I have no doubt that in some way the care I received during my last pregnancy, labour, and delivery was the result of generally held belief about the superiority of 'the natural birth process' - and an utter disregard for the consequences of failing to respect patient autonomy and provide access to the caesarean procedure in a timely way. I think in some way, someone thought it was 'ok' because what I had asked for wasn't based on the generally approved medical indications for a caesarean. That because 'it was my choice' it was okay to impose their beliefs about childbirth on me - delay and deny. The chances are overwhelming that she will be fine and her baby will be fine, so what she 'wants' doesn't really matter.
Examining the guidelines produced by the Society of Obstetricians and Gynaecologists of Canada, and the material produced by the Ministry of Health, it is clear that there is a strong preference for vaginal childbirth. I know that "the state" doesn't approve of my choice in childbirth - I knew that when I was pregnant with my daughter - I also know that many members of the public do not support maternal request Caesarean. However, I also believed then and believe now that the state must respect choice in childbirth and that forcing a particular mode of childbirth on a woman would be / is reprehensible because it violates a woman's right to determine what happens to her body and to make health care decisions for herself and her baby. It's misogynistic and misguided.
The thing is that what mothers want does matter, and respecting maternal choice cannot be a one way street. The system cannot bend over backwards to accommodate natural childbirth, but completely ignore those who would choose to medicalize their births. The system cannot assume that those choosing natural childbirth are doing so as an informed choice, if indeed no choice is actually available. Nor can the system assume that those who would choose to medicalize their births are doing so from an uninformed position - and that their choice should be ignored. To do so is to perpetuate a paternalistic provision of healthcare in obstetrics when it has been long abandoned in most other fields of medicine. To do so, says that it's okay to violate a patient's autonomy, if that patient happens to be a woman who is seeking maternity care.
That is what is wrong and needs to change. It's not about csections. It's not about vaginal births. It's not about epidurals. It's about enabling women to get the best information about their choices, and actually supporting whatever choice a woman makes having been provided that information. It's her body and her child at stake - who else could have a better perspective on what their best interests actually are? When the state and care providers fail to provide for women during childbirth - it is an affront to quality care and often is an unjust enrichment at the expense of mothers and their babies.
I am a registered nurse in Ontario. My nursing experience has been in the Neonatal ICU and as an outpost nurse. I have recently been accepted into a midwifery program and will be starting September 2012.
ReplyDeleteI wonder if you were to choose a midwife as your prenatal caregiver, if your autonomy would be better advocated for.
Hear me out.
Midwives generally promote natural childbirth. But they are also (usually) strong advocates of women's rights. I would imagine the midwife would start by trying to counsel you around the typical "benefits" of natural childbirth. This would lead into a discussion about why you are choosing a cesarean.
You are very well educated re: cesarean. And just from reading your blog, I believe you have a valid medical condition that should be addressed (PTSD).
If I were your midwife, I would refer you to a psychiatrist who would (hopefully) validate what I believe is a legitimate medical reason for you to undergo an elective C/S. With an actual diagnosis made by a psychiatrist, it would be easier to get an OBS to do a C/S because now they have medical reason for it. All the while, you would have another medical professional advocating for you throughout your entire pregnancy.
While I think that your intentions are good, you are misguided. You are suggesting that mrs w needs a psychiatrist to validate her desire for a c-section and that is what may help an obstetrician to provide that? She doesn't need a midwife to advocate for her. Midwives don't do c-sections, and with a due respect, they are not the only care providers who care about women's right and women's autonomy, although to hear a midwife talk, one would certainly think so. One of the reasons I chose obstetrics and gynecology is because I care deeply about women health care, and everything that goes with it. I would never subject a patient to labour against her wishes, with it without a psych referral, thank you very much. She doesn't need it to be validated as a legitimate medical condition. She simply needs a provider who will listen, understand and support. But that someone also needs to be someone who can do a c-section. When I have done patient choice c-sections in my hospital, no one bats an eye, not anesthesia, not nursing, not pediatrics.
DeleteI apologize for giving everyone the assumption that I believe:
Deletea) women need a psychiatry referral for any elective CS
b) that obstetricians do not advocate for their clients
Although I do not believe a psychiatry referral is needed (and shouldn't need to be needed), it would help add some heat on the care providers responsible for the CS. Same goes for the midwife suggestion. It helps having someone in the ring with you...even if that person isn't the one who performs the CS.
My current OBGYN is very supportive of me and I feel that having somebody who can not only provide my prenatal care but also perform the delivery (a midwife is absolutely not qualified to do csections) is important to me. I did 'shared care' last time and despite theoretically having a more receptive view of csections coming from medical background, it did not happen...I will not do shared care again. I am working with a therapist as well, largely to help deal with what happend last time. I do not believe a woman should have to get a psychiatric diagnosis to get a maternal request csection at term - I don't believe I would have gotten one last time. What's ironic is that what happened last time has likely caused the issues I have this time, so likely wouldn't have ever needed a psychologist or to travel to access care if I had received better care last time. Note, last time I would have traveled if it was neccessary to find a provider to have a csection, but I was led to believe that that wasn't neccessary and that ultimately resulted in a non-consensual vaginal birth. I think midwives in bc do a very good job, but philosophically it would be a poor match and would require shared care, and I just can't trust that model of care right now.
ReplyDeleteI should also note (and I could be wrong) that midwives advocate for autonomy, but seem to do so only in cases where it increases the likelihood of a vaginal delivery....so I'm not so sure they actually would support a woman's right to a maternal request csection particularly without a 'medical' indication. Arguably, I'd be in an even worse position if I went with a midwife last time - and what happened still happened....
ReplyDeleteThe point is that a woman should not have to be "mentally ill" to avoid a vaginal delivery if she should wish. She should not need to be "counseled" beyond informed consent. If she makes the choice based on sound medical information and based on personal preference, it should be her choice. Although I understand your point, Ontario nurse, it angers me to think that one needs a diagnosis of mental illness to qualify for a MRCS.
ReplyDelete-The Pragmatist
Agreed. A woman should be able to make this health care decision (and any other health care decision) after looking at the risks and benefits of her options and having a discussion with her health care provider.
DeleteIn BC, I have many consults from midwivery patients for elective repeat c-sections and sections for breech. These patients are still supported by the midwivery model because that is what they choose as best fit for them. The mode of delivery generally only involves one day (physically), and there are 11 other months of care involved.
ReplyDeleteIts unfortunate that you are in the position you are in and I wish you the best of luck. I feel bad that you have to travel out of your community to have the delivery of your choice. I hope it is not to inconvient for you and your family.
I think there's a real difference between an elective repeat c-section and a primary maternal request c-section because a prior c-section is seen as an accepted medical indication for a repeat c-section. It is also my understanding that in order to proceed with a vaginal birth after caesarean that a woman must provide 'informed consent' to do so - those with prior c-sections are very much so (in BC) given a choice as to how the next baby is delivered.
DeleteMrs W had a bad experience with one OB. The idea that a midwife, by virtue of being a midwife, somehow has a monopoly on patient advocacy while a physician must be ultimately self-serving in contrast is just more NCB biased bull-crap. Physicians advocate on behalf of their patients everyday. One bad apple doesn't spoil the bunch and as she says, it makes absolutely no sense to get care from someone not qualified to perform a c/s if a c/s is exactly what you want. Physicians form relationships with their patients too. Would you want someone performing surgery on you that you'd barely spent any time with or would you want someone that had gotten to know you?
ReplyDeleteI think some midwives view obstetricians as their c-section technicians.
DeleteWriting this blog has been very helpful to me in terms of being able to rationalize that it was "a bad apple" and/or potentially one bad care facility. It's hard not to paint the whole system with the same brush, and in the absence of having OBGYNs in BC and careproviders in BC tell me how it works in their practice or their facilities, I might still be thinking that what happend was a much broader problem. At the very least, I know that there exists "good apples", and that provides a certain amount of relief.
DeleteIt is frustrating though not to have better information on the system of care, that its not entirely transparent as to what a patient can expect. Because, also as a result of writing this blog I have come accross other women who have also had bad experiences or who have had a hard time finding a care provider to accommodate their needs. Further, I have come to better understand how much the information on birth needs to be improved upon.