A Roll of the Labia: The Impact of Childbirth on Sex and Vaginas

There are times when I really miss the way things once were "down there" - times when I'm quite honestly miffed that things aren't quite the way they once were, in part because I believe that had I had a c-section things would be 'the same'. Mr. W. swears its good - but sometimes I wonder if he's just being polite, because it isn't the same for me, so I can hardly imagine that it is as it once was for him. That's not to say that it is bad, it's just different. It's like going to your favourite restaurant only to discover that it's no longer there and has been replaced by some other establishment. You don't know the menu and you've got a deep craving for the old restaurant's 'house special' - but the thing is you can never get the old restaurant's 'house special' again, you're hungry and there is no other restaurant in town so you must learn the new menu. You just wish you would have known before hand that your favourite restaurant wasn't going to be around anymore so that you could have enjoyed and savoured the old restaurant's 'house special' one last time before it was no longer available.

Maybe it's un-lady like or vain to care about anything other than whether or not there's a healthy baby and being able to go about mothering in as short order as possible; a vagina's purpose is to give birth after all - using it for sex is just secondary. Except for many women (myself included), childbirth is/was a secondary purpose, one that I certainly would have exempted my vagina from ever having doing if I had been given the choice.

I imagine if men gave birth, they'd know exactly what the impacts of doing so would be on their penises' form and function and how that varied by mode of delivery. They'd have measured every aspect, both before and after - and would have reems of scientific studies and data on the matter. Of course because men don't give birth - there's scant information out there on how childbirth and mode of delivery impacts the form and function of vaginas.

One scientific study I found, "Sexual function, delivery mode history, pelvic floor muscle exercises and incontinence: A cross-sectional study six years post-partum", by Dean, Wilson, Herbison, et. al in the Australian and New Zealand Journal of Obstetrics and Gynaecology 2008; 48: 302-311 - seems to indicate that delivery by caesarean confers some benefit in this department. The study received responses to sexual function questions from 2765 women at 6 years post partum and found that women who had delivered exclusively by caesarean section scored significantly better on questions relating to their perception of vaginal tone for their own and partner's satisfaction compared to those who had vaginal and instrumental deliveries.

While not scientific in nature I decided to ask a group of mothers who had given birth to indicate whether or not they had delivered by cesarean or vaginal birth and whether or not things were "better", "worse" or the "same". Thirty women in total responded, 12 who had experienced vaginal births or vaginal and cesarean births and 18 women who had experienced only cesarean births. Among the vaginal or mixed birthing women only 2 (16.6 percent) indicated that things were "the same" - 4 (33 percent) reported that it was better 5 reported that it was "worse" (42 percent) and one reported that it "was different but not bad". Among the 18 women who experienced caesarean births 10 reported things as being "the same" (55 percent), 3 reported things as being "better" (17 percent), 4 reported things as being worse (22 percent), and one reported that "sex isn't the same" but did not indicate if it was any better or worse. From this informal and non-scientific survey among women who had vaginal births, 50 percent indicated that things were the same or better meanwhile among those who had caesarean births 72 percent indicated that things were the same or better.

I would think that women's sex lives should matter enough to study this further...

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...

Vaginal Birth Roulette (Part 2): Data From the BC Perinatal Services 2007/08

Another source of information on birth in BC is the Perinatal Services Annual Report. The most recent report is for fiscal 2007/08. According to this report, among women giving birth for the first time, fewer than 1 in 2 (49.7 percent) had a spontaneous vaginal delivery, fewer than 1 in 2 (47.5 percent) had epidural anesthesia and more than 1 in 6 (17.3 percent) had an instrument assisted delivery. More than 1 in 3 first time mothers (33 percent) delivered by caesarean.

It is interesting to note that of the 53.2 percent of women considered "normal" at the onset of labour (spontaneous onset of labour, singleton in vertex presentation, no previous caesarean, term gestation of 37-42 weeks), 3 in 4 had a "spontaneous vaginal delivery", with 12.4 percent having an assisted vaginal delivery and 11.3 percent having a cesarean section. Among nulliparous moms meeting this criteria 60.2 percent had a "spontaneous vaginal delivery", while nearly 1 in 5 had either an assisted vaginal delivery or a caesearean section. Among women who have previously given birth meeting the definition of "normal" at the onset of labour, nearly 93 percent go on to have "spontaneous vaginal delivery" while 1 in 20 (4.8 percent) have assisted vaginal deliveries and about 1 in 39 (2.6 percent) have caesarean sections.

Only 38 percent (neraly 2 out of 5) of all caesesareans in British Columbia in 2007/08 were elective caesareans (and of that the vast majority of these had a 'medical indication'). The BC perinatal services annual report lumps in maternal request with VBAC declined indicates that 4.1 percent of births fall into this categoy. Assuming all of those are planned c-sections 543 maternal request/VBAC declined caesareans were undertaken in 2007/08 - accounting for 10.5 percent of all elective caesareans. I note that the vast majority of these are likely to be VBACs that were declined - and I personally would not consider declining a VBAC to be a "maternal request c-section". Sixty-two percent (more than 3 out of 5) of all caesareans in BC in 2007/07 were urgent or emergent.

As a percentage of all vaginal deliveries - the risk of a 3rd or 4th degree laceration was 4 percent. Episiotomies happend in 9 percent of cases. Slightly less than half of all vaginal births in first-time moms involved use of an epidural and around 30 percent of all vaginal births involved use of an epidural. As stated in a previous blog post - there is a large discrepancy in epidural use in BC compared to other provinces - which suggests to me that there may be some issues related to accessing this form of pain relief in BC.

Deconstructing the Cost of Planned Cesarean Delivery

Some people claim that women should not be free to plan a cesarean delivery because cesarean deliveries cost more than vaginal deliveries, and in a publicly run health system (like in Canada), that is unacceptable as it places an unneccessary strain on the system. As a result, the violation of patient autonomy and charter rights is "justified".

This claim needs to be deconstructed because such a violation should only happen when it can be demonstrably justified in a free and democratic society.

I believe this claim can be clearly deconstructed using data from the the Canadian Institute for Health Information's Patient Cost Estimator
I note that all data is for the province of British Columbia.

For convenience, I will assume that all repeat c-sections are planned c-sections, even though many of them will include failed vaginal birth after cesarean attempts (which would be at a higher cost as they would be emergent procedures). The average cost of these in 2008/09 was $3,410. Also for convenience, I will assume that all other births were 'planned vaginal' births regardless of whether or not they resulted in an 'actual vaginal delivery'. I note that some primary c-sections would have been lower cost planned c-sections for bonefide medical reasons, however, the vast majority of them are likely emergent/urgent c-sections done as a result of complications that emerged during labour. Weighing these births by volume, the weighted average of planned vaginal delivery in BC in 2008/09 was: $2,938.45. I note that this is likely an underestimate of the cost of planned vaginal delivery.

So, according to this back-of-the-envelope calcuation, how much does the health system 'save' by denying a women the right to choose a cesarean delivery based on these rough estimations:

That's right ladies and gentlemen - violating a patient's autonomy in BC in 2008/09 saved the health system an estimated $471.55. Assuming that 2 percent of all 'planned vaginal deliveries' would have choosen a cesarean (approximately 721 women in 2008/09), the health system saved $340,091.44. That's less than 0.3% of the money spent on deliveries in the health system in 2008/09 and less than 0.0025% of the total $15 Billion health budget in 2008/09. In 2008/09, to allow all women in British Columbia who would have choosen cesarean delivery to do so would have cost less than the amount that was paid to Vancouver Island Health Authority's CEO in salary and benefits ($417,425) in 2007/08.

I note at my therapist's rate of $160 bucks per hour is less than 3 hours worth of therapy. I'm reasonably convinced that my birth experience will need more than 3 hours of therapy to deal with - so in my particular case, denying my right to choose how my child was born will likely cost the system MORE than if the pre-labour cesarean had been granted.

I also must note that this cost difference does not include the costs that are associated with correcting the impact of vaginal delivery on the pelvic floor, the cost of caring for permanently disabled children who were injured during their mothers' planned vaginal deliveries, or the cost of birth related litigation.

So to those who say that planned elective cesarean is not a valid birth choice on the basis of cost - I would say that they need to take a long, hard look at some real numbers. I would further hope that preservation of one's charter rights should be worth more than $471.55 - which is likely a gross overestimate of the actual cost difference between thes modes of delivery.