Guidelines for Names

Mr. W and I believe that the final addition to our family is likely to be a boy - we certainly aren't going to paint the kids' room yet but we have given some thought as to what this final addition might be called. Of course the acquisition of any additional baby gear or the finishing touches on the room will wait until we get a more definitive answer on what Little Bean definitely is or isn't. We are having to wait for a more definitive answer as to what Little Bean is or isn't because VIHA implemented a policy in March of 2010 (after we found out what our daughter was) not to inform parents of the sex of their baby at the 18-20 week ultrasound. So while we definitely think we saw a penis, we don't know that what we think we saw is actually what we saw.

We have some general guidelines on naming children that worked very well in choosing our daughter's name and we will use them again this time around:

1. The name should be easy to spell.

2. The name should be difficult to mishear.

3. The name should be clearly male or female.

4. The name should not sound silly on a grown adult.

5. The name should be difficult to make fun of. (Note: kids are kids and if they can make fun of a name they will, but at the very least this should be a challenge.)

6. The name should be different from the last name. As such Benjamin Benson would be a no, no - as would William Williamson or Gunnar Gunderson.

7. Either parent can veto a name for any reason, both parents must agree on the moniker that is to be used.

8. The name should not be exceedingly common - so anything in the top 50 is out.

9. The name should suit the child. As such, if the chosen name does not 'fit' the child once it is born, an alternate name should be chosen.

Let the list making begin!

Spotlight on Support: Stillbirthday, An Amazing Resource for Women Contending with Baby Loss

When I was pregnant with my daughter, the Serum Integrated Pregnancy Screening came back with a higher than screen cut-off risk for Trisomy 18 - Edwards Syndrome. My dear daughter's risk of this condition was somewhere in the range of 1 in 400. As I read about the implications of trisomy 18, it became clear that in many cases the condition is incompatable with life and the majority of fetuses with the syndrome die before birth. Children born alive with the syndrome have a low rate of survival as a result of abnormalities of the heart, kidney malformations and internal organ disorders. Given this risk, I needed to know whether or not my daughter was actually afflicted by this condition. I breathed a sigh of relief when I read the results from the amniocentesis that clearly stated that the fetus I was carying was a female with normal chromosomes. I was thankful to be spared from a heartbreaking diagnoses.

However, many women are not spared from the heartbreaking reality of a pregnancy loss, a stillbirth, or a newborn death. For these women the anticipation of a new arrival is replaced by immense and immeasurable sadness - for all of their hopes of parenthood are dashed before they even begin.

Finding support in the face of such tragedy can be a daunting task. Recently, through an online community - I have had the privledge of becoming acquianted with Heidi Faith. Heidi Faith is a remarkable woman, who through her own experience of loss, has created an online community of support for other women who are in the midst of their own tragedies. Stillbirthday offers support for women who have suffered from pregnancy loss, still birth and newborn death.

For offering these women and their families a place to turn to, Heidi Faith and her site Stillbirthday, does amazing work.

One of the Easiest Parenting Decisions We've Made, is also One of the Most Important

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 according to the schedule that has been recommended.

This is a parenting decision that matters - and luckily, it was one of the easiest ones I've made (the evidence is that clear).

Quality Care Means Access to Adequate Pain Relief

I've previously blogged about the epidural rate in British Columbia - in short it is very low and varies fairly substantially between areas of the province. Depending on the reasons for it's lack of use in this province, it might be very concerning as failure to provide access to pain relief when requested, in my opinion, is "a bit of a failure to provide quality care."

The rate has improved somewhat between last year and this year - but it remains low. Among first time mothers in British Columbia with labour, nearly 50 percent of them had an epidural (49.7% - source BC Perinatal Services) in 2010/11. This ranged from a high of 66.2% of moms giving birth at BC Children and Women's hospital to a low of 32.5% of moms giving in the Northern Health Authority. In Vancouver Island Health Authority, 46.4% of first time moms with labour had an epidural, up from 43.8% the year before. In some jurisdictions in North America the epidural rate for first time mothers exceeds 80 percent.

According to the Canadian Institutes for Health Information - the use of epidurals for all vaginal deliveries in British Columbia in 2009/10 was 30.3%, compared to a Canadian average of 56%. This suggests that the use of epidural anaesthesia is even lower among women who have previously given birth.

Anecdotally, I know of women who gave birth in Vancouver Island Health Authority who wanted epidural anesthesia and could not get access to it - I was one of them when I gave birth in 2010.

However, much like how the specific process of giving birth (c-section versus vaginal) should not be used to judge the quality of care - neither should the specific mode of pain relief. A very low rate of epidural use tells me very little about the reasons for the low rate. Given the extreme variation regionally - I suspect that it is a matter of accessibility. However, at the end of the day, I don't care about how a woman achieves relief from her labour pain - rather I care about her right to achieve that relief from her pain if she desires to be relieved of it and her ability to access pain relief that indeed does relieve her of the pain. Unfortunately, there's a "bit of a gap" in the statistics in this regard - and at the very least the discrepency between what is observed (low epidural rates relative to some parts of BC and the rest of Canada) and what would be expected should be investigated further.

Quality care means access to adequate pain relief.

Where I Draw the Line...

I'm pretty much a live and let live kind of girl...I support an individual's right to freely make choices that impact on themselves and others for which they have the responsibility to make decisions. I hope (and largely assume) that the decisions made are ones that are based on good information and best meet the needs of those making the decision. As a result, I tend to be very pro-choice on a large array of issues - particularly those that fall into a personal domain. But I must draw the line on certain things ...

One of those things is vaccine rejection for non-medical reasons.

I believe vaccine rejection is one of the most insidious threats to public health that exists today. Furthermore, I believe that being appropriately vaccinated is part and parcel of the social contract and that everyone who can be vaccinated, should undertake to do so. Choosing not to vaccinate is sociopathic, it's based on a set of conspiracy theories and risks that pale in comparison to the risks of the diseases prevented by vaccines. Those who refuse to be vaccinated rely on everyone else who decide to vaccinate themselves to be protected from disease - as a result the benefit from the herd immunity which has been established without having to take any of the actions needed to establish that protection. Until that immunity is lost - because too many people choose not to do their own part. Then vaccine preventable diseases re-emerge and those who really have no choice due to medical reasons (a known allergy or reaction or a compromised immune system and the very young) pay the price - sometimes the ultimate price - death.

So when it comes to vaccination - I am not pro-choice, I am not pro-choice because those who don't have a choice cannot be expected to pay the price (often tragic) for somebody else's misinformed decision to forgo vaccination.

Targeting Specific Rates of C-sections and VBACs is Misguided at Best and Dangerous at Worse

One of things that really, really perturbs me is the use of rates of VBACs and rates of c-sections as performance measures. I think that these measures might have been well-intentioned but are terribly flawed indicators of maternity care. In short I think that efforts to 'keep down the rate of c-sections', or 'increase the rate of VBACs' are bad policy, for a lot of very good reasons.

1. It places a value judgement on how birth occurs - in short by having a publicly stated goal to reduce the c-section rate or increase the rate of vaginal births after c-sections - it sends a message to moms. That message is "physiological birth is superior to surgical birth" - in short many women get the message that they have failed if they have a c-section or do not attempt/succeed with a VBAC. Birth no longer is about bringing home a healthy baby and a mom who is in the best physical and emotional health as possible - it becomes about how the birth occurred. It's time to realize that a c-section is not a failure and that a vaginal birth is not an accomplishment. A healthy mom and a healthy baby is an accomplishment - as is a process that facilitates that outcome and respects the emotional and physical needs of both mother and baby.

2. The unintended consequences of this focus might be really, really ugly. When the focus shifts to how birth occurs, inevitably there are trade-offs. The trade-off of having a low c-section rate might be an increase in the number of births that are assisted by forceps and vacuum. The trade-off of having a low c-section rate might be a decrease in the rate of inductions after 40 weeks and an increase in the number of still births. The trade-off of having a low c-section rate overall might be an increase in the number of emergent c-sections that occur when delivery with 30 or 20 minutes is critical to avoiding long-term disability. The trade-off of increasing VBACs might be an increase in uterine ruptures. The trade-off having a low c-section rate might mean more 3rd and 4th degree tears. The trade-off of a low c-section rate might be an increase in the rate of severe birth traumas. The trade-off might mean putting the process of how birth occurs ahead of the genuine desires and needs of the patient.

Are these trade-offs ones that we really want to make?

3. These are not indicators that tell us anything meaningful about the quality of care or appropriateness of the care received by maternity patients. By focussing on these measures, and actively seeking to reduce c-section rates or increase the rates of VBACs - we are not measuring what matters or moving closer to achieving the goal of maternity care that is actually better. Effort needs to be made to find the measures that really reflect good quality care and to report on those things.

It's time to quit focussing on reducing the cesarean rate or increasing the rate of VBACs - these measures and goals should be immediately scrapped. Yesterday wouldn't be soon in enough in my opinion.

Mothers and babies deserve better - they deserve quality care that places genuine outcomes that matter ahead of the specific mode of delivery.

Is avoidance of labour pain a reason to opt for an elective cesarean?

In most of the literature on choosing an elective cesarean, the avoidance of labour pain is considered to be an inadequate reason to choose to have an elective cesarean section. It certainly wasn't THE reason I was lobbying for an elective cesarean during my last pregnancy - after all I had no idea what the pain of labour and delivery would be like. I had people assume that it was the reason for my choice, with my own step-mother-in-law greeting the news of our birth plan with "oh honey, just get the epidural". I'd typically responded with "my choice isn't just about the pain of childbirth.". In truth, the first time around, I anticipated that choosing cesarean wouldn't mean less pain overall, just different pain. I was anticipating trading the pain of labour and birth for the longer recovery and a longer duration of pain. I anticipated a qualitatively different kind of pain that on the whole would be roughly equivalent.

The thing is, I never imagined a circumstance in a major urban area in Canada where access to effective pain management (ie. an epidural) would be a problem. I had no reason to believe at that point in time that I would not have access to an epidural should I have decided to proceed with a vaginal birth.

Now, knowing what I know - I feel very differently about this. I think that the avoidance of being in a situation where the pain is not in control and is extreme, is a valid and reasonable reason to elect for a cesarean. It shouldn't be the only reason - but it certainly ranks a heck of lot higher this time around than it did the last time around. If the health system cannot guarantee access to effective pain management when it is known to be available, why should it expect women to just chance it with a natural delivery? If spontaneous labour comes with a risk of unmanaged and insufficiently mitigated pain that is off-the-scales, why should we expect women to willingly submit to that?

Why is pain in childbirth considered to be 'okay' - when pain in any other medical arena is seen to be something that should be managed and mitigated?

I believe part of the reason I found giving birth to my first child was traumatic (apart from a complete violation of my right to determine what happens to my body) - was the insufficiently mitigated pain I experienced during the process.

If access to effective pain relief (epidurals) during labour and delivery was guaranteed to occur on demand, then it likely isn't a valid reason to elect for a c-section. In the absence of that situation - I personally, think its very logical for a woman to choose a cesarean - particularly now that I know what I know about access to epidurals during labour in most of British Columbia.

Retrospective versus Prospective: A Very Important Distinction

There's a cliche that hindsight is 20/20 and it would appear that when it comes to birth few are able to make the distinction between retrospective and prospective. This is where the term "unneccessarian" comes from. This is also where studies that proclaim Homebirth to be safer than hospital birth fail. Ditto for most studies that compare birth outcomes between vaginal births and Caesarian births.

Retrospectively (hindsight) the claims made might be true - but the difficulty is that decisions must be made prospectively (foresight) and there is no crystal ball that will tell you how everything will play out. The decision about where to birth is made before you actually give birth. Many planned home births (more than 10 percent) result in emergent/urgent transfer to a hospital. The decision about how to birth (planned caesarean versus planned vaginal) again is made before hand - however, it should be noted that many planned vaginal births result in emergent/urgent caesarean births.

So as a mother who is prospectively making plans, a woman must consider how her plan will mesh with the wide variety of potential outcomes.

Researchers also need to turn their minds to the issue of "prospective" versus "retrospective" so that they can provide better information to those who are trying to make prospective decisions, but are currently forced to base their decisions on "retrospective" studies.