Luckier Than I Appreciated

I've been reading my medical file with respect to my daughter's birth - and knowing what I know now, my doctors and the hospital are lucky that a worse outcome is not part of the litigation - and I am lucky (fingers crossed) to have what appears to be a neurologically normal toddler.

One of my greatest fears about vaginal childbirth, is the potential for it to result in lifelong neurological disability. Not everyone gets through vaginal childbirth unscathed - some are left with lasting physical and mental disabilities. I understand that it is rare for such things to happen, but the reality is that someone is that one in a thousand person. I have personally known people who did not make it through birth unscathed. It was one of the reasons I was choosing cesarean for the birth of my daughter. I was happy to trade some increased risks for a decreased risk of that particular outcome.

So when I read the following in my medical record - I was taken aback, because the outcome I feared the most was much closer to becoming reality than I had thought.

My daughter had a tight nuchal cord (it could not be reduced over her head), had no spontaneous respiration for the first minute of her life, cord blood gases were ordered with the notation of gases 7.0, bicarb 17 and BE -15.

I'm a little more thankful for my daughter and a little more livid at what happened.

Mrs. W's Comment Policy

Readers should know that I have a very liberal comment policy - basically unless it is spam, I do not delete. Readers should also know that I do not take responsibility for the comments that are made (they are the responsibility of those making them), as such I cannot vouch for the credibility of the comments made. It is up to the reader to assess the credibility and accuracy of the information they are reading (I will note that if I am making a factual claim in my blog, I will cite the source of the claim and would think that when a commentator makes a factual claim, they too should cite the source if they are wanting anyone else who reads it to give any weight to it).

I've taken this policy because maternal request cesarean is controversial and while I have decided it is an appropriate way for me to give birth, I will not assume that it is a good choice for all women - and that they should hear both sides of the debate and make such decisions for themselves in conjunction with their health care providers (people who are licensed and appropriately trained to provide medical advice in specific circumstances). I have an interest in women making decisions that are best for themselves in their own personal circumstances - and as such will not prevent women (or others) from reading or providing opposing views and opinions, even on my own blog. As such, I do not personally agree with or approve of all of the comments that have been made on this blog - some are perfect illustrations of the prevailing ignorance, misconceptions and misinformation that persists when it comes to maternal request cesarean and birth in general.

I love comments when they are left by readers and appreciate the purpose that having a comment section provides - I love the good, but also appreciate the bad and sometimes downright ugly ones too (and will admit that I love when I am not the only one to counter the bad or ugly comments that are left from time to time). The comments section has proven to be one of the most rewarding aspects to blogging - so please continue to leave them!

Hindsight is 20/20

Somewhere between my doctors and the hospital and health authority involved in my daughter's birth, we slipped through the cracks.  I have looked back on what happened countless times, and have come to the conclusion the it should not have been that way, that it was not my fault that it was that way, and that it should not happen again.

I get that maternal request cesarean is controversial and that while there are many doctors who will accede to a woman's request, there are many that won't.  I also get that some hospital policies are more accommodative than others.  I get that health care resources are limited. However, there is an obligation to respect bodily autonomy and ensure that access to medical care is available in timely fashion.

I believe women who wish to plan a cesarean delivery (or an epidural assisted vaginal delivery for that matter) after being informed of the risks and benefits of cesareans AND the risks and benefits of vaginal delivery should be able to do so.  These women should be able to make their plans without fear that their birth plan will be frustrated and that they will be subjected to a vaginal delivery (or an unmedicated delivery) against their clear wishes and without medical cause.  Just as women who desire a unmedicated vaginal delivery need to be able to plan and to know the limitations and conditions of their plan, women who desire cesareans or epidurals need to be able to plan and know the conditions and limitations of their plan.

So, with the benefit of hindsight, what do I think should have or could have been done differently to prevent what happened to me?

1. I think my maternity doctor should have ordered an ultrasound at the earliest possible date to establish a more certain EDD.  I estimated my due date to be July 13 - I had been keeping track of my cycles and was using an ovulation prediction kit.  Yet my care provider decided it was prudent to use a due date based on a 28 day cycle and set it to July 17 - which while consistent with later ultrasounds that I had, it should be noted that when it comes to ultrasound they become less accurate at dating as a pregnancy progresses.  I believe a EDD of July 13 would have also been consistent with those later ultrasounds and should have been used.

2. I think an earlier referral to an OBGYN would have been prudent.  Waiting to refer until I was late in my pregnancy meant that despite my clearly stated desire to deliver by way of cesarean, that there was a risk that the OBGYN would decline to perform the procedure and that insufficient time would remain to make alternate plans.  Further, anxiety about being able to access my desired delivery mode caused undue anxiety during the pregnancy.  Shared care is not necessarily a bad model, but for women who are planning cesarean delivery, knowing that a GP or midwife cannot perform a cesarean, arrangements for the delivery are best made early on.

3. A fixed OR date and time.  The OB involved in my care has claimed that there was a hospital policy in place that did not allow for maternal request cesareans to be scheduled and that as a result my case was added to the add board.  At the time I really did not appreciate how much risk this introduced to my birth plan - I assumed that I would know the day of delivery, but not necessarily the time and when asked what I would like should I happen to go into labour prior to surgery - I indicated that I would still prefer a cesarean.  In fact, I did not worry much when my surgery got bumped the first day, or even the second, as at the time I believed that if I did happen to go into labour that my case would then be considered urgent and would be completed without undue delay (ie. within 2 hours).  I also believed that should I go into labour that an epidural would have been available to manage labour pain prior to delivery.  I should have been warned that if I did go into labour that there was a chance that cesarean delivery would have an undue delay (in excess of two hours) and that an epidural may not be available. I believe if this policy was in place, the effect of the policy led to an inability to access timely medical care and resulted in a contravention of my charter rights.

4. Assessment for the risk of going into labour.  From the time I was admitted to hospital until the time I went into labour I was not physically assessed.  My case was bumped and bumped again without any physical assessments as to the likelihood that I would spontaneously go into labour.  If an assessment had been done, it might have been found that labour was imminent and my case could have been managed accordingly.

5. Upon presenting to the nursing station with signs and symptoms of labour - my OBGYN should have been called immediately.  According to the records - I presented at the nursing station at around 11:45.  This was shortly after I noticed a second contraction after a first contraction 15 minutes prior and wiped bloody mucous when I went to the washroom.   According to the statement of defense submitted my OBGYN was not called until 130 - nearly 2 hours after I first presented to the nursing station.

6. I was told an OR and an anaesthesiologist was not available.  I laboured under the belief that should things go sideways, and the knowledge that if things did go sideways, that my child or myself could suffer serious adverse consequences.  I was not told that there was a back-up on-call anaesthesiologist in the event of life or limb emergencies - and that he/she would be available within 15-30 minutes if needed.  I was terrified. 

7.  Staff and doctors should be trained to respect and support all pregnant mothers.  Pregnant mothers have a diverse array of values and beliefs with respect to birth and not all pregnant mothers desire a vaginal birth without epidural pain relief.  I was told by nursing staff  "my body was made to do this", and that "if I wanted a maternal request cesarean, I should have gone to Brazil", and to "direct my screams into pushing".  From an on-call OB I saw regarding complications after the birth that he "was happy the c-section did not occur" - although he immediately apologized when I responded that I was not happy the c-section did not occur, the words still hurt.  Women choosing cesarean or epidural pain relief are not well supported - the deserve (and should be entitled to) timely access to these desired medical resources - especially when they have indicated well in advance of their deliveries that they would like access to these things.

The sad thing is that maternal request cesarean was available in British Columbia - it was even available on the island at the time I had my daughter.  There are doctors and hospitals that will accommodate women who choose to deliver by way of cesarean - who will schedule a date and time for delivery.  The sad thing is, that what happened to me did not need to happen.  I would have been both willing and able to travel to access care if that was what was needed.  I clearly communicated my preferences early in my pregnancy and throughout my pregnancy.  I did my part.

Somewhere, somehow, the system and my doctors failed us - and for that, there must be some accountability and retribution for the wrong that was done. Further, measures need to be taken to ensure the same wrong is not done again, and again, and again. Access to timely medical care during labour and delivery should not be uncertain - and that includes access to cesarean delivery and epidural anesthesia on maternal request. 

Connecticut.

I was busy most of yesterday and after I dropped the girl off at daycare, I spent my day working on a variety of things - and was away from the internet and television. When I was finally done, I checked in on Facebook and my heart sank. Connecticut. How? Why? There is no sense to be made of it.

I cried.

Parents had dropped their children off at school that morning. Teachers went to work. All were no doubt confident that at the end of the day, after recess and lunch and math and reading and playtime that they would go home. Home to their parents, to their spouses. Home to suppers and baths and bedtime. Home to the mundane things that as parents and spouses we take for granted.

Twenty children did not go home yesterday.

Six spouses, brothers or sisters, mothers or fathers - did not go home yesterday.

We take it for granted that our schools and workplaces are safe places where students go to learn and teachers go to teach.

Yesterday proved that it only takes one to shatter that delicate presumption - one man, with access to efficient weapons of destruction can perpetrate an act so violent, so beyond the pale, on victims so innocent.

I hugged my children a little closer yesterday. I tolerated the chores of motherhood, with a little more gratitude that my mundane life was intact. And I thought about how important it is to better understand what has happened - how important it is to ensure that the risk of such things happening is minimized.

What happened in Connecticut yesterday should never happen again - it did not need to happen, and it does not need to happen again. It is time to look at the tragedy with a critical eye and determine what needs to be done - what might be necessary to restore faith that when parents send their kids to school and spouses to work that they will come home home at night.

It's time to look at what needs to be done so that schools do not need to be the equivalent of high-security prisons in order to provide safe places to learn and work. Maybe better gun control is part of the answer. Maybe better mental health resources and access to those resources (regardless of income or health insurance status) are needed. Maybe schools need to be a little more secure and extra vigilance is needed with respect to those who teach and learn there. Maybe communities need to pull together a little more to know each other a little better so that maybe a future gunman never gets to the point of donning a bullet-proof vest, arming himself with assault riffles, and perpetrating the kind of violence that should be impossible to perpetrate on dozens of innocent victims. Maybe taxes need to be a little higher to pay for the things that need to be done to ensure what happened never happens again.

It's time to focus on what matters - ensuring that parents can take for granted the mundane chores of parenthood matters, ensuring that students can go to school to learn and never have to worry about not going home matters, ensuring that when teachers go to work they can focus on helping children learn matters, ensuring that there is access to mental health resources matters, the families of the twenty children and six innocent adults who lost their lives on Friday matter - access to assault rifles does not.

I hope insult to injury is not added to this utterly tragic circumstance - I hope that America takes the opportunity to understand better what happened and the circumstances that made it possible in the first place and does what needs to be done.

Targeting the Wrong Cesareans

It sometimes seems like a week does not go by without someone, somewhere bemoaning the high rate of cesarean births in developed countries. British Columbia was at one point so concerned with its reputation for having the second highest rate of cesarean sections in Canada that it struck up a Cesarean Task Force and has even put together two campaigns to address the issue - The Power to Push and Optimal Birth BC. Personally, I am not a huge fan of either. The main reason I am not an admirer of these campaigns is because of the emphasis on process rather than outcome. I care about healthy mothers and healthy babies - and I believe that the way an individual mother gets there is very individual - for some mothers planning and achieving a cesarean is just going to be a better path, for other mothers planning a vaginal birth is just going to be a better path - even knowing it has a risk to result in an emergent cesarean or operative vaginal delivery.

I am not opposed to strategies that seek to lower the rate of unwanted and unnecessary cesareans - women who neither want nor need cesareans, should not be needlessly subjected to them. For that reason I am thrilled that women in British Columbia who desire a vaginal birth and have been informed of the risks and benefits of planning a vaginal birth and the risks and benefits of cesarean birth in their individual circumstance and would choose a vaginal birth have access and support even if they have had a prior cesarean or their baby is breech. Being able to plan a vaginal birth after cesarean or a vaginal breech birth, in the safest circumstance possible (in a hospital with trained staff and resources available) is a great thing and reduces the potential for such circumstances to result in death or significant disability to either mother or child. In other parts of North America, women have difficulty accessing the care they need to plan a vaginal birth after a cesarean (VBAC) or a vaginal birth with a breech baby - and as a result many choose to birth unassisted, do not seek assistance with delivery until they are pushing, or choose home birth with an under-qualified birth attendant and lack of access to appropriate resources. These women are exposed to risks to both themselves and their children that could be mitigated if they can find a care provider and a hospital to accommodate them. For some of those women - avoidable death and disability results.

However, selling the idea that a vaginal delivery should be achieved whenever possible - is damaging to women and their children. This is what the "Power to Push" campaign does - it encourages women to pursue a VBAC, it encourages women to attempt a trial of labour with a breech baby under certain circumstances, it encourages the use of external cephalic versions (ECV), and it discourages maternal request cesareans. Rather than providing women with unbiased information regarding their birth options and the risks and benefits associated with those options and letting women decide what is best for them and their families in their individual circumstances - it pushes the idea that vaginal delivery is best - and that a cesarean is sub-optimal. Furthermore, it does this by targeting a group of women for whom cesarean delivery is more likely to be a better choice and targeting the safest and cheapest cesareans - scheduled cesareans. As a result, it is likely that it might succeed in reducing the rate of cesareans - but at the cost of increasing the share of cesareans that are unplanned or emergent, and potentially increasing the numbers of mothers or babies that are injured, disabled or die.

Further, I am disappointed at a system that fails to support all pregnant women - including those who would choose cesarean delivery or even epidural anesthesia and focus on the ultimate goal of maternity care - healthy mothers and healthy children. It's great that women desiring risky vaginal deliveries are supported to do so in the safest environment possible - however, it's a travesty that those seeking planned cesareans are not given the same support. CDMR in British Columbia continues to be difficult to access with women having difficulty finding care providers and facilities to support their informed request for cesarean delivery. It's time we had a maternity care system that didn't try to sell women on a particular mode of delivery - but rather supported a patient-centred model of shared decision making based on the best available evidence that supported the full spectrum of pregnant women to make the decisions and have access to the care they need for both mother and baby to be happy and healthy.

Meet Mrs. W - She isn't who you might think she is...

The other week - an anonymous someone - made the following comment on my blog:

AnonymousNovember 14, 2012 11:41 PM You strike me as one of the type of upper class white person who feels entitled to anything she pleases. This sort of arrogant mindset does not serve you well, it only makes you come across as snooty and reprehensible. Not everything should be accessible simply because you want it. This is a product of the over-consumption way of living that is not healthy nor admirable. It's not anyone else's problem that you have issues with squeezing a baby out of your vagina. It's not anyone else's responsibility to make sure this doesn't happen. It's YOUR responsibility to mature a bit and realize not everything in life is convenient, clean and pain-free. And it's nobody's job to make it that way.

They revealed their assumptions about me - and in doing so, demonstrated what the stereotype is of a woman who wants to avoid delivering her child vaginally and requests a cesarean. It's not a pretty picture. Entitled. Arrogant. Snooty. Reprehensible. Over-consumptive. Self-centred. Immature.

Such vitriol - no wonder this person wished to remain anonymous, it is easy to hate a stereotype and even easier when you can choose to remain nameless and faceless yourself.

So who am I really - and how does it compare to the woman this person thinks I am?

I am 33 years old. I'm caucasian. The second born child of three to two high-school drop-outs - a farmer and a waitress at the time of my birth. I was baptized Anglican. My parents divorced when I was 6 - after the farm failed in the wake of early eighties interest rates. My father graduated from college when I was nine. I went to Catholic school from grades 2 through 7. My father remarried when I was seven - and separated again by the time I was nine. I was bullied in grade school. I was confirmed Catholic. I elected to live at my father's house when I was thirteen. My mom graduated university when I was fifteen. I taught Anglican Sunday school and volunteered at the local hospital in high school. I graduated when I was seventeen. I moved out on my own and started at the University of Victoria when I was nearly eighteen. I worked full-time for most of my undergraduate studies - as a waitress at a family restaurant, as a cashier at Tim Horton's, as a hostess at Japanese Village, as a copy editor for the student newspaper, as a telephone surveyor. I graduated with an undergraduate degree in Economics and Sociology and more than $18,000 in student debt. I then worked as an employment standards officer and started graduate studies in Economics. My mother remarried when I was twenty-two. I was a teacher's assistant during graduate school. I did work terms with the Ministry of Forests and Tourism British Columbia. I worked as a labour relations officer with the federal government for a year. I graduated with my Masters Degree when I was twenty four. I then did economics consulting for a year, at which time I was offered an economist position with the Vital Statistics Agency. After a year with the Vital Statistics Agency my position was transferred to the Ministry of Health. I met my husband shortly before my 28th birthday - at which time his children were 9 and 5. We married shortly after my 30th birthday. His vasectomy was reversed shortly after the wedding. I lost my grand-mother, aunt and uncle to a drunk driver the summer after I married my husband. Our daughter was conceived in the fall. I became a mother at the age of 31 and again to my son this past September.

So who am I? I am a devoted daughter, sister, step-sister, wife, step-mother, mother, and aunt who has worked hard to get where she is. I am a devoted friend. I am educated. I am an economist. I am principled. I am confident. I am independent. I am open-minded. I am responsible. I am articulate. I am thoughtful. I am hard-working. I am respectful. I refuse to be bullied. I am determined to be the kind of woman and mother that I would want my daughter to be - and to do my part to make her world a better place.

So to Anonymous - I say the following, "I know who I am, I am not ashamed, I will not be disempowered and abused - I am not the stereotype you think I am - and it's rather telling that you make such assumptions to begin with."

A Silk Purse from a Sow's Ear

I am still angry about the circumstances of my daughter's birth - and I do not think that I will ever find that set of circumstances acceptable. Not for myself. Not for my friends. Not for my sister. Not for my daughter. Not for any woman living in British Columbia or Canada today or in the future. Women deserve better, their children deserve better. Not for any patient.

I am not angry that my daughter was born healthy - I am thankful for that every day. Motherhood has been a tremendous blessing - and has given me tremendous amounts of joy and wonder as I watch my children grow. Indeed, having a healthy child was my primary goal during my pregnancy - and one of the reasons I had elected for a cesarean delivery: to reduce the risk of truly adverse and life-long health consequences such as severe disability or death.

I am angry that the care I reasonably expected and was entitled to receive was withheld. I am angry at an ideology that seems to be driving the system further, and further away from quality, evidence-based, patient-centred care. I am angry that I was lied to. I am angry that I was abandoned. I am angry that the experience was terrifying and painful and physically and psychologically damaging and left me feeling utterly violated. I am angry that the circumstance was entirely unnecessary. I am angry that there exists people out there that find such circumstances acceptable. I am angry that what I experienced was likely the result of either negligence or willful disregard.

It's okay to be angry about those things - actually, I would be more worried if I wasn't angry about those things as it would likely mean that I had given up and thought that such things just did not matter. Indeed what happened was on its face, a Sow's Ear.

However, that sow's ear has supplied the material for, what someday might indeed be a silk purse. If my daughter's birth had unfolded as my son's birth did two years later - I likely wouldn't be sitting here writing this blog post. I would not have spent the last two years thinking about what quality maternity care really looks like, about what really matters and about what is poorly understood. I would not have become acquainted with an entire community of women who want better - for themselves, for their sisters, for their friends, for their daughters - an entire community of women (and some men) who believe strongly in informed consent and patient-centred, evidence-based care. I would not be pursuing a lawsuit (there would be no need to) - that might result in a precedent that other women can depend on - or at the very least will likely send the message that lying to a woman and subjecting her to a treatment that she did not consent to without cause is actionable, even if that woman was pregnant at the time.

What happened was awful (I'll happily concede it was not the worse that could have happened) - but what has happened since has made a difference and will continue to make a difference, hopefully for the better. After all, shouldn't it be the goal of every mother that her daughter should have a better go of it when it's her turn - and that's why I'm not done. Not yet - there's still a long way to go before I'll look at the situation that exists and think that it's the silk purse that it can be.

Fear of childbirth: An unjustifiable barrier to motherhood for some

Imagine for a moment your worst fear.

Imagine your deepest desire.

Now imagine being told that in order to fulfill one of your deepest desires, you must subject yourself to your worst fear.

Now imagine knowing that there is a way to fulfill your deepest desire without subjecting yourself to your worst fear - that subjecting yourself to your worse fear is completely unnecessary, that you can achieve your deepest desire some other way.

Now imagine being told that it doesn't matter that it is completely unnecessary for you to be subjected to your worst fear, that it doesn't matter that there is a perfectly acceptable alternative for you to achieve your deepest desires, that you *must* do what you do not want to do or forego your deepest desire.

This is what it is like for women who desperately want to be biological mothers but desperately want to avoid vaginal childbirth. For many of them, they know a safe, effective method of childbirth exists (elective cesarean) - but they are told that their bodies are "made to birth", that if they do not wish to do it as 'nature intended' that they should forego motherhood or adopt, that cesareans should only be reserved for those with a physical *need* for the procedure, that they are being hysterical.

Unlike some fears (ie. of clowns or non-poisonous spiders or non-venomous snakes) which may be completely irrational - the fear of vaginal childbirth has some rational basis. There is a real risk of perineal tears. There is a real risk of pelvic floor damage. There is a real risk of birth injuries including hypoxic ischemic encephalopathy (HIE), and brachial plexus injuries. There is a risk that an emergent cesarean delivery may not be available or timely. There is the risk of extreme pain. Indeed, from my perspective, a fear of vaginal childbirth is wholly rational.

Further, it is not like the alternative delivery method (cesarean) available to these women is grossly expensive or inordinately dangerous compared to the conventional delivery method (vaginal birth).

So why is it that so many people think that offering women who fear vaginal birth the choice of either subjecting themselves to a vaginal birth that they do not want, or foregoing biological motherhood is anything less than cruel? And why is it that when these women are subjected to the process that they fear (perhaps without notice) that anyone is surprised that they are at a high-risk to develop PTSD as a result?

This is why it is critically important for maternal request cesarean to be unquestioningly available - because it is cruel for it not to be an option when it is an acceptable choice to meet something as basic as the desire to be a mother or to have more children. And before you ridicule some other moms choice to deliver by way of cesarean, maybe take a moment to imagine what it would be like if you were told you had to subject yourself (unnecessarily) to your worst fear in order to meet a basic desire.

The Flawed Assumption of Cost-effective Natural Birth

I'm an economist by training - but more than that, I am a health economist by profession. I understand (probably better than most) the concepts of scarcity, risk, cost, expected cost and cost effectiveness. I also understand the challenges that are facing our health care system - both today and going into the future.

Perhaps that is why I am particularly perturbed when time and time again I hear that reducing the number of cesareans would save the health system money and in particular how reducing the number of maternal request cesareans would save the health system money. On it's face it seems to be such a no-brainer, after all how could an expensive surgery (cesarean birth) compete with the free birthing procedure that nature gave us (unmedicated vaginal birth)?

Of course not using health system resources is cheaper (on its face) than using the health system.

Have a heart attack and die where you stand: $0 health expenditures, alternatively have a heart attack and go to the hospital, get a coronary artery bypass and go on to live another decade or two: A whole lot more than $0 health expenditures. Develop cancer and let the disease progress as nature intended: $0 health expenditures, alternatively going to your doctor, get diagnosed (likely via some screening program), get chemotherapy/radiation therapy, and either cure the cancer or buy some additional time: A whole lot more than $0 health expenditures.

Yet there is no widespread calls for natural heart attack therapy or natural cancer care. Anyone who stood on the corner saying that people should put the needs of the health care system ahead of their own needs - would be told to apply their 'natural therapies' to themselves and to stuff it.

The natural childbirth movement is standing on the corner and shouting (rather loudly) that women should forego medical care during birth because it will save the system money. What's worse is that government seems to be encouraging them to shout even louder.

The assumption that is behind this is that intervening in birth does not buy better health outcomes. Either that or, because the better health outcomes accrue to women and their children, they simply aren't "worth it". I would hope that it is the former rather than the latter driving the "save the health system money by avoiding cesareans" mantra.

Unfortunately this assumption is flawed and very likely, very wrong.

Intervening in birth by providing pain relief or access to surgical delivery for those who want or need it does buy better health outcomes and may even save the health system money over the longer term.

Those who choose cesarean are doing so for a wide variety of reasons. They are doing it so that they may avoid the risk of an emergent cesarean. They are doing it to avoid the risk of a perineal tears. They are doing it to avoid a pelvic floor injury. They are doing it to reduce the risk of developing urinary or fecal incontinence. They are doing it to reduce the risk of severe disability or death to their unborn child. They are doing it to better arrange the support resources they need during and after the birth. They are doing it to avoid the risk of having a traumatic experience. They are doing it to reduce the risk of developing PTSD or PDD. They are doing it to protect their sex lives. They are doing it to avoid the risk of severe, uncontrolled pain.

Chances are they are doing it for several reasons and in all circumstances they are doing it because the benefits of choosing to intervene exceed the costs and/or risks of not intervening at an individual level.

I would even be so bold as to argue - that the government would do well to spend MORE on maternity than it does now as the expenditures on maternity are likely to buy more than expenditures in other areas of care. Those served by maternity services tend to be young and as such any gains in health outcomes are likely to accrue over many years. A single case of cerebral palsy that is averted could save the health care system millions of dollars in costs of future care. Avoiding a pelvic floor injury that requires subsequent repair, would likely save thousands. Avoiding a case of PTSD or PDD, again would result in significant savings.

Further, it is unclear whether or not maternal request cesarean is even significantly more expensive than planned vaginal delivery to begin with. A study entitled "Cesarean delivery on demand: What will it cost?" in the American Journal of Obstetrics and Gynaecology Volume 188, Issue 6, pp. 1418-1423 found that the average cost difference between women who attempted a vaginal delivery and those who had an elective cesarean was just 0.2% in favour of vaginal delivery. Hardly a cost savings to deprive women of their treatment of choice - which is perhaps why many US health insurers (arguably even more keen to save money to boost profits than Canadian medicare) now cover elective cesarean section.

So why don't we start with the assumption that healthcare providers and mothers who choose cesareans are doing so in their own best interests and that they are no more "milking the system" than those with cancer or cardiac problems are "milking the system"? And maybe, just maybe we ought to look at the real economics of birth choice - the answers might be very surprising indeed.

Is CDMR a societal and professional failure?

In this month's edition of Lamaze's journal Birth - Dr. Michael C. Klein will publish an article entitled "Cesarean Section on Maternal Request: A Societal and Professional Failure and Symptom of a Much Larger Problem".

I wish that this article would focus on the professional and societal failure associated with maternal request cesarean and the much larger problem. However, knowing Dr. Klein as a staunch natural childbirth advocate who is ideological in his belief that medical intervention should play a minimal role in birth; I know that this article will disparage the choice that some women make to deliver by way of cesarean as being driven by misinformation and fear and will completely fail to address the much larger problem.

I would argue that the rates of maternal request cesarean are indeed driven by misinformation and fear. In short, I believe the risks and negative impacts of vaginal delivery are understated and the risks and negative impacts of an elective cesarean delivery are overstated. Further, I believe that the advantages of vaginal delivery are systematically inflated, while those of cesarean delivery are systematically discounted. I believe that the fear of surgery drives many women to avoid it - even when a surgical delivery would have resulted in a better outcome for either mother or child than a vaginal delivery. I also believe fear and misinformation drive a lot of women to forego epidural pain relief. Yes, fear and misinformation are a big problem when it comes to birth - and likely result in lower rates of maternal request cesarean and use of epidural pain relief than would be 'ideal' as many women who would have a much better birth experience by having an elective cesarean or using epidural pain relief forego doing so based on misinformation and fear.

I also believe that the situation around maternal request cesarean is a symptom of a much larger problem. That problem is that not all women are supported when it comes to the choices that they need to make during pregnancy, labour and delivery. That the information given to women regarding pregnancy, labour and delivery is heavily biased. That many women have difficulty finding a provider and a care facility that will be supportive and respectful of a mother's requests for cesarean delivery and in many cases even access to epidural pain relief. That many other women seem to think that it is okay to criticize the informed choices some women make to deliver by way of cesarean or use epidural pain relief.

I will also agree with Dr. Klein that the system of maternity care, particularly in British Columbia, is in dire need of reform - all pregnant women need to be supported and empowered to meet their own needs with unbiased information and access to medical care including access to surgical delivery and epidural anesthesia on request. All pregnant women need to know what their choices are, the risks and benefits of those choices and to have the right to informed consent. Further, all pregnant women need to know that their choices will be respected and confident that just because they are pregnant does not mean that they lose the right to decide what is done with their body.

Mum's the Word on Maternal Choice Cesarean

I never had any desire to have a vaginal birth. In another time or place, I may have considered foregoing motherhood or adopting rather than subjecting myself to the conventional whims of nature. However, knowing that cesarean was an option, I knew that foregoing biological motherhood would be an unnecessary toll for wanting to avoid a vaginal birth. I knew that cesarean birth was a feasible (safe and effective) way to have a baby - I lived in a first world country and could find nothing that indicated that women in Canada weren't allowed to have cesareans on demand or that such a choice would be inaccessible in my own community. For myself, it was clearly preferable over conventional birth. It seemed to me that the biggest challenge would be finding a doctor to accede to the request-but given the controversy around maternal choice cesarean, I knew that while many doctors would not accede to a request, that many other doctors would. I felt confident that I could secure a maternal choice cesarean before I even got pregnant - even if it would have meant travelling to access care.

That being said, I also knew that rejecting a conventional birth (a trial of labour in a hospital) would not be a socially acceptable choice. None the less, I was open about my plans during the pregnancy with my daughter. Not because I wanted the stamp of approval from others, but because I felt that it was important for others to know that it was an informed choice that I had made freely. A choice I felt best met my needs and those of my child. That I was happy with choosing cesarean, and that any concern about my birth plan was misplaced.

By the time I was admitted to hospital for the birth of my daughter, there was nothing that had been said to me that had changed my mind about vaginal birth or cesarean birth - not for the lack of trying by others and a hefty dose of misinformation about cesareans. Others regaled me with the horrors of cesarean birth - It's major abdominal surgery! The recovery is horrid! What about the scar! Adhesions! Infection! They further regaled me with the virtues of vaginal birth - it's the way nature intended! With an epidural, it's not painful! The recovery is easy! Thanks, but no thanks. Conveniently absent in the vaginal birth love-in was any acknowledgement of the virtues of cesarean (indeed it does have advantages) or the genital warts of conventional birth (indeed conventional birth is not completely a thorn-free bed of roses).

I was even open about my choice with hospital staff when I was in hospital awaiting for the cesarean that did not happen for the birth of my daughter.

My experience of vaginal birth proved to me why I had wanted to avoid it in the first place, even in the absence of the worst consequences of vaginal birth. I pooped in front of people. I experienced the worst pain of my life. I was terrified. I tore. My daughter needed narcan and resuscitation. I was left feeling violated and abandoned. I developed a vaginal infection. For more than a year afterwards, I had mild urinary incontinence. My enjoyment of intimate relations with my husband was adversely impacted. Memories of my daughter's birth continued to haunt me, and rather than looking at photos of that day with a sense of joy or accomplishment, they are a reminder of the worst experience of my life. I felt socially isolated among other mothers, particularly those with strongly held beliefs about conventional birth.

After my daughter's birth I understood why so many women who prefer birth by cesarean are mum about their preferred path to motherhood. I understood why some mothers make up a medical reason for their cesarean - it is far more socially acceptable to say you had no choice in the matter and in some cases making up a medical excuse might be the only way to access care. In some cases, where cesarean is seen as being inaccessible, some women are choosing to forego motherhood - choosing to prevent pregnancy, adopting or aborting. Other mothers are paying a hefty financial price for their preferred method of birth.

Indeed, during my pregnancy with my son, I found myself being a lot more mum about my choice.

However, being mum doesn't help other moms who share the same view on birth. Being mum does not make it easier for the next mom to make and exercise her choice. It does nothing to ameliorate the undeserved stigma or shame associated with being a woman who would prefer to avoid a conventional birth and choose cesarean. It does little to address the misinformation or myths about mothers who choose cesarean (the vast majority of whom are not "too posh to push"). It does little to address the misinformation or myths about elective cesareans as medical procedures - or even the misinformation or myths about other birth related medical procedures (such as epidurals). It does little to address the problem of those who would seek to deny moms like me their chosen path to motherhood and it does little to help women make truly informed decisions about the birth choices available to them (have I ever blogged about how little data is out there on maternal request c-sections and how they are not formally tracked in administrative databases???). Maternal choice cesarean needs to be an accessible, accepted, and respected choice - and as such moms like me can remain mum no longer.

Is encouraging homebirth in British Columbia to save healthcare dollars going to come at the expense of women and babies?

This morning I woke up to an article in my local paper with the headline Health Minister encourages home births in low-risk cases.

While I support the option of home birth as an informed choice that should be supported with access to qualified and regulated care providers in low-risk situations, encouraging it is another matter, and encouraging it to save money strikes me as being unethical and short-sighted.

I am tremendously thankful that home birth in British Columbia is highly regulated with care providers who are well trained - as it reduces the harm that may be incurred by those who would choose this option anyways. Further, I will begrudge nobody a natural childbirth - if that is what the woman giving birth desires. However, knowing that home birth in the Netherlands has led to low-risk women undergoing home birth to have worse outcomes than high risk women undergoing hospital birth with an OB, gives me pause for thought. The idea that in the vast majority of studies on home birth perinatal and maternal mortality and morbidity is significantly higher than that experienced with hospital birth (with the exception of the one study cited in the article), again gives me pause for thought. Knowing that a low risk woman can go from being low-risk to high-risk in a matter of minutes, further gives me pause for thought. Knowing that some of the consequences of birth gone wrong can be life long and devastating, further gives me pause for thought. Lastly, knowing there's a lot that "low-risk" women, particularly first-time mothers may not be told about birth and its attendant risks, makes me think that encouraging home birth is irresponsible. It also worries me that such a statement coming from the head of the ministry, a former doctor, may make women think that Homebirth is safer than it really is.

Further, such a stance worries me that the Ministry of Health in British Columbia thinks that it is okay to restrict access to medical care for women during labour and delivery for low risk women. After all if low risk women outside of the hospital do not need medical care (epidurals, cesareans) - then why should low-risk women in the hospital need access to these services?

I would further hope that rather than encouraging a risky birth option such as home birth (note this is ALL about saving money) that the Ministry would strive to make safe birth options (in the hospital) more accessible, available, attractive and more cost-effective. Doing otherwise is just saving money at the expense of women and babies - and there's something very wrong with that.

Cesarean by Choice Awareness Network - now on Facebook

A group has been established on Facebook for cesarean by choice moms, those who support cesarean by choice, those planning on becoming cesarean by choice and care providers who facilitate cesarean by choice. It is called "Cesarean by Choice Awareness Network", and can be found here. It's a closed group, meaning that only members can see what is posted in the group.

I'm hoping it'll be a place where moms and care providers can connect, share information, and work to improve awareness and respect for cesarean by choice.

A Shameful Culture

Shortly before the delivery of my son, my mother was recounting to me a conversation she had with a co-worker (while they were having a smoke break no-less) about the impending arrival of my son - the impending planned cesarean. My mother's coworker asked why a cesarean was planned, and when my mother told her co-worker that it was because it was what I wanted, her co-worker proceeded on a tirade of derogatory commentary about my birth choice. That I was a burden on the health system (that's rich coming from a woman who is on a smoke break). That women had been giving birth the way nature intended for thousands of years. That it was a real shame that I did not have confidence in my body and its ability to birth a baby. That vaginal birth was best for both mother and child and cesareans should be reserved only for those who "need" them. My mother found herself defending me, defending my choice - but more than that, defending my right to make such a choice in the first place, my right to determine what was done with my body.

I love my mom for standing up for me - as her co-worker is not some rarity. I have become far too familiar and tired with such sentiments. I spent my first pregnancy defending my choice only to have my right to choose violated, and my second pregnancy in dread that my right to choose would be violated again.

There is something that is deeply wrong about the culture surrounding birth in Canada today. It is a culture that says that it is okay to criticize the legitimate choices of others. It is a culture of fear. It is a culture of competition. It is a culture that shames women for choosing cesarean. It is a culture that shames women for choosing pain relief. It is a culture that preaches empowerment from a bodily function. It is a culture that legitimizes the denial of choice and access to modern medical technology and the most qualified care providers.

It is a culture that tells women to be proud of vaginally delivering their children and to be proud of rejecting pain relief in the process of doing doing so - it is also a culture that tells women who deliver by cesarean or with the use of epidurals that they are somehow failures or lesser women.

It is perverse and filled with misplaced pride.

I have no shame about the cesarean birth of my son. It was an informed choice. It was a safe choice. It was the choice that best met my needs and those of my baby. I am no less a woman for having had a cesarean. I am proud that I was enabled to make an informed choice about the healthcare I received - one which enabled the healthy and safe arrival of my son. I am proud of my health care providers for giving me excellent care, and for respecting, supporting and enabling my choice with regards to the delivery of my son.

Women who choose cesarean have nothing to be ashamed about, and its time we quit thinking that they do.

Avoiding Birth Trauma: A Laudable Goal

Those that regularly read this blog, know that I do not think much about using rates of cesarean as a measure of quality for maternity care. Yet many health administrators and policy analysts seem to think that lowering the rate of cesareans is a laudable goal. In the more than two years since my daughter was born, I have come to know just how misguided this goal really is - and believe that it is time that quality in maternity care was measured differently.

Birth trauma is a negative outcome of the birth process - one that could and should be avoided in many cases.

Having read the accounts of women who have been traumatized by birth, in addition to my own experience, it is clear that birth trauma is not caused by the mode of delivery. There are women who have vaginal deliveries and are traumatized. There are women who have cesareans and are traumatized. There are women who have vaginal deliveries and are not traumatized. There are women who have cesareans and are not traumatized.

Birth trauma is also not caused by the location of delivery. There are women who are traumatized by home birth. There are women who are traumatized by hospital birth. There are women who are not traumatized by home birth. There are women who are not traumatized by hospital birth.

Further, birth trauma is not caused by the choice of care provider. There are women who have midwives and experience birth trauma. There are women who have doctors or obstetricians and experience birth trauma. Further there are women who have midwives or doctors or obstetricians who do not experience birth trauma.

Also having read the accounts of women traumatized by birth, in addition to my own experience - the impacts are lasting and wide ranging. There are women who would like more children, who choose to forego additional pregnancies. There are women who having had a negative experience in one pregnancy, make risky choices in subsequent pregnancies in the hopes of avoiding a repeat experience. There are women who experience excessive anxiety in their subsequent pregnancies. There are women who suffer from post-partum depression and post-natal post traumatic stress disorder - many of whom suffer in silence. Some women who experience traumatic births are left with lasting physical repercussions for either themselves or their children.

Despite the significance of traumatic birth experiences, for women, their children and their families - it largely goes unmeasured. As a result it remains poorly understood and stigmatized.

Would it not be better to measure things that actually gauge quality care than to monitor a measure because it is easy and pretending that it has anything to do with quality?

Is the patient perspective lacking?

This morning while the boy napped and my daughter burned off some toddler energy (which if it could be harnessed would solve all of the world's energy problems) by bouncing on her Rody while watching cartoons - I read a story in the Times Colonist bemoaning the rates of mastectomy versus lumpectomy it reminded me a lot of the bemoaning that goes on with respect to cesarean sections. Many of the surgeries are labelled as 'unneccessary' - however in both the case of cesareans and mastectomies patients are making decisions prospectively and outcomes are only known retrospectively.

In both cases I wonder if a better understanding of the patient perspective is needed to better assess why a more aggressive treatment is preferred over what is considered a more conservative treatment with equal or better outcomes?

Further, if patients are freely choosing these more aggressive treatments, what are they gaining over the more conservative options? Lastly, if these surgeries are a result of patient choice, should they be bemoaned as unneccessary?

The challenge is that the information in the system is limited to what was actually done and lacks information from the patient and provider perspective on why what was done was done. This leads armchair policy analysts and some health system administrators to conclude that there is waste in the system caused by 'unneccessary procedures' (there is waste in the system, but I for one am not convinced that it is caused by people undergoing 'unneccessary' procedures).

Being a patient who would have undergone what some would consider an unneccessary cesarean for the birth of my daughter and did undergo a cesarean for the recent birth of my son, I feel very strongly that care decisions should be 'patient centered and patient driven' and not 'guideline driven'. I worry that the labeling of some procedures as 'unneccessary' without complete information - in particular without either patient or provider information on why the procedure was undertaken and their satisfaction with the outcome - may result in some patients being forced into treatments that are different from that which they would freely choose for themselves (in consultation with their care providers) - and may result in less patient satisfaction and poorer outcomes than could otherwise be achieved.

We owe it to the healthcare system and the patients it serves to refrain from jumping to the conclusion that certain procedures are unneccessary and to improve upon the information available to better understand why certain treatment decisions are made in the first place. To do otherwise is to risk creating a 'health system centered' model of care.

Are women, babies on Vancouver Island still facing inadequate access?

I've been under a bit of a proverbial rock over the last couple of months - first preparing for the arrival of baby W and then in the sleep deprived after-glow of the first few weeks of life with a newborn.

This past week I have gotten around to reading the defenses that have been filed with regards to the litigation I have decided to pursue with respect to my daughter's 2010 birth. The health authority claims access was available but not exercised by my physicians (a deprivation of patient autonomy). My physicians claim that access to the needed resources was not available, and that use of the back-up anaesthesiologist was limited to "life and limb" emergencies (a deprivation of access to medical services). There's also a sprinkling of blame the victim and inconsistencies of facts. Next stop examinations for discovery.

I also came across this news article which indicates that reports of dedicated obstetric anaesthesiology (DOBA) may have been premature. It would appear that women giving birth at Victoria General are still facing challenges accessing the services of anesthesiologists when they need them as those resources are frequently called upon to provide care to other emergent patients.

Timely access to anesthesiologists should Be a given, and an adequately resourced system should be able to provide for the needs of pregnant women AND other patients. It is deeply concerning that it appears that the problem persists.

The W Family Needs a New Family Doctor

My family doctor shares a practice with the doctor who provided my prenatal care during my last pregnancy. This is not an ideal situation for either my family doctor or for myself. It is uncomfortable to access care there - and in truth, it has caused me to avoid accessing care there while I was pregnant. When there was a minor case of bleeding due to a small sub-chorionic hemmorhage during my first trimester, I went to a walk-in clinic instead of seeing my family doctor. Earlier this summer when my daughter managed to get a case of jock itch diaper rash - again I took her to a walk in clinic instead of my family doctor.

So this past week when I took my son for his one week check-up - it was the first time I had seen my family doctor since getting a referral to my OB for this pregnancy.

I have been with my family doctor for nearly 16 years - she's seen me since I was a university freshman. She had nothing to do with what happened during the last pregnancy and, while foreseeable, it is an unfortunate price that must be paid for what happened last time. She has indicated that she will not leave us before a replacement is found - however, it is clear that a replacement is needed.

So the W family is in need of a new family doctor...which in Victoria is a bit of a daunting prospect given that according to the College of Physicians and Surgeons and the Victoria Medical Society say that no family practices in Victoria are currently accepting new patients.

The search begins - hopefully, my family will get lucky and we'll find a family physician that will guide us through the next chapter of our lives as we raise our children and navigate through "middle age". Hopefully, we will be blessed with the same calibre of professional that I had during my pregnancy and birth of my son.

Winning the Birth Lottery

In the afterglow of my son's birth - I have nothing but gratitude and thankfulness about the care I received and I am very happy that I didn't have to leave the country or take out the equivalent of a car loan to get it. My son's birth, far exceeded every expectation that I had, on every account. It was everything and more than I had hoped for when I planned my daughter's birth. In short, I feel a little like a lottery winner on so many accounts - or at least on any account that really matters.

I got the healthy baby - APGARS of 9 and 9.5. There was nothing sweeter to my ears than to hear him cry within moments of being born. My son has 10 fingers and 10 toes. He has good hearing. His blue eyes checked out. He is perfect from pin-pricked heal, to the top of his fair head.

I did not experience labour this time around. There were some Braxton Hicks contractions, there was a softening of the cervix, there was some dilation - but labour held at bay. Thank god labour held at bay.

Pain management exceeded my expectations - I'll be frank, I expected there to be some pain involved - in truth I always kind of thought that instead of the pain of labour that there was the pain of recovery, and that in the grand scheme of things that the two methods (vaginal birth versus caesarean) were kind of 'on par' in this regard. From the time the spinal was placed until now - 4 days post partum, I haven't experienced any pain that has been worse than a bad period cramp. The pain I experienced during my daughter's delivery was unimaginable. The anaesthesiologist worked magic - and I am extremely grateful for his skills. Further - not once did I feel 'out of it' or high, and there is a lot to be said for being able to remain 'sober' during a time like the birth of your child.

I felt involved in my care, every step of the way. I was given plenty of opportunity to ask questions and was told what was going on and what to expect at each step.

I got continuity of care - the OBGYN who provided my prenatal care was the same person who delivered my son. I knew the person who would be delivering my son had delivered hundreds (and likely thousands) of babies before mine. My Dr. Visited me both days I was in hospital after the surgery.

I got a room full of trained experts - a pediatrician, an OBGyn, an anaesthesiologist, residents and nurses - as a result, I knew that if anything were to go wrong, the right person would be there at the right time. I felt safe.

My mood this time around is dramatically improved - I am not in shock over what happened. Reflecting on the experience generates overwhelmingly positive feelings. For the first time since my experience with my daughter's birth, I feel myself again. It would seem in part (at least right now) that the surgical birth of my son might have helped to alleviate some of my psychological issues.

I had no idea just how much my daughter's birth had really impacted me - but perhaps it's a little like having a bad relationship, in that it's hard to understand how bad it really was until you have had a good relationship to compare it to - after all I got a healthy baby out of that deal, an AMAZINGLY wonderful little girl. However, I now understand just how much more was possible from that experience and how many of the negative consequences could have been avoided.

I feel like I've hit the jackpot with my son, I got the healthy baby and I got so much more than I could have hoped for - I am so thankful for my family, friends, readers, therapist, and healthcare providers who supported me through my pregnancy and the birth of my son as without them, it would not have been possible. I got what every woman giving birth deserves, regardless of the mode of delivery chosen.

Everything, According to Plan - One Happy Mother

Just a quick post today...

The csection was yesterday and went exceptionally well - I could not have asked for a better experience, it was truly pleasant to be able to focus on the arrival of my son in the absence of pain.  All of my Dr.s and nurses have done a very good job and so far, the pain of recovery has been managed very well.  Now knowing how pleasant the experience could have been, it would be wonderful if every woman in BC could have access to the same kind of experience if she desired it or at the very least that such access would not be unreasonably withheld.

I am so very thankful to have gotten everything I wanted this time around, I have a healthy baby, I have had exceptional pain management, I have had respectful care, and I had an uneventful delivery and seem to be having an uneventful recovery. I am counting my blessings, knowing how differently things could have gone and tremendously relieved that this time, it was different.

Vancouver - Home away from home until we take the little Mr. home

The newest little W-to-be managed to stay put over the weekend, for which I am most grateful. I'm asking him to stay put just a little while longer (until the elective c-section date), and am trying my best to help him in that regard by staying off of my feet as much as possible. I'm now in Vancouver - so feel as though even if I were to go into labour my chances are good that a csection, or at a minimum an epidural could be secured and I am relieved that the risk of a delivery at Vic General is now eliminated. I relocated myself yesterday (a thousand and one thank-yous to my brother-in-law for use of his North Vancouver condo)

Mr.W and the girl will be joining me later today. I am quite pleased that they are coming sooner than planned as the original plan was for Mr.W to stay in Victoria with the girl until Tuesday (the day before the c-section) and then for the girl to stay with her aunt and uncle in Victoria until we returned home from Vancouver with the newest little W. However, that meant that I would be in Vancouver solo, and should I go into labour - Mr. W might miss out on the arrival of little W, a prospect I wasn't overly happy with, but given the need to care for the toddler, and my desire to avoid a delivery at Victoria General, seemed a neccessary trade-off. It is a trade-off that I am quite happy to be unlikely have to made.

I'm hopeful that little W will wait until Wednesday - surgery has risks and those risks are minimized when it is undertaken in a planned manner (there's a reason why they ask you to fast beforehand).

Now if only I could donate points from my Bishop's score (I calculate that mine is at a 10-11) to some other woman who could really use them as I have no desire to actually go into labour or have a vaginal birth.

Tokolytic Thoughts at Term

The boy to be is now term - and my only hope is that he stays put until the elective c-section date and time. Since my last OB appointment I've adopted a much more slothful lifestyle - the letter of the final weeks is "R" for rest and relaxation. There will be no more heavy duty gardening (it can wait). Late nights are not going to happen, the dog can do without any long walks, the girl does not need to be carried anywhere, and if it takes me a little longer to get from point a to point b then so be it. While I've learned that sex does not induce labour (that is an old wives' tale) - there will be no nookie. Same goes for spicy foods and pineapples. Further - as soon as its logistically feasible to go to Vancouver, I likely will. That looks like it'll be this upcoming Wednesday.

The logistics would be better if this were my first pregnancy, but it's not and that being the case there's limits to when I can go there, and there will be some trade-offs to doing so. Our lives are in Victoria, and so are all the resources that may be called upon in the event of an "unplanned" labour. It being a second pregnancy, and given the relatively short duration of my first labour - time is unlikely to be a luxury that I will have should the unplanned happen. The time off work that can be taken by my husband is limited...and so as much as I'd like to not be here, now, it really isn't an option until Wednesday.

So until then I'll be thinking tokolytic thoughts and hoping that the labour day long weekend is not taken literally by either the womb dweller or my body.

Sporadic Blogging Likely

I've been somewhat absent from blogging lately - I've tried to compose posts but, there have been more than a few times when doing so in recent days has proven too overwhelming. I've been checking in on the comments - and must thank those who have taken the time to make them - particularly the words of support and encouragement.

The new edition is looming on the horizon, and I find the reality of that when I try to blog to often be a bit much - so I've been trying to do things that allow me to think about that on my own terms. I'm finding that I am preferring to avoid social situations, as invariably someone comments on my burgeoning belly and the imminence of the arrival (please baby boy - just stay put until the csection date and time, please). I'm finding naming hard, actually baby preparations in general are proving somewhat challenging this time. It's not that I'm not looking forward to having a son, but rather the deep desire to be on the otherside of his arrival. The deep desire to know that everything is okay and that this time is not last time. Part of me thinks if I'm just not ready for his arrival, maybe it just won't happen until I am ready for it - logically I know babies don't work that way. Logically, I know that I can be as ready as possible and things can still go sideways - for reasons completely beyond my control. Logically I know that things going well are a result of the actions of other people and I must trust that this time it will be different.

I am very thankful that I have a supportive and watchful OB who has scheduled a date and time that is as soon as is feasible - I appreciate that he seems to appreciate my desire to avoid a vaginally birth and my desire to avoid giving birth at Victoria General Hospital.

I am also thankful for my husband who also is supportive and seems willing to do what is neccessary to put my mind at ease - if the OB thinks labour might be imminent, he seems willing to go to Vancouver to help me avoid Victoria General Hospital...he also seems to be fairly cautious about what I do in the interim.

Further, I am thankful for my therapist - who has her work cut out for her in terms of helping me remain rational - and coaching me as to the what ifs...I'd prefer just not to think about them but, I know that if the what ifs materialize that having not thought of them could be harmful.

So I'm doing what I can to minimize the risk of going into labour prematurely by trying not to let the anxiety get the better of me, reminding myself that my OB is watching me, not overdoing things, reminding myself that this time is not last time.

And what if?

Then I'll do what is neccessary and what I can- I will go to Vic General (even though that is the last place I want to be - because, the alternative is even more scary - at least at Vic General, there is a chance at getting a csection or an epidural), I will let them know that I was planning on giving birth by csection in Vancouver - the name and number of my OB and psychologist. I will let them know that I'd like to avoid a vaginal delivery. I will let them know that I'd like an epidural as soon as possible. I will let them know that I do not want the lights low or to be told that "my body was made to do this", that I do not want the same people who provided care to me last time to provide care to me this time - if at all possible. That I want the best pain relief available to be used. Then I'll try to keep it together as best I can for the sake of my son. But if I have no choice - I will do what must be done, as I did last time - however, I will not waste a year trusting that what happened was with good reason and beyond the control of the hospital or doctors - I will investigate the reasons, and if good reasons for a lack of access to adequate care that respect what I would have liked to have happen with my body are not found - I will again hold the hospital and my care providers to account. And if there are good reasons, well then the circumstance is entirely different and I will just have to deal with that as best I can - I will be thankful for a healthy son, I will relish mothering him, and I will know that my care providers did as best they could and that sometimes bad things happen despite having done everything to ensure that they wouldn't ...

But I am truly hoping the what if doesn't happen...because if it does, I know it will be among the most painful experiences I will have in my life - and that no amount of wishing myself elsewheres will change that, that no breathing exercises hold a candle to an epidural and that my vagina won't be the same again...and the idea that the what if could happen again without good reason - unnecessarily - well that would demonstrate a deep seated misogyny that should be fought with every shred of my being.

It is reasonable to expect that what happened last time, won't happen this time (although I find myself having to often remind myself that I should not expect what happened last time to happen this time) - but if it does (again and without good reason) - I will do what is neccessary.

Freedom to make informed personal decisions...

In my pre-motherhood days, I believed that feminism was a bit of a historical artifact, that its time and usefulness had come and gone.  Women accounted for large portions of university attendees, labour force participation rates among women had climbed, women even occupy positions of power and prestige.  I believed that as a woman, I was free to choose in much the same way as a man (and perhaps in someways, even more free than most men) what I did with myself.  I never really saw being a woman as being a barrier or precluding myself from having fundamental rights and freedoms.  If being a woman meant I could choose to pursue advanced education, choose to pursue a professional career, choose to marry or remain single, choose to be a mother or remain childless - how could it not mean choosing what to do with my body should I decide to be a mother?  How can decisions so fundamentally personal as to *how* a child is born or *how* a child is fed be subject to outsiders determining what is in my and my child's best interests?  Surely as a woman and as a mother, would I not be in the best position to make this determination for myself and my child?

The City of New York and Mayor Bloomberg doesn't think this is the case.

The Society of Obstetricians and Gynaecologists of Canada doesn't think this is the case (although many of its members do support a woman's right to choose how her child is delivered unless a medical reason precludes that choice from being reasonable).

Many Natural Childbirth Advocates, including Dr. Klein, would prefer if access to certain choices, including epidural pain relief in labour and maternal request cesareans, were strictly limited.

It is one thing to undertake research and better understand the reasons and outcomes of the choices that are made - and to seek to better inform those who must ultimately make such decisions.  Knowledge is a good thing, and the pursuit and dissemination of it should be encouraged.

It is quite another thing to assume that those who must make such personal decisions (note these are decisions that have very limited impacts to people outside of the family unit) are incapable of making these decisions for themselves and to develop policies and practices that effectively constrain individuals from making a choice that is ultimately in their own, and their child's own, best interest.

It is admirable to want to increase breastfeeding rates and rates of normal birth - particularly among those who would like to do so and who have determined that doing so is in their own best interest.  However, doing so in such a way that infringes on the right of others to choose differently, in pursuit of their own best interests should be deplored.  Women should not be forced to breastfeed, forgo pain relief during labour and delivery or forced to deliver vaginally, if they have determined for themselves that doing so is not in their and their child's own best interest.

If feminism is ultimately about a woman's right to be fully informed of her personal choices and to freely choose among them - then feminism is as relevant today as it was 100 years ago.  Feminists should not stand for such clear infringements and violations of women's personal autonomy - if a woman cannot decide what to do (or not do) with her own body, she at the most basic level has been deprived of a fundamental human right.

I may not make the same reasonable personal choices as another woman, but I fully respect another women's freedom and right to make those different reasonable personal choices.  To do otherwise is insidiously misguided and misogynistic.

I give a whoop - I vaccinate, RIP, Harper Whitehead

This post is largely a repost of an earlier post I made. I am reposting this week because of a Canadian baby, Harper Whitehead - who died earlier this year at the age of one month. She died of whooping cough - she might not have needed to as whooping cough (pertussis) is a vaccine preventable illness. Unfortunately, newborns must rely on others to be protected from this disease, when others fail to vaccinate, newborns might pay the ultimate price. When vaccination levels drop, newborns are put at risk.

My deepest sympathies to the Whitehead family. Out of respect for Harper and her family - do your part and prevent another family from suffering a similar unnecessary loss. If you haven't had a Pertussis booster in the last 10 years - get one, the baby you save might be a baby you know.

Repost posted below.

One of the Most Importnat Parenting decisions we've made has also been one of the Easiest.

I have come to the conclusion that most parenting decisions don't really matter in terms of the "Big Picture" despite how much we may antagonize over them at the time.

Breastfeeding versus formula feeding - doesn't really matter - just ensure that whatever form of feeding you choose is done safely and meets the nutritional needs of the child.

Crying it out versus night-time parenting - again doesn't really matter - as long as your sleep needs and those of your child are being met.

Daycare versus stay-at-home parenting - again doesn't really matter - as long as whoever is watching your child is providing for their needs - emotional, physical, financial and intellectual.

None of these decisions are ones that I or my husband are likely to have any remorse over - we chose what was best for our family at the time and our decision is unlikely to have any adverse impact on anybody else.

However, when deciding whether or not to immunize and whether or not to follow the recommended schedule - the decision was not one that was overly hard. Why? Because the most credible sources of information on this subject are overwhelmingly in favour of childhood immunization according to the vaccination schedule.

Vaccines are some of the safest medical products out there - there are decades of data on the safety and effectiveness of vaccination. Vaccinating my child is safer than driving her daycare. Vaccinating my child is safer than taking her to the park to play.

Vaccines are incredibly effective at preventing disease. The vast majority of immunized children will not catch the diseases for which they have been immunized.

There was no contra-indication to my child being vaccinated. She is not allergic to any of the components in vaccines. She does not have any condition for which vaccination would be ill-advised.

The possible complications and consequences of the diseases prevented by vaccines are potentially serious. Infants who catch whooping cough stand a better than even chance of being hospitalized with it, and one percent of them will die. Chicken pox and the measles cause a week or more of misery for the kid - and having chicken pox as a child means having a risk of shingles later in life. Mumps can result in deafness or sterility. For every disease that there's a vaccine, the risks of the disease far outweigh the risks of the vaccine - without exception, I found that the data was clear - denying my child the benefits of vaccination would be a parental failing in ensuring her health and well-being.

Furthermore, I discovered that this was a decision that actually mattered. It mattered because not everyone can be vaccinated - some people have medical reasons why they cannot be immunized and others find themselves susceptible to vaccine preventable diseases due to a compromised immune system. For some of these people, coming into contact with a vaccine preventable disease can be life-threatening. Think of those too young to be immunized. Think of pregnant women. Think of those battling cancer or HIV. Think of organ transplant recipients. Not everybody is a winner in the health lottery. Think of those for whom, for whatever reason the vaccine just doesn't work. All of these people rely on the vaccination decision of everyone else. This is because, widespread vaccination establishes 'herd-immunity' - simply put a high-level of vaccination prevents the disease from circulating in the community. Further, I learned that for many of these diseases people are contagious long before any symptoms emerge. As a result, a person could unknowingly spread these diseases. I simply wasn't willing to make my child a potential biological weapon of mass destruction. She'd probably fare all-right if she did catch one of the diseases that are prevented by vaccines - but would the newborn be all right? Would the cancer victim be all right? Would the pregnant woman and her unborn child be all right? It simply wasn't a risk I'd take.

As such, I am disturbed when I read about whooping cough emerging in the Fraser Valley and Vancouver and the recent diagnosis of a case in Sooke (note Sooke is a bedroom community of Victoria). I am disturbed to read that measles cases are at a 15 year high. I am disturbed because this suggests that vaccination rates have fallen to levels where herd immunity has been compromised and the diseases are able to circulate in the community.

As such, I'd ask parents to take a look at the evidence - the real evidence on the safety and effectiveness from Health Canada, from the Centres for Disease Control, from Dr. Offit and Dr. Albietz, from medical journals and experts in the field of immunology and public health. I'd ask them to look at the information on the diseases that are prevented by vaccination - not only for themselves but also for those with compromised immune systems - those who are in their community. I'd ask them to be critical and skeptical of the information they read. I'd ask them to ask themselves whether or not the claim made has been substantiated or debunked. I'd also ask them to ask themselves whether or not the person making the claim has a stake in the claim being made - are they trying to sell a nutritional supplement? Are they credible?

I've looked at the evidence - and to me its clear, to me it's clear that if you give a whoop about your child, or your community its important to vaccinate.

More Unimaginable than an Unnecesarian: An Unjustifiable Deprivation of Personal Autonomy

I still have a hard time wrapping my mind around what happened to me the day my daughter was born. I just never imagined such a thing could happen in the 15th largest city in Canada, in a level 3 hospital, in 2010. I never imagined that a woman’s clearly communicated desires around her medical treatment could be so callously disregarded either negligently or intentionally. I didn’t fathom such an experience could materialize – I trusted the system, I trusted my care providers, I believed fully that a woman (or man) who is competent to make medical decisions could expect that those decisions would be respected - and that the system would do what it could to facilitate the needs of the patient. Before my daughter was born, I had confidence that I could trust those who work in the system, I had confidence that I could trust the hospital, I had confidence that I could trust that my care needs would be met – and that if they couldn’t be met (particularly after the treatment plan was agreed upon) that there was a very good reason why that was the case – a legitimate reason that wasn’t arbitrary in nature.

When I went into labour, I blamed my body for betraying me, I blamed myself for what was happening. As the labour and delivery nurse directed that I not scream and told me “my body was made to do this” – I hated myself. I prayed that maybe labour would be long enough that I would still deliver by way of caesarean – I trusted there was good reason why I could not be given the Caesarean, I trusted that there was good reason why I could not get an epidural. I assumed that others with more urgent needs or other unforeseen events had intervened – my doctor told me that paediatric appendectomies meant there was no OR available for a caesarean at the time I went into labour. It was bad, but maybe, just maybe it was one of those “bad things happen to good people because otherwise even worse things might happen to others, situations.”

After the delivery, few seemed to understand the significance of what had happened – and while I’m sure many meant well with their sentiments that not having the caesarean was “for the best”, and that “everything eventually goes back to the way it was” (bullshit), and “that’s what Kegals are for”, and “at least you have a healthy baby”, and, and, and – my grandparents (who I love dearly) even sent me a news article extolling the evils of caesareans (thanks, but not helpful). Unfortunately, these well-meaning sentiments did little to assuage the hurt and anger I felt, but rather only served to make me feel as though I wasn’t entitled to feel the way I did about what had happened. I felt alone and misunderstood – don’t get me wrong, I felt a bit odd and misunderstood before the delivery for wanting a c-section without medical indication but I understood my reasons for doing so and felt confident in my ability to make and defend that choice – but now I felt even more alone and misunderstood.

The passage of time has allowed me to put what happened into context – to question what really happened – not that the answers to date have offered any comfort. Unfortunately, that too, has done little to assuage the anger and hurt that lingers. If anything I am even more cynical today than I was in the immediate aftermath. There are some truly disturbing questions that run through my mind on a fairly regular basis...Was I subjected to a vaginal delivery without an epidural to save the health care system money? Did the hospital put its desire to lower the caesarean rate ahead of my legitimate right to choose a caesarean? Was I a victim in a labour dispute between anaesthesiologists and the health authority? Did someone else’s belief in the superiority of Natural Child Birth put their own values ahead of mine – the woman giving birth? If things had gone sideways during the delivery, would we have been safe? Why did my health care needs rank so low in terms of priority – surely there were other elective surgeries that could have been bumped with less severe consequences than bumping a woman who at 39 weeks pregnant has a significant risk of going into labour at any time? Did I not matter? Did my right to make health care decisions for myself not matter? Would my daughter have fared better during a caesarean delivery – would she have avoided the need for Narcan and resuscitation if access to the agreed upon treatment plan been realized? Has this experience put me in an unsustainable conflict with my professional life – or will it prevent me in succeeding in that regard going forward? Will I suffer pelvic organ prolapse or a greater degree of stress urinary incontinence at some later point in time because of what happened? Will I regain the confidence I once had? Will therapy be enough to overcome the damage done? Will the anger and hurt ever recede? How many other women have had the same experience? Will there be meaningful accountability for what happened? Will my daughter and other women be protected from this kind of violation in the future?

I am determined to not let what happened influence my parenting of our daughter (or our son after he arrives) – and in that regard I think I’ve mostly succeeded (all be it there are times when I wonder if I would be less frustrated or less exhausted if what happened, hadn’t or if she’d actually have an assembled baby book by now if what happened, hadn’t). I can’t say that what happened hasn’t influenced my marriage or my performance at work or who I am or my subsequent pregnancy – it has, in ways that are very significant. There have been countless hours spent reflecting on what happened – hours that if it hadn’t happened likely would have been spent doing or thinking about other things. It has likely made me less productive at work – I do what needs to get done, but my concentration isn’t what it once was and I don’t seem to quite go as ‘above and beyond’ as I once did, further, I feel conflicted and cynical about much of what I do and am far more sceptical about the health system and its intentions in general (really not a good combination for a person in my position) – thank goodness another maternity leave is around the corner. I sometimes think my husband gets angry with me for being unable to move past the birth – that I’m not as good of a wife as I would be if what happened hadn’t. What has happened has left me feeling powerless, overwhelmed, isolated, vulnerable and violated – there’s a certain confidence in my own abilities that I have struggled to regain – and I fear there are bits of myself that may have been permanently lost.

Is this kind of impact on individual women’s lives really worth avoiding “unnecesarians”? Can this kind of violation really be justified in Canada, in modern times? I must hope that the answer to both of these questions must be a resounding no.

Should 'low-risking' make mothers nervous?

When it comes to pregnancy and birth, chances are really rather good that nothing truly bad will happen. The vast majority of low-risk mothers and babies are fine...except, there are some who aren't.

In the Netherlands, there has been recent reports that high risk women who are cared for by obstetricians in hospitals have better outcomes in terms of morbidity and mortality than low risk women who are cared for by midwives who plan on giving birth at home. That should give some pause for thought - the women who should expect worse outcomes (high-risk patients) actually have better outcomes than many of their low-risk counterparts.

Yet in many parts of the world, there are calls to limit the choices of low-risk women in terms of the care that they can expect to be able to access. In the UK, the new head of the College of Midwives is calling for midwifery led care to be the default care pathway for low-risk women. Here in British Columbia - there have been aggressive campaigns for normal birth (see The Power to Push and Optimal Birth BC) in addition to increased funding for both midwifery and Homebirth. Here in Victoria, it is pretty much impossible for a low-risk woman to choose to be cared for by an OBGYN. In Ontario - Don Drummond recently called for the delisting of elective cesarean sections for the Ontario Health Insurance Plan.

Much of the push for normal and natural childbirth is motivated by a desire to save healthcare dollars, but what has not been answered is the cost at which these savings will be had. How many mothers who want access to epidural pain relief will have to rely on less effective forms of pain relief? How many mothers will be subjected to unneccessary perineal tears? How many mothers will lose their wanted children? How many mothers will suffer PTSD or PDD? How many children will be permanently disabled, because right up until birth, everything was low risk, until suddenly it wasn't? How many women will have their own autonomy violated?

It is one thing to support choice and provide options - and in the context of well-informed patients this should be actively pursued. It is quite another to download risk onto those who would choose to avoid it, particularly in the name of saving money when it is not the system that bears the true cost of bad outcomes.

Thoughts on Informed Consent

I would like to consider myself an intelligent woman – one who is well educated and possesses a fairly high level of information literacy. I am a critical and strategic thinker. I am not a doctor – but I do have advanced training in statistics and can make my way through most scientific papers in peer reviewed journals – I have made a career out of applying my skills in the field of health. I am not generally afraid to find information out from sources who should be “in the know”. I understand risk and uncertainty – and can say that when it comes to things that really matter, like my health or the health of my child, I am not a huge fan of either risk or uncertainty. Provided I have enough information to make a decision – I am a confident decision maker and do not tend to change my mind on a decision unless some new piece of evidence has emerged that merits a change of heart. Further, I tend to be a bit of an independent who is not easily swayed by peer pressure – I do things because I think it is the right thing to do, and do not generally take to being “bullied” into doing something.

As a result, I have regretted very few of the decisions I have made – as I know at the time I made them, I based them on the best information I had available (that was critically assessed) and my own preferences. That and crying over spilled milk does little going forward – whereas cleaning it up promptly and understanding why the milk spilled can prevent a harder clean up job and future spilled milk.

So what does this have to do with anything?

I have been thinking a lot lately about informed consent and medical decisions and how that pertains to maternity care. I have come to a couple of conclusions about it in that context.

First conclusion I have come to is that I was well informed when I made my original decision about how my daughter should have entered the world – I was certainly informed enough to provide “informed consent”, and arguably much better informed than most when they consent to a vaginal delivery. I did not take the original decision lightly – it was very well considered in the context of the available information and my personal context, and looking back, if I had it all to do again – I would still have chosen to deliver by way of caesarean. I might have chosen a different hospital or different doctors – but the choice about caesarean versus vaginal would remain unchanged. That’s with the benefit of hindsight – of having had the experience of a vaginal delivery that resulted in a healthy child and relatively normal physical consequences of a vaginal delivery. I can confidently say that vaginal delivery is not something I would choose for myself – and in particular I can say that vaginal delivery absent an epidural is not something I would choose for myself. I regret still, that the choice was taken from me particularly, absent any real reason for it to have been and feel strongly that denying women informed choice when it comes to mode of delivery is a grievous deprivation of personal autonomy and a serious gap in providing quality maternity care.

The second conclusion I have come to, is that there needs to be improvement in the information provided to women regarding childbirth. The statistics and reporting that are available needs to be better. There needs to be more research on the subject with only one agenda: “improving the health and well-being of mothers and their babies”. Most childbirth education classes probably need a massive re-write to reflect the modern realities of childbirth and to enable women to make reasonable and well informed decisions with regards to their own health and the health of their children. (That being said I was a childbirth education truant for the most part, and so really haven’t sampled a lot of these “classes” but from what I have heard from others, there is more than a little bias in them – at least in BC.) The performance measures used in this area also need to be reassessed.

The third conclusion I have come to is that those women who have informed themselves on what their reasonable options are and have made certain decisions regarding those options, need to be respected and supported for the choices that they have made.

Maternal Choice Caesareans: Misunderstanding, Misinformation and Misogyny is Still Alive and Well in Canada

Recently, Jamie Komarnicki of the Calgary Herald wrote a news story about a doctor (Dr. Magnus Murphy) who is publicly advocating for women to be able to have the choice of caesarean. The story got a lot of play across the country and has been picked up by many other news papers, and has resulted in a number of radio interviews. Dr. Magnus Murphy, is a urogynecologist and a former obstetrician. He has seen first-hand the longer run effects that normal birth has on women and has spent a good part of his career surgically correcting those problems. That’s right, the big push to avoid surgery (c-sections) – often results in surgery months or years later for many women. Recently, Dr. Murphy teamed up with journalist and well-known caesarean advocate Pauline Hull and published what is the most comprehensive and compelling book on the subject to date, Choosing Caesarean, and despite its title, neither Dr. Murphy, nor Pauline Hull is about selling caesareans to everyone or out-rightly abandoning the way children have come into the world since the start of humanity. Rather, they see it as a reasonable treatment option that should be considered relative to the default of vaginal delivery – one that will be appropriate for some and inappropriate for others. They see it as a matter of informed consent and choice – and they also see women being denied an opportunity to make a choice that might be of clear benefit to themselves as individuals. They present clear evidence of the often generally unknown facts of these two delivery options.

It’s good that this information is getting out there and that the universal supremacy of normal birth is being questioned – it’s about time women were made more generally aware of the choice they are making, the risks and the benefits of both vaginal and caesarean delivery options. It’s about time the information given to women about birth didn’t just come from the Natural Childbirth Industry.

What’s sad is that the comments sections in response to the stories are invariably filled with misogynistic, misinformed and misguided sentiments about this subject. People seem more than willing to make other peoples’ bodies, their business. I will happily concede that everyone is entitled to an opinion on a subject, however, the opinions expressed on this subject are generally far from well-informed and many demonstrate a tremendous lack of logic or understanding of the issue. Everyone is an armchair OBGYN. Of the 14 comments made on the story when I looked, 9 were negative – ranging from benign misunderstanding to utterly misogynistic. Here is a small selection of some of the less enlightened comments on this particular news story that I’ve read – I’ve copied them verbatim, so any spelling or grammar errors are not my own:

Golden Years:

“I don’t think they should be elective – but whatever, that’s your choice I guess. If you do “elect” to have on though, you can darn well pay for it on your own. Not on my dime!!!”

Steve Q:

“Quack quack.”

Anon147951286:

“Personally, my opinion. .. A vaginal birth is "natural" our bodies were designed to give birth. C sections are not natural, in some circumstances women need the help of a c section due to complications of child birth. I do not think its right to have a doctor pushing his ideas on women telling us childbirth vaginally is not safe- women have given birth forever . I have given birth 2x and I and my children are healthy and fine. Firstly- pregnancy ruins your bladder, and if your bladder is not drained before pushing a child out that can also ruin it. Get the facts people. I'm not against a c section- but it is also a major surgery. If its because complications with a natural birth- fine. If not, why would we do otherwise?”

Anon916080527:

“I personally would not want a section unless it was an emergency. Women that have a normal vaginal deliver are out of the hospital in a day or two. The women with sections are dragging their IV poles around the recovery is much longer.”

Notnecessarily:

“I’m sure there’s a financial benefit...the health benefit...not sure that is a guarantee for either baby or mother.”

Schapdel:

“Women have been having babies for thousands and thousands of years before modern medicine and we’re over 6 billions on the planet. I think the natural way works fine thank you very much!”

Bill200:

“And tell me again about those ballooning health care costs? What the heck- let’s take what’s normally a low-risk, relatively short and natural procedure involving no surgical intervention, and turn it into a major surgical procedure that requires women stay in hospital for multiple days.

Are their complications from natural childbirth? Yes. The advocates for c-sections suggest the complications from emergency c-sections should not be compared to natural childbirths. Equally, the complications of planned c-sections should be compared to natural childbirth, rather than simply talking about the latter.

Anyone who advocates for this is probably either going to make money off it by performing c-sections, or wants her own choices to be viewed as “natural”. C-section doesn’t form the basis for a “natural birth plan”, notwithstanding their book title.”

Dostros:

“Breaking News....Big pharma company promotes taking expensive pills for whatever ails ya’!”

Toyota:

“If you can’t do the time, don’t do the crime. Honestly, women and their partners today need to get a grip on reality. If you want a c-section for reasons other than an emergency, you should look into a surrogate.”

So what should women who are more informed on this subject do?

They should support those who are brave enough to put themselves out there and advocate for fully informed choice about birth options. They should work to dispel some of the myths and misconceptions that are commonly held by also commenting on these stories. They should call out the stupidity, misogyny, and failure in logic for what it is. They should think critically about what is said, and question whether or not it is actually coming from somebody who knows what they are talking about. Lastly, they should talk with their own health care providers, they should review the legitimate evidence on the subject, and they should proudly make whatever decisions best serve their own needs and those of their children – and respect the decisions of others, even though they may be different from the ones they would make for themselves.

Respect is not just given, it is earned. So go out and earn it!