The Canadian Referral Process

I had my appointment with my GP today to get a referral - I spent more than half the time crying. I told her that I do not want to be referred to Dr. X or Dr. Y because of what happend last time - that I did not want a vaginal birth last time and after being bumped for 2 days wound up with an epidural free vaginal birth. Under no circumstances do I want a vaginal birth this time. I gave her the names of 3 OBGYNs that I'd prefer to be referred to - the problem is that in Canada OBGYNs generally don't handle uncomplicated pregnancies. The practice in BC is to refer to a general practitioner who does maternity care or a midwife - then have that person refer to an OBGYN at 33-35 weeks. My problem with this, is that waiting until 33-35 weeks is cutting things just a little bit close. How do you establish a relationship at that point? How do you trust that they'll go to bat for you at that point? Worse, if you don't like who you're referred to, is there enough time to get a referral somewhere else?

Why is it that only women who desire vaginal births, deserve continuity of care?

I'm hoping one of the OBGYNs on the list will take me on...sooner as opposed to later. If it's not possible, I should just firm up my plan to deliver in the US - and consider it the price to pay for piece of mind.

The Challenge of Finding a CDMR Friendly Doctor in Canada

Maternal request c-section in Canada is controversial - the Society of Obstetricians and Gynaecologists of Canada is explicit in its criticism of the practice and government has aggressively promoted normal birth (see The Power to Push campaign).

In all honesty, it is far easier in BC to find providers supportive of Homebirth, even for first time mothers; than it is to find providers supportive of maternal request c-section. There is no listing of maternal request c-section friendly providers (you can actually google 'home birth' Victoria, BC and get a bunch of names of providers who support this service - including the "Home Birth Association of BC"). Further, providers in Canada must operate within the constraints of the health authorities. As such a mother who requests a c-section, without any underlying medical indication, is directly at odds with aggressive attempts to lower the c-section rate - and at odds with all the other demands for the same set of resources. As such there is little to protect a woman's right to choose delivery mode and have her choice respected.

Today I go to my doctor, much as I did over two years ago - and will ask to be referred to a maternity care provider. Except, this time, I will be more blunt - this time, I will not trust blindly. I'm nervous...and rightly so - I have no confidence that if I were to give birth here, that I could expect any different of an outcome than I had last time.

A Note to Little Bean

Dear Little Bean:

I am sorry, I have not been able to greet news of your pending arrival with the unfettered joy that accompanied news of your sister's pending arrival. I did not pee on three pregnancy tests, as I did with your sister, just to make sure it is real...I peed on one. I peed on one - and greeted the news with a combination of happiness, but also a great deal of anxiety. I did not call every one who needed to know within mere moments of seeing the news - I've told a few people, first your daddy - we drove by daddy's office and had your sister hand him the pregnancy test. And a couple of days later your Grandma J and Grandpa G, your aunts T and W and uncle M and a few close friends - your Grandmas P and B still don't know. I did not immediately call my doctor to get a referral to a maternity care provider - rather I only just placed that call today, a week after 'seeing' the news. Since seeing the news, my sleep has been less than stellar - in part because of your big sister, but also in part because of my own worries and anxieties. My worry that my trust and confidence will be betrayed again. My worry that despite having a plan (albeit a rather pricey one) - that something will happen to frustrate that plan. My utter terror of being again in the worst pain of my life, out of control, and without choices that I thought I had...knowing that this is possible, is very frightening to me.

I am sorry, that I am unable to confidently welcome the news of your pending arrival, I wish that was different - but little bean, please know - that you are very wanted and your mother's anxiety and fears have nothing to do with you, and everything to do with the context in which you are coming to be. You are loved and wanted, and I will deal with it as best I can.

Forgive me little bean - my response to your pending arrival, is just another unfortunate consequence of what happend when your sister came into this world. It's not your fault, it's not hers - but it sucks. It sucks that I can't greet this news with the unfettered joy that it deserves to be greeted with. You are wanted and loved, and I will do everything to ensure your safe arrival into this world.

Love,
Mommy

A Shout Out

I wanted to give a shout out to my readers, particularly those who have commented and let me know that I'm not alone, that my story resonates with them, that my story has generated a better understanding of women who request a surgical birth for delivery of their child.

Because of you, I have felt less alone.

Because of you, I know that this time, it's very likely to be different.

Because of you, I know that writing about this matters.

Thank you.

Mrs. W

Daunting Prospects

I haven't made an appointment with a maternity/prenatal care provider yet. In part, because I don't know who to trust. With Juno, I had peed on a stick in the morning and had made an appointment with my Dr. for a referral to a maternity doctor before morning coffee break. The positive pregnancy test was 5 days ago...

The prospect of finding somebody to trust is daunting. I would prefer an OBGYN to a maternity doctor - but for the most part you need to be referred to an OBGYN by your Dr./Maternity Care Provider. I wish I could self refer, meet a few of them and figure out who might be a best bet in this situation. I hate the idea of repeating what in hindsight may have been a mistake last time.

On the same token I know that its important to plan as though plan A for whatever reason won't materialize. I could go into labour early (given how quickly things progressed last time with me doing everything I could to not assist the progression - this is a very scary thought). I could wind up with a complication that would make travel ill advised. I could find myself with a bonafide 'medical indication' for a c-section. All of which might make plan A infeasable/unneccessary. All of which makes having somebody I can trust here, somebody who will go to bat for me here, that much more important.

So who?

A Chance for Things to Be Different

It's early days, but it appears that the W household will be welcoming a new addition in September. I'm nervous, but I'm also cautiously optimistic that this time I'll succeed where I succeeded last time (a healthy full term baby), but also succeed where I failed last time (securing my delivery mode of choice). In part this is because I have identified a doctor and a hospital that are likely to respect my choice - all be it, it will come at a cost.

As it is early days (I'm anticipating an expected due date of September 20, 2012) my first hope is that I make it past the first trimester. Up to 20% of all pregnancies end in miscarriage - as such, while there's a BFP (big fat positive) on the home pregnancy test, that is just the first hurdle towards the ultimate goal of a healthy and hopefully happy new baby joining our household. At the very least, it's reassuring that Mr. W's vasectomy reversal is holding up well.

Next on the to do list: find an OBGyn for my prenatal care. For obvious reasons, going with the same set of Dr's as I did last time, would be a serious error in judgement. As is, it's going to be hard to establish the trust that was lost as a result of what happened last time around.

So there you have it, option 5 (forego baby #2) is officially struck from the list.

A Canadian Woman's Right to Choose Delivery Method: Is a Legal Precedent Needed?

In Canada, in 2012, a woman who wants to "choose Caesarean", absent any medical indication for one, as her mode of delivery, has little reason to believe that her informed choice to do so will be respected and many reasons to believe that she will be subjected to a trial of labour and potentially a vaginal birth that she does not want.

This is why, I am planning on an elective caesarean at term in the US for my next delivery: I have no reason to fully trust that my informed choice in Canada would be respected.

Don't get me wrong, there are women in Canada who do manage to secure an elective c-section, without medical indication - but it is a bit of a roll of the dice. There is nothing here to assure a woman that she has a "right" to that choice. There is no legal precedent and the Society of Obstetricians and Gynaecologists of Canada (SOGC) are not supportive.

Absent a legal precedent, or a change in policy from the SOGC or being blessed with a medical indication such as "breech" - my next baby will very likely be born on American soil. For the record I think a legal precedent is possible (there IS a charter argument to be had), I also think a change in SOGC guidelines is possible - I just think neither are likely before the arrival of the next baby W.

Agreement for Dedicated Obstetric Anaesthesiology at Victoria General Hospital is Reached

I am very pleased to find the following most welcomed news this morning:

Agreement Reached for Dedicated Obstetrical Anesthesiology Service at VGH

January 9, 2012
JOINT STATEMENT BY THE VANCOUVER ISLAND HEALTH AUTHORITY AND DEPARTMENT OF ANESTHESIOLOGY:

Agreement Reached for Dedicated Obstetrical Anesthesiology Service at VGH

VICTORIA – Mothers giving birth at Victoria General Hospital (VGH) will benefit from enhanced anesthesiology and pain services.

The Vancouver Island Health Authority (VIHA) and Department of Anesthesiology are pleased positive discussions have resulted in an agreement for a program that will deliver dedicated anesthesiology services to obstetrical patients and provide a dedicated pain service for inpatients with a focus on epidural anesthesiology for mothers in labour.

“VIHA is delighted an agreement has been reached,” said Howard Waldner, VIHA President and CEO. “The improved service will provide an increased number of dedicated hours of service for the 3,000 mothers who deliver their babies each year at VGH, and will pave the way for an exceptional program for women and their families.”

Speaking on behalf of the Department of Anesthesiology, Dr. Craig Bosenberg, Medical Director, Anesthesiology and regional head of the department for VIHA stated: “We are extremely pleased to have reached an agreement on this very important service for mothers and their babies. We look forward to partnering with the dedicated professionals who provide obstetrical services at VGH to establish this new service as quickly as possible.”

Improvements will result in 24/7 Dedicated Obstetrical Anesthesiology (DOBA) and pain service at VGH, incorporating an on on-site anesthesiologist dedicated to obstetrical care. VGH is the location for tertiary obstetrical services on Vancouver Island, providing care for high risk mothers and babies, as well as being the site for regular obstetrical services for South Island residents.

Dr. Gavin Sapsford, President of the Association of Victoria Anesthesiologists (AVA) stated: "The AVA welcomes the agreement which will benefit all women admitted to the obstetric unit as well as their families and new babies from both Vancouver Island and the rest of BC.”

The new service will be phased with full implementation in summer 2012, following recruitment of additional anesthesiologists. VIHA and the Department of Anesthesiology have a number of qualified potential applicants for these positions.

The agreement will see additional funding of approximately $1 million to support the development of this important service. The agreement will also allow all parties to make progress on the implementation of the recommendations from the September 2011 independent review commissioned by VIHA into tertiary obstetrical services at VGH.

– 30 –

Media Contact:
Shannon Marshall
VIHA Communications
250.370.8270

I only hope that this is not yet another false start, as it is my understanding that VIHA and Victoria General Hospital tried to implement Dedicated Obstetric Anaesthesiology in 2009, but failed to do so as no anaesthesiologists applied for the position.

Further, my heart goes out to those women who were unable to access timely access to pain relief and medical care during their labours, and those who may be unable to do so until this service is fully implemented in the summer of 2012.

Make Maternity Better: Focus on and Measure What Really Matters

Physically and psychologically healthy mothers and babies are what really matter - the process of how that happens should be secondary. So why do we measure and focus on the process and almost entirely ignore the desired outcome? Further, do the things we measure, really tell us what we need to know, to make maternity care in North America better?

The first goal of maternity care, should be to minimize the number of women and children who die as a result of the childbirth process, particularly those who die preventable deaths. Currently, statistics in Canada and the US are kept on infant and maternal mortality, however, statistics on preventable deaths are generally absent. We should measure what matters: what is the rate of preventable infant and maternal mortality in Canada and the US? Measuring this would be a first step in identifying the circumstances under which a preventable death is more likely and would enable action to minimize the risk of preventable deaths of mothers and their infants.

The second goal of maternity care should be to minimize the rate of serious physical injury to either mothers or babies and in particular the rate of preventable serious physical injuries. We generally measure serious maternal and infant morbidity, but tend not to measure the degree to which such morbidity would be preventable.

The third goal of maternity care should be to minimize the incidence of psychological harm to mothers as a result of the birth process. Currently, this is very poorly measured (if at all). There's a real opportunity to make maternity better by better understanding and measuring maternal psychological morbidity. Birth is a physical process, but its also a psychological process and its time that, that was better recognized.

We need to move away from the goal of maximizing 'normal birth', as normal birth in and of itself is not what really matters (physically and psychologically healthy moms and babies matter - regardless of whether or not they came into the world vaginally or surgically). We need to move away from the goal of maximizing breastfeeding, as breastfeeding in and of itself is not what really matters (physically and psychologically healthy moms and babies matter, regardless if they are breastfed or formula fed). It is entirely possible that by focussing on what really matters, rates of normal birth and breastfeeding might increase - but if they happend to decrease and rates of what really mattered improved, would that be such a bad thing?

It's time to radically change the business and religion of being born in North America, by shifting the focus to measuring what really matters.

On Being Canadian and Wanting a Maternal Request C-section

Despite being cultural cousins, there are significant differences between Canadians and Americans. We have gun control. They have a constitutional right to bear arms. We have universal health care. They don't yet have unversal health care. We have highly trained and regulated midwives. They have the "Certified Professional Midwife"...which is a very different critter (see The Skeptical OB for more on this).

One significant difference that I failed to appreciate while I was awaiting Juno - is the significant difference between the Society of Obstetricians and Gynecologists of Canada(SOGC) and the American Congress of Obstetricians and Gynecologists (ACOG).

The Society of Obstetricians and Gynecologists of Canada (SOGC) has produced a Joint Policy Statement on Normal Childbirth - in December of 2008. In it there are some serious contradictions, on one hand "6. All pregnant and birthing women and their families should be able to make informed choices. All candidates for normal birth should be encourage to pursue it." and on the other hand "4. Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." and "5. A Caesarean section should not be offered to a pregnant woman when there is no obstetrical indication.". Also of interest is In short, the SOGC is supportive of informed choice, so long as that choice is "Normal Birth" wherever and whenever possible. It is clear that the SOGC is well aligned with the practice of midwifery in Canada.

Compare this with the American Congress of Obstetricians and Gynecologists who put out their stance on maternal request c-section in December 2007 and reaffirmed it in 2010. The ACOG recommends that "1. Cesarean delivery on maternal request should not be performed before gestational age of 39 weeks has been accurately determined unless there is documentation of lung maturity. 2. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. & 3. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta and gravid hysterectomy increase with each cesarean delivery." Overall, the ACOG is reasonably supportive of maternal request c-sections, provided some very reasonable conditions are met. I might argue that the unavailability of effective pain management (ie. lack of epidural access) might be considered a legitimate reason to request an elective c-section, given that unmanaged pain during labour likely predisposes a woman to post-natal PTSD.

I should note that I had heard of Canadian women successfully planning c-sections, IN CANADA, without medical indication before - I therefore thought that surely if one was clear in her request, consistent in her wishes, that this was something I too could secure. All I needed to do was ask to be referred to a doctor who was open to maternal request c-section and ask to be referred to an OB who would agree (after providing information on the relative risks and benefits) to perform the procedure. I did that, it didn't happen.

So if I were in those shoes again - a Canadian nullipara, informed on the risks and benefits of elective c-section vs. vaginal birth and intent on planning an elective c-section; knowing what I know now about the stark difference in stance between the ACOG and the SOGC; I would have bit the financial bullet and would have given birth in the USA. It is also pretty clear to me right now, that if I want #2 to be born via elective cesarean at term, I might stand a much better chance of achieving that goal south of the border.

Alternatively, if I were an American worried about the intervention happy ACOG, perhaps I would go North - in pusuit of 'normal birth'.

The Misogyny of Childbirth and Motherhood

There is nothing that is more in the female domain than childbirth and motherhood, and over the last few years, I have come to the conclusion that there is also nothing that is more of a hotbed of unadulterated mysogyny than the discourse on childbirth and motherhood.
And much of the hate is levelled at women, by other women - most of whom are claiming to be feminists while they seek to disenfranchise other women who don't happen to share their same views or wouldn't happen to make the same choices.

The women who trailblazed the freedoms that today we take for granted, would hang their heads in shame and disgust at the current situation. They fought so women could choose to meaningfully and fully participate in society. They fought so that women could be autonomous individuals - who are empowered with the right to free choice.

Would a real 'feminist' sink so low as to outrightly disparage another woman for freely making a decision that is different from her own? Would a real 'feminist' disparage another woman who is working to provide unbiased information that allows other women to make informed decisions? Would a real 'feminist' willfully keep information from other women, to manipulate the choices made by other women? Would a real 'feminist' hold dear to an ideology and continue to repeat its myths, long after it has been debunked? Would a real 'feminist' reduce a woman down to a bodily function and place process ahead of outcomes?

A person who would disenfranchise and disempower other women from freely making informed mothering and childbirth choices is not a feminist, never has been and never will be. That person is a misogynist in the purest sense of the word.

Its sad - that motherhood and childbirth is a bastion of mysogyny, when it should be the first frontier of true feminism.

An Invitation to Join the Cesarean by Choice Awareness Network

The Cesarean by Choice Awareness Network is a social network for mothers who support choosing birth via cesarean. It is for women who have chosen cesarean births and for those who would choose cesearan birth. It's a place to share information and build the CDMR community.

To join, click on the following link:

http://cesareanbychoice.ning.com/?xgi=2rSnVDLbAOUL4Q

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.

Potential Exit Strategy Identified

Shortly before Christmas an American friend messaged me letting me know of an OB who might be willing to perform an elective csection at term for #2 in Oregon. I still need to flesh this option out more, but it seems feasible. It's within driving range.

So depending on cost, this might become plan A...

2012

Happy New Years!

This year I hope that Dedicated Obsteric Anaesthesioligy will become a reality in all level 3 hospitals.

This year I hope more mothers and babies get the kind of care that is truly quality care.

This year I hope to reclaim my right to autonomy, I hope to move closer to achieving accountability for past harms and I hope to move closer to coming to peace with that past.