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

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

Is the 'Power to Push' campaign dangerous?

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

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

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

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

Why doing something is important

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

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

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

Letter Sent to VIHA's Patient Care Quality Office

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

Dear Vancouver Island Health Authority, Patient Care Quality Office;

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

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

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

Sincerely,
Mrs.W

The Cost of Cheap Healthcare

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

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

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

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

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.

Wrapping my head around...everything

I spend a lot of time in the space between my ears. Thinking about my last pregnancy and birth (mostly birth). Thinking about the health care system in BC - often as it pertains to maternity care. Thinking about whether or not any of it really matters...and if it does matter thinking about what I can do about it. Thinking about the future, and the next pregnancy. Thinking about what kind of health system my daughter will face when she is approaching motherhood.

The only conclusion I have come to is that my experience can not be without value or purpose - which is more of a beginning than a conclusion.

I have started in motion what I hope will be an effective way of making my experience (and those of others) matter. Only time will tell if that is truly the result of my actions. I hope for courage and strength...and to repair some of the damage done.

Am I nuts to consider trying for #2 when nothing in the system has changed??

My husband is on board with the idea that we should begin to try for number 2...that active efforts to prevent pregnancy should cease in the hopes that my daughter will have a little sibling.

Am I nuts for even considering this, NOW? Nothing in Victoria has changed, I am not overly convinced that it will change before the end of the as yet to commence next pregnancy. I'm fairly certain that I will again request a c-section...but am I confident that I'd be able to attain such a birth plan? Not in the slightest. The OBGYN I had last time has decided to go into oncology...so I'd even have to find another OBGYN who would be sympathetic to the request, and then I'd have to hope (and pray, and hope some more) that the actual resources would be there when I needed them.

What are my options? A private birth, isn't an option in BC - there simply isn't anywhere where I could even 'pay' to ensure that I'd have access to an epidural/c-section....Perhaps birthing in Alberta? But again that might not be entirely realistic....

And what if its just a replay of the show I've already seen...is the happy ending good enough? Do I just lay back and let my autonomy as a woman be violated again? --there goes my jaw, it's clenched again.

Quality care in our system - it does exist!

Today I got a call from my daughter's daycare - they were trying to get a hold of another mom who works on a different floor and with whom I am friends. Her son had fallen while racing around (as toddler's are apt to do) and he had sustained a gash on his forehead that would need stitches. I volunteered to hunt down the mom, and bring her to the daycare (in the same building). I was able to get to my friend within 5 minutes of recieving the call and we were at the daycare a few moments later. We decided to take my car as it was parked closer, and it was also equipped with an appropriate car seat. My friend was in no condition to drive.

We arrived at the RJH emergency department - I dropped of my friend and her son so that they could check in while I parked the car. Not knowing how long the wait would be I put in 2 hours on the meter. As she was checking in, I called the daycare for further details on the injury as we were in such a rush we didn't ask when we picked up the boy. I went to retrieve a soother for the toddler from the car and by the time I got back, the boy and his mom were waiting for treatment. Within 5-10 minutes we were directed to the treatment room where the doctor assessed the gash, and got nurses to restrain the child while he was stiched up. Five stitches later and we were back on our way. The parking meter still had an hour and 30 minutes on it. I was impressed - and the experience was much better than any other experience of the health system I have had in the last year and a half!

From the time I left my desk, to the time I returned it was an hour and fifteen minutes.

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

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

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

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

External Review into Infant Death Released

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

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

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

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

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

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

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

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.

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?

What I believe in....

Motherhood Parenthood has a way of changing people...often for the better but not always. For myself, I never quite understood things, the way I understand them now.

For example, before I was a mom I couldn't before imagine why a highly educated woman (or man for that matter) with a satisfying career would abandon it for the full-time-stay-at-home-and-get-paid-nothing gig. I understood how a person could put their kid in daycare, day-in-and-day-out but not the flip side. I get it now. If it were possible, I would opt-out of the full-time job (but not fully out of my professional activities) and I would be there more now. I now get that my child is who she is for such a very short period of time and that the role of 'mom' is so much more than I had previously thought. It's so much richer and more meaningful than I gave it credit for - I'll even concede that its more meaningful than what I get paid to do (so perhaps I ought to be doing something more meaningful that gets paid??). That being said - having a stay at home parent must be a joint decision and until certain other things are done, it's just not feasible right now - but if it were, I would be there now instead of in my office.

I now also have a new perspective on a lot of parenting - one that has eased up A LOT. I'm a lot more individualistic now - more of a 'if it works for you, then run with it!' kind of girl - with the caveat of course that a person should be fully informed so that they are making the best choice for themselves and their kids. As a result I'm neither pro-breastfeeding nor pro-formula...I'm neither pro-natural child birth nor pro-medicalized childbirth (but I'm definitely not pro-natural child birth when it comes to me and my girly bits) rather I am pro-whatever-is-in the best interest of the mom/dad and the baby...I now think that many parents are far too hard on themselves and don't give themselves enough credit for what they do right - there's a whole lot of parents who aren't failures (by any measure that really counts - like the health and happiness of their own children and families) that feel like they are. Lastly, I'm more socially minded - I don't think that I matter as much as I used to matter.