Feedback on Ontario's Report "Caesarean Section Rate Review: An Evidence-Based Analysis (DRAFT)" by N. Degani and N. Sikich

Health Quality Ontario is asking for feedback until October 24, 2013 on one of their reports. Here is what I have submitted to them via email:

October 23, 2013

Feedback on: “Caesarean Section Rate Review: An Evidence-Based Analysis (DRAFT)”, N Degani, N Sikich.

Dear Health Quality Ontario –

I am a caesarean by choice mom, a birth trauma survivor, and founder of the facebook group, “Cesarean by Choice Awareness Network” – furthermore, I am a health economist with more than 10 years experience. I am writing to provide feedback on your recent report entitled, “Caesarean Section Rate Review: An Evidence-Based Analysis” from a Caesarean by Choice perspective.

First – let me express that many mothers with a caesarean birth preference are concerned about over-zealous policies aimed at limiting access to caesarean section as they feel that their right to make a medical decision in conjunction with their health care provider about how their baby is to be born will be disregarded. Many mothers with a caesarean birth preference in Ontario (and the rest of Canada) already have a difficult time accessing compassionate care that meets their needs. Those that do find compassionate care – often fear going into labour prior to their caesarean date and having to contend with an on-call OB who does not agree with their treatment plan. Some women are forced into unwanted vaginal deliveries that have significant ramifications both physically and psychologically. Some women who cannot access maternal request caesarean either forego having children that they want or choose to terminate pregnancies rather than face the prospect of an unwanted vaginal delivery.

In terms of the economic impact of caesarean delivery on the system (page 13) – I would urge caution. There is a great deal of variation in the expected costs of caesarean delivery with emergent caesarean deliveries costing significantly more than elective caesarean deliveries. I would also suggest that the expected cost of a planned vaginal delivery is underestimated if it does not include the cost of emergent caesarean deliveries as the vast majority of emergent caesarean deliveries are the result of failed planned vaginal deliveries. Further – I would urge the economic evaluation of caesarean delivery to include the downstream cost savings/expense and that limiting the cost component to the birth and a limited time post-partum likely gives a very inaccurate picture. There are grave and expensive consequences to a vaginal birth that departs from a healthy outcome for both mother and child. In the fall of 2011, the National Institute for Clinical Excellence (NICE) in the UK, updated its clinical guidance on the use of caesarean (CG132) and found that the cost difference between planned vaginal delivery and planned caesarean delivery was just £84 after considering the increased risk of urinary incontinence associated with vaginal delivery .

Lastly, let me express my concern that maternal health policy that is focussed on achieving specific rates of types of deliveries is ideologically based, misguided and undermines the health and well-being of many women and their children. If reducing caesareans results in an increase in the number of late-term still births due to a reluctance to offer a timely induction – that is a worse outcome than a caesarean section. If reducing caesareans results in additional third and fourth degree tears or extensive damage to the pelvic floor – that is a worse outcome than a caesarean section. If reducing caesareans means limiting access to those who would choose it, and that results in traumatic deliveries – that is a worse outcome than a caesarean section. If reducing caesareans results in larger numbers of children grappling with life-long severe disability, such as those that result from intra-partum asphyxia and brachial plexus injuries, those are worse outcomes than caesarean sections.

Further – efforts to reduce caesarean sections often focus on the safest caesareans, planned caesarean sections. These are also likely to be the least traumatic and expensive caesareans. As such – such efforts are unlikely to have the economic impact that is desired.

Maternal health policy needs to shift to focus on the outcomes that matter – physically and emotionally healthy mothers and babies. Policy that is focussed on caesarean rates and managing them does little to address the health needs of mothers and babies and substitutes ideology for quality care.

Sincerely,

Janice Williams, MA (Econ)

Mommy War Criminals and Heroes

I have a real disdain for the "Mommy Wars" - they have turned mothers against one another, and have distracted women from working together to identify and solve the very real problems with which modern women and families must contend. As a result of the "Mommy Wars", motherhood has become a polarized battleground with women arguing and criticizing the specific choices that other mothers make. There's been a whole lot of yelling, and not a whole lot of listening - many mothers have become caricatures and even more have become casualties. Worse yet - the focus on what really matters has been lost and opportunities to realize progress on the issues faced by women who happen to be mothers have been foregone.

This is not to say I do not think that there is not a war to be fought - there most certainly is, but it should not be women waging war on one another, but rather women waging war on the substantive problems faced by women as they contend with motherhood.

I think that the emotional health and wellness of mothers is worth fighting for - this means that resources need to be directed into better understanding and addressing the mental health needs of mothers. There is a lot about modern motherhood that is emotionally toxic to women - from unreasonable expectations about what being a "good mother" is to the stigma associated with admitting difficulty in coping with the circumstances in which a woman finds herself.

I think the physical health and wellness of mothers is worth fighting for - this means enabling women to have timely access to adequate healthcare that promotes and maintains health and wellness. This also means that mothers need to be full partners in their health care and given evidence based information on their choices and empowered to make the choices that best meet their needs and those of their families. It also means that more research on the physical health and wellness of mothers needs to be undertaken - including research on the impacts of pregnancy and childbirth that goes beyond pregnancy and the 6 weeks post-partum.

I think the economic health and wellness of mothers is worth fighting for - many mothers face substantive challenges with regards to being economically healthy. Mothers need tools and support to address the economic challenges they face constructively and to make positive steps towards economic adequacy.

People who blindly promote an ideology and make mothers feel bad about their choices in order to feel better about their own choices - should be considered mommy-war criminals.

In contrast, people who work to support the emotional, physical or economic health and wellbeing of women who happen to be mothers should be celebrated as heroes.

Four Score and Four Years Ago

Four score and four years ago today, the Supreme Court of Canada decided that women were "persons" under the law, after a group of brave women fought to be recognized as such. It was one of the first steps towards women asserting their rights under the law. It paved the way for women to own property and to vote. It paved the way for many of things that women take for granted now. It also highlights how much work there is still to be done, particularly when I think of the treatment of pregnant women in Canada today.

So happy persons day - might we get to a place someday where it is recognized that pregnant women are persons too - persons entitled to informed consent and patient autonomy.

What motivates me?

I view what happened to me as a deprivation of my human rights as a patient and as a woman to make a medical decision for myself and expect that decision to be reasonably respected and facilitated. I gave informed consent for a specific medical procedure (cesarean - or if labour commenced an urgent cesarean) - I knew the risks and benefits of both planned vaginal delivery and planned cesarean delivery and I chose cesarean. When I was deprived of that choice, without warning and without consultation - and a wholly different procedure was imposed upon me (vaginal delivery) - it is difficult to convey how disruptive that was. When I later discovered that such deprivation was without just cause, I was shattered. All my life, I was raised to believe that I had dominion over my own body. I had the right to consent what happened to it. I had the right to not have that right interfered with - and I believed that that right was protected by the Canadian Constitution via the Canadian Charter of Rights and Freedoms. I never believed that choosing to be pregnant would be adequate cause to deprive me of my human rights.

Yet, there I was - stripped of a fundamental human right. There I was, a well-educated, well-informed, confident woman - believing I was entitled to informed consent and respect for my medical decisions and being deprived of both. I never believed it could happen to me, until it did. And, if it could happen to me - then what is to stop it from happening to any other woman? What is to stop it from happening to my daughter?

And after it happened, came the hard questions - What was I going to do about it? What could I do about it? It is all well and good to think that you have rights, but unless you can hold others meaningfully accountable for violations of those rights, did you ever really have the rights to begin with? If I wasn't willing to find some way to hold those who deprived me of my rights accountable - could I expect other women to? If those responsible for depriving pregnant women of their rights to informed consent and autonomy were never held to account, how is it possible for such violations to stop, for the system to change? How is it possible for victims of those violations to move on with their lives without any recourse or acknowledgement that they were wronged in a most serious way?

It is sad when those who find themselves deprived of their rights are left bereft of meaningful recourse - it adds insult to injury. Yet, the way the system currently is, recourse remains tremendously risky and out of reach for many patients who have been deprived of their right to informed consent and autonomy - including pregnant women. In Canada - the healthcare system is structured in such a way that deprivations of rights are almost certain to be free of meaningful consequence. In Canada, defendents (doctors and hospitals) have the full resources of the Canadian Medical Protective Association at their disposal to defend against any patient brave enough to bring forward a claim. Meanwhile patients are left struggling to find access to justice, struggling to find a lawyer to take on their claims, and struggling with the risks that pursuing a claim might involve. In Canada - if a patient brings forward a claim and fails at trial, not only will they bear the costs of their own litigation, but the defendents may also be awarded costs adding further insult to injury. In Canada - damages tend to be so limited that many cases involving deprivations of patient rights, absent catastrophic injury or loss, are simply uneconomic to pursue. In Canada, access to justice for patients wanting to assert their rights is effectively barred.

It is a vicious cycle of human rights violations that will continue. The system will continue to operate as it does, unless it becomes uneconomic to violate patient rights to informed consent and autonomy. It won't become uneconomic to violate those rights, unless patients demand accountability when those rights are violated. Patients will not can not demand accountability, unless they are enabled to do so.

I am determined to assert my human rights and demand accountability for the violation of those rights - the question is, will I (and others) be enabled to do so? Will those who can help make this happen, step forward?

That is what motivates me.

#ForMiriam

Miriam was a mother who paid the ultimate price for having a post-partum mood disorder - she was killed the other week in Washington, D.C.

I do not know the specifics in Miriam's case - I do not know if she had sought help or if she was screened for mental health problems. I do not know if she hid her issues.

What I know is that a young mother is dead - she is not the first, and sadly, tragically - she will not be the last; because of a post-partum mental health issue.

What I also know is that we need to do a better job when it comes to maternal mental health. We need to do a better job of understanding the reasons some mothers face mental health challenges in the months and years following birth. We need to do a better job of identifying mothers at risk. We need to do a better job of treating mothers who face mental health challenges. We need to do a better job of making sure that when a mother faces a mental health challenge - she can access the resources she needs in a timely way. We need to do a better job, when possible, of preventing psychological damage as result of childbirth.

The fact that another mother has lost her life to a post-partum mental health issue is sad and tragic - if we continue to not do anything to do better - that is a travesty.

#ForMiriam

Post-Traumatic Growth after Childbirth Trauma

It has now been more than three years since my daughter was born - and while my recollections of her birth remain highly negative (I suspect they always will be) and at times intrusive and disruptive (thank-you post-natal PTSD) a lot has happened in the time since, that has been and has the potential to be tremendously positive. I am currently at a place where I am more focussed on how to move forward in a positive and meaningful way - rather than being mired in the past. I believe, as a result of the efforts I have made to understand and heal from the experience - I have been fortunate to benefit from what is known as Post-Traumatic Growth.

In the immediate aftermath of the birth - I was over whelmed and distressed. I believed, that I did not matter - that I had no right to decide what to do with my body, that I was not even entitled to feel badly about the birth because I had a healthy baby and there were countless women who would happily trade places with my circumstances. My beliefs about who I was and what my rights were, and how the health care system worked were completely rended asunder. My trust both in the system, and in my own doctors was decimated. I did not feel I could share my thoughts and feelings, with even my husband - for fear of being labeled ungrateful for all that I did have, for fear of being labeled or thought of as a "bad mother". I quickly learned that few would understand and that many would hear my complaints as trivial whining. My initial response was to just try harder at being a "good mother" - after all, I had been told that I was "good at birth" - so why not repress the fact I hated it, that it felt like such a violation, an extreme cruelty. I dove into a mother's group - and tried to see the benefits of natural birth - the thing that most of the women there had aspired to. I suffered silently, often breaking down in the shower or in other fleeting moments that I had to myself and put on a brave and stoic face.

The thing I've learned about trauma, is that repressing it and suffering silently does not work - or at least it wasn't working for me. It bred cynicism. It bred anger. It bred flashbacks. It bred distraction. It bred shame. It bred isolation. It bred depression and anxiety. It bred resentment. It bred helplessness, and hopelessness. When I returned to work - I was marginally functional, and the ample amounts of time in front of a computer looking at health statistics did me very few favours. I needed to do something, so that at the very least, I would not lose my job.

That was when the real work of trying to address and heal from the experience began. I could not continue doing what I was doing (repressing the experience and trying to accept what had happened) - it was making me angry, and cyncial, and negative. If I did not do something that worked - I would risk losing my job, losing my husband, losing everything that mattered in my life - including myself. I owed it to my family and to myself to at least try to not let what happened to me - consume every last part of who I once was.

It was then that I started to really blog. I needed to get what I was thinking, out of my head. I needed to really think about things, I needed to process them.

I also needed to know what really happened (I still do) - and to do what I could to prevent the same thing from happening to others.

I wasn't really expecting everything that has happened as a result of blogging. I wasn't expecting the blog to even be read all that much (we are now at nearly 70,000 hits). I wasn't expecting to change minds on the issue. I wasn't expecting to help other women. I wasn't expecting to meet other women who were as passionate and concerned about the issues facing childbearing women as I was. I wasn't expecting to learn as much as I have learned. I wasn't expecting to create a facebook community of likeminded women "Cesarean by Choice Awareness Network" or be instrumental in the creation of a legal action fund that is focussed on protecting the rights of childbearing women to informed consent and timely access to care (the Maternity Legal Action Fund). Yet - that is exactly what has happened.

Looking ahead, my goals are clear: keep going, keep growing - there is still much work to do.

Value Women and Children: Medicalize Birth!

There has been a real push to normalize pregnancy and childbirth - a real rebellion against the "medicalization" of childbirth by governments, midwives and some doctors. Some patients have also bought into the idea that pregnancy and childbirth are not diseases, and should not be treated as such. Unfortunately - in the drive to save money and preserve market share - the reality that pregnancy and childbirth is a condition that brings with it significant health vulnerability for both women and their children, seems to have been forgotten. The idea that the choices a woman makes during pregnancy and childbirth are medical decisions that are deserving of informed consent and respect, also seems elusive.

Pregnancy and childbirth, in modern developed countries - are not normal states of being for the vast majority of women. The normal state of being for an average Canadian woman is not pregnant or breastfeeding - these are brief diversions from normalcy that typically occur 2 or 3 times during a woman's lifespan - assuming a breastfeeding duration of a year, this accounts for a mere 4-6 years out of the 30 years that are considered "childbearing". It is not normal to gain - and lose 35 or more pounds in the space of two years. It is not normal to be nauseaous for months on end. It is not normal to be winded after ascending a few flights of stairs or to be in immense pain from activities that in a non-pregnant state are of no-consequence (ie. a shopping trip to costco with a full cart, mowing the lawn). It is not normal get all kinds of unsolicitated advice on how you should conduct yourself. Further, it is not normal to be at such a heightened risk of death or long-term disability as is the case with pregnancy, childbirth, and the year post-partum. Indeed - there is little about the state of pregnancy, childbirth and the year post-partum that should be considered "normal".

Indeed, it is the degree of health vulnerability while pregnant, childbearing and the year post-partum that makes it ideally suited for "medicalization" - after all there are few conditions where the application of intervention can have such a profound impact on the ultimate outcome for both mothers and their children. As such, the choices during pregnancy, childbirth and the year post-partum, should be considered medical decisions and given the same degree of deference -in terms of informed consent and respect- as decisions that are made with respect to any other medical condition (many of which are far more benign than pregnancy and childbirth).

Indeed, neglecting to recognize the profound need to medicalize pregnancy and childbirth can have profound consequences. Neglecting to recognize the need for folic acid supplementation leads to preventable cases of neural tube defects (they range from relatively minor cases of Spina Biffida to profound disabilities that are incompatable with life such as Anencephaly). Neglecting to identify gestational diabetes and respond accordingly leads to over-sized babies that are at risk of delivery complications (ie. shoulder dystocia) and other adverse events including stillbirth. Failing to identify and respond to pre-eclampsia (abnormally high blood pressure) can result in maternal death. Neglecting to address the potential for a severe tear, and the adverse consequences of a severe tear or to improperly repair a severe tear can lead to urinary and or fecal incontinence, pelvic organ prolapse, and sexual dysfunction. Failure to provide access to effective pain relief (ie. epidural), leads to profound suffering which may be associated with longer-term psychological problems such as post-natal PTSD. Failure to provide timely access to cesarean delivery may also inflict considerable harm to both mother and child - and the choice of planned delivery method is a significant one.

In closing, I believe that the greatest disservice we can do to women and children is to demedicalize birth - decisions that are not “medical decisions” do not demand informed consent. Conditions that are not “medical conditions” do not merit research or the scientific process – and do not benefit from the improvements that result. If we value women and children, as humans – the very least we can do, is medicalize an event that has a profound impact on their health and well-being over their lifespans.

This isn't the third world - so why adopt maternal health policies that pretend it is?

I think the level of health care access and health outcomes for mothers in developing countries is nothing short of atrocious. It is a tremendous tragedy when women and children die preventable deaths every day while giving birth. It is heartbreaking to think of conditions that have been obliterated in the developed world, being common place in the developing world (ie. obstetric fistula). Access to safe cesarean section and epidural pain relief, is simply beyond the reach of what can be offered to those mothers - the resources are simply not there. When thinking of the stark reality of birth, for many women who truly have no choice in the matter, what we have access to here - IS amazing. There is nothing romantic or empowering about the situation. It needs to be addressed - and I applaud the many organizations that are working on addressing and improving maternal health in developing countries.

However, it is a real shame that the deplorable conditions in developing countries are used as some kind of excuse for denying and ignoring the needs of mothers in developed countries. This is because failing to address the needs of Canadian mothers does nothing to address the needs of mothers in developing countries (newsflash: the government won't be sending the money they didn't spend on your healthcare to a provider in a developing country) and it also ignores the responsibility and desireability of actually meeting the needs of mothers in developed countries. The mentality that one should be grateful for what they have, ignores the need for improving upon the status quo. It's great that we do better than the developing world - but is that really the comparator that we want to use?

Setting health policy according to the lowest common denominator - particularly with regards to women and their health issues should be deplored. We don't set health policy for diabetes care or cancer care according to what is accessible in the developing world - so why are we keen to do so when it comes to issues around pregnancy and childbirth? Why are we keen to oversell vaginal unmedicated delivery and breastfeeding to mothers in the developed world while ignoring the valid choice of cesarean delivery and formula feeding? Why are we so keen to discount the value of being free to make such decisions in the first place? Policies to discourage cesareans absent medical neccessity and to encourage breastfeeding -might make a lot of sense in the developing world, but we should be strongly questioning such policies in the developed world as they may be costing many mothers very dearly in terms of their health and wellbeing.

Mothers are not lesser Women

I am severely disturbed by the prevailing attitudes with respect to mothers – in short I think that there is far too much enthusiasm for telling women who happen to be mothers, what to do with their bodies, and that the person to whom the body belongs has long ago become an afterthought. In short, I fear that we have let an entire group of women (and a rather large one at that), become a lesser class of people because they have taken it upon themselves to reproduce – to ensure that there is a future generation. We have allowed these women, to be reduced to their breasts, vaginas and uteri – and that is wrong – because it neglects the most important body part a woman has, her brain.

Yes, having a healthy baby matters – it matters a lot, and it particularly matters to mothers. However, having a healthy mother also matters – and that is where extolling the virtues of specific choices – like vaginal delivery and breastfeeding, neglects the person who must undertake those activities. That is where having performance measures that reflect these choices is doing a huge disservice to the health (and particularly the mental health) of mothers.

We have come to a place, where rather than informing the individual woman of the risks and benefits of her choices and allowing her to make the decisions that best meet her needs (and those of her family) and respecting those choices – we have told her what choices to make. By extolling specific choices, we tell certain mothers that they have succeeded, but we have also told certain other mothers that they have failed. What is sad, is that many of the women who we have told are failures – haven’t failed at all, rather they have made the choices that best meet their needs and those of their family best. Yet, there is a lot of stigma and shame that attaches to things like having a caesarean section or formula feeding a child.

There has been a lot of lip service to caring about the needs of mothers – but very little recognition of a mother’s need for bodily autonomy. Is it any wonder that many mothers find themselves depressed?

Mothers Matter - Thoughts on Maternal Suicide and Suffering in Canada

The Canadian Medical Association Journal editor – Kirsten Patrick - believes that maternal suicide needs more attention - I agree, however, why wait until mothers are dead to examine what is wrong and do what needs to be done to prevent harm?

When a mother decides to take her own life it is an outright tragedy – a family is shattered, and often times the lives of her children are also in jeopardy. The fact that Canada does little in comparison to other countries to better understand and address the issue is a shameful reflection on Canada and its commitment to those who decide to bear children. In the UK and in several other countries, there is a case-by-case analysis of maternal deaths. If we bothered to do the same we might learn a lot about what can be done to prevent such a tragic outcome.

That being said, why wait until a mother is dead to examine whether or not the needs of those bearing children are being met? Those who ultimately take their lives are likely a very small portion of the mothers who suffer as a result of childbirth. We need to better understand the impact of childbirth on women in Canada – and we need to go beyond what we currently use as performance measures of our maternity care system (whether or not a caesarean was performed, or a VBAC was attempted IS very superficial). We need to go beyond the period of pregnancy and the 6 weeks’ following birth. We need to go beyond administrative data - data that reflects only on what was actually done and does not reflect at all on what SHOULD have been done. We need to invest in mothers by investing in better information – information that could actually be used to improve the system of care and prevent the most tragic outcomes. We need to invest in mothers by investing in better care in the first place. We also need to invest in supporting mothers and demanding accountability for when mothers are failed either by the system or those who care for them.

In the aftermath of my daughter’s birth – I experienced the most negative emotions I had ever felt in my life and have had some of the darkest thoughts. Anger. Betrayal. Pain. Inability to concentrate. Terror. Isolation. Shame. Disempowerment. Disillusionment. Feeling as though I no longer mattered and that I did not even have the right to be angry about it all (I had a healthy baby, after all). Feeling as though asking for accountability for what happened was asking too much. Feeling as though the only thing I could do was suck-it-up and move on, and at the same time being completely unable to actually move on. Feeling as though others were at risk for the same thing to happen to them. These thoughts that absent the hope that things will get better, that things can get better and that I still had much to be very thankful for -are likely not much different from those that plague the mothers who take their lives. I am very thankful, that hope never left – even with what had happened and the damage it had done. However, I remain very angry as I see that what happened to me was entirely preventable.

Yes, there is a pressing need to better understand why mothers commit suicide – but it is just the tip of the iceberg. There is a pressing need to understand the whole toll of having children on Canadian mothers – and doing what can and should be done to minimize that toll. A superficial examination will continue to fail to address the real needs Canadian mothers as it will fail to enable an understanding of what is wrong in the first place. Looking only at mothers who eventually kill themselves, is still a superficial examination of the broader problem. Further, unlike Kirsten Patrick – I believe that we may even have to (and should – for in some cases the mothers are the last people who are “at fault”) lay some blame and demand accountability in order for things to actually change – particularly if part of the reason mothers are suffering is a result of glaring violations of patient rights and negligence in care that have gone undetected and unaddressed for far too long.

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...)