Is the BOBB effect dangerous?

I believe that there is a BOBB effect...in much of what I've read in the birthing blogosphere, there is a common refrain:

"I watched the Business of Being Born and it was then that...." which is ended in one of five ways:

a) "I decided on a home birth."
b) "I decided to avoid the 'cascade of interventions'."
c) "that a midwife was the best care provider for me and my baby."
d) "that freebirthing might even be an option for future children."
e) "I wanted to puke at all the misinformation and NCB bullshit."

The thing is that responses A-C are what 90 percent of the responses to that particular documentary are. Response D is also fairly rare (I'd say maybe 1 percent of women) and Response E only occurs among those who are skeptical enough to look for more information on birth and its risks.

What is dangerous is that the BOBB effect might be causing higher-risk women to push for non-interventionist births even when a more "hands-on" approach is safer for themselves and their babies. This might not be such a big deal in Canada where the regulations around midwives and their qualifications are pretty tight - but it might be in places like the US where regulations are more lax. I also wonder if it causes women to actively eschew tests that might demonstrate that they are higher risk, for fear of losing their preferred birth experience.

If there is a BOBB effect at work - it's not good - as at the end of the day babies and moms might be making some bad decisions when it comes to accessing appropriate care. Those bad decisions might lead to something far worse than an "unneccessarian" - a preventable death or a life-long disability.

It's time for the "Beyond Reason: The Religion of Being Born" to be produced - the anti-BOBB is needed, now more than ever.

The Perils of Mommy Group

I throughly enjoy my mommy group - we are all well-educated moms in our late twenties to mid-thirties with babies born within 2 months of each other. When we get together we talk about all sorts of thing....our husbands, our work (for those who went back to work), our kids and the joy of taming toddlers. All sorts of stuff. Last night, we had our "moms night out" it was quite enjoyable - we talked about saggy balls (apparently men in their geriatric years are also not immune to the effects of gravity), placenta consumption and other uses (for myself I just let it go the way of biohazardous waste or teaching material, although I had a very funny thought about a couple who are awaken in the middle of the night by raccoons fighting over a freshly "planted" placenta.....placenta is strewn everywhere in the morning....neighbors ask what it is....), work, the trials and tribulations of nap time/bed time/toddler discipline, mortgages...I am very happy to hear of the new pregnancy of one of my mommy friend. And then the conversation turned to birth.

I should have known better, I should have politely found an excuse to hurry home, but I didn't. And then I was there again, as the other women talked of all they did to speed up their labors and avoid the dreaded 'interventions'...I recall lying there hoping labour would stop or slow down, praying for a csection or at the very least an epidural...but more than anything praying that nothing would go sideways. My eyes glazed over and I starred at the red menu on the table....I tried to mentally absent myself from the conversation. It was hard to hear.... I think only one other mommy noticed my distress. My hand trembled as I reached for my water. Eventually the conversation ended and we departed, the drive home was difficult. My mind was still racing, my heart pounding. Upon my arrival home I poured myself two stiff cocktails to wind down from it.

Yep, I am nuts to consider #2....

Focus on Quality Care and the Efficiency will Follow

In healthcare, there's much talk about the "sustainability of the system" - the system of providing health care services. There's a prevailing attitude that the health system is not sustainable. Typically, most of the conversation focuses on the cost of providing health services and how growth in those costs are what is not sustainable.

I frequently question the 'sustainability' of the Canadian health care system (and more usually as it exists in BC) - and I do not think it is sustainable, but not because of 'cost' aspects. Rather, I think its unsustainable because of the investments that haven't been made, the costs that have not been incurred and should be.

It is not sustainable to have health care providers who do not have the tools and resources to do their jobs and do them well.

It is not sustainable to have a health care system that delays and denies access to care that is deemed appropriate by health professionals and their patients.

It is not sustainable to focus on a narrow range of acute services and ignore a broad range of preventative care.

It is not sustainable to put 'cheap care' ahead of 'quality care'.

Lastly, when thinking about whether or not the system is 'sustainable', it is not sustainable to exclude patients from the conversation.

I sometimes think if there was a fundamental shift - away from 'cost consciousness' towards 'quality consciousness' that the healthcare system would move much more expeditiously towards a more efficient and effective system. It should be about delivering the best care and generating the best health outcomes in the way that makes the most sense.

But it seems for now we're stuck...but not sustainably so.

There Should be Middle Ground in Maternity Care

In Victoria, and indeed in most of Canada, there is no middle ground of Maternity Care. A woman can choose a hospital or a woman can choose home. In a hospital (at least in BC) you can be attended by a GP, a midwife or an Obstetrician. At home you can be attended by a midwife. At a hospital, the environment may be less than appealing - uncomfortable beds, lack of privacy, potential exposure to some germs. At home, the lack of immediate access to medical intervention may not be appealing - there is no way an epidural happens at home. At the hospital (at least in Victoria) there is no birthing tubs.

This in and of itself is not really a problem, except that it is. There are women who would probably choose a home birth but for the lack of access to medical care (they like the safety net and who knows maybe their a fan of the epidural option), on the flip side there are women who choose home births who would benefit from choosing a hospital birth instead (like the 16 percent who transfer to a hospital during a home birth).

The obstetric community needs to ask itself what it can do to make the services it offers more attractive to women who would benefit from it. At the same time the midwifery/homebirth community need to ask what they can do to make birth safer.

If it were up to me, I'd establish stand-alone Maternal Health and Education Centres. These would be full-service maternity care centres that would take the best of all care approaches. They would have more family friendly birthing rooms, birthing pools, dedicated obstetric anaesthesiology, dedicated obstetric OR. They would also provide prenatal and postnatal education services - in an unbiased way. They would be focused on meeting the needs (both physical and psychological) of mothers and their babies (up to age 1). They would be a resource and a one-stop place to get connected to the resources available.

Care would truly be integrated - and mothers and families would feel truly valued....

But its a bit of a pipe dream...after all if such a hybrid was so great - why doesn't it exist yet?

BC Government Cuts Public Health Nurse Visits to New Moms and Babies

In classic up is down fashion, the BC government recently announced that it was cutting public health nurse visits to new moms and babies - and redirecting the resources to poor moms under the age of 25. The things is, a new mom, is a new mom - and she, regardless of age or economic resources may greatly benefit from the public health visit. Many new moms (regardless of age or economic status) do not know what is 'normal' when it comes to babies, or 'normal' when it comes to their thoughts and feelings around the birth. As a result there are cases of post-partum depression, jaundice, feeding difficulties, etc. that may go undetected. This puts at risk the health and well-being of BC moms and babies.

I'm starting to think that this government has it out for mothers and babies...

Am I anti-'normal/natural' birth?

In general I would have to say that I am not anti-normal/natural birth.

I know that for myself, it's not an option that I like. It doesn't make me less of a mom. It doesn't make me a bad parent. It doesn't make me think that those who choose natural birth are somehow crazy for wanting that experience - nor do I think that those who enjoy that experience are 'weird'. Rather that given the information I know about myself, and information I know about birth - I prefer medicalized birth (ideally elective pre-labour c-section).

What I wish is that every woman was empowered with the information that she needed to make a choice that best meets her needs and the needs of her baby. This might be normal/natural birth, at a hospital or at a home - or it might be medicalized birth in a hospital.

I also wish that every woman was treated with respect - respect from her careproviders and respect from others about the decisions which are hers and hers alone to make.

So it's not about maternal choice c-sections, or maternal choice planned vaginal births. It's about maternal choice...and that choice should be fully informed and respected.

Quality care needs to be about meeting the needs of mothers and babies - healthy mom, healthy baby should be the goal and that includes physical as well as psychological health.

Dear Materniy Care Providers

Found this on Birthing Beautiful Ideas and thought it was worth reposting.


Dear Maternity Care Providers of the World:

On behalf of all women who are, or have been, or ever will be pregnant, I wish to make the following requests and pleas and clarifications.
I make these requests and pleas and clarifications to you not because I think that you are callous or unwise or deficient in your skills.  In fact, I don’t think you, on the whole, are any one thing at all.
You are not a homogenous group, and we are not a homogenous group, and we all come from places and perspectives that are radically unique and individual.
But still.
But still.
I make the following requests of you because, in addition to the quality prenatal care that we all deserve, regardless of our social and economic backgrounds, I also think that we pregnant women–we who have been pregnant, or who are pregnant, or who will be pregnant–deserve a special and robust sort of respect from our care providers.
And I think that too many of us are not receiving this respect.
Perhaps, you might argue, this is because we don’t know  how to properly engage with you.  Perhaps our own advocacy for ourselves and our babies seems disrespectful to you.
For sometimes we state our cases inelegantly.  We use medical terms incorrectly.  We print out pages upon pages of information gleaned from internet sources of varying repute.  We make requests that seem ridiculous or useless or even harmful to you.
And sometimes you find us to be annoying or petulant or curious or infuriating or stupid.
But what many of us really are is desperate.
We’re desperate to find a care provider who respects our autonomy, and not just theoretical respect for our theoretical autonomy but a real, earnest respect for the actual exercise of our autonomy.
We’re desperate to find a care provider to listens to us, and who responds to us without condescension.
We’re desperate to find a care provider who is willing to admit when they don’t know the answer to one of our questions.
We’re desperate to find a care provider who avoids exaggeration and coercion and manipulation in conversation with us.
We’re desperate to find a care provider who supports our active engagement in our pregnancy and birth.
And we’re desperate to find a care provider who simply sees us as persons.  Who treats us as persons.
Not as ticking time bombs.  Not as potential lawsuits.  Not as fetus carriers.  As persons.
And this is regardless of whether we want to give birth in a home or birth center or hospital.
Notably, to expect this from you–to want this, and even demand it from you–we know that we have responsibilities too.
We have a responsibility to treat you with the same courtesy that we expect from you.
We have a responsibility to research our options with care and discretion.
We too have a responsibility to appreciate the differences in your perspectives and values and practices.
We have a responsibility care for ourselves and our babies as best as we are able to (though please note that these abilities vary widely).
Yet despite how well or how badly we manage these responsibilities, we still have a right to your respect.
All your years of training–the blood, the sweat, the tears, the money spent on education, the hours sacrificed to your profession–give you extraordinary skills and abilities and knowledge, but they do not give you  the knowledge of what it’s like to be any one of us.
To inhabit our bodies, to know our bodies as we do, to have the exact and unique values and perspectives and preferences and commitments and plans and dedications that we have.
And all your years of experience do not give you infallibility, nor do they grant you the right to approach us with domination and paternalism instead of mutual respect and partnership.
So we ask you to grant us this respect.  To treat us as partners in our maternity care.
Even those of us who don’t yet have the skills or knowledge or resources to act on these rights.
For we all deserve it.
Every single one of us.
 
Sincerely,
A pregnant woman, who also wants and deserves this respect from you.

*image credit seanmcgrath on flickr
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Pushing for Better Access to Maternity Care in BC

BC Children's and Women's hospital continues to be the only level 3 hospital in BC with Dedicated Obstetric Anaesthesiology to provide anesthesia services to women who are in labour and delivery. Royal Columbian, Surrey Memorial, and Victoria General Hospital are also level 3 hospitals. Both the government and the health authorities have known (or ought to have known) that failing to have anesthesiologists to meet the needs of pregnant and labouring women would result in delayed and denied access to epidurals, delayed and denied access to elective c-sections, delayed access to urgent c-sections and delayed access to emergency c-sections.

As a result of these delays and denials women have been harmed. Those who had their access to epidurals unreasonably delayed have had to endure unneccessary labour pain. Those who have had their access to epidurals denied have faced unneccessary labour pain and have faced the risk of general anesthesia in the event of an urgent or emergent c-section, the risk of inadequate pain management in the event of an instrumental delivery, and an increased risk of their child needing to be resuscitated due to exposure to intrapartum narcotics. Those who have had elective c-sections delayed have faced increased risk including the increased risk of going into labour prior to the c-section and an increased risk of an unwanted vaginal delivery, and for those who did go into labour awaiting their elective c-section they endured unneccessary labour pain and increased surgical risks. For those who had their c-sections denied, they endured an unwanted vaginal delivery, unneccessary labour pain, and all the sequalae and risks of vaginal delivery that would have been avoided if the planned c-section had taken place. For some their husbands and loved ones have had to watch as they suffered unneccessarily. For some they continue to experience increased levels of anxiety and may have PTSD and PDD as a result of their poor birth experiences. Some are hesitant to trust the health system and some are choosing to forego having additional children out of fear that the medical services that they need won't be there when they need them.

Thankfully for vast majority of these women who have been impacted there have been no long-run damage to their health or the health of their child, but unfortunately for some there have been disasterous consequences.

Women who have been impacted need to take a stand and demand better from their government and the health authorities. They need to write to the Patient Care Quality Offices of their respective health authorities. They need to write to their MLAs. They need to take a stand and say that it is wrong to unreasonably delay or deny access to epidurals and c-sections to women at level 3 hospitals. It is particularly wrong when women and their care providers have determined that access to these services are in the woman's and her infant's best medical interest (both physical and psychological).

Government needs to be held accountable for this apalling breach - or nothing will change.

Email me at qualitycareforbcmothers@gmail.com if you have been impacted by this issue and are interested in making a difference in BC.

The Disservice of Biased Information

I skipped out on the prenatal childbirth preparation classes - not to say that I didn't prepare myself for childbirth, I did - but I focussed my attention and education on surgical childbirth, as that was what I had planned on doing. I skimmed the other stuff (I went to the meet the doctor night at the hospital) - but mostly found that it confirmed what I did not want to do - give birth the 'normal' way. One of the reasons I opted out was that I perceived that I would be a poor fit in the traditional class - the maternal request c-section mom - no doubt I'd be singled out and potential ridiculed for my choice. I wasn't going to put myself in that position. This was a perception of bias (on my part) about the information that would be given in the class. Of the moms who did attend pre-natal class, they confirmed for me that indeed there was a 'natural childbirth' bias in the information given. Thanks, but, no thanks.

Unfortunately this left me somewhat flat-footed when I was faced with no other choice but to give birth 'naturally'.

I don't think biased information is limited to the 'natural childbirth community', I think the medicalised birth also has some degree of bias and perhaps an over emphasis on the avoidance of risk at all costs.

My problem is that I don't think there's much of a middle ground, and as a result women are left trying to decipher the information they receive about childbirth. For some women, likely those with higher levels of information literacy, they can sift through the information and make decisions that work best for them. Unfortunately for many women, they are ill-equipped to sift through the information in a way that identifies the bias (and corrects for it) and may make decisions that are less than ideal for themselves and their babies.

Good decisions that meet the needs of women and their babies would allow women to determine what matters most to them and which course of action is most likely to result in the most satisfaction when the job of parenting begins. I think this is the underlying problem with birth plans and can explain the sometimes large gap between what women expect of childbirth (and after) and what women actually experience of childbirth (and after).

The other big problem with bias, is that it tends to generate a paradigm where there is only one right way to give birth or parent. It generates the "if I didn't do it this way, I'm a failure" feeling and provides fertile ground for the development of "sanctimommies" and that is also damaging. Every woman should be able to stand by her decisions and say with conviction "I looked at the information available, and I made the choice that works for me and my child" with pride and with knowledge that it's okay to make a decision that is different from somebody else's decision.

Bias in information is bad, informed choice is good - but good choices rely on good (unbiased) information - a difficult challenge for any pregnant or birthing woman or parent today.

Elective c-section at 39 weeks, could prevent some very unpleasant consequences of vaginal delivery

Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise.
Semin Perinatol. 2006; 30(5):276-87 (ISSN: 0146-0005)
Hankins GD; Clark SM; Munn MB
The University of Texas Medical Branch, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Galveston, TX 77555-0587, USA. ghankins@utmb.edu

PURPOSE: The purpose of this analysis was to determine the impact on specific forms of neonatal morbidity and mortality by allowing women to opt for delivery by elective cesarean section at 39 weeks of gestation (EGA). According to the National Vital Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational ages>or=39 weeks EGA. Estimating that over 4 million deliveries occur annually in the United States, this would yield approximately 3 million pregnancies wherein the woman may exercise her choice for either primary or repeat cesarean section at 39 weeks EGA or at the point when labor is established. METHODS: A search was conducted using Ovid Medline spanning the past 10 years using the following key words: fetal trauma, shoulder dystocia, brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal encephalopathy. Using this search technique, over 2100 articles were identified. The abstracts were reviewed and pertinent articles were chosen for further consideration. The identified articles and their applicable references were obtained for inclusion in this review. Preference was given to publications on or after the year 2000 with the exception of classical or sentinel articles, which were included without regard to year of publication. RESULTS: Four major categories of neonatal morbidity and mortality are discussed: Shoulder dystocia: Accepting that we do not have a successful method for the prediction or prevention of shoulder dystocia, the question becomes, "What is the chance that a baby will sustain a permanent brachial plexus injury at delivery?" Additionally, is there a significant protective effect of cesarean section in reducing the risk of such injury? Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a composite estimate of the risk of 0.15% for vaginal deliveries and applying it to the 3 million deliveries>or=39 weeks EGA, approximately 4500 cases of brachial plexus palsy would occur. If only 15% of these injuries were permanent, 675 permanent brachial plexus palsies would occur annually. If the risk of permanent injury is 1 in 10,000 as reported by Chauhan, 300 permanent brachial plexus palsies would occur annually in the United States. The range then for permanent brachial plexus injury that could be avoided with cesarean section on request would appear to vary between 1 in 5000 and 1 in 10,000 vaginal births. Fetal trauma: The incidence of significant birth trauma varies from 0.2 to 1 to 2 per 1000 births. The use of sequential instruments, for example, vacuum followed by forceps or vice versa, is specifically associated with an unacceptably high injury rate. Intrapartum-related neonatal deaths of vertex singleton fetuses with birthweights>2500 g from traumatic cranial or cervical spine injury secondary to vacuum- or forceps-assisted vaginal delivery are still occurring. Overall, the frequency of significant fetal injury is significantly greater with vaginal delivery, especially operative vaginal delivery, than with cesarean section for the nonlaboring woman at 39 weeks EGA or near term when early labor has been established. Neonatal encephalopathy: The prevalence of moderate to severe neonatal encephalopathy is 3.8/1000 term live births with a neonatal fatality rate of 9.1%. In 4% to 10% of cases, the etiology appears to be pure intrapartum hypoxia. Intrapartum hypoxia superimposed on antepartum risk factors may account for up to 25% of the moderate to severe encephalopathies, according to one cohort. A paradox in the data thus far is that infants born to nonlaboring women delivered by cesarean section had an 83% reduction in the occurrence of moderate or severe encephalopathy. Considering a prevalence of moderate or severe neonatal encephalopathy of 0.38% and applying it to the 3 million deliveries occurring at >or=39 weeks EGA in the United States annually, 11,400 cases of moderate to severe encephalopathy would occur. The rate of encephalopathy observed in infants delivered by cesarean section would yield approximately 1938 cases. This net difference in moderate to severe encephalopathy would represent 9462 cases annually in the United States that could be prevented with elective cesarean section. Although cesarean delivery may be protective for the development of neonatal encephalopathy, to date it has not proven to be protective of long-term neurologic injury in the form of cerebral palsy with or without mental retardation and/or seizure disorders. Intrauterine fetal demise: Copper reported that the rate of stillbirth is consistent from 23 to 40 weeks EGA with about 5% of all stillbirths occurring at each week of gestation. Yudkin reported a rate of 0.6 stillbirths per 1000 live births from 33 to 39 weeks EGA. After 39 weeks EGA, a significant increase in the stillbirth rate was reported (1.9 per 1000 live births). Fretts reported on fetal deaths per 1000 live births from 37 to 41 weeks of gestational age, showing that the rate progressively increased from 1.3 to 4.6 with each week of gestation. It can be estimated that delivery at 39 weeks EGA would prevent 2 fetal deaths per 1000 living fetuses. This would translate into the prevention of as many as 6000 intrauterine fetal demises in the United States annually-an impact that far exceeds any other strategy implemented for stillbirth reduction thus far. CONCLUSION: It is reasonable to inform the pregnant woman of the risk of each of the above categories, in addition to counseling her regarding the potential risks of a cesarean section for the current and any subsequent pregnancies. The clinician's role should be to provide the best evidence-based counseling possible to the pregnant woman and to respect her autonomy and decision-making capabilities when considering route of delivery.

Major Subject Heading(s) Minor Subject Heading(s)
Birth Injuries [epidemiology] [prevention & control]
Brachial Plexus Neuropathies [prevention & control]
Brain Diseases [etiology] [prevention & control]
Cesarean Section [trends]
Dystocia [etiology] [prevention & control]
Female
Fetal Death [epidemiology] [prevention & control]
Fetal Diseases [epidemiology] [prevention & control]
Fetal Hypoxia [prevention & control]
Gestational Age
Humans
Infant, Newborn
Patient Participation
Pregnancy
Stillbirth [epidemiology]
Surgical Procedures, Elective
United States [epidemiology]


PreMedline Identifier: 17011400

Inadequate Resources to Support Maternal Choice in Birth in BC is Unreasonable

The numbers of women who give birth in British Columbia have been fairly stable with the rate per 1,000 population being aroun 10 since 1999 (ranging from a high of 10.4 in 1999 to a low of 9.69 in 2005 - source BC Vital Statistics Agency 2009 annual report). As such, the demand for services related to childbirth and pregnancy should be fairly well known. Further, many women make decisions regarding the birth of their children well in advance of labour - choices about whether or not to have an epidural and in some cases about how to deliver their child (ie. planned c-sections). As such, when women go to give birth and cannot access epidurals and c-sections in a timely way, is it really excusable to blame a lack of resources?

Is the 'Power to Push' campaign dangerous?

In BC there is a well known campaign that is called the Power to Push, and while at first glance it appears to support woman's choices in childbirth, it is decidedly "Pushy" about pushing natural child birth. This is particularly true of it's facebook page.

I have several concerns about the campaign. First, it's intended purpose is to 'push' down the Caesarean section rate in BC. Second, when discussing birth options, very few statistics are given about the relative risks of the options. Third, the benefits of medical intervention are downplayed. Fourth, the risks of natural birth are downplayed.

In short I think the campaign is irresponsible and I'm somewhat concerned that a major hospital (BC Children and Women's - the only hospital in BC with dedicated obstetric anaesthesiology) would support such a biased campaign.

Women need to be empowered to make decisions regarding birth - decisions that are safe and informed. Further, women need access to the services that support those decisions. Failing to provide unbiased and complete information (like real statistics on the risks and benefits) is irresponsible and dangerous.

Why doing something is important

Nothing I do now can change the past experience I have had of childbirth, it will always be what it was. However, knowing that what it was and what it should have been are two very different things, remaining silent about it sends the message that somehow that is okay. Burrying it in the past will not help me move forward. What happend was wrong on many different levels. Knowing that I am not alone in my experience of being unable to access appropriate care, makes it more wrong not less...

Which is why I am finding that doing something about it is helpful. It is why speaking out, is important. It is why talking to other moms matters - because mothers matter and they deserve better. I hope that what I do today will reduce the chance of the same wrong continuing to be done. I want my daughter to get the care that she deserves when she decides (if she decides) to be a mom.

I can't change the past - but I might be able to change the future, but only if I refuse to be silent. What happened to me was wrong, if it happens to my daughter and I could have prevented that in some way - then I will have truly failed.

Letter Sent to VIHA's Patient Care Quality Office

Today I sent the following to the Patient Care Quality Office of the Vancouver Island Health Authority:

Dear Vancouver Island Health Authority, Patient Care Quality Office;

I write more than a year after I gave birth on July 11, 2010 - because I feel that the care I received failed to meet an acceptable standard.

I was supposed to give birth by way of a scheduled c-section on July 9, 2010. I recieved the call from the hospital, fasted accordingly and arrived as directed and waited. As I was a gestational diabetic, the lack of food eventually caused my blood sugar to drop into a hypoglycemic range and a glucose drip was started. We continued to wait. Surgery did not happen that day and I spent the night in the hospital hoping it would happen the next day. Again we fasted and waited, and again surgery did not happen and again I prepared to spend another night in the hospital - with the promise that surgery would occur first thing the next morning. Unfortunately, I went into labour at quarter to midnight, at which point I was informed that there was no anaesthesiologist available. There was no access to an epidural. My daughter was born vaginally at 4:42 am and needed to be resuscitated. I sustained 2nd degree tears and experience a minor degree of stress urinary incontinance. My labour was terrifying and painful. To this day I have difficulty reflecting upon the experience without feeling stress and anxiety. My autonomy as a woman was violated that day as I was subjected to a natural vaginal delivery, despite having planned for an elective pre-labour c-section.

I am apalled at the level of care I received and am further apalled that VIHA was aware or should have been aware that reducing the level of anaesthesia access to labouring women would result in access to c-sections and epidurals being unreasonably delayed or denied.

Sincerely,
Mrs.W

The Cost of Cheap Healthcare

Before I was a mom, I would have never believed that a woman living in Canada, in an urban centre, in the 2000's would be denied an informed choice about where and how to give birth. In my pre-mom naivete I believed that birth plans carried weight and were a critical element of quality, patient-centred care. I knew that birth had all kinds of twists and turns - that often those planning vaginal birth had a need for c-section or found the pain of labour too great and needed pain medications. However, I believed (wrongly!) that such flexibility was reserved for the exceptional circumstance. I mistakenly thought that the phenomenon of waitlists and care rationing was absent from maternity care - after all it seems absurd that such things would apply in this area of care. As anyone with any experience with babies knows - babies do not wait! Further, the care needs of pregnant woman are known largely in advance - there are a good 7 to 8 months of advance notice...

I certainly did not just show up at the hospital one day and say - I'd like my c-section now please. Rather from the first prenatal appointment, I let it be known that that was my preferred method of birth.

The decision to inadequately resource labour and delivery services has undoubtedly saved the system money - but at what cost? Would I be sitting here more than 15 months after the event still thinking about it, if I had gotten the care that was appropriate in a timely way? Would I be so trepiditous about venturing towards having another baby? How many other women in BC feel as I do?

Forcing women to endure the pain of childbirth against their will when there is medical technology available that is on a whole, safe, to alleviate the pain of childbirth seems really misogynistic and antiquated. Doing so to save money, is just cheap!

Does Morgentaler set a precedent for a woman's right to timely access to medical care?

More than 20 years ago on January 28, 1988, the Supreme Court of Canada handed down the decision in R. v. Morgentaler. Despite being a criminal case, the case examined a women's rights in the context of the Charter of Rights and Freedoms. The Morgentaler case found that the criminal legislation governing abortions in Canada was unconstitutional. The reasoning for the unconstitutionality of Canada's abortion laws was that it interfered with section 7 of the Charter which states that "Everyone has the right to life, liberty and security of the person and the right not to be deprieved thereof except in accordance with the princples of fundamental justice". Part of the reasoning for striking down Canada's abortion laws was the delay in obtaining therapeutic abortions that the was caused by the mandatory procedures for procuring an abortion at the time - the delay resulted in a higher probability of complications and greater risk which infringed upon a woman's section 7 charter right. (Judges Dicson and Lamer). Judges Beetz and Estey reasoned that section 7 of the Charter must include a right of access to medical treatment for a condition that represents a danger to life or health without fear of criminal sanction. Judge Wilson also agreed that the abortion laws were uncontitutional as it "takes a personal and private decision away from the woman and gives it to a committee which bases its decision on "criteria entirely unrelated to the pregnant woman's own priorities and aspirations." Judge Wilson also found that s.7 of the Charter should protect both the physical and psycological integrity of the individual and that section 251 was deeply flawed by subjecting women to considerable emotional stress and unnecessary physical risk and that putting woman's capacity to reproduce in the control of the state was a direct interference with the woman's physical person. (Note: Information on the Morgantaler case is from the University of Alberta's law website: http://www.law.ualberta.ca/centres/ccs/rulings/rvmorgentaler.php.

A woman who cannot procure an abortion in a timely way without fear of criminal sanctions, has been deprived of her right to life, liberty and security of the person. This is settled law.

Yet, in British Columbia women who are giving birth may have their access to medical intervention limited because of decisions made by the BC Government, the Health Authorities, the BCMA and BC Anaesthesiologist Society. Have these women been deprived of their section 7 charter rights?

I'll take my own personal experience as an example. I wished to procure a c-section without medical reason. My motivations were primarily psychological and included a desire to avoid an emergency c-section, desire to avoid damage to my pelvic floor, desire to avoid the pain of labour, desire to avoid serious harm to my child including the risk of brachial plexus injury, and cerebral palsy. I had throughly researched the issue, I was aware of the risks and benefits of both modes of delivery and I had made a choice. I found a care provider who was supportive of that choice and we booked a delivery date (July 9, 2010). Due to resource limitations (that the government and health authorities were well aware of) - I could not access timely medical care (a pre-labour c-section) and was for all intents and purposes - forced to give birth vaginally.

Similarly, access to epidurals is also constrained in BC.

Inability to access c-sections and epidurals in a timely way (39 weeks for elective, scheduled c-section, 2 hours for urgent c-sections, 30 minutes for emergency c-section and 2 hours for epidural) strikes me as a violation to a woman's section 7 rights, particularly when the only choice a woman has for giving birth is the public health system.

Wrapping my head around...everything

I spend a lot of time in the space between my ears. Thinking about my last pregnancy and birth (mostly birth). Thinking about the health care system in BC - often as it pertains to maternity care. Thinking about whether or not any of it really matters...and if it does matter thinking about what I can do about it. Thinking about the future, and the next pregnancy. Thinking about what kind of health system my daughter will face when she is approaching motherhood.

The only conclusion I have come to is that my experience can not be without value or purpose - which is more of a beginning than a conclusion.

I have started in motion what I hope will be an effective way of making my experience (and those of others) matter. Only time will tell if that is truly the result of my actions. I hope for courage and strength...and to repair some of the damage done.

Am I nuts to consider trying for #2 when nothing in the system has changed??

My husband is on board with the idea that we should begin to try for number 2...that active efforts to prevent pregnancy should cease in the hopes that my daughter will have a little sibling.

Am I nuts for even considering this, NOW? Nothing in Victoria has changed, I am not overly convinced that it will change before the end of the as yet to commence next pregnancy. I'm fairly certain that I will again request a c-section...but am I confident that I'd be able to attain such a birth plan? Not in the slightest. The OBGYN I had last time has decided to go into oncology...so I'd even have to find another OBGYN who would be sympathetic to the request, and then I'd have to hope (and pray, and hope some more) that the actual resources would be there when I needed them.

What are my options? A private birth, isn't an option in BC - there simply isn't anywhere where I could even 'pay' to ensure that I'd have access to an epidural/c-section....Perhaps birthing in Alberta? But again that might not be entirely realistic....

And what if its just a replay of the show I've already seen...is the happy ending good enough? Do I just lay back and let my autonomy as a woman be violated again? --there goes my jaw, it's clenched again.

Quality care in our system - it does exist!

Today I got a call from my daughter's daycare - they were trying to get a hold of another mom who works on a different floor and with whom I am friends. Her son had fallen while racing around (as toddler's are apt to do) and he had sustained a gash on his forehead that would need stitches. I volunteered to hunt down the mom, and bring her to the daycare (in the same building). I was able to get to my friend within 5 minutes of recieving the call and we were at the daycare a few moments later. We decided to take my car as it was parked closer, and it was also equipped with an appropriate car seat. My friend was in no condition to drive.

We arrived at the RJH emergency department - I dropped of my friend and her son so that they could check in while I parked the car. Not knowing how long the wait would be I put in 2 hours on the meter. As she was checking in, I called the daycare for further details on the injury as we were in such a rush we didn't ask when we picked up the boy. I went to retrieve a soother for the toddler from the car and by the time I got back, the boy and his mom were waiting for treatment. Within 5-10 minutes we were directed to the treatment room where the doctor assessed the gash, and got nurses to restrain the child while he was stiched up. Five stitches later and we were back on our way. The parking meter still had an hour and 30 minutes on it. I was impressed - and the experience was much better than any other experience of the health system I have had in the last year and a half!

From the time I left my desk, to the time I returned it was an hour and fifteen minutes.