms (“OR”s) but only one anaesthetist and one OR team on duty at any given time throughout the day that Mrs. Cojocaru was induced. Anticipating these conditions, the Hospital had scheduled no caesarean sections for the day, as it would have on a normal day. Rather, the operating room was taking only statim (urgent, emergency) caesarean sections. The undisputed evidence was that the waiting list that day for caesarean sections designated “urgent” was one to two hours long and that they were given priority. A bradycardia was detected at 6:18pm, Monica was assessed at 6:22pm and found to have signs of a partial tearing or rupture of the uterus, an attempt to attach a scalp electrode to the fetus was unsuccessful and a stat c-section was ordered. Monica arrived at the OR at 18:29, the c-section was started at 18:30 and Eric was deliveried at 18:41 (23 minutes after the initial bradycardia was detected). The evidence, unchallenged and uncontradicted, was that the only anaesthetist and OR team at the appellant Hospital were engaged between 18:00 and 18:30 in performing an emergency caesarean section; that the decision to call in a second anaesthetist was for the anaesthetist at the hospital to make; and that, had the on-duty anaesthetist called for them, it would have taken 20 to 30 minutes for a second anaesthetist and OR team to be assembled to perform an emergency caesarean section on Mrs. Cojocaru. It was found that the bradycardia detected at 6:18pm was caused by a uterine rupture and complete placental abruption. In order to avoid brain damage, a baby must be delivered within 10 to 15 minutes of a placental abruption (by 6:28pm and 6:33pm, which due to resource constraints would not have been possible). Eric Cojocaru suffers from a form of cerebral palsy and has many physical disabilities, as well as impairments to his ability to think, learn and develop social skills. The orginal judgement awarded the Cojocarus $4 million dollars and found that there was negligence in regards to "informed consent" and "malpractice".

The decision was reversed on appeal and will be heard by the Supreme Court of Canada.

I am struck that a woman, attempting a VBAC would be induced on a day when the hospital is short-staffed and at risk of being unable to provide timely access to medical care (a c-section within 10 to 15 minutes) should they be needed. There was only 4 ORs and 1 anesthetist on duty that day. A back up anesthetist would take 20 to 30 minutes to arrive. There was a 1 to 2 hour wait for urgent c-sections. How is it that a woman, who was at risk of a uterine rupture (1 in 200) was allowed to be induced and proceed to a Trial of Labour when, should she need a c-section the wait would likely exceed the 10 to 15 minute wait that would avoid brain damage? Does the hospital not have a responsiblity to ensure that such services are available if a known high-risk patient is labouring? Why wasn't a second anesthetist at the hospital on that day, given the prevailing conditions (a full high-risk ward, a 1-2 hour wait for urgent c-sections)? Was the risk of being unable to access timely medical care communicated with the patient at the time the induction was started? Under the circumstances should Monica have been offered a repeat c-section that day instead of a trial of labour?

I wish the Cojocarus the best under the circumstances, and hope that the Supreme Court of Canada will uphold the $4 million award of damages - it seems to me that the system failed to deliver quality care to the Cojocarus and that Eric's injuries were entirely preventable. I will be watching this case with interest.

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."

Post - Over at 10 Centimeters Blog Today

While I am somewhat skeptical of the Canadian research on homebirth (every other country in the world shows an increase in relative risk to homebirth) - I am very thankful for the relative strength of the Canadian system of midwifery (highly regulated with high levels of credentials - at least in BC) and am thankful for the good work of midwives in Canada providing quality care to pregnant women.

In the US, the situation is much different. My understanding is that CNMs (Certified Nurse Midwives) are similar to Canadian midwives, and are respected professionals who provide quality care to pregnant women - frequently providing that care in hospitals in collaboration with other professionals such as OBGYNs. However, many midwives who provide services to women who desire to birth at home in the US have little more than a post-high school certificate. This is concerning and dangerous. As such my comments on the HomeBirth Consensus Summit apply to the situation (as I understand it) in the US. My post on http://www.10centimeters.com/ is as follows:

The Nine Statements of Consensus from the Home Birth Summit: Nine Times Nothing is Still Nothing

There are substantive and real issues confronting the home birth and obstetric communities in the United States. Having a summit could have moved things forward, fairly substantially, if they actually took the 9 pre-determined agreed upon consensus statements and used them as starting points, instead of accomplishments – because nothing is accomplished as a result of the statements made.

#1. We uphold the autonomy of all childbearing women…

Autonomy in the absence of complete and unbiased information is meaningless – there cannot be free informed choice when the information given to women on childbirth is incomplete or biased. A woman must be informed of the risks and benefits of the choice she is making if she is to be empowered to make the choice that best meets her needs and the needs of her child. If the autonomy of childbearing women is to be upheld, there must be a consensus on what the real facts of childbirth are, and a commitment to providing that information to women in an unbiased and accessible way.

#2. We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…

Again a really lovely idea, but, clearly there are substantial barriers to making this a reality in the current system. In order to collaborate, midwives and OBGYNs need to speak the same language. In order to collaborate, midwives and OBGYNs would need to hold each other in esteem and respect. In order to collaborate, they need to facilitate the work of one another. This means that when a woman who is at risk in labor is transferred to hospital for care, the hospital is prepared for her arrival before hand and the midwife is capable of giving full and appropriate information about the woman and her labor to the OBGYN upon arrival.

#3. We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…


Homebirth as it exists in the US today does not ameliorate disparities in access, delivery of care, or outcomes – it accentuates them.

Women in the US are far more at risk accessing the homebirth system than the hospital birth system. They are at risk of having a care provider who does not undertake standard and appropriate prenatal care (gestational diabetes testing, group B strep testing, weight and fundal height measurements, and pre-natal ultrasounds). They are at risk of having a provider who does not have adequate and appropriate education and experience. They and their babies are at greater risk of death or disability and they are at risk of having a provider who does not carry malpractice insurance and who would be held accountable to a lower standard of care in the event of death or disability.

There will continue to be disparities in access, delivery of care and outcomes and these seem unavoidable in the current context.

#4. All health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice…

This begs the question what is the appropriate standard? Furthermore, in the absence of legislation, what would be the consequence of failing to meet the standard?

#5. We believe that increased participation by consumers … is essential to improving maternity care…

Is this the facilitation of informed joint decision making during the care delivery process? If so, See number 1. Or, perhaps more meaningfully, will this mean that consumers would have a way of voicing their concerns and having those concerns heard in much the same way that hospital patients can have a formal review of the care they received?

#6. Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…

See #2.

#7. We are committed to improving the current medical liability system …

Another starting point – what medical liability system currently applies to homebirth midwives? Doesn’t a system need to be in place before it can be improved upon? Is there an insurer that would take on the risk in the current environment?

#8. We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….

So. Data is collected. MANA collects data. Does a $#!T load of good – unless you commit to releasing the data, it means nothing. Data existing does nothing without it being available to be analyzed, actually having it analyzed and releasing the results of that analysis. Furthermore, there needs to consensus on what data elements are critical and the definitions of those elements – this is essential if the data across birth settings are to be comparable and the data is to be transformed into meaningful information.

#9 We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies…

This seems at odds with valuing patient autonomy, particularly when not all pregnant women giving birth would choose physiologic birth if given complete information to make an informed choice. Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?