Under what circumstances should women be able to "Choose Cesarean"?

In the years since I first considered having a child and the relative risks and benefits of different modes of delivery for my particular situation, I have read a lot of material on the subject - both in the mainstream media and in the scientific literature. There continues to be an active debate on the subject. There continues to be a relative paucity of research that is "on all fours". There continues to be judgement and a persistent derogation of women who elect cesarean delivery. There continues to be uncertainty regarding a woman's "right" to choose cesarean. There continues to be a lack of awareness and respect, support and empathy. There continues to be tremendous barriers to exercising the choice of cesarean delivery, including difficulties in finding supportive health care providers and unreasonable and obscure hospital policies and practices.

That being said, tremendous headway has been made in those years. The commentary that news articles and related forums attract is becoming less vitriolic and more respectful of the choice. The National Institute of Clinical Excellence in the UK confirmed in November 2011 a British woman's right to elect cesarean on the NHS. Pauline Hull and Magnus Murphy published their revolutionary book "Choosing Cesarean". There is now a Cesarean by Choice group on Facebook. A lawsuit in Canada has been filed with hopes that it might formally recognize the right of women to make this medical decision and confirm that a failure to provide reasonable access is a reprehensible violation of patient autonomy - and may constitute a form of malpractice for which hospitals and/or doctors can be held liable.

So under what circumstances should women be able to choose cesarean? Under the exact same circumstances that women or men are able to direct any medical care - that is, after they have been provided with enough information on the available treatment options for their particular medical condition and the risks and benefits associated with those options (they have met the requirements of informed consent). Further, they should expect timely access to the care that has been chosen - otherwise the right to direct one's own medical care is rendered void - after all what good is the ability to choose treatment, if time makes that treatment choice meaningless?

Forging Ahead While Looking Behind

My son's birth proved to me that birth could be an enjoyable, relatively pain free experience that affirms a woman of her ability to make medical decisions and to expect those decisions to be respected. For that I am thankful. He is healthy, I am healthy, I do not dwell on his birth and when I think about it or see pictures from it my emotional response is positive.

However, because I have been working on the litigation associated with my daughter's birth - I have been thinking about what happened then, a lot. Even when I am not wanting to. To say that it is emotionally difficult work is putting it mildly. Reading my medical file. Reading the statements of defense. Thinking about it all. The only thing positive about my daughter's birth - is my daughter. I survived the experience, I did the best I could at the time and it was enough (my daughter is fine) but it is abundantly clear that what happened did not need to happen and that my doctor's and the hospital failed me and failed my daughter.

It is trite to say that in preparing for birth, a mother should prepare not only for the birth experience that she wants, but also for the birth experience she doesn't want. I did not do antenatal classes - but I did educate myself on vaginal delivery (which was part of the reason why I wanted to avoid it), and when it was clear I did not have a choice in the matter, I did as best I could and for my daughter's sake it was enough. We survived.

And yet, in terms of coping with what happened - I still find myself, at times, overwhelmed. I cannot help but think that if what happened was truly neccessary - that if there was no way it could have been avoided, I could accept what happened (as awful as it was) as the price of admission to motherhood. However, now knowing more about what happened and what did not happen - I know that what happened was clearly not neccessary - it could have been avoided (easily). It does not make coping with what happened easier - rather it generates a profound need for accountability and justice.

Surviving the Days Before the Elective Cesarean Date

I chose cesarean because I was uncomfortable with the realities of planned vaginal delivery. I was uncomfortable with the idea of needing an emergent cesarean. I was uncomfortable with the idea of tearing. I was uncomfortable with how much pain might be involved with a vaginal delivery. I was uncomfortable with the uncertainty of the impact on my sex life. I was uncomfortable with the risk of permanent neurological damage to my child. I was uncomfortable with the idea of defecating in front of others. I was uncomfortable with the risk of urinary or fecal incontinence. I could not find peace planning a vaginal delivery - the ugliness of vaginal delivery at its worst (and even a wide range was enter than worst) was a possibility that I wanted to completely preclude even if meant giving up the chance for a vaginal delivery at its best. This was true when I was pregnant with my daughter, and more true when I was pregnant with my son.

As such, there was considerable anxiety (particularly when I was pregnant with my son) about not making it to the elective cesarean date. So how did I cope and survive those final weeks of pregnancy and what can a woman do to make that last stretch of pregnancy a little less anxiety ridden?

1. Work with a therapist. I was working with a psychologist throughout my second pregnancy and think that it helped in finding coping strategies that worked for me in my particular situation.

2. Talk to your OBGYN about your risk of going into labour and what the plan is should that happen - discuss whether or not an urgent cesarean is likely to be available if you should go into labour prior to your cesarean date. Your doctor is the person who is most informed about your particular pregnancy and your particular plans with regard to that pregnancy and is likely in the best position to advise you accordingly. If at all possible, try to arrange for the earliest safe date possible to minimize the risk of going into labour spontaneously (generally speaking this is at 39 weeks gestation - but should be discussed with your own care provider to determine what is best in your particular situation).

3. Find an appropriate activity to distract yourself and that you find enjoyable.

4. Do not over exert yourself and keep well hydrated and well nourished.

5. Avoid anxiety provoking situations. I found myself avoiding social situations in my final weeks of pregnancy.

6. Relocate if neccessary to be near to where accessing care is planned - this is particularly true if where you plan on having your baby is significantly far from where you live.

7. Arrange for the care of older children, pets, help for after the delivery, meals, etcetera.

8. Reassure yourself that even if things do not go as planned, that your primary concern is for the health of yourself and your child, and that regardless of how things unfold you will find a way to deal with it and will deal with whatever situations arise as best you can - and that is all you can do, and it will be enough because it has to be enough.

The best thing about the pregnancy with my son was his safe arrival and knowing that the worry about that arrival was behind me and that the time had come for me to enjoy my son and all the happy days that lay ahead.

Luckier Than I Appreciated

I've been reading my medical file with respect to my daughter's birth - and knowing what I know now, my doctors and the hospital are lucky that a worse outcome is not part of the litigation - and I am lucky (fingers crossed) to have what appears to be a neurologically normal toddler.

One of my greatest fears about vaginal childbirth, is the potential for it to result in lifelong neurological disability. Not everyone gets through vaginal childbirth unscathed - some are left with lasting physical and mental disabilities. I understand that it is rare for such things to happen, but the reality is that someone is that one in a thousand person. I have personally known people who did not make it through birth unscathed. It was one of the reasons I was choosing cesarean for the birth of my daughter. I was happy to trade some increased risks for a decreased risk of that particular outcome.

So when I read the following in my medical record - I was taken aback, because the outcome I feared the most was much closer to becoming reality than I had thought.

My daughter had a tight nuchal cord (it could not be reduced over her head), had no spontaneous respiration for the first minute of her life, cord blood gases were ordered with the notation of gases 7.0, bicarb 17 and BE -15.

I'm a little more thankful for my daughter and a little more livid at what happened.

Mrs. W's Comment Policy

Readers should know that I have a very liberal comment policy - basically unless it is spam, I do not delete. Readers should also know that I do not take responsibility for the comments that are made (they are the responsibility of those making them), as such I cannot vouch for the credibility of the comments made. It is up to the reader to assess the credibility and accuracy of the information they are reading (I will note that if I am making a factual claim in my blog, I will cite the source of the claim and would think that when a commentator makes a factual claim, they too should cite the source if they are wanting anyone else who reads it to give any weight to it).

I've taken this policy because maternal request cesarean is controversial and while I have decided it is an appropriate way for me to give birth, I will not assume that it is a good choice for all women - and that they should hear both sides of the debate and make such decisions for themselves in conjunction with their health care providers (people who are licensed and appropriately trained to provide medical advice in specific circumstances). I have an interest in women making decisions that are best for themselves in their own personal circumstances - and as such will not prevent women (or others) from reading or providing opposing views and opinions, even on my own blog. As such, I do not personally agree with or approve of all of the comments that have been made on this blog - some are perfect illustrations of the prevailing ignorance, misconceptions and misinformation that persists when it comes to maternal request cesarean and birth in general.

I love comments when they are left by readers and appreciate the purpose that having a comment section provides - I love the good, but also appreciate the bad and sometimes downright ugly ones too (and will admit that I love when I am not the only one to counter the bad or ugly comments that are left from time to time). The comments section has proven to be one of the most rewarding aspects to blogging - so please continue to leave them!

Hindsight is 20/20

Somewhere between my doctors and the hospital and health authority involved in my daughter's birth, we slipped through the cracks.  I have looked back on what happened countless times, and have come to the conclusion the it should not have been that way, that it was not my fault that it was that way, and that it should not happen again.

I get that maternal request cesarean is controversial and that while there are many doctors who will accede to a woman's request, there are many that won't.  I also get that some hospital policies are more accommodative than others.  I get that health care resources are limited. However, there is an obligation to respect bodily autonomy and ensure that access to medical care is available in timely fashion.

I believe women who wish to plan a cesarean delivery (or an epidural assisted vaginal delivery for that matter) after being informed of the risks and benefits of cesareans AND the risks and benefits of vaginal delivery should be able to do so.  These women should be able to make their plans without fear that their birth plan will be frustrated and that they will be subjected to a vaginal delivery (or an unmedicated delivery) against their clear wishes and without medical cause.  Just as women who desire a unmedicated vaginal delivery need to be able to plan and to know the limitations and conditions of their plan, women who desire cesareans or epidurals need to be able to plan and know the conditions and limitations of their plan.

So, with the benefit of hindsight, what do I think should have or could have been done differently to prevent what happened to me?

1. I think my maternity doctor should have ordered an ultrasound at the earliest possible date to establish a more certain EDD.  I estimated my due date to be July 13 - I had been keeping track of my cycles and was using an ovulation prediction kit.  Yet my care provider decided it was prudent to use a due date based on a 28 day cycle and set it to July 17 - which while consistent with later ultrasounds that I had, it should be noted that when it comes to ultrasound they become less accurate at dating as a pregnancy progresses.  I believe a EDD of July 13 would have also been consistent with those later ultrasounds and should have been used.

2. I think an earlier referral to an OBGYN would have been prudent.  Waiting to refer until I was late in my pregnancy meant that despite my clearly stated desire to deliver by way of cesarean, that there was a risk that the OBGYN would decline to perform the procedure and that insufficient time would remain to make alternate plans.  Further, anxiety about being able to access my desired delivery mode caused undue anxiety during the pregnancy.  Shared care is not necessarily a bad model, but for women who are planning cesarean delivery, knowing that a GP or midwife cannot perform a cesarean, arrangements for the delivery are best made early on.

3. A fixed OR date and time.  The OB involved in my care has claimed that there was a hospital policy in place that did not allow for maternal request cesareans to be scheduled and that as a result my case was added to the add board.  At the time I really did not appreciate how much risk this introduced to my birth plan - I assumed that I would know the day of delivery, but not necessarily the time and when asked what I would like should I happen to go into labour prior to surgery - I indicated that I would still prefer a cesarean.  In fact, I did not worry much when my surgery got bumped the first day, or even the second, as at the time I believed that if I did happen to go into labour that my case would then be considered urgent and would be completed without undue delay (ie. within 2 hours).  I also believed that should I go into labour that an epidural would have been available to manage labour pain prior to delivery.  I should have been warned that if I did go into labour that there was a chance that cesarean delivery would have an undue delay (in excess of two hours) and that an epidural may not be available. I believe if this policy was in place, the effect of the policy led to an inability to access timely medical care and resulted in a contravention of my charter rights.

4. Assessment for the risk of going into labour.  From the time I was admitted to hospital until the time I went into labour I was not physically assessed.  My case was bumped and bumped again without any physical assessments as to the likelihood that I would spontaneously go into labour.  If an assessment had been done, it might have been found that labour was imminent and my case could have been managed accordingly.

5. Upon presenting to the nursing station with signs and symptoms of labour - my OBGYN should have been called immediately.  According to the records - I presented at the nursing station at around 11:45.  This was shortly after I noticed a second contraction after a first contraction 15 minutes prior and wiped bloody mucous when I went to the washroom.   According to the statement of defense submitted my OBGYN was not called until 130 - nearly 2 hours after I first presented to the nursing station.

6. I was told an OR and an anaesthesiologist was not available.  I laboured under the belief that should things go sideways, and the knowledge that if things did go sideways, that my child or myself could suffer serious adverse consequences.  I was not told that there was a back-up on-call anaesthesiologist in the event of life or limb emergencies - and that he/she would be available within 15-30 minutes if needed.  I was terrified. 

7.  Staff and doctors should be trained to respect and support all pregnant mothers.  Pregnant mothers have a diverse array of values and beliefs with respect to birth and not all pregnant mothers desire a vaginal birth without epidural pain relief.  I was told by nursing staff  "my body was made to do this", and that "if I wanted a maternal request cesarean, I should have gone to Brazil", and to "direct my screams into pushing".  From an on-call OB I saw regarding complications after the birth that he "was happy the c-section did not occur" - although he immediately apologized when I responded that I was not happy the c-section did not occur, the words still hurt.  Women choosing cesarean or epidural pain relief are not well supported - the deserve (and should be entitled to) timely access to these desired medical resources - especially when they have indicated well in advance of their deliveries that they would like access to these things.

The sad thing is that maternal request cesarean was available in British Columbia - it was even available on the island at the time I had my daughter.  There are doctors and hospitals that will accommodate women who choose to deliver by way of cesarean - who will schedule a date and time for delivery.  The sad thing is, that what happened to me did not need to happen.  I would have been both willing and able to travel to access care if that was what was needed.  I clearly communicated my preferences early in my pregnancy and throughout my pregnancy.  I did my part.

Somewhere, somehow, the system and my doctors failed us - and for that, there must be some accountability and retribution for the wrong that was done. Further, measures need to be taken to ensure the same wrong is not done again, and again, and again. Access to timely medical care during labour and delivery should not be uncertain - and that includes access to cesarean delivery and epidural anesthesia on maternal request. 

Connecticut.

I was busy most of yesterday and after I dropped the girl off at daycare, I spent my day working on a variety of things - and was away from the internet and television. When I was finally done, I checked in on Facebook and my heart sank. Connecticut. How? Why? There is no sense to be made of it.

I cried.

Parents had dropped their children off at school that morning. Teachers went to work. All were no doubt confident that at the end of the day, after recess and lunch and math and reading and playtime that they would go home. Home to their parents, to their spouses. Home to suppers and baths and bedtime. Home to the mundane things that as parents and spouses we take for granted.

Twenty children did not go home yesterday.

Six spouses, brothers or sisters, mothers or fathers - did not go home yesterday.

We take it for granted that our schools and workplaces are safe places where students go to learn and teachers go to teach.

Yesterday proved that it only takes one to shatter that delicate presumption - one man, with access to efficient weapons of destruction can perpetrate an act so violent, so beyond the pale, on victims so innocent.

I hugged my children a little closer yesterday. I tolerated the chores of motherhood, with a little more gratitude that my mundane life was intact. And I thought about how important it is to better understand what has happened - how important it is to ensure that the risk of such things happening is minimized.

What happened in Connecticut yesterday should never happen again - it did not need to happen, and it does not need to happen again. It is time to look at the tragedy with a critical eye and determine what needs to be done - what might be necessary to restore faith that when parents send their kids to school and spouses to work that they will come home home at night.

It's time to look at what needs to be done so that schools do not need to be the equivalent of high-security prisons in order to provide safe places to learn and work. Maybe better gun control is part of the answer. Maybe better mental health resources and access to those resources (regardless of income or health insurance status) are needed. Maybe schools need to be a little more secure and extra vigilance is needed with respect to those who teach and learn there. Maybe communities need to pull together a little more to know each other a little better so that maybe a future gunman never gets to the point of donning a bullet-proof vest, arming himself with assault riffles, and perpetrating the kind of violence that should be impossible to perpetrate on dozens of innocent victims. Maybe taxes need to be a little higher to pay for the things that need to be done to ensure what happened never happens again.

It's time to focus on what matters - ensuring that parents can take for granted the mundane chores of parenthood matters, ensuring that students can go to school to learn and never have to worry about not going home matters, ensuring that when teachers go to work they can focus on helping children learn matters, ensuring that there is access to mental health resources matters, the families of the twenty children and six innocent adults who lost their lives on Friday matter - access to assault rifles does not.

I hope insult to injury is not added to this utterly tragic circumstance - I hope that America takes the opportunity to understand better what happened and the circumstances that made it possible in the first place and does what needs to be done.

Targeting the Wrong Cesareans

It sometimes seems like a week does not go by without someone, somewhere bemoaning the high rate of cesarean births in developed countries. British Columbia was at one point so concerned with its reputation for having the second highest rate of cesarean sections in Canada that it struck up a Cesarean Task Force and has even put together two campaigns to address the issue - The Power to Push and Optimal Birth BC. Personally, I am not a huge fan of either. The main reason I am not an admirer of these campaigns is because of the emphasis on process rather than outcome. I care about healthy mothers and healthy babies - and I believe that the way an individual mother gets there is very individual - for some mothers planning and achieving a cesarean is just going to be a better path, for other mothers planning a vaginal birth is just going to be a better path - even knowing it has a risk to result in an emergent cesarean or operative vaginal delivery.

I am not opposed to strategies that seek to lower the rate of unwanted and unnecessary cesareans - women who neither want nor need cesareans, should not be needlessly subjected to them. For that reason I am thrilled that women in British Columbia who desire a vaginal birth and have been informed of the risks and benefits of planning a vaginal birth and the risks and benefits of cesarean birth in their individual circumstance and would choose a vaginal birth have access and support even if they have had a prior cesarean or their baby is breech. Being able to plan a vaginal birth after cesarean or a vaginal breech birth, in the safest circumstance possible (in a hospital with trained staff and resources available) is a great thing and reduces the potential for such circumstances to result in death or significant disability to either mother or child. In other parts of North America, women have difficulty accessing the care they need to plan a vaginal birth after a cesarean (VBAC) or a vaginal birth with a breech baby - and as a result many choose to birth unassisted, do not seek assistance with delivery until they are pushing, or choose home birth with an under-qualified birth attendant and lack of access to appropriate resources. These women are exposed to risks to both themselves and their children that could be mitigated if they can find a care provider and a hospital to accommodate them. For some of those women - avoidable death and disability results.

However, selling the idea that a vaginal delivery should be achieved whenever possible - is damaging to women and their children. This is what the "Power to Push" campaign does - it encourages women to pursue a VBAC, it encourages women to attempt a trial of labour with a breech baby under certain circumstances, it encourages the use of external cephalic versions (ECV), and it discourages maternal request cesareans. Rather than providing women with unbiased information regarding their birth options and the risks and benefits associated with those options and letting women decide what is best for them and their families in their individual circumstances - it pushes the idea that vaginal delivery is best - and that a cesarean is sub-optimal. Furthermore, it does this by targeting a group of women for whom cesarean delivery is more likely to be a better choice and targeting the safest and cheapest cesareans - scheduled cesareans. As a result, it is likely that it might succeed in reducing the rate of cesareans - but at the cost of increasing the share of cesareans that are unplanned or emergent, and potentially increasing the numbers of mothers or babies that are injured, disabled or die.

Further, I am disappointed at a system that fails to support all pregnant women - including those who would choose cesarean delivery or even epidural anesthesia and focus on the ultimate goal of maternity care - healthy mothers and healthy children. It's great that women desiring risky vaginal deliveries are supported to do so in the safest environment possible - however, it's a travesty that those seeking planned cesareans are not given the same support. CDMR in British Columbia continues to be difficult to access with women having difficulty finding care providers and facilities to support their informed request for cesarean delivery. It's time we had a maternity care system that didn't try to sell women on a particular mode of delivery - but rather supported a patient-centred model of shared decision making based on the best available evidence that supported the full spectrum of pregnant women to make the decisions and have access to the care they need for both mother and baby to be happy and healthy.

Meet Mrs. W - She isn't who you might think she is...

The other week - an anonymous someone - made the following comment on my blog:

AnonymousNovember 14, 2012 11:41 PM You strike me as one of the type of upper class white person who feels entitled to anything she pleases. This sort of arrogant mindset does not serve you well, it only makes you come across as snooty and reprehensible. Not everything should be accessible simply because you want it. This is a product of the over-consumption way of living that is not healthy nor admirable. It's not anyone else's problem that you have issues with squeezing a baby out of your vagina. It's not anyone else's responsibility to make sure this doesn't happen. It's YOUR responsibility to mature a bit and realize not everything in life is convenient, clean and pain-free. And it's nobody's job to make it that way.

They revealed their assumptions about me - and in doing so, demonstrated what the stereotype is of a woman who wants to avoid delivering her child vaginally and requests a cesarean. It's not a pretty picture. Entitled. Arrogant. Snooty. Reprehensible. Over-consumptive. Self-centred. Immature.

Such vitriol - no wonder this person wished to remain anonymous, it is easy to hate a stereotype and even easier when you can choose to remain nameless and faceless yourself.

So who am I really - and how does it compare to the woman this person thinks I am?

I am 33 years old. I'm caucasian. The second born child of three to two high-school drop-outs - a farmer and a waitress at the time of my birth. I was baptized Anglican. My parents divorced when I was 6 - after the farm failed in the wake of early eighties interest rates. My father graduated from college when I was nine. I went to Catholic school from grades 2 through 7. My father remarried when I was seven - and separated again by the time I was nine. I was bullied in grade school. I was confirmed Catholic. I elected to live at my father's house when I was thirteen. My mom graduated university when I was fifteen. I taught Anglican Sunday school and volunteered at the local hospital in high school. I graduated when I was seventeen. I moved out on my own and started at the University of Victoria when I was nearly eighteen. I worked full-time for most of my undergraduate studies - as a waitress at a family restaurant, as a cashier at Tim Horton's, as a hostess at Japanese Village, as a copy editor for the student newspaper, as a telephone surveyor. I graduated with an undergraduate degree in Economics and Sociology and more than $18,000 in student debt. I then worked as an employment standards officer and started graduate studies in Economics. My mother remarried when I was twenty-two. I was a teacher's assistant during graduate school. I did work terms with the Ministry of Forests and Tourism British Columbia. I worked as a labour relations officer with the federal government for a year. I graduated with my Masters Degree when I was twenty four. I then did economics consulting for a year, at which time I was offered an economist position with the Vital Statistics Agency. After a year with the Vital Statistics Agency my position was transferred to the Ministry of Health. I met my husband shortly before my 28th birthday - at which time his children were 9 and 5. We married shortly after my 30th birthday. His vasectomy was reversed shortly after the wedding. I lost my grand-mother, aunt and uncle to a drunk driver the summer after I married my husband. Our daughter was conceived in the fall. I became a mother at the age of 31 and again to my son this past September.

So who am I? I am a devoted daughter, sister, step-sister, wife, step-mother, mother, and aunt who has worked hard to get where she is. I am a devoted friend. I am educated. I am an economist. I am principled. I am confident. I am independent. I am open-minded. I am responsible. I am articulate. I am thoughtful. I am hard-working. I am respectful. I refuse to be bullied. I am determined to be the kind of woman and mother that I would want my daughter to be - and to do my part to make her world a better place.

So to Anonymous - I say the following, "I know who I am, I am not ashamed, I will not be disempowered and abused - I am not the stereotype you think I am - and it's rather telling that you make such assumptions to begin with."

A Silk Purse from a Sow's Ear

I am still angry about the circumstances of my daughter's birth - and I do not think that I will ever find that set of circumstances acceptable. Not for myself. Not for my friends. Not for my sister. Not for my daughter. Not for any woman living in British Columbia or Canada today or in the future. Women deserve better, their children deserve better. Not for any patient.

I am not angry that my daughter was born healthy - I am thankful for that every day. Motherhood has been a tremendous blessing - and has given me tremendous amounts of joy and wonder as I watch my children grow. Indeed, having a healthy child was my primary goal during my pregnancy - and one of the reasons I had elected for a cesarean delivery: to reduce the risk of truly adverse and life-long health consequences such as severe disability or death.

I am angry that the care I reasonably expected and was entitled to receive was withheld. I am angry at an ideology that seems to be driving the system further, and further away from quality, evidence-based, patient-centred care. I am angry that I was lied to. I am angry that I was abandoned. I am angry that the experience was terrifying and painful and physically and psychologically damaging and left me feeling utterly violated. I am angry that the circumstance was entirely unnecessary. I am angry that there exists people out there that find such circumstances acceptable. I am angry that what I experienced was likely the result of either negligence or willful disregard.

It's okay to be angry about those things - actually, I would be more worried if I wasn't angry about those things as it would likely mean that I had given up and thought that such things just did not matter. Indeed what happened was on its face, a Sow's Ear.

However, that sow's ear has supplied the material for, what someday might indeed be a silk purse. If my daughter's birth had unfolded as my son's birth did two years later - I likely wouldn't be sitting here writing this blog post. I would not have spent the last two years thinking about what quality maternity care really looks like, about what really matters and about what is poorly understood. I would not have become acquainted with an entire community of women who want better - for themselves, for their sisters, for their friends, for their daughters - an entire community of women (and some men) who believe strongly in informed consent and patient-centred, evidence-based care. I would not be pursuing a lawsuit (there would be no need to) - that might result in a precedent that other women can depend on - or at the very least will likely send the message that lying to a woman and subjecting her to a treatment that she did not consent to without cause is actionable, even if that woman was pregnant at the time.

What happened was awful (I'll happily concede it was not the worse that could have happened) - but what has happened since has made a difference and will continue to make a difference, hopefully for the better. After all, shouldn't it be the goal of every mother that her daughter should have a better go of it when it's her turn - and that's why I'm not done. Not yet - there's still a long way to go before I'll look at the situation that exists and think that it's the silk purse that it can be.

Fear of childbirth: An unjustifiable barrier to motherhood for some

Imagine for a moment your worst fear.

Imagine your deepest desire.

Now imagine being told that in order to fulfill one of your deepest desires, you must subject yourself to your worst fear.

Now imagine knowing that there is a way to fulfill your deepest desire without subjecting yourself to your worst fear - that subjecting yourself to your worse fear is completely unnecessary, that you can achieve your deepest desire some other way.

Now imagine being told that it doesn't matter that it is completely unnecessary for you to be subjected to your worst fear, that it doesn't matter that there is a perfectly acceptable alternative for you to achieve your deepest desires, that you *must* do what you do not want to do or forego your deepest desire.

This is what it is like for women who desperately want to be biological mothers but desperately want to avoid vaginal childbirth. For many of them, they know a safe, effective method of childbirth exists (elective cesarean) - but they are told that their bodies are "made to birth", that if they do not wish to do it as 'nature intended' that they should forego motherhood or adopt, that cesareans should only be reserved for those with a physical *need* for the procedure, that they are being hysterical.

Unlike some fears (ie. of clowns or non-poisonous spiders or non-venomous snakes) which may be completely irrational - the fear of vaginal childbirth has some rational basis. There is a real risk of perineal tears. There is a real risk of pelvic floor damage. There is a real risk of birth injuries including hypoxic ischemic encephalopathy (HIE), and brachial plexus injuries. There is a risk that an emergent cesarean delivery may not be available or timely. There is the risk of extreme pain. Indeed, from my perspective, a fear of vaginal childbirth is wholly rational.

Further, it is not like the alternative delivery method (cesarean) available to these women is grossly expensive or inordinately dangerous compared to the conventional delivery method (vaginal birth).

So why is it that so many people think that offering women who fear vaginal birth the choice of either subjecting themselves to a vaginal birth that they do not want, or foregoing biological motherhood is anything less than cruel? And why is it that when these women are subjected to the process that they fear (perhaps without notice) that anyone is surprised that they are at a high-risk to develop PTSD as a result?

This is why it is critically important for maternal request cesarean to be unquestioningly available - because it is cruel for it not to be an option when it is an acceptable choice to meet something as basic as the desire to be a mother or to have more children. And before you ridicule some other moms choice to deliver by way of cesarean, maybe take a moment to imagine what it would be like if you were told you had to subject yourself (unnecessarily) to your worst fear in order to meet a basic desire.

The Flawed Assumption of Cost-effective Natural Birth

I'm an economist by training - but more than that, I am a health economist by profession. I understand (probably better than most) the concepts of scarcity, risk, cost, expected cost and cost effectiveness. I also understand the challenges that are facing our health care system - both today and going into the future.

Perhaps that is why I am particularly perturbed when time and time again I hear that reducing the number of cesareans would save the health system money and in particular how reducing the number of maternal request cesareans would save the health system money. On it's face it seems to be such a no-brainer, after all how could an expensive surgery (cesarean birth) compete with the free birthing procedure that nature gave us (unmedicated vaginal birth)?

Of course not using health system resources is cheaper (on its face) than using the health system.

Have a heart attack and die where you stand: $0 health expenditures, alternatively have a heart attack and go to the hospital, get a coronary artery bypass and go on to live another decade or two: A whole lot more than $0 health expenditures. Develop cancer and let the disease progress as nature intended: $0 health expenditures, alternatively going to your doctor, get diagnosed (likely via some screening program), get chemotherapy/radiation therapy, and either cure the cancer or buy some additional time: A whole lot more than $0 health expenditures.

Yet there is no widespread calls for natural heart attack therapy or natural cancer care. Anyone who stood on the corner saying that people should put the needs of the health care system ahead of their own needs - would be told to apply their 'natural therapies' to themselves and to stuff it.

The natural childbirth movement is standing on the corner and shouting (rather loudly) that women should forego medical care during birth because it will save the system money. What's worse is that government seems to be encouraging them to shout even louder.

The assumption that is behind this is that intervening in birth does not buy better health outcomes. Either that or, because the better health outcomes accrue to women and their children, they simply aren't "worth it". I would hope that it is the former rather than the latter driving the "save the health system money by avoiding cesareans" mantra.

Unfortunately this assumption is flawed and very likely, very wrong.

Intervening in birth by providing pain relief or access to surgical delivery for those who want or need it does buy better health outcomes and may even save the health system money over the longer term.

Those who choose cesarean are doing so for a wide variety of reasons. They are doing it so that they may avoid the risk of an emergent cesarean. They are doing it to avoid the risk of a perineal tears. They are doing it to avoid a pelvic floor injury. They are doing it to reduce the risk of developing urinary or fecal incontinence. They are doing it to reduce the risk of severe disability or death to their unborn child. They are doing it to better arrange the support resources they need during and after the birth. They are doing it to avoid the risk of having a traumatic experience. They are doing it to reduce the risk of developing PTSD or PDD. They are doing it to protect their sex lives. They are doing it to avoid the risk of severe, uncontrolled pain.

Chances are they are doing it for several reasons and in all circumstances they are doing it because the benefits of choosing to intervene exceed the costs and/or risks of not intervening at an individual level.

I would even be so bold as to argue - that the government would do well to spend MORE on maternity than it does now as the expenditures on maternity are likely to buy more than expenditures in other areas of care. Those served by maternity services tend to be young and as such any gains in health outcomes are likely to accrue over many years. A single case of cerebral palsy that is averted could save the health care system millions of dollars in costs of future care. Avoiding a pelvic floor injury that requires subsequent repair, would likely save thousands. Avoiding a case of PTSD or PDD, again would result in significant savings.

Further, it is unclear whether or not maternal request cesarean is even significantly more expensive than planned vaginal delivery to begin with. A study entitled "Cesarean delivery on demand: What will it cost?" in the American Journal of Obstetrics and Gynaecology Volume 188, Issue 6, pp. 1418-1423 found that the average cost difference between women who attempted a vaginal delivery and those who had an elective cesarean was just 0.2% in favour of vaginal delivery. Hardly a cost savings to deprive women of their treatment of choice - which is perhaps why many US health insurers (arguably even more keen to save money to boost profits than Canadian medicare) now cover elective cesarean section.

So why don't we start with the assumption that healthcare providers and mothers who choose cesareans are doing so in their own best interests and that they are no more "milking the system" than those with cancer or cardiac problems are "milking the system"? And maybe, just maybe we ought to look at the real economics of birth choice - the answers might be very surprising indeed.

Is CDMR a societal and professional failure?

In this month's edition of Lamaze's journal Birth - Dr. Michael C. Klein will publish an article entitled "Cesarean Section on Maternal Request: A Societal and Professional Failure and Symptom of a Much Larger Problem".

I wish that this article would focus on the professional and societal failure associated with maternal request cesarean and the much larger problem. However, knowing Dr. Klein as a staunch natural childbirth advocate who is ideological in his belief that medical intervention should play a minimal role in birth; I know that this article will disparage the choice that some women make to deliver by way of cesarean as being driven by misinformation and fear and will completely fail to address the much larger problem.

I would argue that the rates of maternal request cesarean are indeed driven by misinformation and fear. In short, I believe the risks and negative impacts of vaginal delivery are understated and the risks and negative impacts of an elective cesarean delivery are overstated. Further, I believe that the advantages of vaginal delivery are systematically inflated, while those of cesarean delivery are systematically discounted. I believe that the fear of surgery drives many women to avoid it - even when a surgical delivery would have resulted in a better outcome for either mother or child than a vaginal delivery. I also believe fear and misinformation drive a lot of women to forego epidural pain relief. Yes, fear and misinformation are a big problem when it comes to birth - and likely result in lower rates of maternal request cesarean and use of epidural pain relief than would be 'ideal' as many women who would have a much better birth experience by having an elective cesarean or using epidural pain relief forego doing so based on misinformation and fear.

I also believe that the situation around maternal request cesarean is a symptom of a much larger problem. That problem is that not all women are supported when it comes to the choices that they need to make during pregnancy, labour and delivery. That the information given to women regarding pregnancy, labour and delivery is heavily biased. That many women have difficulty finding a provider and a care facility that will be supportive and respectful of a mother's requests for cesarean delivery and in many cases even access to epidural pain relief. That many other women seem to think that it is okay to criticize the informed choices some women make to deliver by way of cesarean or use epidural pain relief.

I will also agree with Dr. Klein that the system of maternity care, particularly in British Columbia, is in dire need of reform - all pregnant women need to be supported and empowered to meet their own needs with unbiased information and access to medical care including access to surgical delivery and epidural anesthesia on request. All pregnant women need to know what their choices are, the risks and benefits of those choices and to have the right to informed consent. Further, all pregnant women need to know that their choices will be respected and confident that just because they are pregnant does not mean that they lose the right to decide what is done with their body.

Mum's the Word on Maternal Choice Cesarean

I never had any desire to have a vaginal birth. In another time or place, I may have considered foregoing motherhood or adopting rather than subjecting myself to the conventional whims of nature. However, knowing that cesarean was an option, I knew that foregoing biological motherhood would be an unnecessary toll for wanting to avoid a vaginal birth. I knew that cesarean birth was a feasible (safe and effective) way to have a baby - I lived in a first world country and could find nothing that indicated that women in Canada weren't allowed to have cesareans on demand or that such a choice would be inaccessible in my own community. For myself, it was clearly preferable over conventional birth. It seemed to me that the biggest challenge would be finding a doctor to accede to the request-but given the controversy around maternal choice cesarean, I knew that while many doctors would not accede to a request, that many other doctors would. I felt confident that I could secure a maternal choice cesarean before I even got pregnant - even if it would have meant travelling to access care.

That being said, I also knew that rejecting a conventional birth (a trial of labour in a hospital) would not be a socially acceptable choice. None the less, I was open about my plans during the pregnancy with my daughter. Not because I wanted the stamp of approval from others, but because I felt that it was important for others to know that it was an informed choice that I had made freely. A choice I felt best met my needs and those of my child. That I was happy with choosing cesarean, and that any concern about my birth plan was misplaced.

By the time I was admitted to hospital for the birth of my daughter, there was nothing that had been said to me that had changed my mind about vaginal birth or cesarean birth - not for the lack of trying by others and a hefty dose of misinformation about cesareans. Others regaled me with the horrors of cesarean birth - It's major abdominal surgery! The recovery is horrid! What about the scar! Adhesions! Infection! They further regaled me with the virtues of vaginal birth - it's the way nature intended! With an epidural, it's not painful! The recovery is easy! Thanks, but no thanks. Conveniently absent in the vaginal birth love-in was any acknowledgement of the virtues of cesarean (indeed it does have advantages) or the genital warts of conventional birth (indeed conventional birth is not completely a thorn-free bed of roses).

I was even open about my choice with hospital staff when I was in hospital awaiting for the cesarean that did not happen for the birth of my daughter.

My experience of vaginal birth proved to me why I had wanted to avoid it in the first place, even in the absence of the worst consequences of vaginal birth. I pooped in front of people. I experienced the worst pain of my life. I was terrified. I tore. My daughter needed narcan and resuscitation. I was left feeling violated and abandoned. I developed a vaginal infection. For more than a year afterwards, I had mild urinary incontinence. My enjoyment of intimate relations with my husband was adversely impacted. Memories of my daughter's birth continued to haunt me, and rather than looking at photos of that day with a sense of joy or accomplishment, they are a reminder of the worst experience of my life. I felt socially isolated among other mothers, particularly those with strongly held beliefs about conventional birth.

After my daughter's birth I understood why so many women who prefer birth by cesarean are mum about their preferred path to motherhood. I understood why some mothers make up a medical reason for their cesarean - it is far more socially acceptable to say you had no choice in the matter and in some cases making up a medical excuse might be the only way to access care. In some cases, where cesarean is seen as being inaccessible, some women are choosing to forego motherhood - choosing to prevent pregnancy, adopting or aborting. Other mothers are paying a hefty financial price for their preferred method of birth.

Indeed, during my pregnancy with my son, I found myself being a lot more mum about my choice.

However, being mum doesn't help other moms who share the same view on birth. Being mum does not make it easier for the next mom to make and exercise her choice. It does nothing to ameliorate the undeserved stigma or shame associated with being a woman who would prefer to avoid a conventional birth and choose cesarean. It does little to address the misinformation or myths about mothers who choose cesarean (the vast majority of whom are not "too posh to push"). It does little to address the misinformation or myths about elective cesareans as medical procedures - or even the misinformation or myths about other birth related medical procedures (such as epidurals). It does little to address the problem of those who would seek to deny moms like me their chosen path to motherhood and it does little to help women make truly informed decisions about the birth choices available to them (have I ever blogged about how little data is out there on maternal request c-sections and how they are not formally tracked in administrative databases???). Maternal choice cesarean needs to be an accessible, accepted, and respected choice - and as such moms like me can remain mum no longer.

Is encouraging homebirth in British Columbia to save healthcare dollars going to come at the expense of women and babies?

This morning I woke up to an article in my local paper with the headline Health Minister encourages home births in low-risk cases.

While I support the option of home birth as an informed choice that should be supported with access to qualified and regulated care providers in low-risk situations, encouraging it is another matter, and encouraging it to save money strikes me as being unethical and short-sighted.

I am tremendously thankful that home birth in British Columbia is highly regulated with care providers who are well trained - as it reduces the harm that may be incurred by those who would choose this option anyways. Further, I will begrudge nobody a natural childbirth - if that is what the woman giving birth desires. However, knowing that home birth in the Netherlands has led to low-risk women undergoing home birth to have worse outcomes than high risk women undergoing hospital birth with an OB, gives me pause for thought. The idea that in the vast majority of studies on home birth perinatal and maternal mortality and morbidity is significantly higher than that experienced with hospital birth (with the exception of the one study cited in the article), again gives me pause for thought. Knowing that a low risk woman can go from being low-risk to high-risk in a matter of minutes, further gives me pause for thought. Knowing that some of the consequences of birth gone wrong can be life long and devastating, further gives me pause for thought. Lastly, knowing there's a lot that "low-risk" women, particularly first-time mothers may not be told about birth and its attendant risks, makes me think that encouraging home birth is irresponsible. It also worries me that such a statement coming from the head of the ministry, a former doctor, may make women think that Homebirth is safer than it really is.

Further, such a stance worries me that the Ministry of Health in British Columbia thinks that it is okay to restrict access to medical care for women during labour and delivery for low risk women. After all if low risk women outside of the hospital do not need medical care (epidurals, cesareans) - then why should low-risk women in the hospital need access to these services?

I would further hope that rather than encouraging a risky birth option such as home birth (note this is ALL about saving money) that the Ministry would strive to make safe birth options (in the hospital) more accessible, available, attractive and more cost-effective. Doing otherwise is just saving money at the expense of women and babies - and there's something very wrong with that.