Best-feeding May Mean Less Breast-feeding

With my daughter, I breastfed pretty much exclusively for the first five or so months when she started displaying signs that she was ready for the introduction of solids (reaching for our food, no longer having the tongue ejection reflex, etc.). Her main source of liquid nutrition continued to be breastmilk until she was 10 or so months old, when it was decided that we should introduce formula into her diet in preparation for daycare. Before then, formula was very rarely used (I could probably count on my fingers the number of ounces my daughter had consumed it). That's not to say that my daughter wasn't accustomed to bottle feeding, she was, as we had introduced a bottle at around 5 days of age (I liked the idea of my husband feeding our daughter at least once a day - to give myself a break and to allow him to have those minutes with her)- but in general the contents of that bottle was pumped breast milk.

It's not that breastfeeding was difficult for me - it wasn't. I didn't have supply issues and it was not painful. My daughter gained weight and seemed to 'get' the hang of breastfeeding readily. In general, breastfeeding was convenient - there was always a meal, at the right temperature, and at the time it was needed.

However, looking back, it was also inconvenient. It meant that we had to buy a breastpump. It meant that I always had to wear clothing that would allow access to my breasts - and so after the maternity clothes served their purpose there was yet another wardrobe of nursing clothes. It meant that the child had to be with me or alternatively that I had to pump and plan for their to be a sufficient quantity of pumped milk on hand. While I pumped, I could not do whatever I pleased but had to engage in pumping compatable activities - so time wise, pumping did not so much 'save' time as it reallocated time. If feeding time happend while we were out and about, it meant I had to stop and find an appropriate place to nurse (at the very least somewhere to sit for a while). It meant that I had to watch what I ate or drank. It meant that when I couldn't nurse at the expected time, I could expect to become engorged or leak (there was a time or two when I woke up in a literal puddle).

I was quite happy when my daughter was fully weaned from breastfeeding shortly after her first birthday - I was happy to have my body back as an independent one from hers. After nearly two years (pregnancy + breast feeding) of sharing myself with her to such a physical degree, I was ready to end the breastfeeding relationship. And she really didn't seem to mind when the morning nursings ended and then when the bedtime nursings ended.

The inconveniences I experienced, are absent some of the real challenges that many women face when they choose to breastfeed. I had the luxury of a year-long maternity leave and no other children to care for while I was nursing my daughter - many women do not get maternity leave (those who are self-employed in Canada or do not have employer provided top-offs may find it financially difficult and those in the US). I did not need drugs or supplements to increase my milk supply - many women find this neccessary. I did not need to undertake an elimination diet due to food sensitivities of my daughter - many women do. Breastfeeding was not painful - it is for many women. I did not have a history of sexual abuse or eating disorders - many women are survivors. My daughter did not have problems with latching or gaining an appropriate amount of weight while she breastfed - many infants may fail to gain weight or may need assistance latching.

And yet looking back, knowing what I know now, I think I might do things a little differently this next time (even if it were under the exact same circumstances as the first time). For one, I will have another child to care for - an active toddler, albeit the plan is to keep her in her daycare full-time. But, also I am more aware that breastfeeding is not the only appropriate choice for infant feeding and that having a little more independence from my child might be good a thing. I also think that there's really no reason to believe that a mother can't have the best of both worlds and that more combo-feeding might be realistic goal this next time around. So for myself, best-feeding my next infant, very well might mean less breast-feeding.

Correlation is not Causation, a.k.a. "Look at the Confounders Batman!"

In the past week or so, a study has been making the rounds. This one claims that babies born via c-section have twice the risk of being obese as those who are born vaginally. The anti-csection brigade is using it as yet another reason to clamp down on the epidemic of unneccessary c-sections, and at the same time making moms who would willfully choose c-section, absent any medical indication, feel as though their choice is posing some risk to their child.

I've had a brief look at the study in question - and here is my conclusion:

Correlation is not causation, and "Look at the confounders, Batman!".

There are a lot of reasons why the rate of c-sections has increased over the past few decades. Moms are older by the time they have children - there are things that seem to be pre-requisites to starting a family now, many women want to be married for a while before starting a family, many women want to own a house before starting a family, many women want to have a career before starting a family, and as a result of wanting a career many women must complete post-secondary education before starting a family. At the end of a day a woman is often in her thirties before she even tries getting pregnant. As a result of being in your thirties before you even start on the "mommy track" you might be more likely to need help getting pregnant in the first place. This might mean fertility drugs. This might mean IVF. Even if it doesn't mean those things, your risk of having multiples increases with age. Many moms might only be planning on having small families. Moms also seem to be more likely to be starting their pregnancies with higher BMI's than in the past and they also seem to be having higher rates of gestational diabetes. Women also seem to becoming more aware that vaginal birth is not risk-free and may also have some unpleasant risks. And all of this is in a context of having the risk associated with having a c-section plummet - surgical methods have improved immensely over the past few decades. So in short, I'm not shocked that the use of c-sections in birth has increased - quite simply because in an increasing number of cases the benefits of surgical birth outweigh the risks and costs associated with surgical birth.

Now the question that needs to be asked, and wasn't asked by this study - is whether or not all of those things that wind up causing an increase in the c-section rate might also increase the risk of childhood obesity. In which case, it wasn't the c-section that caused the babies to be beefier - and doing things to address the rate of c-sections alone (without addressing the underlying causes of the increase) won't do anything to address the rate of childhood obesity. You might just wind up with just as many beefy kids, but more birth injured moms and babies.

I also found it quite interesting, that the risk of obesity seemed to be HIGHER among those who were having urgent or emergent c-sections than among those having planned c-sections. This would seem to indicate to me, that the causes of the c-section in the first place are probably much stronger determinants of childhood obesity than the method of delivery.

In short, this study does little but add to the hysteria around the debate surrounding childbirth and further confuses the very complex problem of childhood obesity. I can see it now, the mother in line at McDonald's with her chubby little cherub playing their PS3, saying "The kid is a c-section baby - it's got nothing to do with everything else we do."

Interesting: The Patient Voices Network of BC

I recently came across the the Patient Voices Network - an interesting initiative that seeks to facilitate patient involvement in the health care system. I must applaud the government for reaching out to patient groups, and hope that it is doing so with an open ear. I am encouraged by the existence of this organization, and think it has tremendous potential to affect change in the health system of British Columbia - particularly if it sheds light on the reality patients face as they access the system for their health care needs.

It would appear that the network has a broad scope - and is aimed at all patients who interact with the healthcare system in British Columbia.

Personally, I am interested in the maternity care system in British Columbia - as it is the part of the system that I've had the most experience with in the last two years on a personal level - and over the next 6 months will continue to be the part of the system that I am most likely to be personally touched by. I hope this network will achieve an adequate representation of mothers from accross the childbirth spectrum - and would not/will not be swamped by those who are strong proponents of natural childbirth, as proponents of access to medical intervention in childbirth also need to be heard and represented.

I hope other mothers in British Columbia who have concerns about the maternity care system will also speak up and be heard. In particular, I hope that mainstream mothers who want access to epidural pain relief, who do not want to choose between the 'niceities' of homebirth and the safety of hospital birth, those who want to be able to exercise informed choice on all available childbirth options, and those who would like to see outcomes placed ahead of process, will also speak up. If not for yourself, then for the prospect that your children might be able to bear their children in a better and more balanced system.

So I have decided to park my general skepticism and cynicism at least momentarily and I've decided to learn more about this initiative, as a maternity care patient - I hope other BC mothers will do the same.

A (very wonkish and very economics based) post on how healthcare might be better structured in Canada

Let me preface this post with the following:

This is a very wonkish health policy post - and reflects personal opinion only.

The healthcare system in Canada is incredibly complex and the challenges that will emerge over the decades to come are significant. It is clear that the current system, as it has evolved over the past several decades has many strengths to it, but also many weaknesses. It is also clear that meeting the challenges will require colloboration and mutual respect between healthcare providers, patients, and government. Facilitating those changes might be better achieved if the very structure of how healthcare in Canada is funded and organized was changed to reflect the reality of what the healthcare system is and what it sets out to achieve for Canadians.

Currently, healthcare in Canada is funded via general tax revenues (provincial and federal) and in some provinces (like BC) per-capita premiums (like MSP) that may be waived for low-income individuals. Provinces each administer their own health care system - so in effect there are 10 provincial health care systems in Canada.

As a result of this structure, there are some significant weaknesses (well-known) that result.

1. Provinces compete against each other for resources and tend to out-bid each other in sequential rounds of bargaining with health care provinces.

2. There is wide variation in terms of the health care services that are accessible to Canadians based on their province of residence. There are procedures that might be "insured services" in one province but not in another. The wait time for access varies widely across the country. In general the province with the most resources to devote to health care services has the best health services available in terms of what is covered by the public system and wait times for access.

3. Governments tend to be hesitant to raise taxes in response to rising demands for healthcare services. As a result health services are either underfunded or other areas of public services are restrained to pay for the services provided in the health care system.

4. There is no relationship between what an individual pays towards the healthcare system and their health care needs or their controllable health behaviours. If you make a lot of money, you pay high income tax and contribute high amounts towards the health care system. It is a myth that health care is "free" in Canada, income=health care premiums in Canada - it is only "free" if you happen to be so poor as to not pay any taxes at all.

5. There is limited flexibility in the types of services that can be accessed in Canada. Services that are not publicly provided as insured health services are supplied via the private health industry - these are things like cosmetic surgery, sterilization reversals, dentistry, etc. Services that are publicly insured and provided often lack choice - there are few "frills" in the Canadian system, a patient generally cannot choose to access services faster (but pay for the privledge) nor can they choose to access services that might be qualitatively different (ie. a surgical delivery versus a vaginal delivery when not medically indicated) and pay for the difference in resource use. In general, a patient also cannot "choose" a nicer facility for a price for a publically provided service. Generally, facilities do not compete against one another for market share. If a Canadian wants choice or frills for a 'publicly insured' health service, they often must pay for that service completely out of pocket and access that service abroad.

6. There is a lot of administrative duplication and inefficiency that results from the running of 10 different health systems.

7. The system tends to be prone to politicization. Decisions regarding what is or isn't covered or how resources are allocated or even what information on the system is provided to the public are often political in nature.

That's not to say the system is without it's advantages.

It is a tremendous advantage that there is no problem of "uninsured" Canadians - every Canadian has health insurance and access to health services. They might not be the best health services that are technologically feasible. They might be services in older facilities. Canadians might have to wait a long while to access those services.

So how might Canada retain the current advantages of the existing system while correcting some of the disadvantages?

While there are likely many different ways to do this, I think that one way to do it would be to do the following:

First, create a Public Health Insurance Agency of Canada (PHIAC) that provides mandatory basic health insurance to all Canadians and pays for those services via a combination of individual premiums that are based on income, age, and health behaviours that are under the control of the individual and a government grant from corporate taxes. Risk associated with genetic predispositions or accidents could and should be pooled accross the entire population. The amount of premiums needed to be paid would be based on the health services needed. Health premiums would be separate from taxes - but mandatory and collected in a similar fashion to how taxes are collected. All Canadians of legal age would be shareholders in the PHIAC.

Second, create an independent organization (the Healthcare Senate) with a fixed-term appointed board with nominations from health care providers, provincial governments, patients, and PHIAC that can make binding decisions on the insurer and facilitate collaboration between patients, health care providers and the insurer. This organization would set compensation levels and make decisions regarding resource allocation, determine which services are covered, undertake quality improvement and review initiatives, collect and analyse data on health service use and outcomes, and report to the public.

Third, open the door to optional private insurers and private payment for services not covered under PHIAC and for 'frills' such as expedited access to services, nicer facilities, and patient choice.

No doubt there would also pitfalls to this kind of system, but it does provide "some food for thought" - and I would tend to think that such a system may retain many of the advantages of the current system while remedying some of the disadvantages. I am also curious if there is any health sytem in the world that is structured in this way and if so, what are its results?

Cost Studies on Cesarean Birth versus Vaginal Birth Short-Changes Mothers and Babies

As an economist, I am often dismayed by the existing studies that compare the costs of vaginal birth with the costs of caesarean birth - and then come to the conclusion that a great deal of money could be saved by promoting "normal birth". I am further dismayed, when without question or critical thought the media then goes on to parrot the cost difference, as being $4,863 versus $2,486, as in this recent Toronto Star article . The problem with most existing cost studies and a simple parroting of cost statistics is that it over simplifies the issue of cost as it pertains to childbirth.

The first flaw in the basic statistics on the cost of mode of delivery, is that they are retrospective in nature. This means that they do not reflect the planned mode of birth but rather are the result of the actual mode of birth.

As such, the statistics on the costs of caesarean sections include the costs of both elective or planned cesarean sections as well as the costs of emergent caesarean sections. The vast majority of emergent cesarean sections are the result of planned vaginal births that do not go as expected. Emergent caesarean sections cost significantly more than their planned counterparts as many of these births involve the interventions (and their costs) that are common to vaginal births as well as the costs of caesarean births and may also involve increased costs associated with a substantially increased risk of complications. This artificially inflates the reported cost of cesarean birth.

While the basic statistics inflate the cost of caesarean birth, they also diminish the cost of vaginal birth. A "straight forward" vaginal delivery - is a delivery that does not involve the use of an epidural or augmentation, and does not involve the use of forceps or vacuum to assist with the delivery of the child. This is the type of delivery that those who subscribe to the philosophy of natural childbirth aspire to achieve. The reality is that for many women achieving this kind of delivery is simply either not possible or not desireable (it could be done, but at a great risk of harm to either the mother or the child). Many women elect or need epidural pain relief. Some women have fetuses that are simply too large or are not ideally positioned for their bodies to safely accommodate a natural delivery. Many women and babies need help with the delivery process and will require assistance by way of either forceps or vacuum (which in the absence of an epidural can be excruciatingly painful). Some who planned on a "straight forward" vaginal delivery will ultimately need an urgent or emergent caesarean. Yet, the costs associated with epidurals, forceps, vacuum, or emergent caesareans are conveniently left out of the tally associated with "straight-forward" vaginal birth - and as such do not even reflect the reality of the "average vaginal birth".

As a result, readers are erroneously left comparing the discounted costs of vaginal birth with the inflated costs of caesarean births.

If that wasn't bad enough, it should also be noted that the vast majority of existing cost studies completely ignore longer-run costs that may be associated with the mode of delivery. If the delivery results in a cost that is incurred more than 42 days after the birth, the costs are frequently not allocated to the mode of delivery. A child born with a life-long disability as a result of mode of delivery - will not have the life-long costs allocated to that mode of delivery. A mother with urinary or fecal incontinence attributable to the mode of delivery that needs to be repaired (through surgery or physiotherapy) months or years later will not have those costs allocated to the mode of delivery. A mother with PTSD or PPD associated with her mode of delivery will not have the costs of those mental health issues allocated to the mode of delivery.

Furthermore, the costs that occur as a result of mode of delivery that are incurred privately are never accounted for in cost-studies of different modes of birth. There are private costs associated with either mode of delivery - including time off work, costs of preparing for the birth, and costs of recuperating after the birth.

Lastly, the costs that are "expected" by planned mode of delivery are likely to be very different on a case-by-case basis. There are many women for whom the "expected" total cost of a planned vaginal delivery is likely to be lower than the "expected" total cost of a planned caesarean delivery. There are other women (particularly in a time when mothers are getting older, heavier and having fewer children) for whom the "expected" total cost of delivery would be cheaper by planning an elective caesarean delivery.

As a health system, the goal should be to encourage women to discuss their circumstance and options with their healthcare providers and to choose the mode of delivery that is most efficient for them in their individual circumstances with an objective to reduce unnecessary morbidity and reduce unnecessary mortality for mothers and and babies. If this were done, a reduction in the overall healthcare costs would likely follow, even if a reduction in the rates of caesarean sections did not.

Spending Money Where it Matters: Maternity Care

I fully understand that resources in the health care system are limited - and that decisions must be made with regard to resource allocation. I know that providing health care services to the population is expensive. I know that these costs are increasing over time for a wide variety of reasons, including an increasingly older population, an increasing ability to treat what once was untreatable, increasing expectations to access treatment and inflation. I know there is tremendous pressure to 'bend the cost-curve' and improve health care system sustainability and that bending the cost-curve and ensuring health system sustainability is imperative.

I also know that maternity care is not the place to 'save money' and that doing so will and does come at a tremendous cost.

I am more than a little disturbed at efforts to turn back the clock on this area of care. I am disturbed at the efforts by provincial governments to encourage home births and 'invest' in birth centres that are basically places where women give birth 'in somebody else's home', and in particular I am disturbed because the primary motivation for encouraging these things is to save money. Money indeed will be saved, but it will be saved by limiting access to medical care and services during birth. Of course homebirth and birth centre births are cheaper than hospital births - if a woman does not have access to an epidural, the system does not have to pay for one. If a woman does not have access to fetal monitoring, then again, the system does not need to pay for it. If a woman does not have immediate access to a cesarean section - there is a chance a 'normal' birth will happen instead. When technology is not available, it does not get used.

I also know that proponents of homebirth will point to the few studies, like the recent BMJ article entitled "Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study," that show that outcomes between homebirth and hospital birth are comparable. However, they will fail to examine those studies with a critical eye. A study that uses composites for perinatal outcomes and maternal morbidity completely fails to recognize the huge difference between a death or a lifelong disability, with having a cesarean section or a fractured clavicle. This study also limits its scope to the birth itself and the period immediately after the birth (42 days) and as such fails to recognize the consequence and costs of longer-run morbidity and mortality. Further the study considers "normal birth" (defined as being without induction of labour, epidural or spinal anesthesia, general anesthesia, episiotomy, use of forceps, ventouse or cesarean section) as being a "good" in and of itself - without any justification for that position.

The fundamental flaw of course is the underlying assumption that the use of technology in birth in hospitals is done so without reason or merit and that using technology in birth does not 'buy' anything of value. This strikes me as being a rather large assumption, that should be extensively tested prior to being accepted. Use of technology in birth buys reduced pain. Use of technology in birth buys reduced risk of very severe outcomes and long-term disability. Use of technology in birth may make the difference between life and death, and it may make the difference between a 'normal' life and one filled with life-long challenges. Given the nature of the population being served (typically young, and healthy) what is being 'bought' with the use of technology in birth will have benefits over a very long time horizon, potentially 80 or more years.

It should be crystal clear that the government's embrace of out-of-hospital birth has nothing to do with supporting choice and everything to do with saving money. If it was truly about choice, government would increase access to hospital-based midwifery and make hospital environments nicer to facilitate the choices of women (for example private rooms, birthing tubs, increasing the ability of partners to stay with parturients, etc.) WITHOUT sacrificing their access to medical advancements. Facilitating a choice that denies or delays access to medical technology, particularly if it is proven to be needed is not good policy. It's cheap, but should not be considered cost-effective.

Reflections on Unnecessary Things

Women who choose cesarean absent a medical indication for cesarean in North America are often portrayed in a negative light. They are deemed a drain on the medical system (at least in Canada). They are called "too posh to push". They are called vain. There are those who would even deride them as being somehow unworthy of motherhood - after all, giving birth vaginally is the way "nature intended". Some people might even declare that women who gave birth surgically, have not "given birth" and are somehow "lesser women". Any woman who has had a cesarean or is planning a cesarean, feels compelled to defend her choice or the reason for it, as there seems no bigger travesty than an "Unnecesarean". Even Canadian policy makers feel as though a worthy goal is to "reduce the rate of cesarean births" and "increase the rate of attempted VBACs".

This situation generates many Unnecessary Things, far worse than surgery among a group of women who could have had a "normal birth" if only they let "nature take its course", but freely and with informed consent opted out of "normal birth".

This situation "unnecessarily" legitimizes the denial of patient autonomy - a woman denied a cesearean absent a medical indication for it has no recourse. She often does not even have the empathy of others - after all she has only been subjected to what is considered "normal".

This situation makes finding sympathetic care providers "unnecessarily" difficult for those who would prefer an elective cesarean birth. Many women are forced into a situation that lacks continuity of care, or may have to travel to access the care they need.

This situation "unnecessarily" generates feelings of inadequacy among those who through no fault of their own were unable to "achieve" a vaginal birth.

This situation "unnecessarily" increases the risk of truly traumatic outcomes for mothers and infants. Many mothers believe that if they just push a little longer, labour more, or refuse an epidural that they can avoid a cesarean birth. Many might delay to the point of an emergent situation which then risks being "unnecessarily" unconscious for the delivery of their child, "unnecessary" complications, "unnecessary" disability, and "unnecessary" death.

Other "unnecessary" things that result from this situation are "unnecessary" pain, "unnecessary" vaginal tearing, "unnecessary" sexual dysfunction, "unnecessary" post-natal mental health problems, "unnecessary" reconstructive surgery, "unnecessary" incontinance, "unnecessary" bias in the information given to women planning on giving birth and "unnecessary" guilt.

In sum, the situation as it is today, "unnecessarily" jeopardizes quality maternity care. It puts process ahead of outcomes, and that is what necessarily needs to change.

Recollections: Crisp and Absent

There are things about the last time I gave birth that I remember very, very crisply - the bits that revisit me every now and again, in a dream or suddenly during a conversation or are triggered by something I have read. Mostly it's the emotions I remember, the terror, the pain. The conversation my doctor had with me shortly after I went into labour indicating there was no OR available, no anaesthetist available (therefor no epidural), that there were pediatric appendectomies and I would have to wait (lies!). I remember hoping that labour would progress slowly - that time might be on my side as a first timer. I remember hoping that nothing would go sideways. I remember thinking if I stayed still enough, maybe the child could wait until an OR was free and I could still have the birth I wanted. I remember as I was in great pain, asking my husband if I could sue in whispered tones...and I remember being told I was 10 centimetres and the c-section was not going to happen...I remember breaking down and sobbing at that time knowing I had no choice - or at least I had not been given any choice. I remember them breaking my water. I remember the nurse telling me that "my body was made to do this" and that "direct my screams into pushing." I remember hating my body at that time, despising it, feeling it was responsible for the betrayal, for not taking long enough to labour, for causing me such immense pain. I remember being offered a mirror to watch the birth (why on earth would I want to?) and turning it down. I remember my daughter not crying when she was born, needing to be resuscitated after birth, and again watching hoping that she would be okay. I remember being stitched up, and taken back to my room. I remember showering my bloody self after the birth, and sobbing in the shower.

That is what is crisp. It still overwhelms.

Then there's everything that seems to be absent from my memory.

I don't remember where my husband was during the pushing phase. - He indicates he was at my knees, but I do not recall.

I don't remember the name of the doctor who actually delivered my child.

I don't remember my in-laws coming to the hospital when I was actually in labour.

I don't remember having any conversations with my OB after the first conversation, shortly after labour started.

I don't remember the details...

My recollections are both crisp and absent.

There is still a sadness that this is what is there, that terror and pain are what I can recall when joy is what should be the overwhelming recollection (it is not) - it cannot be changed. I am eternally grateful for every memory of my daughter since - for every smile, for every moment of motherhood that I have been blessed with. At least those memories bring overwheling joy. I am also eternally grateful that my experience was not more negative (I am well aware that it might have been worse). But I am angry still, knowing that the ability to recall my daughter's birth - coherently, without being overwhelmed by such negative emotions, was taken from me.

Making Choices: The Definition of Being an Autonomous Human Being

There's an idea out there that says a good mother does certain things - she gives birth naturally unless there is a medical need to do otherwise. She breastfeeds unless there is a medical need to do otherwise. She stays at home with the children if possible until they are of school age.

And when she doesn't do these "ideal" things, she must explain why.

I had a cesarean section because...

We formula fed because...

I went back to work because...

And rarely is it okay for a woman to finish these sentences with "I wanted to." or "I chose to." To answer in that way is to ask to be judged - with the ultimate damnation "she must be a bad mother."

There is a certain shame in making these choices.

And oddly enough when the child does something undesireable mothers "who do all the right things" feel the need to preface their situation with, "I did everything right, I just don't understand why little Aiden won't"...and those who made other choices might be scorned "she let little Ethan watch too many violent video games and farmed out the parenting to daycare...that's why that kid is the ultimate demon spawn."

Equally, there is an urge to take credit for the child's accomplishments - "little Aiden gets straight A's because (insert parenting choice here)", or conversely the "bad mom" who happens to "have a good kid", just "got lucky".

I've come to the conclusion that, parenting isn't math or an exact science and there are no "universally right" answers because far too much depends on the context in which the choice was made. Far too much depends on the specific mother. Far too much depends on the specific child. Far too much depends on the specific context in which the family must live.

I've also come to the conclusion that there's a lot to be said for not being ashamed for making a choice that is different from what might be considered the "universally right" choice, for having confidence that regardless of the choice made, if it was based on the best information available applied to the specific context at hand, that it was "the right choice".

Like in many things in life, the focus needs to be on what is ultimately a "good outcome" - rather than on the specific processes that may or may not have been used to get there.

And ultimately, if there's an outcome I'd want for my child, it would be for my child to have the ability to make a choice, based on the best information that they have available and applied to the specific circumstances my child finds themselves in - and to be confident in whatever choice they actually make.