Friday, January 6, 2012

On Being Canadian and Wanting a Maternal Request C-section

Despite being cultural cousins, there are significant differences between Canadians and Americans. We have gun control. They have a constitutional right to bear arms. We have universal health care. They don't yet have unversal health care. We have highly trained and regulated midwives. They have the "Certified Professional Midwife"...which is a very different critter (see The Skeptical OB for more on this).

One significant difference that I failed to appreciate while I was awaiting Juno - is the significant difference between the Society of Obstetricians and Gynecologists of Canada(SOGC) and the American Congress of Obstetricians and Gynecologists (ACOG).

The Society of Obstetricians and Gynecologists of Canada (SOGC) has produced a Joint Policy Statement on Normal Childbirth - in December of 2008. In it there are some serious contradictions, on one hand "6. All pregnant and birthing women and their families should be able to make informed choices. All candidates for normal birth should be encourage to pursue it." and on the other hand "4. Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." and "5. A Caesarean section should not be offered to a pregnant woman when there is no obstetrical indication.". Also of interest is In short, the SOGC is supportive of informed choice, so long as that choice is "Normal Birth" wherever and whenever possible. It is clear that the SOGC is well aligned with the practice of midwifery in Canada.

Compare this with the American Congress of Obstetricians and Gynecologists who put out their stance on maternal request c-section in December 2007 and reaffirmed it in 2010. The ACOG recommends that "1. Cesarean delivery on maternal request should not be performed before gestational age of 39 weeks has been accurately determined unless there is documentation of lung maturity. 2. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. & 3. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta and gravid hysterectomy increase with each cesarean delivery." Overall, the ACOG is reasonably supportive of maternal request c-sections, provided some very reasonable conditions are met. I might argue that the unavailability of effective pain management (ie. lack of epidural access) might be considered a legitimate reason to request an elective c-section, given that unmanaged pain during labour likely predisposes a woman to post-natal PTSD.

I should note that I had heard of Canadian women successfully planning c-sections, IN CANADA, without medical indication before - I therefore thought that surely if one was clear in her request, consistent in her wishes, that this was something I too could secure. All I needed to do was ask to be referred to a doctor who was open to maternal request c-section and ask to be referred to an OB who would agree (after providing information on the relative risks and benefits) to perform the procedure. I did that, it didn't happen.

So if I were in those shoes again - a Canadian nullipara, informed on the risks and benefits of elective c-section vs. vaginal birth and intent on planning an elective c-section; knowing what I know now about the stark difference in stance between the ACOG and the SOGC; I would have bit the financial bullet and would have given birth in the USA. It is also pretty clear to me right now, that if I want #2 to be born via elective cesarean at term, I might stand a much better chance of achieving that goal south of the border.

Alternatively, if I were an American worried about the intervention happy ACOG, perhaps I would go North - in pusuit of 'normal birth'.


  1. I'm rather shocked, not to mention disappointed, that the SOGC does not adhere more to an evidence-based approach. On the one hand, they tolerate enough risk to support a policy for vaginal breech births, but are not open-minded enough to support maternal request c-sections??

    What is going on? Is it infiltration of woo-inspired practitioners (well... as it happens, yes -- same fellow responsible for the breech guidelines) or misogyny? (or both?) Hmm... could it be the influence of a single man and his coterie?

    I am very, very disappointed.

  2. ...I'd love to know what is really going on. Could it be that process now trumps outcome? I think the SOGC guidelines need to change, but they won't without more awareness of what they actually are.

  3. When SOGC considers outcome they think of the entire Canadian society. Not just the baby & Mom & family. If it is not cost effective, they do not back it.

    ACOG = You can have anything, you just need to pay for it.

    SOGC = Best practice in relation to cost effectiveness.

    Take going to the dentist...

    I am sure it would be beneficial for your oral health to get your teeth cleaned by a hygienist (or better yet a dentist!) every month. Obviously some best practice guidelines could do a study comparing those people who had their teeth cleaned monthly versus those who had them cleaned every 6 months and conclude that monthly cleanings are superior.

    However that would cost a lot more. So the next question is how many people would need to be treated to prevent a negative outcome (like a cavity)? And exactly how many cavities are we preventing?

    When you have universal health care you need to consider this. It is unfortunate but a realistic consideration.

    1. How is it cost effective to treat women for third and fourth-degree perineal tears, to provide surgery for pelvic floor disorders, and to provide therapy for postpartum PTSD to the women who are traumatized by having their needs and preferences completely overlooked?

      C-sections may cost more up front, but when you consider the total cost over the woman's life (particularly the cost of treating pelvic floor disorders, which are difficult and expensive to treat), VB and CS come out about equal.

      And particularly when you remember that the number of women who request CS with no medical indication is minuscule, on the order of 3% of all pregnant women, it doesn't exactly bust the budget to respect their right to choose what happens to their own bodies.

  4. Anonymous,

    This problem can be easily addressed by asking women to pay for the difference between a c- section and vaginal birth out of pocket. The difference in cost in the UK comes out to be roughly £800(I don't think it would be all that different in Canada) and I am sure that a woman who really desires a c section will happily pay that cost. In the USA as well, many insurance companies request women having elective cesareans to pay for the difference in cost between a vaginal delivery and a c section.

    There are procedures you have to pay for out of pocket even in universal health care systems and this can just be another one of them.

    Refusing to perform the procedure altogether and denying women the choice is not the solution.

    On a different note, I don't really think ACOG is saying that if you can pay, you can have anything. There are safety guidelines like the completion of 39 weeks of gestation in place to ensure that the procedure doesn't do more harm than good.

    Cost effectiveness does not have to equal a denial of choices. There are ways to work around it.

    1. The outcome of planned vaginal birth overall has to cost the health care system way more in general than elective c-sections. If you did a cost analysis and looked at how many women planning elective csections at term had prolonged dhospital stays for complications , including NICU stays and compared it to a similar population having planned vaginal birth, the costs have to be higher. I would be very surprised if the planned vaginal birth group was cheaper overall. Not many NICU stays in the planned elective csection group I would guess. No calls to birth trauma canada either. There is no way that a woman should have to pay for a maternal request csection in Canada, especially when you look at what our health care dollars go to pay for. The views towards MRCS are somewhat antiquated, in my opinion.

  5. Unbelievable! Anyone suggesting elective surgical intervention births are OK need to become more aware of the related science. In addition to the increased risk to Mom & Babe and dollars in the docs wallet one ought to consider if they are comfortable using the already scarce surgical resources that someone requiring a surgical procedure might need. I have worked in both the Canadian & American health care systems. It was both disturbing and disappointing to see the impact of health care when it is a business

    1. What's unbelievable is the assumption that those who believe elective cesarean births are not acquainted with the related science. I urge you to reconsider your position - women wanting cesareans have just as much right to access those scarce surgical resources as others who are doing so - they are doing so out of a legitimate set of needs. The resource argument is very debatable, and when a closer examination of the relative resource use of planned cesarean and planned vaginal delivery is undertaken, planned cesarean is not disproportionately more resource intensive. I'd read "Choosing Cesarean: A Natural Birthplan" - it provides a very good over view of the current state of the science on this issue...and it's written by a journalist (Pauline McDonaugh-Hull) and a Dr. - a urogynaecologist (Dr. Magnus Murphy).

  6. I'm curious about your comment of "going south" to give birth. I am having extreme difficulty getting into see an OB in order to request an elective c-section here in Canada. It is beyond frustrating and depressing. I would be more than happy to pay for the cost of the OB appointments and the surgery. Is this something that is actually possible? I have researched and haven't had any luck with this topic.

    1. Hi anonymous - it certainly is possible but there are some logistics to contend with. I investigated doing so in Oregon, and had a quote from an OB and hospital. Thankfully I was able to find a Canadian OB and hospital to accommodate my request. Email me.