Mojito Por Favor

I've been enjoying some sun, some sand, some nuptials, more sun, more sand and mojitos the last 5 days, as such posting has been sporatic, Imanticipate more regular posting upon my return to Northern climes November 22...

The Haunting of Mrs. W.

I never took the decision to request a csection lightly. I had my reasons for wanting one - I wanted to know with a fair degree of certainty what my experience would be like, I wanted to reduce the already small chance of a catastrophic outcome for my baby, I wanted to protect my pelvic floor, I wanted to avoid an emergency csection and the risks associated with that, and I wanted to keep the girly bits I had largely as they were - for they were mine and I was comfortable with them. I didn't particularly fear labour pain (although I certainly do now), as I could not conceive what labour pain was like. It was my body, my choice and I decided c-section.

I breathed a big sigh of relief when I secured a date for the surgery.

Then, I arrived and fasted and I got bumped....

No worries, it's not like I was in labour.

And then bumped again...oh well, I still wasn't in labour.....AND then I was....

The c-section didn't happen. An epidural didn't happen. Fentanyl and gas. 2nd degree tears. Upon birth, my daughter needed resuscitation and Narcan.

The experience haunts me to this day....

I could have handled surgery, I would have been over surgery by now. Instead every now and again it hits me like a steam engine. It's a terribly depressing thing to know that choice, particularly choice on a matter so personal is an illusion. I have no confidence I won't (if I decide to have another child), be there again.

But isn't it worth it, to have a healthy child?

I would give my life for my child....but it's disturbing to think that my autonomy as a person, my ability to say my body, my choice could be so readily violated - in the absence of any medical justification to be deprived of those services. It's revolting to know that such services exist, and that as a result of some sick game between the BCMA, the anesthetists, the ministry of health and VIHA, timely access to medical care was denied.

The Sound of Crickets Chirping

There are days when I feel incredibly alone. Today is one of those days. There are not many women who plan an elective pre-labour c-section, make it to the surgery date at 39wks+1d, get bumped 2 days and then have an epidural free SVD.

I know I should not be mired in that day, but today I am, and it sucks.

I don't know when (or even if) I'll ever make peace with that day, if I'll ever get over the anger at the system.

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."

What I want

I want to know that if I plan on an elective csection at 39 weeks gestation - I will get an elective csection at 39 weeks. Is that so much to ask?

It didn't happen last time. I have no reason to believe it will this time.

And this time isn't even 39 weeks away yet.

And that is why, I am in a less than stellar mood today.

Three Months...

Three months have passed since baby Ava was born still at Victoria General Hospital. Still there is no dedicated obstetric anaesthesiology at Victoria General Hospital, Royal Columbian Hospital or Surrey Memorial Hospital.

How many more months before women in BC giving birth in level 3 hospitals get access to appropriate resources during labour and delivery?

Why care about Dedicated Obstetric Anesthesiology in level 3 hospitals in BC?

I'm not an an anesthesiologist. I'm not a hospital administrator. I'm a mom, and by the time the situation changes in Victoria, I'll likely be done having my babies. I guess that also makes me a pessimist because baby number 2 isn't even conceived as of yet - so it reveals how confident I am that the situation will change anytime soon.

I will also say, that my biggest problem with a lack of dedicated obstetric anesthesiology at VGH, Royal Columbian and Surrey Memorial isn't even that it removes the ability of women to reasonably decide whether or not they'd like a surgical birth, or have access to epidural pain relief (although I do believe this is a big issue - that is wrong and should be addressed). These are major hospitals that handle a high volume of births every year and serve high risk mothers. And there is the true rub.

There's a false perception of safety at these hospitals. Women believe that when the cards are down, they'll be able to get the care they need when they need it. If I were a mom who had decided that I wanted to attempt a vaginal birth after c-section - could I be confident that if my uterus ruptured, I'd get access to an OR within the critical timeframe and be saved from the agony of having to bury or care for a severely disabled child who was much wanted? Is it reasonable to think that the anaesthesiologist who is handling other acute cases will be able to drop everything and tend to my needs? Will the back-up anesthesiologists actually be called, will he/she answer the call and provide the service?

It's sad and frustrating. The province claims to be bending over backwards on this and saying the anesthesiologists won't budge. The anesthesiologists claim that its the BCMA and the province who are at fault and not budging to bring their pay up to what colleagues in other provinces receive. The patients are in the middle paying the real price.

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.

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?

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.

We Need More Krugmans in this World

One of the people who I greatly admire is Dr. Paul Krugman - he is an economist who has demonstrated a level of integrity and intellectual honesty that is rarely found. Furthermore, he's been brave enough to go beyond being an academic and has worked tirelessly to criticize bad public policy in a way that is widely accessible.

We need more Krugmans in this world. We need more people who really think about things, who can really identify problems and analyze them, and who are brave enough to voice their thoughts to the wider world. We need more thoughtful dissenters who refuse to go with the flow when evidence says that there's something wrong.

So when you see a Krugman - be thankful for the work that they do. It's not easy work, saying what doesn't want to be heard but needs to be said. They identify the problems and make solving those problems possible - and that work is immensely valuable and does affect change. Support the Krugman's you know, and encourage them. Without them our world would be a much lesser place.

Dr. Roland Orfaly - "B.C.'s health care is failing mothers, babies"

On October 5, 2011 the following story was published in the Times Colonist.

B.C.'s health care is failing mothers, babies

An external review of the Aug. 9 newborn death at Victoria General Hospital is now complete. Expectant mothers on Vancouver Island deserve better than the care which is currently available. So do mothers elsewhere in B.C., where the same problems are also being ignored by the provincial government.

By Times Colonist (Victoria)October 5, 2011

An external review of the Aug. 9 newborn death at Victoria General Hospital is now complete. Expectant mothers on Vancouver Island deserve better than the care which is currently available. So do mothers elsewhere in B.C., where the same problems are also being ignored by the provincial government.

Released last week, the report is critical of unresolved safety issues in VIHA's maternal and fetal program, many of which were identified in a 2010 report by Accreditation Canada. Among other safety issues cited in both reports, at issue is whether anesthesiologists' staffing was up to standards and adequate to properly meet the needs of higher risk obstetrical patients.

The external report is very clear. "There is restricted availability of anesthesia services to support obstetric operative procedures [C-sections]. This is a significant risk issue for the VIHA, which should be addressed immediately."

The reviewers recommend that Victoria General Hospital "establish a dedicated obstetrical anesthesiology [DOBA] service."

However, the review, commissioned by VIHA, is dismissive about the 20minute delay experienced Aug. 9 between the time the obstetrician called for a C-section and when that C-section began.

This is at odds with a resolution proposed by Liberal MLA Dr. Moira Stillwell and approved by a Surrey Memorial Hospital advisory committee in 2009. The motion reads, "Obstetrical anesthesia services at Surrey Memorial Hospital should be available within a timeframe of 15 minutes, 24 hours per day, seven days per week to ensure safe patient care."

I'm not sure why the standard for what is safe for women in Surrey is different from the standard for women in Victoria.

What is equally newsworthy is the report's view on staffing. "The Department [of Anesthesiology] would have to recruit additional members to provide DOBA 24/7." And that is the problem. Both VIHA and the Health Ministry claimed in August that "there is no shortage of anesthesiologists at Victoria General Hospital."

By denying a shortage that is evident to everyone else, the government is exposing its true colours. It has no intention of providing the additional anesthesiologist resources needed to ensure the safety of mothers.

Between July and October 2009, the Health Ministry directly contacted over 3,000 anesthesiologists from across Canada in an attempt to recruit staff for a DOBA program. Not a single applicant replied. The external report recommends, "Priority should be given to candidates with specialized training in obstetric anesthesiology." There were no interested candidates, with or without that training.

Instead of admitting its failure, the government has been cynically playing politics with the issue ever since. While ignoring women in the rest of the province, they've tried to download blame for the failed provincial recruitment onto the Victoria Department of Anesthesia.

The DOBA "offer" made through VIHA was identical to what had already been offered by B.C. - and rejected - by anesthesiologists everywhere else in Canada. As VIHA had to admit in August, much of the funding for the "offer" originated from money that was already being paid for current services being provided, leaving little to help attract new anesthesiologists to Victoria.

Solutions are available. Eighteen months ago, B.C.'s anesthesiologists offered to dedicate some of their own funding to help attract more anesthesiologists to staff DOBA in Victoria and elsewhere in B.C. With government approval, DOBA would have been up and running by now. The Health Ministry rejected our offer.

Meanwhile, taxpayers would also be better off with DOBA. Over $12 million per year in operating room resources are wasted due to the lack of DOBA staffing. While the on-site anesthesiologist is attending to obstetrical patients, the OR and its staff come to a standstill waiting.

Gordon Campbell kept promising, "The right care, in the right place, at the right time." What happened to that promise?

Patients and taxpayers in B.C. deserve better.

Dr. Roland Orfaly is spokesman for the Coalition of B.C. Anesthesiologists for Change. He practices at Royal Columbian Hospital in New Westminster.

© (c) CanWest MediaWorks Publications Inc.

Lack of Anesthetists Made Women Suffer

A letter I wrote a while ago to the Times Colonist was published September 29, 2011 as a story. Here is the story:

Lack of anesthetists made women suffer

It seems patient-centred care in British Columbia means that patients are left in the middle of the mess of the health-care system.

By Times Colonist (Victoria)September 29, 2011

It seems patient-centred care in British Columbia means that patients are left in the middle of the mess of the health-care system.

The review of the August stillbirth at Victoria General Hospital found the reduction in access to anesthesiology since May 31, 2010, resulted in a decline in the quality of care experienced by maternity patients, as those patients are now dependent on the resources of the main operating room.

This has resulted in many scheduled C-sections being delayed, inadequate access to timely pain relief during labour and delivery and increased risks to both mothers and babies. These problems were identified in the Failure Modes and Effects Analysis in 2010 and when Qmentum completed its accreditation process in 2010.

Further, there were resignations and reports in the media about concerns over the quality of care for labour and delivery in Victoria, and in other tertiary level hospitals that do not have access to dedicated obstetric anesthesiology.

Despite this prior information on the risks and impacts of reduced access to anesthesiology for labour and delivery patients in level III hospitals (Victoria General, Surrey Memorial, and Royal Columbian), the health authorities, Health Ministry and anesthetists did not remedy the problem in a timely way. The only level III hospital with dedicated obstetric anesthesiology continues to be B.C. Children's Hospital in Vancouver.

The women who have given birth in these hospitals and have had scheduled C-sections delayed or denied and the women who have had epidurals delayed or denied have suffered immensely.

The ministry, the health authorities and anesthetists need to be accountable for the denial of access to quality, timely and medically necessary services.

Janice Williams

Victoria

© (c) CanWest MediaWorks Publications Inc.

Zombie Statistics that Just Won't Die

A couple of years ago the WHO retracted their statement that c-section rates above 10-15 percent illustrated an excess use of the procedure. They retracted this statement in 2009 - because it was based on absolutely no real evidence. Yet in 2011 - this zombie statistic continues in it's undead form to haunt everywhere, all the time.

Targeting any particular rate of intervention or non-intervention is a fool's quest. Targeting a particular method of delivery is absurd. These targets put process ahead of outcome and do nothing to advance the health and well being of mothers and babies.

Want a meaningful target - how about lowering the rate of maternal mortality. Lowering infant mortality. Lowering rates of birth attributable disability. Improving maternal satisfaction. How about reducing the rate of post-partum depression. Maybe reducing the rate of post-traumatic stress disorder might be good too.

Shift the focus to OUTCOMES, real OUTCOMES and maybe, just maybe, things will get better for moms and babies.

Celebrating the Updated NICE Guidelines in the UK

I am thrilled that in the new NICE guidelines in the UK, women will be given the right to request an elective c-section for the delivery of their child. This is a hard fought victory for many women that has come after years of hard work.

It's a huge step forward because it recognizes that patient autonomy matters. That the right of women to decide how they birth their child matters. It signals that women and their health matters and that access to healthcare should not be limited because the patient is a woman and the condition is pregnancy. It says informed choice matters, and part of informed choice is being aware of the risks of 'natural' childbirth and being able to choose which risks to accept. Further, it signals that health care should be about quality care, and not just cheap care.

I'm particularly proud of the work done by Pauline McDonough-Hull in making the recent guidelines a reality. She has worked tirelessly on this issue for many years, and now something real to show for it. She is an inspiration.