A Good Cause – Protecting Every Woman’s Right to Informed Consent

In recent weeks, I have been busy – preparing to return to work, and figuring out how to move forward in a way that recognizes the needs of my family and my own personal needs. I have a personal need to know exactly what happened with respect to my daughter’s birth. I have a personal need for accountability for what happened. I have a personal need to gain some confidence that the same thing will not continue to happen to other women. My family needs me to meet my personal needs in a way that does not put at risk our financial and emotional well-being.

This has posed a tremendous problem – on one hand, the only way to get answers and accountability for what happened AND to ensure that the same thing does not continue to happen is to litigate. On the other hand, litigation is tremendously expensive and risky. There are many, very good, reasons why very few women ever sue as a result of their birth experiences in Canada – and now, I can say I am familiar with all of them. The problem is that because women do not, or rather cannot – assert their rights, those same rights are at risk of being disregarded.

I do not believe that I am alone in my experience. Far from it. Nor do I believe that anything will ever really change, unless the incentive structure in maternity care is changed. I believe women are entitled to informed consent and that they should be reasonably entitled to make choices in childbirth. They should be able to choose to pursue a vaginal delivery or a caesarean delivery. They should be able to choose to have an epidural or to forego pain relief. They should be able to have a discussion regarding the risks and benefits of their choices and to expect reasonable access to care to facilitate their choices.

This is not about natural or normal childbirth versus medicalized childbirth – this is about informed consent, timely access to care and minimizing the very negative consequences that can result when a woman is deprived of informed consent and timely access to care.

At this moment – I am hopeful, because in recent weeks an amazing group of women have established what could be capable of transforming maternity care in Canada.

I am overjoyed at the launch of the Birth Trauma Canada Maternity Legal Action Fund – and I look forward to the difference it will make.

Being "Open" about "Cesarean by Choice"

It is not easy being a cesarean by choice mom - either, you are open about your views on how you prefer your child is born or you keep them private with a very tight circle of "need to knows", with only your doctor, your husband and yourself knowing about your choice. In the worst scenario you repress doing what you really want to do and subject yourself to a process that you find, well kind of horrifying, all because a bunch of people who may not even be in the delivery room or changing the dirty diapers afterwards think it is what you "should" do.

I have come to the conclusion, that how women prefer to birth, is a part of "who" we are - and maybe women should not be so quick to hide or repress that part of ourselves - or at the very least women should should not hide it anymore than women would hide any other aspect of ourselves. That is not to say that women should not discuss the available delivery options with our care providers - along with their respective risks and benefits. That is also not to say that women should make choices based on misconceptions about the options available - if it is purely the pain of vaginal delivery that is the problem, then there might be appropriate alternatives to address that. But rather - we should be free to make a *medical decision* for ourselves, and to be comfortable with those choices, regardless of what they happen to be.

I think there is a lot of damage done, when how women prefer to birth is some kind of taboo, where only the dominant choice is seen as being socially acceptable. I think it is awful, that many women who prefer to birth by cesarean - feel the need to be ashamed of that choice. I think it is awful, that women cannot respectfully discuss their preferences with respect to birth. I believe women who prefer cesarean are just as deserving of a supportive community as those who prefer natural unmedicated childbirth, or medicated vaginal delivery. I believe women who prefer cesarean are just as deserving of access to care that respects that choice. I think that by failing to recognize cesarean by choice as valid - myths about cesarean and vaginal birth are allowed to remain, and instead of supporting each other to make the best choices for ourselves, many women either make a personally wrong choice or feel isolated by the choice that they have made.

Being cesarean by choice, is as much a part of me as being a mother, being an economist, being an agnostic, being a liberal, being a wife, being thirty-something - and I am not ashamed of that.

What is a Good Birth?

I recently read an article interviewing a doctor who had conducted a large study "The Good Birth Project" and then had written a book A Good Birth: Finding the Positive and Profound in Your Birth Experiencewritten by a doctor, Anne Lyerly, MD. In the interview, Dr. Lyerly summarizes 5 characteristics that make. Those characteristics are described as being:

1. Agency: a good birth is one in which we have a hand in shaping, that is informed by the things we value – a birth in which we feel involved and present.

2. Personal security: a good birth is one in which we feel safe and secure, in trustworthy hands.

3. Connectedness: the degree to which we feel meaningfully connected to our loved ones, our care providers, and of course our baby.

4. Respect: a good birth is one in which we feel others respect us, our newborn, and more broadly birth as a meaningful event in our lives.

5. Knowledge: a good birth is one in which we have enough information before and during the event that we have a sense of what is happening and why; but it also depends on the wisdom we garner by virtue of going through it.

Dr. Lyerly goes on to say that

these things can all be cultivated no matter where you give birth (home, birth center, or hospital) and no matter how (vaginally or by cesarean).

What Dr. Lyerly had to say about what makes for a good birth truly resonated with me - and I feel that many women who choose cesareans are wanting "Good Births", births that meet their individual needs for agency, personal security, connectedness, respect, and knowledge. I know that my planned cesarean with my son was truly "A Good Birth" - and I can conclude that it met all of Dr. Lyerly's criterion for a good birth.

Applying the same lens to my daughter's birth, only highlights the unnecessary challenges that many cesarean by choice moms face - and in my own case highlights how big of a chasm there is between the "Good Birth" I sought and the one I was ultimately left to reconcile.

If the interview is anything to go by - I have a new book on my reading list.

Feminism: It's About Having Choices and the Freedom to Make Them, Not the Choices Themselves

I'm an economist, as such, I have spent a lot of time in my career thinking about choices, and how people make them and trying to understand the conditions that lead to good choices - and conversely the conditions that lead to bad choices, and what can be done to get to a place where better choices are made more often. Any good economist understands that all people try to maximize their own satisfaction - but that because all people are different - with different preferences, not all people will make the same choices. And that is okay, actually, it's better than okay - it is absolutely critical!

I have come to the conclusion, that the true meaning of feminism - is about having choices and being free to make them - being free to lead a life that is most satisfying to the individual woman in her individual reality. Feminism is not, and should not be about the specific choices that individual women make - and much damage is done when biological essentialism is passed off as feminism. Much damage is done when women sit in judgement about the specific choices that other women make. Much damage is done when women fail to focus on making the best choices in their own life. Much damage is done when women fail to support other women in making their own choices.

Something wonderful happens when women shift from thinking that everyone needs to make the same choices to understanding the importance of having choice and facilitating choice. Women become more compassionate. Women become more confident in their own choices. Women become more tolerant of choices that are different from their own. Women are better able to help other women discover the choices that are best in their own individual lives, without judgement.

When the focus is on having choices, and the process of making choices - it is okay to breastfeed - it is okay to formula feed - it is okay to have children - it is okay to remain child-free - it is okay to plan a vaginal delivery - it is okay to plan a cesarean delivery - it is okay to stay at home - it is okay to work out of the home - it is okay to get a degree - it is okay not to get a degree - it is okay to get married - it is okay to stay single - it is okay to cloth diaper - it is okay to use disposables - it is okay to baby wear - it is okay to use a stroller - it is okay to send the kid to daycare - it is okay to home school - it is okay to use public schools - it is okay to use private schools - it is okay eat organic - it is okay to not eat organic - it is okay to circumcise - it is okay to not circumcise - it is okay to cry-it-out - it is okay to not cry-it-out. And none of those things make one woman a better woman than another woman who happened to make a different choice.

When the focus is on having choices and the process of making and facilitating choice - Women become empowered and empower other women - the mommy wars end and the focus shifts to what is really important - leading satisfying and fulfilling lives as individuals.

Getting There From Here

It's too early to blog about details - but it looks like there is a way to get there from here. I'm excited. It is early days - not unlike first seeing two much wanted lines appear on a pregnancy test - there's a lot of hope and potential, but just a bit of hesitation. I'll blog about details after we are through the proverbial "First Trimester" with this project. (Note: just to avoid any confusion, the W household is not expecting a baby...)

The Reality of a Traumatic Birth

The reality of having the day my child entered the world also be the day in which I had the worse experience of my life - a severe deprivation of personal autonomy - is that it has not faded from the forefront of my mind. It has been more than three years and very rarely does a day go by when I do not think about that day. On a good day, it is just there. On a bad day, it brings with it all the negative emotions - the terror, the anger, the abandonment, the pain, the helplessness. On a bad day, there is little reprieve and I find my mood sinking like a lead weight in an overwhelming ocean. The upside is that the good days, the days when it just is what it is, are growing in frequency, while the truly bad days - the days when the thoughts come with all the baggage of the negative emotions associated with it are diminishing.

I have come to the conclusion that this is the reality of my traumatic birth experience. There will always be a psychological scar - it'll fade, sometimes it may not be painful - but it will always be there. The negative experience cannot be reframed as being a necessary evil. Which is why I feel compelled to do something about what happened to me - something concrete, something that might make a difference for another woman. It is why I blog. It is why I am holding my care providers, the hospital, and the health authority to account - in the only way I truly can. It is why I can't just move on - because moving on when things still need to change, means that what happened to me will always just suck, for no good reason - and in some way feels as though it would be accepting that the way things are is somehow acceptable. There will not be closure until I feel like I have done what I could to change what is wrong with maternity care - I do not believe I can move on until I am done doing what I can to make it better for other women, other moms, like myself.

I hope that those who love me, can support me in what I need to do - in order to reclaim the woman I once was. The woman who was confident that what she thought, felt and did - actually mattered. I hope that they do not see what I am trying to do as being the actions of a "selfish bitch" - and see that what I am trying to do, needs to be done. I hope that they can be proud of what I do accomplish - and I hope they might understand a little about why I cannot just move on. I hope that I can make a difference. I hope that I can be the mother my children and husband deserve.

How to get there from here?

I want to live in a world where women are empowered to make medical decisions for themselves and can be assured of timely access to medical care to facilitate those decisions. I want to live in a world where access to epidurals and maternal request cesarean is not a matter of luck. I want to live in a world, where no woman chooses to give birth at home because she thinks her right to make medical decisions will be violated in the hospital. I want to live in a world where being psychologically scarred from the experience of birth is better understood and a far rarer event. I want to live in a world, where the information provided on birth is balanced and reflects current evidence. I want to live in a world where women do not feel the need to justify having had a cesarean or having chosen to formula feed. I want to live in a world where there is a lot less focus on the things that do not really matter (mode of birth, type of feeding), a lot more focus on the things that do matter (physical and psychological well being), and a whole lot less mommy guilt.

I want to live in a world where the voices of moms like me are not drowned out by voices of advocates of natural birth or home birth. I want to live in a world where maternal request cesarean is as understood and as researched as home birth. I want to live in a world of truly informed choice - where women are not "sold" on what they should do, but rather are given the information they need on the choices available to them and are free to make the decisions that best meet their needs and those of their family.

The reality is, that the world as it exists now - is still distant from the world as I wish it were. That's the challenge - getting there from here. Improving pre-natal education and the information available to pregnant women. Improving access to reasonable choices. Improving the hospital environment. Improving the legal context. Improving access to resources for those who have been through a traumatic birth or for those who are grappling with difficult pregnancies. Improving the knowledge base through research. Giving voice to the women who have no desire to buy into the ideology of Natural Childbirth. It seems as though there is still a lot of work to be done.

So how can we get the work that needs to be done, underway? What is the next logical step?

This side of the spectrum has no Lamaze. This side of the spectrum has no Childbirth Connection. This side of the spectrum has no mothering.com. This side of the spectrum has no International Cesarean Awareness Network. This side of the spectrum has no National Childbirth Trust. This side of the spectrum has no Power to Push Campaign. This side of the spectrum has no Business of Being Born. In short - this side of the spectrum has no large organization that is advocating for the interests of it's members and undertaking the work that needs to be done to improve maternity care for women who want to avail themselves of the advantages that modern medical technology can provide to make birth less painful and safer for themselves and their children.

That's not to say that this side of the spectrum is completely bereft of resources and advocates. This side of the spectrum includes Birth Trauma Canada. This side of the spectrum includes the Fearless Formula Feeder, Suzanne Barston. This side of the spectrum includes The Adequate Mother, a Canadian Anesthesiologist. This side of the spectrum has published a very well researched book by Dr. Magnus Murphy and Pauline MacDonagh-Hull "Choosing Cesarean: A natural birth plan". This side of the spectrum also includes Cesarean Debate. This side of the spectrum includes Dr. Amy Tutuer, the Skeptical OB. This side of the spectrum includes the facebook group the "Cesarean by Choice Awareness Network". This side of the spectrum includes me. This side of the spectrum has tremendously educated women who are working as best they can to facilitate change - to improve maternity care for mothers and their families. However, it remains under-organized and as a result is not meeting the potential to make maternity better for a large number of women. It needs to be better organized and better resourced in order to facilitate the work that needs to be done - there is a large mandate that is waiting to be met.

So how do we become better organized and better resourced? How do we catapult ourselves to compete with the well organized and well resourced Natural Childbirth industry? How do we harness what is a group of intelligent and motivated women and interested others to make change happen?

Those are the questions I am trying to grapple with. There must be answers. There is a will, there must be a way.

Penny Wisdom and Pound Foolishness in Maternity Care

It is fashionable to bemoan the high cost of health care - it does not matter if you live in Canada or the United States - and that extends to the costs associated with maternity care. Never mind that comparing the costs of maternity care between countries is fraught with difficulties - different countries have wholly different population health statuses, wholly different litigation systems, wholly different health care systems - all of which might contribute to differences in the price paid for maternity care. Unfortunately, what gets forgotten is what is bought with the money spent on health care during pregnancy and childbirth - and the value of those things, in terms of improved outcomes and satisfaction with the care received. It is not unlike bemoaning the high-cost of pursuing a university education that is likely to lead to a much higher paying job AND completely ignoring the likely increase in income (and productivity) that will be realized after graduation. Unfortunately, the economics of pregnancy and birth, for whatever reason, seems to be done rather poorly - with a focus on very broad measures of outcomes (mortality) and very limited timeframes (sometimes only counting costs that accrue within 30 days of birth).

It is often forgotten that countries that have realized a lower cost of care for pregnancy and birth, may have done so by cutting corners on the quality of care available to women and their children - limiting reasonable access to options and sacrificing the lives and well-being of some women and children. Examples of the sort of tragedies that can result fill the pages of the Action to Improve Maternity (AIM) website a New Zealand based organization that has tried to bring some accountability and improvements to the midwife led system that is focussed on promoting normal birth. It is also not uncommon to hear tales of epidurals being denied or delayed in the UK or parts of Canada - again both countries where integrating midwifery into the system of care and promoting "normal birth" is the norm. A birth that does not involve an epidural is cheaper than one that does, but that does not mean that quality care was provided - particularly if the woman wanted an epidural and endured a painful and traumatic delivery as a result. A birth that results in a vaginal delivery is not necessarily quality care either - particularly if it leaves the woman traumatized, or herself or her child disabled.

I would not be surprised if well done economic studies on birth and intervention in birth would show that an ideologically driven system focussed on promoting and facilitating normal birth actually comes at a tremendous cost.

Sweet and Sour

Recently, a friend pointed me in the direction of a blogpost - one where the author was excited about having a date for her elective cesarean. Of course, such a post will draw some criticism, typically from a Natural Child Birth True Believer - the following is just such a comment on the original post.

Anonymous - June 26, 2013 at 9:20 AM

Every mother has the choice to schedule a C- section. I understand that it may be right for you but I also very much believe that women need to be informed about the ways to have an empowering birth. Women need to trust in their bodies and research midwifery and the benefits of having natural birth. The birthing process begins the bond betweek mother and child. If both are on drugs and unable to have that immediate bond, it starts a life and a relationship out with stress and disconnect. With thousands of readers, I find that you have an amazing platform to discuss empowering birth options and educate women and pregnant mothers everywhere. I find that the rate of C-sections IS an issue, an important one to talk about. While you may not want to appear apologetic, I still feel that talking about it would continue a conversation that needs to be brought up again and again. I am a long time reader of your blog and I really do respect all mother's decisions. I just feel strongly about the casual nature of this post and the casual nature of all the women commenting about planned C- sections.

It's these kinds of comments that continue to astound me - how can women be so ignorant and judgemental of other women's choices? I found myself responding with the following comment.

Mrs. W. June 26, 2013 at 10:58 PM

Danielle - you are so much more gracious than I would be.

Anonymous - Danielle or anyone else does not need to justify their choice to have a cesarean to you - you are not their doctor, you are not their spouse and you are not their child. Please start with the assumption that women who choose cesarean are doing so from a position of choosing the birth that is best for themselves in their own particular circumstance. After all, most mothers who choose cesarean are capable of assuming that your choice to pursue a natural birth is an informed choice that you have made after having determined that it is best for you and your family in your particular situation.

I understand you are concerned about the rate of cesareans - however, I would argue that such concern is woefully misplaced and the focus on a specific procedure or process (normal birth), results in a complete blindness to what really matters. What really matters is getting through birth healthy and happy - what really matters is avoiding trauma and life long disability or death. Having a normal birth is not and should not be the goal - it forgets all the days that follow. If it can be achieved (and the mother wants it) safely, then great - but if the mother doesn't want it or it puts her life or the life of her child at risk, then is it worth being able to say that you pushed a baby through your vagina? Isn't being a woman about more than what you can do with your body, isn't it time that biological essentialism be laid to rest? Further, it's a rather cheap shot to declare that cesarean mothers don't or can't bond with their children as well as mothers who gave birth naturally - as a mother who ADORES her 3 year old, I can say that bonding with her was far more difficult than bonding with my 9 month old - I love them both but the PTSD her unwanted normal birth resulted presented specific challenges.

We don't measure the rates of women denied informed consent during birth. We don't measure the rates of women unable to access adequately trained and qualified care providers for prenatal care and birth. We don't measure the rates of births that result in post-natal PTSD. All of these things matter far more than whether or not the birth was a result of a cesarean.

I challenge you to become more informed on the issue of Cesarean by Choice. A good place to start might be Pauline Hull and Magnus Murphy's book "Choosing Cesarean: A Natural Birth Plan". Also look at the blogs Cesarean Debate and Awaiting Juno. And though you may hate me for it - browse through Dr. Tuteur's blog (the Skeptical OB) for a look at the seedier and far less respectable side of natural birth.

A Cesarean by any other name

There seems to be some confusion when cesareans are discussed, with elective cesareans often being confused as all being maternal request or patient choice cesareans. While the vast majority of maternal request or patient choice cesarean are elective, not all elective cesareans are patient choice or maternal request cesareans and the vast majority of elective cesareans have clear medical indications for being performed. The term "elective" simply means that the procedure was scheduled in advance - and given that maternal choice cesareans account for maybe 2 percent of all deliveries - it is very likely that the elective cesarean in question had a medical indication for being performed (breech, big baby (macrocosmic), etc.).

Maternal request or patient choice cesareans are those that are performed because the mother has decided that she prefers cesarean delivery over an attempt to deliver vaginally. And for some reason, many people get all hot and bothered when a woman who potentially could deliver vaginally chooses not to. It is almost as though they see a woman making a choice that is different from the one that they would make as being some kind of criticism of the choice they would make. It is very similar to those who are up in arms about a man or a woman's right to marry a partner of the same sex - even though giving a person the right to marry who they want to has absolutely no impact on their own ability to marry who they want to.

To be fair the terminology in discussing maternal request and patient choice cesareans does leave a little to be desired. I find request to be a really weak word - it paints the woman as almost having to "beg" for the treatment of choice. Similarly I find the word demand - as in "patient demanded cesarean delivery" to be really aggressive. I have come to prefer "patient choice cesarean delivery", but even that seems to negate the very real need for a cesarean delivery to occur once a patient has decided that it is her preferred mode of delivery. After all, we do not call patient chosen cancer treatment, patient choice chemo or patient choice radiotherapy. That being said, I am not sure what better terminology could be used.

Regardless, patient choice cesareans are not worthy of the disdain they seem to attract - particularly from those with absolutely no medical training.

Congratulations Kanye and Kim - Wishing You the Best of Luck

Kim Kardashian gave birth today - and invariably there was reports it was an elective cesarean. And then a while later it was reported that she delivered "naturally".

The comments section on the elective cesarean story is like NCB (Natural Child Birth) activists greatest hits. With such tried and true statements like, "a cesarean is major surgery", "recovery from a vaginal delivery is so much easier", "our bodies were designed to do this", "how selfish", "cesareans should be reserved for those who need them", "cesareans are more dangerous for the baby", etc.. It seems as though almost everyone is an armchair OB, and if they could have a natural delivery - why couldn't Kim suck it up and have a natural delivery too?

I'm a little tired of the armchair OB's in this world and would like to put out the following:

1. Yes, cesarean is surgery it has risks, but vaginal delivery is a major medical event that also has risks. Discuss both options and their associated risks and benefits with your care provider - ideally someone with a real qualification for childbirth that was earned at an accredited post-secondary institution and not Google U or Anecdote High.

2. Recovery from a vaginal delivery is not always easier than recovery from a cesarean delivery.

3. Our bodies weren't designed. They evolved - somewhat awkwardly with tradeoffs made between head size and pelvic girth. Birth is not an easy process for many women. Many women historically died. Many babies historically died. Some were disabled. Birth is incredibly painful for many women. If this is something we're "designed" to do - would someone please fire the designer, or at least start a class action for negligent design.

4. Cesareans have some serious risk avoidance benefits for the baby and for the mother and may in many cases be safer for the baby and comparably safe for the mother - again discuss this with a qualified care provider.

5. Choosing a cesarean is often the anti-thesis of "selfish", mothers who choose cesarean often knowingly increase some of their risks in order to reduce the risks of delivery to their child. That seems pretty unselfish to me. Or at the very least not more selfish than mothers who choose vaginal deliveries for the sake of "easier recoveries".

I do not really care whether or not Kim had a natural delivery (maybe she did) or elected to have a cesarean (maybe she did) for the birth of her child. I care that she was able to have an open and honest discussion with her care providers about the options available to her, that she was empowered to make a decision and have that decision respected, and that she and new baby are happy and healthy at the end of the day. It's what I hope every pregnant women is able to do - have access to appropriately trained care providers who can advise accordingly, retain the right to make medical decisions, have access to timely care and go home at the end of the day with a healthy baby in her arms being mentally and physically ready to start parenthood.

I partly wonder if reporting one mode of delivery and then the other mode of delivery is strategic - a way of keeping the actual mode of delivery between the mother and her care providers confidential. If so - that is not such a bad thing, but wouldn't it be even better if they were straight up with it and take a few notes from a commenter here a few days ago who offered something along the lines of the following "We'd like to maintain the confidentiality of the medical care received, but we assure you that the baby and the mother will be receiving the best care possible."

It is rather sad though, that such a personal decision can spark such derision. But given the derision that is associated with other personal mothering choices right now (formula versus breast-feeding, cry-it-out versus never cry, stay at home versus work out of the home, cloth versus disposables) that it is not really overly surprising.

I guess we're still a ways off from a world where the majority of comments following a celebrity birth announcement manage to ignore the mode of delivery and focus on what really matters - a healthy and happy mother and baby!

In closing, "Congratulations Kanye and Kim and Little Baby Girl K - wishing you a long, healthy and happy life together as a family!"

Why do women choose cesarean?

I still get annoyed when those who just don't get it attempt to speculate why women choose a cesarean delivery for their child, particularly in the absence of a medical indication for one. They continue to speculate that it is because some celebrities have chosen it. Or because they need to choose a particular day for their child to be born. Or because they need to schedule the rest of their lives to accommodate the arrival of their child. Or that women who choose cesarean are just uneducated and ignorant of the wonders of vaginal birth. The paradoxical bemoaning of cesarean being "major surgery that is much harder to recover from", while at the same time being "the easy way out" continues to boggle my mind.

The reality is that the women who choose cesarean are among the most informed women I have ever encountered - not only on the specifics of delivery by planned cesarean, but also the realities of planned vaginal deliveries. They have seriously considered both options and have decided that they prefer the risks and benefits of cesarean delivery over the risks and benefits of vaginal delivery for themselves in their own circumstances. Most of them have encountered significant resistance and challenge to their choice from family, friends and their own care providers. Few women who choose cesarean (particularly among primiparous women), simply choose an elective cesarean delivery and then have that choice respected and facilitated without challenge throughout their pregnancy. Women who choose cesarean, particularly without a medical indication for one, have to be strong advocates for themselves in order to survive the inevitable criticism of their choice and to overcome barriers to realizing that choice.

The reality is that women who choose cesarean, are not doing it to emulate some celebrity idol.

The reality is that women who choose cesarean, are not generally doing it to achieve some favourable birth day for their child as most women who choose cesarean also choose a delivery that is at 39 weeks gestation unless there is a medical indication for an earlier delivery.

Some women who choose cesarean are doing it out of an unreasoning dread of vaginal delivery. Sometimes this can be addressed with counselling, sometimes it cannot. For these women, a planned cesarean provides a tremendous amount of psychological relief and enables them to enjoy their pregnancies.

Some women who choose cesarean are doing it to avoid the vagaries of vaginal delivery. It's generally accepted that an uncomplicated vaginal delivery is easier to recover from and considered better for both mother and baby - but knowing that an uncomplicated vaginal delivery will actually materialize is something that can only be known retrospectively. Many women who choose cesarean are knowingly sacrificing a chance at the ideal outcome, in the hopes of maximizing the chance of a good outcome.

Some women who choose cesarean are doing so to protect the integrity of their pelvic floors and to reduce the risk of urinary and/or fecal incontinence later in life. It is true that pregnancy on it's own poses a significant challenge to the pelvic floor - but a vaginal delivery further increases the risk of damage. Often the solution to pelvic floor problems is surgery but unfortunately surgery often fails - incontinence products and pessaries are also an option to manage the symptoms. To some women, a cesarean is a fair price to pay to minimize the risk.

Some women choose cesarean because of serious doubts about the availability of effective epidural pain relief at their planned facility of delivery. For facilities that do not have dedicated obstetric anaesthesiology - there might be delays or complete lack of availability of epidural pain relief. Sometimes this can be addressed with a planned induction, sometimes it cannot.

Some women choose cesarean because of prior birth experiences that were traumatic. Birth experiences that resulted in extensive tearing. Birth experiences that had unmanaged and intolerable amounts of pain. Birth experiences that might have lead to urinary or fecal incontinance. Birth experiences that might have resulted in long term or permanent injury to their children (HIE, brachial plexus injuries). Birth experiences that might have resulted in PTSD.

Saying that women who choose cesarean do so because celebrities choose cesarean, or to fit a child into their busy schedules, trivializes what is a very serious choice for many women. It discounts the real reasons women choose cesareans and it makes life that much more challenging for those who are wanting to choose cesarean for the delivery of their child.

We don't say women choose vaginal delivery just because "they want an easier recovery" and go on to decry the choice of planned vaginal delivery as being selfish - so why do we trivialize and disparage moms who choose cesarean, after all for many moms who are choosing cesarean, their reasons for doing so are just as valid as the moms who are choosing a vaginal delivery?

Morgentaler and Women's Reproductive Rights

Yesterday, Dr. Morgentaler died at the age of 90. For those who are not Canadian - Dr. Morgentaler is the person who brought to the Supreme Court of Canada the case that struck down Canada's abortion law as being unconstitutional in 1988.

It was a landmark decision - one that made it clear that a woman alone has the right to autonomy over her own body and that the law as it was, was an infringement on a woman's constitutional rights. The law as it was before 1988 imposed considerable barriers to accessing abortion in Canada. An abortion had to be medically indicated and approved by a panel of physicians as being appropriate. A woman could not have an abortion "just because" she did not want to endure pregnancy and childbirth. As a result, illegal abortions and their consequences were far more common. It is also likely that more children were put up for adoption, more children may have been neglected or abused, more women were derailed from the pursuit of education or careers. To the degree that Dr. Morgentaler made certain that women could determine for themselves whether or not to take on the mantle of pregnancy and childbirth, and improved the lives of women and children - he is a man who is to be applauded.

Although abortion remains controversial in Canada - a woman's right to access one is clear and it is a decision that is hers alone. Her care provider is not obligated to perform an abortion, but is obligated to not interfere with her right to access one.

Shockingly, the situation surrounding patient choice cesarean in Canada is more akin to the situation facing women wanting to access abortion prior to 1988. Currently, access to patient choice cesarean is subject to the whims of care providers and facilities and it seems as though some doctors and hospitals interfere with a woman's right to choose cesarean with impunity. In any other context - such interference with a patient's autonomy would rightfully be met with outrage, but when it comes to patient choice cesarean it seems as though the interference is met by only judgement for the woman who wants a cesarean. It seems as though the idea that a woman has the right to decide what is done with her body is forgotten when the decision is about how her child is born, even though the consequences of that choice are borne by the woman and her child alone.

As a result, women are often denied informed consent and informed choice in childbirth. As a result, tokophobic women, unsure of their ability to access a patient choice cesarean, may choose to abort much wanted children. As a result, some women who are subjected needlessly to a delivery they did not choose may suffer from PTSD. As a result, some women might have difficulties bonding with their children. Some may choose to only have one child. As a result, full reproductive freedom in Canada remains elusive.

There's a lot that can be learned by Canada's approach to abortion and applied to the situation regarding patient choice cesareans in Canada. I hope that one day - a woman's right to choose a cesarean and to informed consent will be as respected and as tolerated as her right to choose an abortion.

Cojucaru v. British Columbia Women's Hospital and Health Centre - The SCC Decides

I have written previously about the case of Monica Cojucaru - a Romanian mother who endured an attempted vaginal birth after cesarean (VBAC) that resulted in an emergent cesarean and permanent brain damage to her son, Eric. She sued, she won at trial (a $4 million dollar judgement) - and they appealed, in part because substantial portions of the judgement were taken from the plaintiff's submission. The appeal was allowed - and Cojucaru appealed to the Supreme Court of Canada. The case was heard in November, and today, the Supreme Court issued its decision.

To the relief of many lawyers and judges, the plagiarism was found to be acceptable.

To my relief - the court confirmed that Mrs. Cojucaru had the right to informed consent, and that Dr. Yue failed to acquire informed consent from Mrs. Cojucaru to undergo a VBAC and as a result Dr. Yue was found liable to Mrs. Cojucaru and her son for the damages that resulted from his delivery. Logically, this means that Mrs. Cojucaru had the right to choose a repeat cesarean for the delivery of her son as that was the alternative treatment that could have been undertaken.

So if a woman has a right to informed consent to undergo a VBAC (implying a right to choose a repeat cesarean), does she have the right to a primary elective cesarean and does the failure to obtain consent for a vaginal delivery result in a liability should a vaginal delivery be imposed upon her?

CDMR is a Women's Rights Issue

Maternal request cesarean is a women's rights issue - every bit as much as abortion or participation in the paid labour force, or the right to vote or own property. At its very core, it about a woman's right to self determination - her right to choose what to do with her own body, her right to decide which risks she is willing to accept and which risks she refuses. It is about a woman's right to be treated the same as any other patient - and not differently because she is a maternity patient. Both access to choice and recourse for unreasonable denial of choice is needed. I look forward to the day when I will know that a similar experience is extremely unlikely to happen to another woman - and while that day is closer now than it was three years ago, there is still a ways to go.

It is frustrating knowing that planning a homebirth in British Columbia, even a home birth after a previous cesarean is far easier than planning an elective cesarean. Finding a care provider who is willing to facilitate a maternal request cesarean is difficult as they do not generally advertise that they are willing to facilitate a woman's desire for one - and many family physicians, midwives and OBGYN's do not support maternal choice cesarean. This is despite rather clear evidence that a planned cesarean at 39 or greater weeks poses some health and safety advantages for the child and may be comparably safe for the mother as a planned vaginal delivery. Personally, I believe that planned maternal request cesarean at 39 weeks' is a far less risky proposition than planned home birth and a far, far less risky proposition than planned home birth after a previous cesarean.

If it is a matter of cost - I would think that there are some very strange economics at work. A single preventable brain injury or death would make the cost difference between planned home birth and planned cesarean disappear many times over. Even a preventable pelvic floor injury that results in some incontinence nearly obliterates the cost difference. Further - home birth does not eliminate the need for hospital resources to be available as many home births (upwards of 40 percent in first time mothers) result in a transfer to hospital. In deed, planned cesareans could be cost competitive with planned vaginal deliveries as the ability to plan resource availability is improved.

At the end of the day - I cannot see how one choice (planned home birth, and planned home birth after cesarean) is widely supported in British Columbia, and another choice - maternal request cesarean - generates a kind of loathing usually reserved for pregnant women who choose to light up publicly while swilling Manhattens and Martinis.