Legal Issues: The Right to Timely Access to Medical Care and the Right to Choose Treatment

In British Columbia, many women who are in labour and delivery do not have access to timely medical care and effectively cannot choose treatment because reasonable resources (dedicated obstetric anaesthesiology in level 3 hospitals) are not available. Is this a violation of their charter rights and should government be held accountable for the resulting psychological and physical harm?

Section 7 of the Canadian Charter of Rights and Freedoms states that:

7. Everyone has the right to life, liberty and security of the person and the right not to be deprived therof except in accordance with the principles of fundamental justice.

External Review into Infant Death Released

The Vancouver Island Health Authority (VIHA) has released its external review into the death of an infant at Victoria General Hospital in August 2011. That review concluded that a c-section was provided within guidelines (20 minutes after being ordered).

It really is an interesting read and gives the depiction of an ongoing situation of sub-optimal maternal and fetal care in Victoria, particularly since the provision of anesthesia services to the labour and delivery ward was reduced as of May 31, 2010. VIHA has also released its response to the recommendations.

The problem I have is that the review indicates that there have been past concerns - these concerns were identified both prospectively (Failure Modes and Effects Analysis) as well as retrospectively (the Qmentum accreditation process also identified and recommended an immediate remediation of the problem). Those reports happend in 2010 - and yet it took a baby death in August 2011 to spark an external review that basically recommends what has already been recommended. I'm not left with a lot of confidence that anything will change.

Is it time for a 'counter-revolution' in Birth?

There's another voice in the birth debate that has been squelched in the last couple of decades by those who view a 100% natural birth experience as being superior to the medical alternatives. There's a bias in childbirth education classes. There's a bias on the web. It's not a scientific bias - despite what Ina M. Gaskin and Rikki Lake might have you believe. Worse - it harms women and babies by restricting their choices and leading them to make decisions that wind up making them (and their babies) worse off. It makes women who do not subscribe to their beliefs feel as though they've failed in mothering or parenting.

The voice of the 'Natural Child Birth' (NCB) movement is exceptionally loud - they have their figureheads and their documentaries ("The Business of Being Born").

The counter-voice is quiet and must be sought out - it exists but it seems less charged. Where is the anti-NCB documentary "Beyond Reason: The Religion of Being Born"??.

Are women who fear childbirth given a fair deal by the health system?

The Globe and Mail today published that women who fear child birth were more likely to have c-sections (both elective and emergency) compared to those who do not fear birth.

What I found remarkable were the comments after the story. In particular there is a stark contrast between those from women who 'get' the fear of childbirth, and those who are hard core natural birth advocates. Those who get it would never denigrate the choice of a woman to opt for an elective c-section (or a natural birth if that is what she desires). Meanwhile the natural birth advocates are hellbent on enforcing their views on other women and would actively ban informed choice.

Thinking about round two...

I am not even pregnant with bean 2...and yet I'm thinking about the inevitable end to that pregnancy. The birth end. And when I think about that end, I still get angry about the end to the first birth (aside from the healthy baby).

I so very deeply want a different ending this time (aside from the healthy baby, that can stay the same).

I don't want to labour in such extreme pain, knowing that its completely unneccessary. I don't want to feel as though I don't matter and that I don't have a choice, when I know that I do. I also don't want to have the fear that if shit goes sideways - as it can and does in birth that the right people who know how to do the right thing at the right time won't be there. I don't want to experience the changes that go along with pushing a baby out the way 'nature intended'. I researched my options last time (not that it did a fuck load of good) and I came to the reasonable answer for myself - one that had on a whole comparable risks and that I felt would yield the best outcome. I did everything I could to get what I thought would lead to the best outcome for myself and my child, and I didn't get it. The baby waited, I waited, and the system failed us.

How do I avoid going down the same road again? How do I guarantee an anaesthesiologist will be there? When it comes to birth in Canada - there is no private option...so what's an informed elective c-section desiring girl to do?

What I believe in....

Motherhood Parenthood has a way of changing people...often for the better but not always. For myself, I never quite understood things, the way I understand them now.

For example, before I was a mom I couldn't before imagine why a highly educated woman (or man for that matter) with a satisfying career would abandon it for the full-time-stay-at-home-and-get-paid-nothing gig. I understood how a person could put their kid in daycare, day-in-and-day-out but not the flip side. I get it now. If it were possible, I would opt-out of the full-time job (but not fully out of my professional activities) and I would be there more now. I now get that my child is who she is for such a very short period of time and that the role of 'mom' is so much more than I had previously thought. It's so much richer and more meaningful than I gave it credit for - I'll even concede that its more meaningful than what I get paid to do (so perhaps I ought to be doing something more meaningful that gets paid??). That being said - having a stay at home parent must be a joint decision and until certain other things are done, it's just not feasible right now - but if it were, I would be there now instead of in my office.

I now also have a new perspective on a lot of parenting - one that has eased up A LOT. I'm a lot more individualistic now - more of a 'if it works for you, then run with it!' kind of girl - with the caveat of course that a person should be fully informed so that they are making the best choice for themselves and their kids. As a result I'm neither pro-breastfeeding nor pro-formula...I'm neither pro-natural child birth nor pro-medicalized childbirth (but I'm definitely not pro-natural child birth when it comes to me and my girly bits) rather I am pro-whatever-is-in the best interest of the mom/dad and the baby...I now think that many parents are far too hard on themselves and don't give themselves enough credit for what they do right - there's a whole lot of parents who aren't failures (by any measure that really counts - like the health and happiness of their own children and families) that feel like they are. Lastly, I'm more socially minded - I don't think that I matter as much as I used to matter.

Maternity in BC - the system is twisted

I'm fairly convinced that the care I received during the birth of my daughter was not quality care. I will concede I got a healthy baby out of the deal...but I was damaged in the process. I still experience a level of stress when I think of her birth or for that matter read about other people's births...and don't even get me started on the idea of the next birth. I'm still angry - it's been more than a year and I'm right pissed off, in part (in large part) because I know nothing has changed in the year since I gave birth and that things are unlikely to change before I next give birth (more than a year from now - quite possibly in another province if I have any say in the matter). It's 2011. I live in Canada. I live in a major city in Canada - and access to medically neccessary services during labour and delivery are questionable at best.

So what would quality care look like...here's a few ideas:

1. The childbirth approach decided upon by women and their care providers is respected and access is provided in a timely way. That means that if a woman and her care provider decide that a csection is the way to go then the woman gets her csection as planned. That means that if an induction is needed, the woman gets the induction - as planned. That means if a woman asks for an f*n epidural - she gets it without undue delay (within an hour).

2. Adequate resources are provided - this means that if its a level three hospital there should be dedicated obstetric anaesthesiology. If every other province can somehow manage to meet this standard why can't BC?

3. Outcomes would be measured - not just the broad measures (like infant and maternal mortality) but some of the other stuff that also matters like maternal satisfaction, rates of post-natal PTSD and post-natal depression, wait times for access to service, etc. Problems would be identified and solved...there would be a continual process of making things better.

Still angry though - don't know when or if it will pass.

What we don't know...

I am in the 'real world' a health economist, who makes a living by supplying information to decision makers about the health care system. I work for the organization that has the responsibility for ensuring that quality, appropriate, cost effective and timely health services are available to all British Columbians. Granted, it's a hefty mandate and there are real and significant challenges to meeting it - an aging population, the rising incidence of chronic disease, technological advancement, human resource limitations, and funding limitations.

Having experienced an aspect of the health care system in BC - I am troubled. From my perspective the system 'failed' to delivery quality, appropriate, cost-effective and timely health services. What's worse, is that I know that from the system's perspective there is no way for the system to know that it has failed because it does not collect the kind of information it would need to in order to come to that conclusion. My experience does not 'show up' statistically...and that is problematic - because if my experience does not matter (in a statistical sense) then all of the women who have a similar experience also don't matter (in a statistical sense). Worse - how do we get to a better system that actually delivers what it is supposed to (quality, appropriate, cost-effective and timely health services) if we are not brave enough to collect the information that would actually enable an accurate and meaningful assessment of system performance?

So what do we not know, that we need to know (with respect to maternity care)?
1. We need to know how many women actually deliver their babies in the way that they and their doctors or care providers planned to deliver their babies.
2. We need to know how many women actually receive elective c-sections on the date that they planned to receive the c-sections.
3. We need to know if women are satisfied with the care they recieved - and if they aren't we need to know why.
4. We need to know how many women want to recieve epidural anaesthesia, how long they wait, and if they can't get it, we need to know why.
5. We need better information on rates of post partum depression (PPD) and post-natal post-traumatic stress disorder (PN PTSD).
6. We need better information on delays to accessing c-sections when they are deemed neccessary - near misses and the reasons for them need to be known.

What we know right now, what show's up statistically - just isn't good enough...

Conflicted

I work for an organization that espouses patient centred care - and at the same time appears to with hold the resources that would provide for that care. It says one thing and does another.

I love being a mother and would like to have another baby - but, am seriously terrified of being put in the same situation again.

I'm still angry...

A year later and...

Nothing in Victoria has changed with respect to a woman's access to medically neccessary care during labour and delivery. I used to think that I was an unfortunate one-off having my personal autonomy violated and a natural birth forced on me due to the inavailability of an anaesthesiologist. That was until August 17, 2011 - when I read the very tragic report of another mom in Victoria who gave birth, but her baby didn't live - potentially because she could not get access to a c-section fast enough. It through me off kilter, and brought me back to my own experience, just over a year ago. Being out of control and terrified that something might go sideways and knowing that an anaesthesiologist wasn't available...

The news report angered me...how is it that in Victoria, at a hospital that is a level 3 hospital (handles high risk pregnancies), that does more than 3,000 deliveries a year that women do not have access to anaesthesiologists?

I've done more research, and am shocked to find that the rate of epidural use in 2009-2010 is around 34% for vaginal deliveries on South Vancouver Island compared to 49% in Vancouver campared to 56% for Canada as a whole. Among first time moms the rates of epidural use are 43.9% on South Vancouver Island compared to 59.6% in Vancouver Coastal Health Authority. So what's the difference? There is no Dedicated Obstetrical Anaesthesiology available at Victoria General Hospital, whereas there is at BC Women's and Children's hospital. Actually BC women's and children's hospital is the only level 3 hospital in BC to have dedicated obstetric anaesthesiology - even though the national standard is for level 3 hospitals to have this resources.

Are women being denied access to epidurals do to shortages of staff/anaesthesiologists? I know I was. I also know other women who were (actually it's shocking when you begin to talk about it with other moms). I am further aware of women who had to wait a long time to get access to an epidural. I am aware of delayed csections.

If women on South Vancouver Island want epidurals at a rate similar to the rest of the province - there are more than 350 women a year being denied access to them!