Why minimizing childbirth pain and improving birth experience matters

One of the things that made my experience particularly traumatic, to me, was the degree of pain that I had experienced.  I had some pharmaceutical pain management techniques offered to me, specifically, Fentanyl and Nitrous oxide gas – but I still recall being in more pain than I had ever been in my life up to that point and in more pain than I ever care to be again in my life.  I had given some thought to the management of pain that I could expect after a caesarean delivery and how to mitigate and cope with that pain – in fact I had some fairly realistic idea of what I could expect having had an open gall bladder surgery 13 years prior to my first pregnancy.  Needless to say, though such strategies are useless for coping with the circumstance that I was facing.  I had not given any thought as to how I would manage the pain of labour and delivery, because, I had not planned on ever having to manage the pain of labour and vaginal delivery.

 

There is some evidence that suggests that the circumstance I was in, being unprepared and completely lacking control over it, likely made it much more painful than it might have been otherwise (see:  Tinti, C. Schmidt S., & Businaro N, (2011) “Pain and emotions reported after childbirth and recalled 6 months later: the role of controllability,” Journal of Psychosomatic Obstetrics and Gynaecology, Vol. 32 (2), pp. 98-103).  This suggests that adequately preparing women for what they are likely to experience and providing them with some degree of control over it might mitigate their experience of childbirth pain.

 

I also have little reason to believe that the memory of the pain I experienced is likely to fade over time.  I know that now, nearly 2 years after the event, I still remember it as being extremely painful and distressing.  One longitudinal study has found that the memory of labour pain among those with negative birth experiences tends to remain negative over time – with little change even 5 years after birth (see: Waldenström, U., & Schytt, E., (2009) “A longitudinal study of women’s memory of labour pain – from 2 months to 5 years after the birth,”BJOG: An International Journal of Obstetrics and Gynaecology, Vol. 116 Issue 4, pp. 577 to 583).  This suggests that efforts to mitigate the experience of pain among childbearing women and efforts to mitigate the risk of negative birth experiences are worth it as pain in birth is not something that women generally forget about, particularly when their experience has been negative.

 

Further, there is some evidence that severe, unrelieved pain may contribute to the development of Post-traumatic Stress Disorder (PTSD) as a result of childbirth (see: Reynolds, J.L. (1997) “Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth,” Canadian Medical Association Journal, Vol. 156 (6), pp. 831-835 and Denis, A., Parant, O. & Callahan S. (2011) “Post-traumatic stress disorder related to birth: a prospective longitudinal study in a French Population,” Journal of Reproductive and Infant Psychology, Vol. 29, No. 2, pp. 125-135) .  There is also some evidence that unexpected events may also contribute to PTSD after childbirth (see: Leeds, L. & Hargreaves, I. (2008) “The psychological consequences of childbirth,” Journal of Reproductive and Infant Psychology, Vol. 26, No. 2, p.p.108-122).  While I am working with a psychologist, I have not been officially diagnosed with post-natal PTSD, however, if it looks like a duck, walks like a duck and sounds like a duck – it is in all likelihood a duck or at the very least a duck-variant and no amount of “putting up a good external show” is going to fix it.  This evidence also suggests that the provision of quality maternity care services might prevent serious psychological morbidity.

Given this evidence – it appears that:

*minimizing unexpected events during childbirth,

*improving childbirth education to accurately portray the realities of childbirth,

* improving the information given to women about their realistic options for pain relief in labour,

* improving access to a broader range of pain relief options in hospitals that serve women during labour and delivery,

* improving facilities that serve childbearing women during labour and delivery – particularly with a view to improving access to pain management techniques, and improving the physical environment of these facilities;

*and, improving the ability of women to exercise personal autonomy during labour and delivery by respecting an informed decision making process whenever practical -

Would likely result in a much higher quality of care and would likely mitigate the risk of adverse psychological and physical outcomes for mothers and their babies.  What is particularly shocking is that none of these suggestions have anything to do with decreasing the rate of caesareans or increasing the numbers of women who attempt to VBAC – both of which seem to be the only measures of quality maternity care that the BC government seems to care about at this time.

You have a healthy baby, why sue?

One of the reasons I have decided to litigate is that the idea that the principles of informed consent and patient autonomy could be wilfully frustrated in favour of achieving other specific goals (reducing c-sections and increasing the rate of VBACs) and saving health care dollars, is really disturbing.  When such things are done in the context of pregnant women and their foetuses, people who are vulnerable and very dependent on the healthcare system - it is even more disturbing to me at a foundational level.  It sends a message that people, pregnant women, can be violated and abused if it results in achieving other objectives - even those that are just held by an individual care provider or hospital.   It makes me cynical.  On really bad days, it is down-right depressing.

I believe it is a reprehensible breach of the fiduciary duties that are owed by the state, hospitals and healthcare providers, to their patients and that such actions result in significant emotional and physical harm.  I believe it is an abuse of power and amounts to nothing less than battery and assault – state sanctioned torture, if it is not addressed and corrected.  I feel as though a stand needs to be taken – and there needs to be a strong disincentive to frustrating a person’s right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice .

    

I believe the system, and those who work in it have an obligation to facilitate informed consent and to respect patient autonomy – to remember that healthcare should be a service that is done for people and not to them.  Further, I do not believe in modern day Canada, that there is any legitimate reason why a woman should be restricted in making medically legitimate and reasonable choice regarding the management of her pregnancy and the delivery of her child.  Caesarean birth has a long history and is a proven method of delivering a child, its risks and benefits are known, it is a medically legitimate option.  Epidurals also have a long history and are a proven method of managing the pain of childbirth, and similarly its risks and benefits are known, similarly it is a medically legitimate option.  Vaginal childbirth and other methods of pain relief are also options for the delivery of a child and the management of labour pain and also come with their own risks and benefits and are also medically legitimate options.  I believe a woman is entitled to know what her options are, to be provided accurate information on the risks and benefits of those options, to have access to professional advice and that her decisions regarding those options should be respected and facilitated.  I further believe that these services need to be reasonably available, and that access to them should not be arbitrarily withheld where they are available. I believe excellent care providers and hospitals understand that this is a critical element in providing quality care to the mothers and babies they serve - and that hospitals and care providers who do not understand this, need to and that they need to understand it now.

 

I believe what happend to me needs to be held to account and prevented from happening to other women and their families. Maternity care is not an exception and cannot be an exception.

 

That’s not to say that the sustainability of the healthcare system isn’t a concern and that endeavours should not be made to save health care dollars, it is and efforts most definitely should be made to save health care dollars – however, that should never come at the cost of misleading patients to make choices that are not in their own best interests and it absolutely should never come at the cost of quality care.  

Healthcare Paternalism and Obstetrics in Canada

I have no doubt that in some way the care I received during my last pregnancy, labour, and delivery was the result of generally held belief about the superiority of 'the natural birth process' - and an utter disregard for the consequences of failing to respect patient autonomy and provide access to the caesarean procedure in a timely way. I think in some way, someone thought it was 'ok' because what I had asked for wasn't based on the generally approved medical indications for a caesarean. That because 'it was my choice' it was okay to impose their beliefs about childbirth on me - delay and deny. The chances are overwhelming that she will be fine and her baby will be fine, so what she 'wants' doesn't really matter.

Examining the guidelines produced by the Society of Obstetricians and Gynaecologists of Canada, and the material produced by the Ministry of Health, it is clear that there is a strong preference for vaginal childbirth. I know that "the state" doesn't approve of my choice in childbirth - I knew that when I was pregnant with my daughter - I also know that many members of the public do not support maternal request Caesarean. However, I also believed then and believe now that the state must respect choice in childbirth and that forcing a particular mode of childbirth on a woman would be / is reprehensible because it violates a woman's right to determine what happens to her body and to make health care decisions for herself and her baby. It's misogynistic and misguided.

The thing is that what mothers want does matter, and respecting maternal choice cannot be a one way street. The system cannot bend over backwards to accommodate natural childbirth, but completely ignore those who would choose to medicalize their births. The system cannot assume that those choosing natural childbirth are doing so as an informed choice, if indeed no choice is actually available. Nor can the system assume that those who would choose to medicalize their births are doing so from an uninformed position - and that their choice should be ignored. To do so is to perpetuate a paternalistic provision of healthcare in obstetrics when it has been long abandoned in most other fields of medicine. To do so, says that it's okay to violate a patient's autonomy, if that patient happens to be a woman who is seeking maternity care.

That is what is wrong and needs to change. It's not about csections. It's not about vaginal births. It's not about epidurals. It's about enabling women to get the best information about their choices, and actually supporting whatever choice a woman makes having been provided that information. It's her body and her child at stake - who else could have a better perspective on what their best interests actually are? When the state and care providers fail to provide for women during childbirth - it is an affront to quality care and often is an unjust enrichment at the expense of mothers and their babies.

At a loss for terms: Affronts to Birth and Sex

There are a lot of parallels between birth and sex.

Sex between two people who have chosen to be intimate with each other - is an important part of many people's lives - for many people their sex life is a critical part of their life from which they derive much enjoyment and fulfilment. It is part of being human. It is respectful and both people have their needs met. It is intimate and trusting. It is a willful sharing of self with another human being. It is respected. It has the potential to have lasting reprecussions for the individuals involved and should not be entered into lightly. The decision to have sex should be well informed and an act of free will. Consensual sex is empowering and satisfying for both parties to it. Under the best circumstances, sex is one of the most beautiful and intimate experiences a person can have.

Similarly, pregnancy and birth are an important part of many people's lives. It is part of being human. It involves making oneself vulnerable and having to trust others. It is an event which many people plan and prepare for well in advance. It has the potential to have lasting reprecussions for the individuals involved and should not be approached lightly. The decision to become pregnant, continue with the pregnancy and give birth should also be well informed and an act of free will. Under the best circumstances, birth is also one of the most beautiful and intimate experiences a person can have - it can be both empowering and satisfying.

Both birth and sex are parts of being human that are considered sacred and both are deserving of the same degree of respect and protection at law.

Sexual crimes are well defined and understood. They are considered to be among the most repugnant, unconscionable, and reprehensible crimes that an indivdual can perpetrate on another. When a person uses the term "rape" it is well understood the seriousness of the violation. Calling rape, "non-consensual sex" sanitizes the act, it is effectively "the same" but it does not conjure up the same strong feelings about the degree of the wrong done to the person subjected to it. Similarly, calling rape an assualt is also technically correct, rape is a type of assualt - but when a person says that they have been assaulted, there again is some ambiguity about the wrong that has been done to that person. When a person says they've been raped, it is understood that they have been aggrieved in a most serious way during one of the most intimate acts - rape is a violent deprivation of personal autonomy. The victim is given support and understanding, and the perpetrator is subject to being accountable for his or her actions. Sex is protected, certain actions during sex, particularly those that are non-consensual or take advantage of the vulnerable are considered criminal and are subject to sanction - the limitation period for prosecuting "sex crimes" is often extended in light of the emotional toll these crimes take upon their victims.

Despite having many strong parallels to sex, birth seems to be a part of being human that is still subject to abuse and grave violations of personal autonomy - it appears to enjoy a lesser degree of respect and protection at law. Most violations during birth are not criminal, and many are not subject to sanction. The limitation period for prosecuting violations during birth is often limited, despite often having a similar emotional toll on victims. The violations perpetrated during pregnancy and birth are poorly defined and understood and in many ways the protection at law given to birth is much like the protection of sex, decades ago - back when blaming and shaming the victim for the crime perpetrated on them was still considered the norm, back when it was thought that a husband could never rape his wife. Back when holding the perpetrator to account was much more challenging. Back before the laws and jurisprudence evolved. Many victims never came forward, shouldering the burden of the abuse alone - ashamed and fearful of what others might think of them should they come forward and speak out about what they had experienced. Back when only the most egregious violations were ever prosecuted.

Currently, there is little language that adequately describes the experience of many women and the deep feelings of violation that have been experienced by those women. They are left with the terms of "medical malpractice", "medical battery", "breach of fiduciary duty", "medical negligence" - all while technically correct are lacking in describing the significance of the violation experienced for many women. Women who have experienced what is nothing less than maternal assault, abuse and neglect - are left even without adequate language to uniquely describe their experience, and so many have adopted the language that has long been associated with sexual assault and abuse. It is an understandable adoption - and in no way are they meaning to discount the experience of rape and sexual assault victims. Rather they are merely trying convey the grave seriousness of the violation of personal autonomy that they may have experienced, one that may indeed be on par with those who have survived sexual assault. Many of these women have been violated by those who they trusted most deeply at a time in their life when they were at their most vulnerable and some have had their own health and safety or that of their children threatened. I do not wish to use the term "birth rape" in describing my experience - however, I find myself at a loss for a term that adequately describes what happend to me. If I were to define it, it would be as follows: an intended or negligent violation of personal autonomy that threatens or is reasonably perceived to threaten the physical or emotional health and safety of an individual or their fetus during partuition."

Don't Ask, Don't Tell

There's a critical difference between this time around and last time around.

Last time around, I was pretty open about my plans for delivery and had gotten pretty use to explaining why I was choosing cesarean. Often, my plans were met with "but recovery from a vaginal delivery is so much easier" or "that's what epidurals are for", or even "Are you nuts? Birth is a natural process.". To which I'd usually respond with, "my decision is not about the recovery or labour pain" or even "no, I'm not nuts.". Perhaps they were just defending the childbirth plans that they, themselves had had and were in someway threatened by a woman who would make a plan that was different from what they, themselves had chosen. Planning to deliver vaginally is the norm - it is nearly seen as a right of passage into motherhood, one that is perceived as being only justifiably avoided if there are clear "medical indications" for a cesarean birth. To be planning a cesarean birth in absence of any clear "medical indications" is taboo, and perhaps that is something I failed to appreciate then. I naively believed that it was my body, that there were risks to either birth plan, and that deciding which birth plan to persue was my choice and my choice alone.

By the end of my last pregnancy I was tired of defending my choice and was just looking forward to having my birth plan realized and meeting my child.

And then it didn't happen. And, as well meaning as many family, friends and acquaitenances have been, many of their comments have been unintentionally hurtful and fail to recognize the travesty of what has happend. Glass half-full, look at the bright side.

The fact it didn't happen remains a somewhat sensitive issue for me (putting it mildly). If anything I have become more defensive about a woman's right to choose a birth plan that best meets her needs - and I am particularly sensitive to moms who for whatever reason, would choose to deliver by cesarean section.

So in real life, I'm a bit reserved when it comes to what my plans are for this pregnancy. I'm in no mood to defend my choices. I'm just quietly going about making them, and hoping that this time it will be different. And if anybody asks why, I leave it at "I don't want what happend last time, to happen this time."

What are you afraid of??

Everybody has fears. Being pregnant is a state that perhaps makes one more fearful than they might otherwise be. The first time around, a lot of those fears are based on the unknown. If a first or previous pregnancy resulted in a good outcome, I think a lot of the fear in a subsequent pregnancy is mitigated. Being pregnant after a previously negative experience - means that instead of being fearful of the unknown, of the possible, a lot of those fears have very legitimate grounds.

Last pregnancy, I had very rational and logical reasons for wanting a planned cesarean at term. I remember fearing that my request would be denied - and I remember the relief I felt at finding an OBGYN who I thought had agreed to my request. I remember fearing that I wouldn't make it to the surgery date - and feeling relieved the day I did. I felt that even if I went into labour, that a cesarean would still be the way that my child would make her way into the world. I was comfortable with that idea. I trusted my care providers, I had no reason to believe that they, the system, would fail me. I believed in informed choice and patient autonomy - I believed that it was my body and that I was entitled to make plans regarding how my child would be delivered, it seemed so basic. I never imagined it could unfold the way it did. I never imagined that despite having my wishes known (repeatedly), and the resources available that I would be forced to undergo a vaginal delivery, unprepared and terrified and without access to epidural anesthesia. And then, it happend - and logically I know that it wasn't the worse possible outcome (I have a healthy baby) - but it was substantial portion of what I had sought to avoid and in many ways was worse than I had thought would be likely.

This pregnancy there's a whole new set of fears and I know that a lot of what I'm doing this pregnancy has a lot to do with what happend last time.

If things had gone as expected, I would have been a lot more at ease with news of this pregnancy.

If things had gone as expected, I would be comfortable accessing prenatal care locally and planning a delivery at Victoria General Hospital. I would be open to the idea of having my pregnancy 'co-managed' by a GP and an OBGYN.

If things had gone as expected, I wouldn't be terrified of the idea of going into labour before my surgery date - and being unable to get to the hospital of my choice in time or unable to access adequate pain relief. Note: I'm thinking a relocation for a few weeks prior to the surgery date might be a good strategy if the anxiety of being unable to access the hospital of my choice in a short time frame proves to be too overwhelming.

If things had gone as expected, perhaps I wouldn't be so guarded around family, friends and acquaintances this time around. Perhaps, I wouldn't seek to avoid certain situations.

If things had gone as expected, perhaps I wouldn't wonder whether or not peeing when coughing or puking could have been avoided. Perhaps, I wouldn't miss the way my vagina used to be or be afraid of what another childbirth might do it. I might worry less that at some point I could become incontinent or suffer a pelvic organ prolapse. I might not wonder whether or not the aches and pains I feel after mowing the lawn or going for a long walk during this pregnancy could have been avoided.

But things didn't go as expected, so I'm dealing with it as best I can and while I'm thankful that I've found an OBGYN/hospital that has put my mind at ease as best they can - I know I will breathe a huge sigh of relief if and when things actually go as expected.

Best-feeding May Mean Less Breast-feeding

With my daughter, I breastfed pretty much exclusively for the first five or so months when she started displaying signs that she was ready for the introduction of solids (reaching for our food, no longer having the tongue ejection reflex, etc.). Her main source of liquid nutrition continued to be breastmilk until she was 10 or so months old, when it was decided that we should introduce formula into her diet in preparation for daycare. Before then, formula was very rarely used (I could probably count on my fingers the number of ounces my daughter had consumed it). That's not to say that my daughter wasn't accustomed to bottle feeding, she was, as we had introduced a bottle at around 5 days of age (I liked the idea of my husband feeding our daughter at least once a day - to give myself a break and to allow him to have those minutes with her)- but in general the contents of that bottle was pumped breast milk.

It's not that breastfeeding was difficult for me - it wasn't. I didn't have supply issues and it was not painful. My daughter gained weight and seemed to 'get' the hang of breastfeeding readily. In general, breastfeeding was convenient - there was always a meal, at the right temperature, and at the time it was needed.

However, looking back, it was also inconvenient. It meant that we had to buy a breastpump. It meant that I always had to wear clothing that would allow access to my breasts - and so after the maternity clothes served their purpose there was yet another wardrobe of nursing clothes. It meant that the child had to be with me or alternatively that I had to pump and plan for their to be a sufficient quantity of pumped milk on hand. While I pumped, I could not do whatever I pleased but had to engage in pumping compatable activities - so time wise, pumping did not so much 'save' time as it reallocated time. If feeding time happend while we were out and about, it meant I had to stop and find an appropriate place to nurse (at the very least somewhere to sit for a while). It meant that I had to watch what I ate or drank. It meant that when I couldn't nurse at the expected time, I could expect to become engorged or leak (there was a time or two when I woke up in a literal puddle).

I was quite happy when my daughter was fully weaned from breastfeeding shortly after her first birthday - I was happy to have my body back as an independent one from hers. After nearly two years (pregnancy + breast feeding) of sharing myself with her to such a physical degree, I was ready to end the breastfeeding relationship. And she really didn't seem to mind when the morning nursings ended and then when the bedtime nursings ended.

The inconveniences I experienced, are absent some of the real challenges that many women face when they choose to breastfeed. I had the luxury of a year-long maternity leave and no other children to care for while I was nursing my daughter - many women do not get maternity leave (those who are self-employed in Canada or do not have employer provided top-offs may find it financially difficult and those in the US). I did not need drugs or supplements to increase my milk supply - many women find this neccessary. I did not need to undertake an elimination diet due to food sensitivities of my daughter - many women do. Breastfeeding was not painful - it is for many women. I did not have a history of sexual abuse or eating disorders - many women are survivors. My daughter did not have problems with latching or gaining an appropriate amount of weight while she breastfed - many infants may fail to gain weight or may need assistance latching.

And yet looking back, knowing what I know now, I think I might do things a little differently this next time (even if it were under the exact same circumstances as the first time). For one, I will have another child to care for - an active toddler, albeit the plan is to keep her in her daycare full-time. But, also I am more aware that breastfeeding is not the only appropriate choice for infant feeding and that having a little more independence from my child might be good a thing. I also think that there's really no reason to believe that a mother can't have the best of both worlds and that more combo-feeding might be realistic goal this next time around. So for myself, best-feeding my next infant, very well might mean less breast-feeding.

Correlation is not Causation, a.k.a. "Look at the Confounders Batman!"

In the past week or so, a study has been making the rounds. This one claims that babies born via c-section have twice the risk of being obese as those who are born vaginally. The anti-csection brigade is using it as yet another reason to clamp down on the epidemic of unneccessary c-sections, and at the same time making moms who would willfully choose c-section, absent any medical indication, feel as though their choice is posing some risk to their child.

I've had a brief look at the study in question - and here is my conclusion:

Correlation is not causation, and "Look at the confounders, Batman!".

There are a lot of reasons why the rate of c-sections has increased over the past few decades. Moms are older by the time they have children - there are things that seem to be pre-requisites to starting a family now, many women want to be married for a while before starting a family, many women want to own a house before starting a family, many women want to have a career before starting a family, and as a result of wanting a career many women must complete post-secondary education before starting a family. At the end of a day a woman is often in her thirties before she even tries getting pregnant. As a result of being in your thirties before you even start on the "mommy track" you might be more likely to need help getting pregnant in the first place. This might mean fertility drugs. This might mean IVF. Even if it doesn't mean those things, your risk of having multiples increases with age. Many moms might only be planning on having small families. Moms also seem to be more likely to be starting their pregnancies with higher BMI's than in the past and they also seem to be having higher rates of gestational diabetes. Women also seem to becoming more aware that vaginal birth is not risk-free and may also have some unpleasant risks. And all of this is in a context of having the risk associated with having a c-section plummet - surgical methods have improved immensely over the past few decades. So in short, I'm not shocked that the use of c-sections in birth has increased - quite simply because in an increasing number of cases the benefits of surgical birth outweigh the risks and costs associated with surgical birth.

Now the question that needs to be asked, and wasn't asked by this study - is whether or not all of those things that wind up causing an increase in the c-section rate might also increase the risk of childhood obesity. In which case, it wasn't the c-section that caused the babies to be beefier - and doing things to address the rate of c-sections alone (without addressing the underlying causes of the increase) won't do anything to address the rate of childhood obesity. You might just wind up with just as many beefy kids, but more birth injured moms and babies.

I also found it quite interesting, that the risk of obesity seemed to be HIGHER among those who were having urgent or emergent c-sections than among those having planned c-sections. This would seem to indicate to me, that the causes of the c-section in the first place are probably much stronger determinants of childhood obesity than the method of delivery.

In short, this study does little but add to the hysteria around the debate surrounding childbirth and further confuses the very complex problem of childhood obesity. I can see it now, the mother in line at McDonald's with her chubby little cherub playing their PS3, saying "The kid is a c-section baby - it's got nothing to do with everything else we do."

Interesting: The Patient Voices Network of BC

I recently came across the the Patient Voices Network - an interesting initiative that seeks to facilitate patient involvement in the health care system. I must applaud the government for reaching out to patient groups, and hope that it is doing so with an open ear. I am encouraged by the existence of this organization, and think it has tremendous potential to affect change in the health system of British Columbia - particularly if it sheds light on the reality patients face as they access the system for their health care needs.

It would appear that the network has a broad scope - and is aimed at all patients who interact with the healthcare system in British Columbia.

Personally, I am interested in the maternity care system in British Columbia - as it is the part of the system that I've had the most experience with in the last two years on a personal level - and over the next 6 months will continue to be the part of the system that I am most likely to be personally touched by. I hope this network will achieve an adequate representation of mothers from accross the childbirth spectrum - and would not/will not be swamped by those who are strong proponents of natural childbirth, as proponents of access to medical intervention in childbirth also need to be heard and represented.

I hope other mothers in British Columbia who have concerns about the maternity care system will also speak up and be heard. In particular, I hope that mainstream mothers who want access to epidural pain relief, who do not want to choose between the 'niceities' of homebirth and the safety of hospital birth, those who want to be able to exercise informed choice on all available childbirth options, and those who would like to see outcomes placed ahead of process, will also speak up. If not for yourself, then for the prospect that your children might be able to bear their children in a better and more balanced system.

So I have decided to park my general skepticism and cynicism at least momentarily and I've decided to learn more about this initiative, as a maternity care patient - I hope other BC mothers will do the same.

A (very wonkish and very economics based) post on how healthcare might be better structured in Canada

Let me preface this post with the following:

This is a very wonkish health policy post - and reflects personal opinion only.

The healthcare system in Canada is incredibly complex and the challenges that will emerge over the decades to come are significant. It is clear that the current system, as it has evolved over the past several decades has many strengths to it, but also many weaknesses. It is also clear that meeting the challenges will require colloboration and mutual respect between healthcare providers, patients, and government. Facilitating those changes might be better achieved if the very structure of how healthcare in Canada is funded and organized was changed to reflect the reality of what the healthcare system is and what it sets out to achieve for Canadians.

Currently, healthcare in Canada is funded via general tax revenues (provincial and federal) and in some provinces (like BC) per-capita premiums (like MSP) that may be waived for low-income individuals. Provinces each administer their own health care system - so in effect there are 10 provincial health care systems in Canada.

As a result of this structure, there are some significant weaknesses (well-known) that result.

1. Provinces compete against each other for resources and tend to out-bid each other in sequential rounds of bargaining with health care provinces.

2. There is wide variation in terms of the health care services that are accessible to Canadians based on their province of residence. There are procedures that might be "insured services" in one province but not in another. The wait time for access varies widely across the country. In general the province with the most resources to devote to health care services has the best health services available in terms of what is covered by the public system and wait times for access.

3. Governments tend to be hesitant to raise taxes in response to rising demands for healthcare services. As a result health services are either underfunded or other areas of public services are restrained to pay for the services provided in the health care system.

4. There is no relationship between what an individual pays towards the healthcare system and their health care needs or their controllable health behaviours. If you make a lot of money, you pay high income tax and contribute high amounts towards the health care system. It is a myth that health care is "free" in Canada, income=health care premiums in Canada - it is only "free" if you happen to be so poor as to not pay any taxes at all.

5. There is limited flexibility in the types of services that can be accessed in Canada. Services that are not publicly provided as insured health services are supplied via the private health industry - these are things like cosmetic surgery, sterilization reversals, dentistry, etc. Services that are publicly insured and provided often lack choice - there are few "frills" in the Canadian system, a patient generally cannot choose to access services faster (but pay for the privledge) nor can they choose to access services that might be qualitatively different (ie. a surgical delivery versus a vaginal delivery when not medically indicated) and pay for the difference in resource use. In general, a patient also cannot "choose" a nicer facility for a price for a publically provided service. Generally, facilities do not compete against one another for market share. If a Canadian wants choice or frills for a 'publicly insured' health service, they often must pay for that service completely out of pocket and access that service abroad.

6. There is a lot of administrative duplication and inefficiency that results from the running of 10 different health systems.

7. The system tends to be prone to politicization. Decisions regarding what is or isn't covered or how resources are allocated or even what information on the system is provided to the public are often political in nature.

That's not to say the system is without it's advantages.

It is a tremendous advantage that there is no problem of "uninsured" Canadians - every Canadian has health insurance and access to health services. They might not be the best health services that are technologically feasible. They might be services in older facilities. Canadians might have to wait a long while to access those services.

So how might Canada retain the current advantages of the existing system while correcting some of the disadvantages?

While there are likely many different ways to do this, I think that one way to do it would be to do the following:

First, create a Public Health Insurance Agency of Canada (PHIAC) that provides mandatory basic health insurance to all Canadians and pays for those services via a combination of individual premiums that are based on income, age, and health behaviours that are under the control of the individual and a government grant from corporate taxes. Risk associated with genetic predispositions or accidents could and should be pooled accross the entire population. The amount of premiums needed to be paid would be based on the health services needed. Health premiums would be separate from taxes - but mandatory and collected in a similar fashion to how taxes are collected. All Canadians of legal age would be shareholders in the PHIAC.

Second, create an independent organization (the Healthcare Senate) with a fixed-term appointed board with nominations from health care providers, provincial governments, patients, and PHIAC that can make binding decisions on the insurer and facilitate collaboration between patients, health care providers and the insurer. This organization would set compensation levels and make decisions regarding resource allocation, determine which services are covered, undertake quality improvement and review initiatives, collect and analyse data on health service use and outcomes, and report to the public.

Third, open the door to optional private insurers and private payment for services not covered under PHIAC and for 'frills' such as expedited access to services, nicer facilities, and patient choice.

No doubt there would also pitfalls to this kind of system, but it does provide "some food for thought" - and I would tend to think that such a system may retain many of the advantages of the current system while remedying some of the disadvantages. I am also curious if there is any health sytem in the world that is structured in this way and if so, what are its results?

Cost Studies on Cesarean Birth versus Vaginal Birth Short-Changes Mothers and Babies

As an economist, I am often dismayed by the existing studies that compare the costs of vaginal birth with the costs of caesarean birth - and then come to the conclusion that a great deal of money could be saved by promoting "normal birth". I am further dismayed, when without question or critical thought the media then goes on to parrot the cost difference, as being $4,863 versus $2,486, as in this recent Toronto Star article . The problem with most existing cost studies and a simple parroting of cost statistics is that it over simplifies the issue of cost as it pertains to childbirth.

The first flaw in the basic statistics on the cost of mode of delivery, is that they are retrospective in nature. This means that they do not reflect the planned mode of birth but rather are the result of the actual mode of birth.

As such, the statistics on the costs of caesarean sections include the costs of both elective or planned cesarean sections as well as the costs of emergent caesarean sections. The vast majority of emergent cesarean sections are the result of planned vaginal births that do not go as expected. Emergent caesarean sections cost significantly more than their planned counterparts as many of these births involve the interventions (and their costs) that are common to vaginal births as well as the costs of caesarean births and may also involve increased costs associated with a substantially increased risk of complications. This artificially inflates the reported cost of cesarean birth.

While the basic statistics inflate the cost of caesarean birth, they also diminish the cost of vaginal birth. A "straight forward" vaginal delivery - is a delivery that does not involve the use of an epidural or augmentation, and does not involve the use of forceps or vacuum to assist with the delivery of the child. This is the type of delivery that those who subscribe to the philosophy of natural childbirth aspire to achieve. The reality is that for many women achieving this kind of delivery is simply either not possible or not desireable (it could be done, but at a great risk of harm to either the mother or the child). Many women elect or need epidural pain relief. Some women have fetuses that are simply too large or are not ideally positioned for their bodies to safely accommodate a natural delivery. Many women and babies need help with the delivery process and will require assistance by way of either forceps or vacuum (which in the absence of an epidural can be excruciatingly painful). Some who planned on a "straight forward" vaginal delivery will ultimately need an urgent or emergent caesarean. Yet, the costs associated with epidurals, forceps, vacuum, or emergent caesareans are conveniently left out of the tally associated with "straight-forward" vaginal birth - and as such do not even reflect the reality of the "average vaginal birth".

As a result, readers are erroneously left comparing the discounted costs of vaginal birth with the inflated costs of caesarean births.

If that wasn't bad enough, it should also be noted that the vast majority of existing cost studies completely ignore longer-run costs that may be associated with the mode of delivery. If the delivery results in a cost that is incurred more than 42 days after the birth, the costs are frequently not allocated to the mode of delivery. A child born with a life-long disability as a result of mode of delivery - will not have the life-long costs allocated to that mode of delivery. A mother with urinary or fecal incontinence attributable to the mode of delivery that needs to be repaired (through surgery or physiotherapy) months or years later will not have those costs allocated to the mode of delivery. A mother with PTSD or PPD associated with her mode of delivery will not have the costs of those mental health issues allocated to the mode of delivery.

Furthermore, the costs that occur as a result of mode of delivery that are incurred privately are never accounted for in cost-studies of different modes of birth. There are private costs associated with either mode of delivery - including time off work, costs of preparing for the birth, and costs of recuperating after the birth.

Lastly, the costs that are "expected" by planned mode of delivery are likely to be very different on a case-by-case basis. There are many women for whom the "expected" total cost of a planned vaginal delivery is likely to be lower than the "expected" total cost of a planned caesarean delivery. There are other women (particularly in a time when mothers are getting older, heavier and having fewer children) for whom the "expected" total cost of delivery would be cheaper by planning an elective caesarean delivery.

As a health system, the goal should be to encourage women to discuss their circumstance and options with their healthcare providers and to choose the mode of delivery that is most efficient for them in their individual circumstances with an objective to reduce unnecessary morbidity and reduce unnecessary mortality for mothers and and babies. If this were done, a reduction in the overall healthcare costs would likely follow, even if a reduction in the rates of caesarean sections did not.

Spending Money Where it Matters: Maternity Care

I fully understand that resources in the health care system are limited - and that decisions must be made with regard to resource allocation. I know that providing health care services to the population is expensive. I know that these costs are increasing over time for a wide variety of reasons, including an increasingly older population, an increasing ability to treat what once was untreatable, increasing expectations to access treatment and inflation. I know there is tremendous pressure to 'bend the cost-curve' and improve health care system sustainability and that bending the cost-curve and ensuring health system sustainability is imperative.

I also know that maternity care is not the place to 'save money' and that doing so will and does come at a tremendous cost.

I am more than a little disturbed at efforts to turn back the clock on this area of care. I am disturbed at the efforts by provincial governments to encourage home births and 'invest' in birth centres that are basically places where women give birth 'in somebody else's home', and in particular I am disturbed because the primary motivation for encouraging these things is to save money. Money indeed will be saved, but it will be saved by limiting access to medical care and services during birth. Of course homebirth and birth centre births are cheaper than hospital births - if a woman does not have access to an epidural, the system does not have to pay for one. If a woman does not have access to fetal monitoring, then again, the system does not need to pay for it. If a woman does not have immediate access to a cesarean section - there is a chance a 'normal' birth will happen instead. When technology is not available, it does not get used.

I also know that proponents of homebirth will point to the few studies, like the recent BMJ article entitled "Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study," that show that outcomes between homebirth and hospital birth are comparable. However, they will fail to examine those studies with a critical eye. A study that uses composites for perinatal outcomes and maternal morbidity completely fails to recognize the huge difference between a death or a lifelong disability, with having a cesarean section or a fractured clavicle. This study also limits its scope to the birth itself and the period immediately after the birth (42 days) and as such fails to recognize the consequence and costs of longer-run morbidity and mortality. Further the study considers "normal birth" (defined as being without induction of labour, epidural or spinal anesthesia, general anesthesia, episiotomy, use of forceps, ventouse or cesarean section) as being a "good" in and of itself - without any justification for that position.

The fundamental flaw of course is the underlying assumption that the use of technology in birth in hospitals is done so without reason or merit and that using technology in birth does not 'buy' anything of value. This strikes me as being a rather large assumption, that should be extensively tested prior to being accepted. Use of technology in birth buys reduced pain. Use of technology in birth buys reduced risk of very severe outcomes and long-term disability. Use of technology in birth may make the difference between life and death, and it may make the difference between a 'normal' life and one filled with life-long challenges. Given the nature of the population being served (typically young, and healthy) what is being 'bought' with the use of technology in birth will have benefits over a very long time horizon, potentially 80 or more years.

It should be crystal clear that the government's embrace of out-of-hospital birth has nothing to do with supporting choice and everything to do with saving money. If it was truly about choice, government would increase access to hospital-based midwifery and make hospital environments nicer to facilitate the choices of women (for example private rooms, birthing tubs, increasing the ability of partners to stay with parturients, etc.) WITHOUT sacrificing their access to medical advancements. Facilitating a choice that denies or delays access to medical technology, particularly if it is proven to be needed is not good policy. It's cheap, but should not be considered cost-effective.

Reflections on Unnecessary Things

Women who choose cesarean absent a medical indication for cesarean in North America are often portrayed in a negative light. They are deemed a drain on the medical system (at least in Canada). They are called "too posh to push". They are called vain. There are those who would even deride them as being somehow unworthy of motherhood - after all, giving birth vaginally is the way "nature intended". Some people might even declare that women who gave birth surgically, have not "given birth" and are somehow "lesser women". Any woman who has had a cesarean or is planning a cesarean, feels compelled to defend her choice or the reason for it, as there seems no bigger travesty than an "Unnecesarean". Even Canadian policy makers feel as though a worthy goal is to "reduce the rate of cesarean births" and "increase the rate of attempted VBACs".

This situation generates many Unnecessary Things, far worse than surgery among a group of women who could have had a "normal birth" if only they let "nature take its course", but freely and with informed consent opted out of "normal birth".

This situation "unnecessarily" legitimizes the denial of patient autonomy - a woman denied a cesearean absent a medical indication for it has no recourse. She often does not even have the empathy of others - after all she has only been subjected to what is considered "normal".

This situation makes finding sympathetic care providers "unnecessarily" difficult for those who would prefer an elective cesarean birth. Many women are forced into a situation that lacks continuity of care, or may have to travel to access the care they need.

This situation "unnecessarily" generates feelings of inadequacy among those who through no fault of their own were unable to "achieve" a vaginal birth.

This situation "unnecessarily" increases the risk of truly traumatic outcomes for mothers and infants. Many mothers believe that if they just push a little longer, labour more, or refuse an epidural that they can avoid a cesarean birth. Many might delay to the point of an emergent situation which then risks being "unnecessarily" unconscious for the delivery of their child, "unnecessary" complications, "unnecessary" disability, and "unnecessary" death.

Other "unnecessary" things that result from this situation are "unnecessary" pain, "unnecessary" vaginal tearing, "unnecessary" sexual dysfunction, "unnecessary" post-natal mental health problems, "unnecessary" reconstructive surgery, "unnecessary" incontinance, "unnecessary" bias in the information given to women planning on giving birth and "unnecessary" guilt.

In sum, the situation as it is today, "unnecessarily" jeopardizes quality maternity care. It puts process ahead of outcomes, and that is what necessarily needs to change.

Recollections: Crisp and Absent

There are things about the last time I gave birth that I remember very, very crisply - the bits that revisit me every now and again, in a dream or suddenly during a conversation or are triggered by something I have read. Mostly it's the emotions I remember, the terror, the pain. The conversation my doctor had with me shortly after I went into labour indicating there was no OR available, no anaesthetist available (therefor no epidural), that there were pediatric appendectomies and I would have to wait (lies!). I remember hoping that labour would progress slowly - that time might be on my side as a first timer. I remember hoping that nothing would go sideways. I remember thinking if I stayed still enough, maybe the child could wait until an OR was free and I could still have the birth I wanted. I remember as I was in great pain, asking my husband if I could sue in whispered tones...and I remember being told I was 10 centimetres and the c-section was not going to happen...I remember breaking down and sobbing at that time knowing I had no choice - or at least I had not been given any choice. I remember them breaking my water. I remember the nurse telling me that "my body was made to do this" and that "direct my screams into pushing." I remember hating my body at that time, despising it, feeling it was responsible for the betrayal, for not taking long enough to labour, for causing me such immense pain. I remember being offered a mirror to watch the birth (why on earth would I want to?) and turning it down. I remember my daughter not crying when she was born, needing to be resuscitated after birth, and again watching hoping that she would be okay. I remember being stitched up, and taken back to my room. I remember showering my bloody self after the birth, and sobbing in the shower.

That is what is crisp. It still overwhelms.

Then there's everything that seems to be absent from my memory.

I don't remember where my husband was during the pushing phase. - He indicates he was at my knees, but I do not recall.

I don't remember the name of the doctor who actually delivered my child.

I don't remember my in-laws coming to the hospital when I was actually in labour.

I don't remember having any conversations with my OB after the first conversation, shortly after labour started.

I don't remember the details...

My recollections are both crisp and absent.

There is still a sadness that this is what is there, that terror and pain are what I can recall when joy is what should be the overwhelming recollection (it is not) - it cannot be changed. I am eternally grateful for every memory of my daughter since - for every smile, for every moment of motherhood that I have been blessed with. At least those memories bring overwheling joy. I am also eternally grateful that my experience was not more negative (I am well aware that it might have been worse). But I am angry still, knowing that the ability to recall my daughter's birth - coherently, without being overwhelmed by such negative emotions, was taken from me.

Making Choices: The Definition of Being an Autonomous Human Being

There's an idea out there that says a good mother does certain things - she gives birth naturally unless there is a medical need to do otherwise. She breastfeeds unless there is a medical need to do otherwise. She stays at home with the children if possible until they are of school age.

And when she doesn't do these "ideal" things, she must explain why.

I had a cesarean section because...

We formula fed because...

I went back to work because...

And rarely is it okay for a woman to finish these sentences with "I wanted to." or "I chose to." To answer in that way is to ask to be judged - with the ultimate damnation "she must be a bad mother."

There is a certain shame in making these choices.

And oddly enough when the child does something undesireable mothers "who do all the right things" feel the need to preface their situation with, "I did everything right, I just don't understand why little Aiden won't"...and those who made other choices might be scorned "she let little Ethan watch too many violent video games and farmed out the parenting to daycare...that's why that kid is the ultimate demon spawn."

Equally, there is an urge to take credit for the child's accomplishments - "little Aiden gets straight A's because (insert parenting choice here)", or conversely the "bad mom" who happens to "have a good kid", just "got lucky".

I've come to the conclusion that, parenting isn't math or an exact science and there are no "universally right" answers because far too much depends on the context in which the choice was made. Far too much depends on the specific mother. Far too much depends on the specific child. Far too much depends on the specific context in which the family must live.

I've also come to the conclusion that there's a lot to be said for not being ashamed for making a choice that is different from what might be considered the "universally right" choice, for having confidence that regardless of the choice made, if it was based on the best information available applied to the specific context at hand, that it was "the right choice".

Like in many things in life, the focus needs to be on what is ultimately a "good outcome" - rather than on the specific processes that may or may not have been used to get there.

And ultimately, if there's an outcome I'd want for my child, it would be for my child to have the ability to make a choice, based on the best information that they have available and applied to the specific circumstances my child finds themselves in - and to be confident in whatever choice they actually make.