Patient Choice Cesarean, Urgent/Emergent Cesarean or Forced Vaginal Delivery - Is it Really That Hard to Choose?

There's a phrase I hear from healthcare providers and others who oppose patient choice cesarean, "No physician is obligated to perform a procedure that he or she thinks is not medically indicated."

They see the denial of choice as being justified. Perhaps they think that they are saving the healthcare system resources by denying the choice. Perhaps they worry that women are unable to make an informed decision in this regard. Perhaps they see performing a cesarean without medical indication as causing harm, to either the woman or the child.

For whatever reason, there are those, who when faced with performing a patient choice cesarean, will outrightly refuse to undertake the procedure.

This would not be problematic if timely access to an alternate provider who is willing and able to undertake the cesarean can be realized. Unfortunately, under the current system - this is often not possible.

So if a woman cannot access patient choice cesarean when it is needed (either planned at 39 weeks or done urgently after the commencement of labour) - what will happen to the patient?

Perhaps care providers simply haven't thought about this in full - what happens to the woman, pregnant and desiring of a cesarean who is not provided timely access to one? What really happens?

Nature is a cruel wench - she isn't particularly patient, and the woman cannot just delay delivery until she finds a provider and a facility who can accommodate. The woman will eventually go into labour - this is nearly guaranteed. Either a medical need will then arise for a cesarean - in which case an urgent/emergent one will hopefully be provided - or medical need won't arise and at some point the woman will be fully dilated, and given no choice as to what she will have to do whether she wants to or not. She will deliver vaginally. The experience of which is foreseeably traumatic - or at least should be - as the patient will have been subjected to what can only be considered a Forced Vaginal Delivery or an urgent/emergent cesarean where either her life or her baby's is put at risk.

And the thing with traumatic experiences is that they don't just go away - and sometimes they don't ever go away. The physician will have avoided doing what he/she saw as a medically unneccessary procedure - but in so doing will have likely inflicted a rather large emotional toll on a woman as she is entering a very significant life transition.

I can speak to the experience of forced vaginal delivery as it is my own lived experience. I can speak to the toll it has taken on me, and how it has changed me and how having had that lived experience - I would not wish it on any other woman because it is it's own kind of hell.

That is the real choice facing health care providers when women come to them asking for a patient choice cesarean: Do you facilitate the request after having provided informed consent, or do you subject your patient to a Forced Vaginal Delivery or an urgent/emergent cesarean after medical need arises?

A Doctor who Listens: Worth Their Weight in Gold

I appreciate that my experience with the medical system has changed what I expect of it, and has sensitized me to certain things. In particular, I blame part of what happened with my pregnancy and birth of my daughter as a failure of my health care providers to listen and understand what my needs were as a patient, and to facilitate those needs as best they could. I communicated my wishes clearly, and expected them to be respected.

As I've blogged about before, also as a result of what happened, I needed to find a new family doctor. It took nearly a year, but I found one. It is a new relationship - and like any new realationship, it is particularly fragile. We've had a few encounters - and while I think the new Dr. is a good person, I think that it just is not going to work out.

Advocating for oneself in the health system is already a challenge. Recently (now a month ago), I had some female oddness happen - I emailed an OB I knew and asked what I should do about it. I made an appointment with the GP - and the GP's answer was basically to just do another appointment for a pap (no physical was done at that time). I asked for a referral to an OB and that it seemed like a good idea for a pelvic ultrasound to be done. He ordered the ultrasound but refused to do the referral at that time. We did the ultrasound, and I had another appointment with him to discuss the results. My Mirena is partially imbedded in my myometrium. I decided to ask for the referral to the OB I prefer to determine what should be done. My GP is refusing to refer and insists on removing the Mirena himself (a. I'm not sure removal is fully neccessary and I'd like a second opinion on that, and b. if it does need to be removed, I'd prefer to have an OB (and preferably the OB in Vancouver) remove it because if there are any complications the last place in the world, I want to go is Victoria General Hospital). Last Monday his receptionist called - and told me that he'd prefer to remove it - I reiterated the request for the referral. I called today (10 days later) to see if the referral had been put through. It hasn't. This is the last time I'm asking for it - and frankly, this experience has demonstrated that he is not listening to me and makes me question whether or not he would listen to me in the future with any issues that may arise. I am frustrated and annoyed.

I think the hunt for a family physician for the W family is back on - and I foresee going to a walk-in clinic in the interim to get the referral I need to access the care I need.

If anyone knows of (or is!) a family physician in Victoria who is accepting new patients and who listens to their patients - I promise a low-maintenance and grateful young family.

For Spouses of Women Struggling with Birth Trauma

Birth Trauma is hard on women - but its also hard on their spouses and on marriages and partnerships. A post done by the Good Men Project for spouses of those with depression has inspired me to think about what partners of women traumatized by birth can or should do for the women they love as many of the things mentioned in the post resonated with me and my experience. Nobody tells the partners of birth trauma victims how to cope or what to do - and for the most part how can they be expected to know what to do? This post is intended to try and offer some advice to those loved ones, who desperately want to do something, but just don't know what.

Birth Trauma is devastating for women - when a woman is traumatized by her birth, her entire notion of herself as a woman and her role as a mother have been shattered. It can be a massive struggle for a woman just to make it through the day - many moms continually relive their birth experience and accompanied with the demands of motherhood, they feel overwhelmed. Spouses of women might try a gentle approach, they might try a firm approach, they might try to get them to open up, they might suggest things they think will help, they might buy presents and say encouraging things, they might get frustrated and argue. It seems as nothing a spouse does for a birth traumatized woman makes any difference - she just will not move-on. She seems unable to be grateful for all the good that remains.

Spouses of those traumatized by birth need to know, that birth trauma is not about women being in a "bad mood", or being upset because things during the birth didn't go "their way". Birth trauma is serious and debilitating. It is not about women "playing the victim" - or being trapped in "pity parties" - or being "selfish". Having a traumatic birth experience is like being in a car accident, or having your home destroyed by a flood. There might have been things that could have been done (or there might not be anything that could have been done) to avoid what happened - but the traumatized woman never asked for what happened to happen. The circumstances were entirely beyond her control - and if she could go back in time and have things happen differently, she would.

If your wife was injured in a car accident and had several broken bones - you wouldn't tell her to brush it off and continue as though nothing happened. If your wife was car-jacked and assaulted - you wouldn't tell her that sometimes that happens, and she was just unlucky but that she should be grateful to be alive. You would be patient, you would understand that she might be shaken from the experience - that she will likely need time (maybe a lot of time) and rehabilitation. Depending on how bad the experience was you might even have to come to terms with the idea that your wife might never be the same again. She might have to find ways to cope with the lingering injuries, she might not be able to do the same things she used to do, she might not ever be as social or as unguarded as she once was.

This is what birth trauma is.

Just because your wife made it through the birth physically, doesn't mean she wasn't injured psychologically. And just because you can't see the injury, does not mean that it does not exist, does not mean she is not debilitated.

After my daughter's birth, I was left reeling. It has taken years and a lot of therapy and self-care to get where I am. Three and a half-years on and I am not the same as I was and I doubt I ever will be. I won't seek care from Victoria General Hospital if I can avoid it. I am sensitive to feeling like my care providers are not listening to me. I am far more territorial of my person. I avoid movies with birth scenes in them. I am far more critical of those who judge personal decisions. I am less tolerant of intolerance and injustice. I am more skeptical and cynical. I am more angry. There are friendships I have had to discontinue - and other ones that have begun because of what happened. Birth trauma completely changed my outlook on life and who I am as a person.

When a woman is battling Birth Trauma - it is like she is in the deepest, darkest ocean - being crushed by the pressure of the water, and unable to determine the direction in which she should swim to reach the surface. All a woman wants to do is not feel the way she does, to not feel as though the day their child was born was also the worst one of their lives. They want to reach the surface and breathe -they want to swim to shore.

The natural reaction is to throw them a rope and pull them up to safety - to make them "see" how wonderful things are, to not focus on what happened, but on all the good that is. To make them move forward.

The problem is, that trying to pull women from the depths of Birth Trauma - might make things worse. Telling her to be grateful for her healthy baby. Telling her that what happened to her has happened countless times to countless other women. Telling her that she can not let what happened impact her mothering. Telling her to snap out of it and move on. Telling her that she should be happy as other women have it far worse. All these things are just as likely to drive the woman deeper into the trauma - and might add a dose of depression to go with it. Not only will she be unable to swim to the surface for air, the pressure to deny her feelings and needs for the sake of others might well crush her as she becomes a means to an end, rather than an end in and of herself.

For mothers, there is already tremendous pressure to sacrifice and put aside your needs for those of your family. Mothers already fear harming their children in some way by failing to do things the "right way". Mothers fear being labelled, they fear being seen as ungrateful. Mothers fear being judged as being weak - motherhood and birth are a kind of female machismo - and to admit that birth defeated you in some ways, is almost like admitting you are a lesser woman. There is tremendous stigma attached to mothers who are not blissful in their births and motherhood. We have been told from the time we are little girls, that being mothers is what women do and that good mothers are self-sacrificing. It does not matter that by accepting the stereotype of the good mother, we restrict women to biological essentialism - and that the sentiment is decades out of date and harms many women. The instinctual reaction for a mother is to sacrifice herself and her needs - to insist on soldiering on as a good mother does, personal needs be damned! Mothers will revert into themselves, put emotional barriers up and they will shut down. Trying to force a woman to move on, at what is likely the most emotionally challenging time of her life creates far more problems than it solves.

What spouses of the birth traumatized need to do - is to be there for their wives. If and when they talk, listen - refrain from giving opinions, just really listen. Women who are traumatized by their experiences need to be heard - they don't need your opinion about why everything is or should be okay (your body did not give birth). The thing I wanted more than anything, and the times when I felt my husband was really there for me, are the times when I felt validated and heard and sometimes just held. Your wife needs you to not be angry with her. Your wife needs you to be patient while she finds her own way out of the awful - she needs to feel and be safe when talking about it with you. However awful, the things your wife has to say - listen, and when you are done listening reaffirm that you love them still, reaffirm that you will be there for them, however long it takes and wait until they are strong enough to swim to the surface and the shore. Tell her it is okay for her to do what she needs to do for herself. It probably will be hard, you might need some help, but do not give up on your wife. Support her, love her, and be there for her until she gets to shore - she's the mother of your child, it is the right thing to do.

Forced Homebirth in a Hotel Takes BC Maternity Care to a New Low

I believe in access to adequate and timely healthcare to facilitate the needs of patients - and in particular the needs of mothers and their babies. I believe in informed consent. I believe in the prevention of birth trauma. I believe that when moms want access to medical care during pregnancy and childbirth - we owe it to them to provide that access.

Which is why I am scraping my jaw off my desk this today - I am shocked and appalled. I am also incredibly thankful, that for this mom and baby that the circumstances in which they were forced to give birth did not result in any physical harm.

A 17-year, first time mother was 8 days overdue and needed to be induced. They travelled to the Vernon Jubilee Hospital for the induction at 9 am on November 15. They needed to book a hotel room to wait for labour to begin - they returned to the hospital at 3:30 am and despite being unable to walk, the mother wasn't dilated enough and was turned away. They returned to the hotel and sometime after 4:30 am active labour began and progressed so quickly that they could not go back to the hospital. The aunt and grand-mother delivered the baby in the hotel room.

How is this acceptable care? How is this safe care? How does this respect the needs of pregnant women for informed consent and timely access to care?

This is wrong on so many levels. This apparently happened a year ago - I wonder if anything in Vernon has changed since it did?

On Causes

The other week we were flying back from a weekend vacation (a whole weekend of uninterrupted sleep and adult time with my husband) - and I did not have alot of reading material on my iPad and I was tired of scrabble, so I was reading the case law I had pulled sometime ago in support of my case. I was reading the Morgentaler decision - the decision that struck down Canada's abortion law in 1988 - there are so many striking parallels between a woman's access to abortion and a woman's access to planned cesarean. I was thinking how sad it is - how clear the law seems to be on the issues, yet at the same time - how insurmountable the challenge ahead is seeming. I was also thinking about how my experience changed me and mourning the loss of the wife and mother my husband and kids deserved to have - the woman who, had things unfolded differently, would be thinking and doing so many other things - a woman who would not be burdened by a cause.

Having a cause is a lot like having a chronic illness. A cause isn't something you give passing attention to - nor is it something you fully choose - it is the choice you make when the alternative is for whatever reason, unacceptable. It is what is done, when nothing else can be done and doing nothing is reprehensive.

The cause is also a life-preserver - a coping mechanism...it holds out hope that change is possible. That what is and what was, doesn't have to be what will be. Remaining committed to it, means that hope has not yet departed. It means that what happened to me does not have to happen to other women.

I have no doubt with respect to the right of women to expect the same rights as other patients with respect to their healthcare and their abilities to make medical decisions for themselves. There are tremendous barriers to exercising those rights and asserting those rights when they are violated - and those barriers need to be eliminated. That's not a small task - and it will require many who are committed to the changes that matter - mothers, doctors, OBGYN's, midwives, nurses, lawyers, judges and administrators. It will require a certain bravery and tenacity - and those who see the value beyond their own individual experience. It will require research and awareness. It will require resources and organizational capacity.

But none of these things should be seen as unattainable for far more has been found for things that matter far less.

Bad Evidence Drives Bad Decisions

Before I ever was a mom (and even now), I spent a lot of time with health statistics. Health statistics are experiences that have been reduced to numbers - they represent what happens to real people and describe how often specific things happen. Statistical analysis is a tool that is used to help figure out why those things happen - but it is far from perfect and far too often correlation is confused for causation. Equally problematic - the things that are not measured, often go unaddressed. When health statistics are done well - they shine a light on a problem and motivate positive change. When health statistics are done poorly - they keep real problems in the dark and hinder progress. Often, ideology colours the research that is undertaken and the result is a body of evidence that is at best poorly understood, and at worst used to make policy that does far more harm to those who it was meant to benefit.

I have come to the terrible and tragic realization that health statistics done poorly and obscured by ideology are endemic when it comes to pregnancy and childbirth.

It is the only way I can possibly understand the widespread propaganda that is largely focussed on promoting a specific kind of birth (normal birth) and a specific kind of infant feeding (breastfeeding) - even at the cost of the physical and emotional health and well-being of mothers and their children.

It is the only way I can explain Ottawa's and Toronto's public health stance on breastfeeding.

It is the only way I can explain the BC Minister of Health encouraging homebirth last year.

It is the only way I can explain all the "failure" felt by women who do not manage to have a normal birth or to breastfeed - all the while ignoring whether or not it really matters in the first place.

It is the only way I can explain why cesareans and VBACs are used as system measures, but rates of psychological trauma are not - it is also the only way I can explain why the costs associated with birth seem to end 6 weeks post-partum.

If health statistics and research in this area were being done well - the things that really mattered would be measured and better understood. If that was the case, maybe I wouldn't get the feeling that we are being penny wise and pound foolish, and short-changing the health and well-being of women and their children in the process.

Baby, I'd like My Boobs back - Thanks, Love, Mom

I've breastfed my son far longer and far more than I thought I would. I got a little lazy around Christmas last year and neglected to bottlefeed him for a few weeks. At the end - he wouldn't take a bottle. No way, no how. Not of formula, not of pumped boob juice. If it wasn't my boob, he didn't want it. I have been booby-trapped ever since.

It's kind of worked for us though. Aside from the night shift, where my now 14 month old toddler still insists on waking several times a night for some snuggles and some evening nourishment. I mean what's a little sleep deprivation - who really needs more than 3 hours at stretch anyways?

But the Mr. and I would like to go away for a weekend...and well...the boobs cannot be left behind. Furthermore I am ready to move on and would really like to get maybe a 6 or 7 hour stretch of sleep on a consistent basis. So, there's weaning ahead. And if my experience of weaning his big sister from the bottle is anything to go by, well, I don't imagine it'll get any easier - so I may as well bite the bullet and get done with it. That and leaving my mom with a baby who isn't yet weaned for a weekend seems kind of cruel...so best to get a start on it before that happens.

I get the sense that the wee little W won't be happy - I also know he'll get over it, and he'll still love me, because I'm mom and that has a lot of sway - even if it doesn't come with an all you can eat boob-fet.

But the WHO and their 2 year recommendation can go find a different boob to suck as mine are retiring in the very near future!

Ottawa Public Health Responds

I'll leave the following response from Ottawa Public Health with my readers:

Hello Ms. Williams,

Thank you for your valuable feedback on the Ottawa Public Health Make An Informed Decision About Feeding Your Baby web-page.

In 2013, Ottawa Public Health met the provincial requirement to qualify as a World Health Organization designated Baby-Friendly Initiative health facility. Our website was reviewed by assessors experienced in infant feeding to ensure quality and currency of the information. Our information sources include the World Health Organization, Health Canada, the Best Start Resource Centre.

We wish to reassure you that OPH strives to support all families regardless of the infant feeding decisions they make. Support is available for mothers who are breast-feeding, bottle-feeding with breast milk, or formula feeding. Avenues for offering information and support include prenatal education, Baby Express drop-ins and the Ottawa Public Health Information Line.

We are committed to meeting the needs of our community. The way in which information is presented on our web-site is being reviewed with your concerns in mind.

Many thanks for your interest in this most important subject.

Regards,

Tania

Tania O'Connor, RN, B.Sc.N

Supervisor (A)

Ottawa Public Health

Health Promotion and Disease Prevention

If that is what assessors experienced in infant feeding consider "quality and current" information - we have to ask ourselves, who are these people and why do they hate mothers who do not breastfeed so much?

Dear City of Ottawa: Lactavism is NOT Public Health

The other day, I was outraged by something a friend in Ottawa had pointed out on one of the discussion boards I participate in - I was shocked that a body of government would stoop to such a low level of unabashed fear-mongering and outright lactavism. It is one thing to find such things on biased webpages (The Alpha Parent, The Feminist Breeder, Natural News, etc.), but quite another to find something on the Public Health page of a major Canadian city. I always believed that such organization would hold themselves to a much higher standard - that they would have people employed who were actually committed to the health and well-being of women and as a result would be more immune from this kind of garbage.

This is not about making an informed choice - that would mean encouraging women to have a discussion with their doctor about what is best for themselves and their babies in their particular circumstance. This is about fear-mongering and bullying moms into breastfeeding and that is wrong. The information on this page is exclusively about the benefits of breastfeeding and the risks of formula feeding. There are no sources provided or even statistics on what the actual relative risks are. According to this page, breastfeeding is the magic bullet that is the golden brick road to good health, and formula feeding is plagued with illness, obesity, tooth decay, cancer and death.

I can only imagine how such information would be received by a new mother - who like all mothers, only wants to do the best for her child. How this information might drive such a mother to make truly bad choices with regards to her own health and that of her child - including buying unscreeened breast milk from donors over the internet rather than feeding her child formula, or waiting until there is a health crisis to switch to formula - and then feeling terrible about it.

That is not good Public Health.

So I emailed the City of Ottawa (and would encourage you to do the same - they can be reached at healthsante@ottawa.ca ) the following:

Dear City of Ottawa -

I am a mother and I write out of concern about the following webpage: http://ottawa.ca/... that purports to encourage women to make an "informed decision" regarding infant feeding. I am disappointed that the City of Ottawa would consider such a webpage appropriate or helpful to mothers.

Many mothers, for whatever reason, find that breastfeeding is not appropriate for themselves in their particular situation. Some mothers do not make enough milk. Some mothers are survivors of childhood sexual abuse and find breastfeeding psychologically difficult. Some mothers must return to work in order to economically provide for their children and cannot accommodate breastfeeding. Some mothers are on medications that are not compatible with breastfeeding and pose risks to the infant. Some mothers find breastfeeding painful and inconvenient.

These women need to know that formula feeding is a safe and appropriate option for meeting the nutritional needs of their babies and they need clear instructions on how to formula feed appropriately.

The webpage by the City of Ottawa is nothing less than fear-mongering and does little to provide for the informational needs of mothers. Worse, the information provided by the City of Ottawa may inflict emotional harm on many women - as they are lead to believe that the choice to formula feed will lead to tooth decay, obesity, cancer and death.

All women deserve to be supported during pregnancy, childbirth, and the year post-partum - and the City of Ottawa has determined that it should make women who for whatever reason need to formula feed to feel worse than they already do. Please revise the information on your website to be more balanced and sensitive to the the emotional and informational needs of mothers.

Sincerely,

Janice Williams

Perhaps if more women take a stand against this kind of garbage - it can be treated as the toxic trash it truly is.

Canaries in a Coal Mine: Birth Trauma Survivors

The experience of the birth of my daughter has been by far, the most negative experience of my life - it was the most terrifying, most painful, most disempowering, most psychologically wounding and dehumanizing thing that I have ever known. The only saving feature is that my daughter emerged from that experience, ultimately unscathed - and for that I will always be grateful. It was the kind of experience, that having had it - knowing it first hand - you would do anything to prevent any other human from experiencing the same. Indeed - I expect that I never will be the same, that I never will look at things in the way I would have had I never known Birth Trauma.

Much as veterans look upon war with different eyes than civilians, or, those who have never known war - survivors of Birth Trauma look upon birth much differently. They see the destructive potential of birth, they know it can decimate the lives of women and their families. Their struggles in the aftermath are often silent - the stigma of admitting that birth was not what you thought it should be, that birth was negative - is often too great. Their pain is often dismissed (this is particularly true if the child born of the birth is ultimately healthy). So rather than learn from them, rather than honour them, rather than help them in whatever ways are possible: we expect them to get on with the business of mothering.

And that is shameful, because these mothers see what others can not: the toxicity of the system and the culture that is prevailing. Birth Trauma victims are the literal canaries in a coal mine. Furthermore, by empowering these women, to speak up and speak out about their experiences AND just as importantly, to HEAR what they have to say and to LEARN from them- it is possible that the system could change. That other women might avoid the same suffering - or that when such suffering happens, that maybe it doesn't have to be as damaging.

The experiences of Birth Trauma victims are awful - worse is to fail to take the opportunity to learn from them and to prevent others from enduring the same harm.

Supporting Maternal Request Cesarean - Legal Action

Fingers crossed - I'm hoping a more personal touch to fundraising might increase the amount of support we have available to move forward with the case. Today, I launched a GoFundMe campaign - it provides a good background of the case and the amount of money that might be needed to move forward and mitigate the risk of a loss. I note that any monies raised in excess of what is actually needed will go towards establishing a Community Contribution Company that will support projects aimed at improving the health and well-being of women who are pregnant, childbearing or new moms - and will take over the Maternity Legal Action Fund once established.

Wish me Luck.

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.