What if??

Occasionally I will read about a woman who is planning on having a cesarean for the birth of her child, such as Ms. Magee. She's done her research. She knows the risks and benefits of cesarean and vaginal delivery, and is prepared to put up with the static of choosing cesarean. It is her body and her choice.

However, because of my experience with my daughter's birth, and hearing of other women who planned on having a cesarean but ultimately did not - I find myself asking the question "What if?". It is all well and good to know what you want and to pursue it and women should expect to have their choices regarding childbirth respected to the degree possible. But what if the cesarean does not happen, then what?

That is the situation I found myself in after my daughter's birth.

That is the situation I worried about throughout my pregnancy with my son.

When I was pregnant with my daughter - I thought the risk of not delivering by cesarean was fairly small - I knew about 10 percent of women did not make it to their scheduled surgery date, but I also knew that few first time mothers had exceedingly short labours, and that the hospital I was delivering at was a tertiary care facility. I believed that if the hospital could provide emergent cesareans for those who needed them within a half hour, that surely if I did go into labour that I would be able to get a cesarean within two hours, and that it would be extremely unlikely that as a first time mother my labour would be less than two hours. In short, I thought the risk of enduring a labour and vaginal delivery, in the circumstance I was in, was vanishingly small - small enough that I discounted the possibility nearly entirely.

What I did not account for, and should not have needed to account for - was the possibility that the hospital and/or my doctors would fail to actually and reasonably facilitate and respect the choice that had been made. I believed that I might get bumped for more urgent cases, but when the chips were down, if I should happen to actually go into labour - I believed I would be an urgent case and would have my care facilitated (possibly bumping others). I believed that my ability to determine what happened with my own body would be respected to the degree possible. I fully trusted, that the system, while not perfect - would be "good enough" - and completely disillusioned when it proved otherwise.

So now I know what if, what if a chosen cesarean does not happen and a woman endures a vaginal delivery she does not want. I know that when it happened to me - I felt violated; I felt isolated; I felt betrayed; I feared the worse; I felt disempowered; I felt traumatized; I questioned my desire for a subsequent child; and, when I was pregnant with my second child I was anxious; I still worry about the longer run impacts to my pelvic floor and psychological health; I am both angry and numb; and I struggle with the experience and the large chasm between what should have been and what is. I know the answer to the question "what if?" - and know that the answer to that question is often not, "The woman will have a vaginal delivery like the billions of women before her, will likely have a healthy child, and get over it so it really is not a big deal to force her to have a vaginal delivery she does not want."

Forcing women who do not want to have vaginal deliveries, when cesarean is an acceptable and available alternative, to have vaginal deliveries - is a big deal, it is wrong, it needs to be addressed and stopped. Further, women need to be confident that their care providers and the facilities they go to give birth will actually and reasonably facilitate and respect the choices that they have made.

Oh, ACOG - Say it ain't so

On facebook in the Cesarean by Choice Awareness Network group there's been a lot of discussion about the American College of Obstetrics and Gynaecologists committee opinion on cesarean delivery on maternal request. I am fairly disappointed at the new committee opinion, one that seems to take a step closer to the stance taken by the Canadian Society of Obstetricians and Gynaecologists - it does not condemn or disallow maternal request cesarean, but makes it quite clear that its members should recommend vaginal delivery in circumstances where there are no medical indications for a cesarean delivery. Which is fairly different from the stance that a physician is ethically justified in performing a maternal request cesarean if he or she believes it is in the interest of his or her patient. In many ways it is no different than the kind of approach taken to mothers who for whatever reason determine that their needs are better met by formula feeding - they are repeatedly told that "Breast is Best" and made to feel no end of guilt for needing or wanting to use formula to feed their children. ACOG has decided to tell women that Vaginas are meant for birthing children, and if you want a cesarean we might do it, but only after you are reminded that a "vaginal birth is best". Many women who are requesting a cesarean already face barriers in finding a physician who will accommodate their needs, to add the feeling that what they are asking for is something "against medical advice" - seems above and beyond what women who are requesting cesarean need.

What women who are asking for cesarean need are physicians who listen to their request, provide them with the risks and benefits of planned cesarean delivery and the risks and benefits of planned vaginal delivery, answer whatever questions they have about their treatment options AND ultimately respect, and facilitate the decision they make regarding the planned delivery of their child. They do not need to have someone else's ideology about childbirth imposed on them. What women who are choosing cesarean need is better information on their choice (much of the information that is currently available is not about "maternal choice" cesarean, but rather about cesareans that are performed as a result of medical indications for cesarean). What women who are choosing cesarean need is the confidence that their choice will be respected, even if their OB doesn't happen to be on-call when they go into labour.

Nothing is more empowering than having the confidence that you have the right to decide what to do with your own body - and nothing is more disempowering than feeling as though you do not have the right to decide what to do with your own body. Perhaps it is time that the ACOG, the SOGC, the mayor of New York and anybody else who feels that women should not have a choice about how their child is born or fed is reminded that - it is the woman's body, let her be free to decide what to do (or not do) with it.

The Beliefs of Canadian Maternity Care Providers - Who to choose when your choice is cesarean?

The Canadian Journal of Midwifery Research and Practice published a study entitled "Midwives' Belief in Normal Birth: The Canadian Survey of Maternity Care Providers' Attitudes Toward Labour and Birth", by McNiven, et al. in Volume 10, Number 2, Summer 2011. The paper examines the results of a survey conducted in 2007.

It should be noted that midwives generally believed that a vaginal birth was a more empowering experience than a cesarean birth, that those who deliver by cesarean miss an important life experience, did not believe that cesarean prevented urinary incontinence or sexual dysfunction, agreed that there should be an organized pre-cesarean section peer review of all cesarean sections to reduce the cesarean rate, and agreed that all cesareans should be subject to a peer review to reduce the cesarean rate. Further, midwives are most likely to believe that childbirth can be considered normal prospectively, that childbirth doesn't usually require medical intervention, to prefer natural methods of pain relief, and that home birth is as safe as or safer than hospital birth. Personally, I did not find my vaginal birth to be more empowering than my cesarean birth (quite the opposite), and in terms of life experiences, frankly, I wish I would have missed out on the "life experience" of vaginal birth. That being said, I always believed that having a midwife as a prenatal care provider would be a poor fit personally, and the results of this survey seem to confirm that belief.

However, midwives have a tendency to portray themselves as some kind of guardians of patient autonomy. So what did the midwives of this survey think about a woman's right to choose cesareans?

More than half (58.6 percent) did not believe a woman had a right to choose a cesarean in the absence of a medical indication. Slightly fewer than one in five (18.5 percent) believed in a woman's right to choose cesarean.

What was surprising is that the view regarding cesarean sections was largely consistent with the views held by both Registered Nurses and Family Physicians who provided prenatal care with 60.4 percent and 60.8 percent of those providers disagreeing with a woman's right to choose a cesarean even in the absence of medical indications.

With regards to the right to choose cesarean, obstetricians were the most likely to agree that a woman has a right to choose a cesarean with 42.3 percent agreeing a woman has a right to a cesarean and 15.3 percent taking a neutral position.

I find it somewhat disconcerting, that the right to choose a cesarean in Canada among those providing prenatal care is so widely disagreed with (but particularly among midwives, RN's and family physicians). It seems trite to me that a patient has the right to decide what is done with their body (among the available options, after considering the advice of care providers) - the fact that it is not trite in prenatal care in Canada is disturbing.

Hopefully the memo that was sent regarding patient autonomy more than 25 years ago in the Morgentaler case will soon be received by the majority of those providing prenatal care in Canada.

Birth Trauma and Productivity

Looking back at the year that I was back at work between maternity leaves - I hate to admit that I was not as productive as I could have been. Beyond juggling a child and work - I was also juggling a considerable psychological burden - as much as I may have wanted to focus on work, I found myself distracted. I was distracted by what had happened. I was distracted by my subsequent pregnancy and what was going to happen. I also found myself trying to deal with a degree of cognitive dissonance between what I do, and what I had experienced. I was able to get what needed to be done, done and managed to accommodate the travel back and forth to Vancouver to access care - but there was a considerable hidden cost to my birth trauma. My productivity was damaged.

The loss of productivity as a result of birth trauma is a cost that is largely hidden and difficult to quantify. Some women forego the paid labour force entirely as the demands that result from the birth trauma are too great to accommodate paid work. Other women, like myself, manage to accommodate their birth traumas and their careers, but are less productive than they would be otherwise. In both cases, there are no statistics that even attempt to get at the presence of this phenomenon or the degree of impact it has. Perhaps some of the differences that persist between men and women in the paid labour force can be attributed to the impact birth trauma has on women. After all if your coping but not thriving, you will not be promoted.

Still I must consider myself lucky. The work I do could accommodate the psychological burden I was carrying. I had four-walls and a door. I did not need to interact with the public or others on a daily basis. I could do what I needed to do (usually write a blog post on what I was thinking) to allow myself to focus enough on the work at hand. I could work longer days to accommodate days off for travel. I had an understanding supervisor. Indeed, I was lucky - and under different circumstances - arguably under most other circumstances, it probably would have been likely that my career could have been collateral damage to what had happened.

I am thankful that my son's birth went well - and I am hopeful that by the time I return to work from this maternity leave, I will not be carrying the same psychological burden and that my ability to work to capacity will be restored. Still, I can't help but wonder - in the absence of what happened, would I have been a better economist and mother?

200th Post

When I started this blog, I was pregnant with my daughter. A first time mother-to-be, who really had no idea what was about to happen. When I started this blog, I was worried about finding a doctor who would support my request for a cesarean, I was confident that I would find one or do what needed to be done to have a planned cesarean delivery - but I really did not imagine that after finding a doctor who agreed that I would be in a position where I would be delivering my child by the very way that I had sought to avoid. When I started this blog, I anticipated that it would remain just another mommy blog - a place where I would have written about the cesarean birth of my daughter and then quickly moved on to the one-hundred-and-one different things that happen as a baby becomes a toddler, a big sister, a child. I did not imagine that it would remain focussed on maternal request cesarean, maternity care and birth trauma. I did not imagine that it would become one of the main ways that I would process my experience. I did not imagine that it would help other women. I did not imagine that it would have the kind of impact it has had. I did not imagine that it would even be read much at all.

So two-hundred posts later, I cannot help but look back on the last few years (most of the posts have been within the last year and a half) - and be somewhat pleased with the work that has been done. And in the ways that this blog has exceeded my expectations - I look forward to seeing what work will be done - as it still seems clear, that there is still much work yet to be done.

Thank-you.

The Power of Numbers - the Math of Maternity Care

When I am working, I spend most of my time immersed in numbers and thinking about indicators that can be used to measure health and the health care system. As a result, I am acutely aware of the power of numbers and the importance of understanding what numbers are available, how the numbers used are calculated, what the numbers include or exclude, and what it might mean when the numbers change over time. As a result, I read statistics and particularly health statistics, with a different lens. Specifically, I am much more critical of the numbers I see - as I know that the story being told by the numbers depends critically on the numbers used and how they are being interpreted. I have become particularly aware and interested in the numbers used (and not used) to tell the story of maternity care, particularly in the news media. The thing is numbers have power, and by focussing on the wrong numbers or interpreting the numbers in the wrong way - there may be unintended negative consequences for women and their babies. Currently, the most commonly used statistics in the news media with respect maternity care are: infant mortality, cesarean section rates, and cost estimates - and, sadly these numbers and they way they are used are telling a story which may be leading many women, care providers, and health administrators astray.

Infant mortality is the number of babies who die from birth to one year of age relative to all babies who are born alive. As a result improvements in the rate of accidental death or access to paediatric care - perhaps as a result of better car safety, sleep safety or better health insurance coverage - will lower the rate of infant mortality. While fewer very young children dying is a very good thing, saying it is the result of better maternity care is a bit of a stretch. Unfortunately, many media reports make that stretch and equate infant mortality rates with maternity care.

With respect to cesarean section rates - little quality information can be gained by looking at the headline rate (number of c/sections as a share of all births). This is because nothing is known about how many of those cesareans are planned cesareans, how many are emergent cesareans, how many are maternal choice, how many have complications, how many are traumatic, or how many avoid much more severe complications that would have occurred in the absence of a cesarean. Given a choice between a third or fourth degree tear, an instrumental delivery, or an oxygen deprived baby - most moms are better off and would likely choose a cesarean section. Further, the cesarean section rate is not risk adjusted, and as such it is nearly impossible to say whether or not any specific rate is too high or too low without knowing the characteristics of the population being served - is it older? are the mothers of a healthy weight? are there other co-morbidities (heart problems, kidney problems, diabetes, etc.)? When the relative risks of cesarean are reported on, both emergent and planned cesareans are frequently lumped together and as a result the risks of an emergent cesarean are underestimated while the risks of an elective cesarean are overestimated. Lastly, the only thing the cesarean section rate tells us is how many cesareans were performed, the supply of cesareans, but it tells us nothing about how many cesareans should have been performed, the demand for cesareans.

Finally, the cost estimates that are available are at best flawed in that the costs included are only the immediate costs (those that occur within 30 days of the birth), and the costs of cesarean lump together emergent and elective surgeries and as a result do not reflect the costs associated with planned mode of birth. From an economics perspective, spending money on birth (including spending money on cesareans or other interventions) might be a good investment if it avoids other costs in the long run, such as those costs involved in coping with a damaged pelvic floor, birth trauma, or a birth injury.

There are better statistics that already exist - like the perinatal mortality rate. There are also better statistics that could exist - like the rate of unmet need (ie. epidurals requested but not given), the rate of adverse mental health outcomes, and patient reported outcome measures. Numbers are powerful, unfortunately it is quite possible that when it comes to maternity care, the focus is on the wrong numbers.

Are the common practices with respect to Maternal Request Cesarean negligent?

I have been wondering if the common practices that are applied by many physicians in Canada and in many Canadian hospitals with respect to maternal request cesarean are negligent and unreasonably frustrate the rights of women to make medical decisions for themselves.

In my own case with respect to the birth of my daughter (and I do not believe this is uncommon), my maternity doctor did not refer me until I was 32 weeks pregnant. This might be common practice with respect to elective cesareans in general, but I would argue that it is negligent when it comes to maternal request cesareans. This is because under most circumstances an elective cesarean has an underlying medical need and as a result there is little doubt that the doctor who is receiving the patient will agree to undertake the procedure. In contrast - many doctors will not agree to perform a maternal request cesarean - just as many doctors will not agree to perform an abortion - and that is their prerogative (frankly, having a doctor who disagrees with treatment is probably not a good thing anyways). This may lead to the need to see more than one doctor to request the cesarean. Further, many mothers who are requesting cesareans are doing so because of anxiety over the prospect of a vaginal birth - and often that anxiety is not resolved until there is some certainty that the desired mode of birth will be realized. As such, the doctor who is referring the patient needs to be reasonably confident that the doctor that the patient is being referred to will agree to the request or at the very least it would appear prudent for the physician to refer as soon as the request is made and facilitate shared care of the maternal request cesarean patient with an OBGyn. To do otherwise seems to have a high risk of frustrating the patient's ability to direct her own medical care.

Also with respect to my birth of my daughter, it has been alleged that Vancouver Island Health Authority had no OR booking schedule for elective cesarean deliveries and as a result my case was necessarily added to the OR Slate. Failing to provide a fixed time and date leaves elective cesarean patients particularly vulnerable as they are competing with other emergent cases on the open slate. As a result, it is fairly predictable that an elective cesarean patient (unless she's in labour) is likely to be bumped by more urgent cases. This unreasonably frustrates the woman's right to choose a pre-labour cesarean - particularly in large hospitals with a high volume of emergent cases that arise. I would argue that it is negligent and discriminatory to provide for other elective surgeries on the regular slate but not elective cesarean deliveries. It is plain and obvious that a woman at 39 weeks' gestation is at high risk of going into labour, and that subjecting her to uncertain access to an OR puts her at risk of having her medical decision frustrated. Why should patients who choose tubal ligations, adult circumcisions, bladder suspensions, or any number of other elective surgeries be allowed a spot on the regular OR slate, but women in need of elective cesareans be denied space on the regular OR slate? This is particularly true when a delay in access to OR resources may result in that woman being deprived of exercising her right to make a medical decision for herself with regards to how her child is to be delivered. It is obvious that patients in need of elective cesarean deliveries deserve to have more certain access to OR resources as their conditions are arguably more time sensitive than many other elective surgeries. Again, I do not think that it is uncommon practice for hospitals to deny space on a regular OR slate to elective cesarean patients - even though it is plainly obvious that the practice of doing so poses unnecessary risks.

Women who choose cesarean section deserve to have their medical wishes respected and practices that unreasonably frustrate their ability to exercise their autonomy with respect to the delivery of their child should end. If the woman is going to need an OBGyn eventually - what purpose does delayed referral serve? If the woman is going to need OR resources for the delivery of her child - again what purpose does denying space on the regular OR slate serve? The only logical purpose these practices serve is to prevent women from obtaining the medical care they desire in a timely way - and there's something that's wrong with that.

Failing Mothers - Maternal Request Cesarean in Canada

A while ago, a mom-to-be contacted me asking if I knew an OBGYN in her area (Hamilton, Ontario) who would agree to a maternal request cesarean. I asked the grapevine, and managed to wrangle a name - and with high hopes I hoped that this mother would be able to get what she needed when she needed it. I recently got an update from that mother - and my heart sank. She went into labour the day before she was to meet with the OBGYN (she was 36 weeks pregnant) the doctor on call did not support her request and she ultimately delivered her son vaginally. His respiration was depressed, he needed to spend some time in the NICU, he had some broken blood vessels and blood pooled between his skull and his scalp, he needed a blood transfusion and has been on morphine and the mother had some tearing that required stitches.

Her story - is illustrative of the many problems that persist with respect to maternal requests cesareans in Canada. Finding an OB supportive of the request, and hoping that if you do go into labour the OB on-call will be supportive of your request is a risky proposition. You may go from OB to OB (or have you primary maternity care physician neglect to refer you until late in your pregnancy) with each having a wait of several weeks for an appointment (how is that quality care???), or you may go into labour and have someone who disagrees with your choice and withhold the care that is needed, when it is needed. Or you may find a supportive OB but run head-long into a hospital policy that makes acquiring your delivery all but impossible.

It's a situation that must be addressed - all these mothers want is to be counseled on the risks and benefits of their treatment options (planned cesarean delivery and planned vaginal delivery) - and to be free to choose the treatment that best meets their needs and to expect that whatever choice they make will be respected and facilitated to the degree possible. They are asking not to be unfairly deprived of their personal autonomy without good cause - seems perfectly reasonable to me.

There are doctors and hospitals in Canada that do accomodate the needs of these mothers - but the difficulty is that it is difficult to know which doctors and hospitals they are when the time comes.

As I do get requests from time to time from mothers looking to have their needs met (I currently know of a woman who isn't even pregnant yet who wants to find a supportive doctor in Ottawa) - if you are an OBGYN who provides maternal request cesarean or your hospital has an accomodative policy (fixed OR date and time for MRCS and assurance that CS will be accessible if it is wanted should the woman go into labour before her scheduled date/time) - email me at qualitycareforbcmothers@gmail.com - as I'd like nothing more than to be able to help moms find the care they need when they need it.

Thank-you in advance.

Improving Maternal Health and Wellbeing: Measuring what Matters

I love the story of the APGAR score and am moved how such a simple composite measure could improve the outcomes of babies by helping care providers focus on what matters. The story of APGAR demonstrates the power of good measurement.

Right now, British Columbia uses two measures - the rate of cesarean sections and the rate of attempted vaginal births after cesarean (VBAC) as performance measures for maternity care where good performance is considered to be a reduction in cesarean rates and an increase in the number of attempted vaginal births after cesarean. The use of these statistics as performance measures provides an incentive for hospitals and care providers to deny access to cesarean sections, sends a not-so-subtle message that vaginal birth is a good thing in and of itself, fails to adjust for risk, and has little or no relationship to what might be considered quality care. The problem is these measures place too much emphasis on process and not enough on outcome and may be undermining the health and well-being of women and their babies - in short driving the system towards providing care based on an ideology (natural/vaginal childbirth) and failing to provide patient centred care.

To highlight what I mean - my first birth would count positively in the measures used - it avoided a cesarean that would have otherwise been done. My second birth would count negatively in the measures used - it contributed to the cesarean section rate at the hospital I delivered. In terms of outcomes though, the second birth was by far, "the better birth" - at least from my perspective. Similarly, a vaginal birth that results in the use of forceps and yields extensive tearing and a brain damaged baby is still "good" by these measures, but a cesarean that results in a healthy baby and no post-operative complications is "bad" by these measures. Even a birth that results in a ruptured uterus and a permanently disabled baby is "good" but a repeat cesarean is "bad". These "performance measures" have the potential to drive truly Orwellian care - and should be abandoned in favour of measures that are capable of actually reflecting "good births" and "bad births" and driving care that is most likely to result in "good births".

I do not think it would be terribly difficult to come up with a better composite guage of whether or not a birth was a "good" birth - or at the very least measures that do not result in the provision of care that is not in the interests of the patient being cared for. Perhaps a composite measure that considers treatment plan compared to treatment outcome, APGAR scores, physical damage and psychological damage - would assist far more in the goal of providing care that results in "good births" than the silliness of measuring cesarean and VBAC rates. Is mom and baby healthy? Is mom happy? - those are the two questions that deserve to be answered, not how was baby delivered?

Systemic Barriers to Maternal Request Cesarean are Prevalent in Canada

It is difficult to be a cesarean by choice mom - most people do not understand your choice and may even think that you are nuts for wanting to choose a surgical process over a natural process. It is a choice that is stigmatized and even denigrated. It is a choice where it is still debated openly whether or not women should "have the right to choose" and the term "too posh to push" is still thrown around. Many moms have an uphill battle in Canada when they choose cesarean that extends far beyond what their friends and family may think of their choice though - there are prevalent systemic barriers that prevent many women from being able to exercise their legitimate right to choose cesarean.

Many primary care givers - family doctors and OBGyn's do not support maternal request cesarean. When women ask their doctors about it, few are receptive to the request. It is not uncommon to hear of women not being referred to an OBGyn (family physicians and midwives do not and can not perform cesareans) until their pregnancies are very advanced. When I was pregnant with my daughter, I did not get to even meet with an OBGyn until I was practically at term (referred at 32 weeks and saw the OBGyn at 36 weeks) - despite having made my desire for a cesarean known at my appointment to refer to a maternity doctor and at my first and subsequent prenatal appointments with my maternity doctor. Many women who request cesarean have anxiety about the delivery and that anxiety often is not resolved until they have confirmation from an OBGyn about the delivery plan. I found it very difficult to enjoy either of my pregnancies until I knew what the plan was regarding the delivery. Further, there tends to be significant waits to access OBGyn's and as a result it is not uncommon for a woman to wait 4 or more weeks after referral to be seen by an OBGyn.

Unfortunately, many OBGyns in Canada are also not supportive of maternal request cesarean and I do not know of many who openly offer this choice. Quite simply a woman cannot go to a phone book or even online and see that CDMR is one of the services offered by a particular OBGyn. Perhaps this is because the Society of Obstetricians and Gynaecologists of Canada does not currently support CDMR and has stated that “Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." As such, if a woman is referred late in her pregnancy to an OBGyn for the purposes of getting a cesarean, and the OBGyn she is referred to is not supportive of the request, by virtue of the time sensitive nature of pregnancy she may be unable to get a CDMR.

Then add hospital policies that might present additional challenges to women wanting maternal request cesareans. For example, at BC Children and Women's hospital - the home of the "Power to Push Campaign", women desiring maternal request cesarean are encouraged to undergo counselling at the "Best Birth Clinic" and the power to push website repeatedly reminds women that vaginal delivery is the "normal" method of childbirth. This makes women who wish to choose cesarean feel abnormal or wonder if they are in need of psychological services because they prefer surgical delivery for their children. At the time of my daughter's birth I was told by my OBGyn that an elective cesarean needed to be an "add to slate" procedure, that he could not give me a specific time and date for the surgery. What he failed to inform me, is that by not having a fixed time and day for the surgery meant that there was a very real risk the surgery quite simply would not happen at all, as it would have to compete with all the other "add to slate" surgeries and that unless he advocated and made the case that my cesarean should be a priority that it would get bumped until it was ultimately denied.

So what is the impact of these systemic barriers to maternal request cesareans? Many women who would prefer to deliver by way of cesarean cannot access timely medical care and ultimately are forced to deliver vaginally. The current system unjustifiably imposes risks on mothers who would choose cesarean - it imposes anxiety as a result of the delay in having an OBGyn "approve" the planned delivery, and it imposes increased risk that a planned elective pre-labour cesarean will need to be an urgent cesarean or emergent cesarean or may even be an unwanted vaginal delivery. At the most basic level, every pregnant woman is currently told by this system that she cannot submit to a generally safe medical procedure unless she meets criteria entirely unrelated to her own priorities and aspirations - this removal of decision making power threatens women in a physical sense and the indecision of knowing whether a maternal request cesarean will be granted inflicts emotional stress. Depriving women of their right to make medical decisions for themselves is a travesty and a grave injustice - one that I am battling to change.

Timely Access to Medical Care - Lawsuits and the Blame Game

There's a lawsuit that has been launched by Dr. Day alleging that the government has failed to provide timely access to medical care and in doing so has violated patient's charter rights to security of the person. The government has submitted in its statement of defence that it is not responsible and that it is the doctor's who failed to provide their patients with timely access.

Back when I had my daughter - I was told that by my doctors that they could not access the resources. My doctors told me that the OR was not available, that my case had been bumped by other more urgent surgeries. Then when I wrote the patient care quality office a year later to find out more about what had happened - the response I received back clearly indicated that it was not that the resources were unavailable, but rather that my doctors had failed to facilitate access to them when they were available.

As a result, I was left not knowing what happened - my doctors had said the resources were unavailable and the health authority had said that they were available. Either my doctors were lying and had committed a malpractice or the health authority/hospital was lying and had failed to ensure adequate resources were available when they were needed.

In the Day case, as in my own - it is clear that the doctors are pointing their fingers squarely at the system (the health authorities and the government) - only to find the government pointing squarely back at the doctors. Unfortunately, this leaves patients in a difficult position - in order to get accountability for being unable to get timely medical care, they must sue both the system (government/health authorities) and their own doctors.

It is a very daunting prospect - but given the realities of health care in Canada - do patients have any other choice?

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.