Patient Choice Cesarean, Urgent/Emergent Cesarean or Forced Vaginal Delivery - Is it Really That Hard to Choose?

There's a phrase I hear from healthcare providers and others who oppose patient choice cesarean, "No physician is obligated to perform a procedure that he or she thinks is not medically indicated."

They see the denial of choice as being justified. Perhaps they think that they are saving the healthcare system resources by denying the choice. Perhaps they worry that women are unable to make an informed decision in this regard. Perhaps they see performing a cesarean without medical indication as causing harm, to either the woman or the child.

For whatever reason, there are those, who when faced with performing a patient choice cesarean, will outrightly refuse to undertake the procedure.

This would not be problematic if timely access to an alternate provider who is willing and able to undertake the cesarean can be realized. Unfortunately, under the current system - this is often not possible.

So if a woman cannot access patient choice cesarean when it is needed (either planned at 39 weeks or done urgently after the commencement of labour) - what will happen to the patient?

Perhaps care providers simply haven't thought about this in full - what happens to the woman, pregnant and desiring of a cesarean who is not provided timely access to one? What really happens?

Nature is a cruel wench - she isn't particularly patient, and the woman cannot just delay delivery until she finds a provider and a facility who can accommodate. The woman will eventually go into labour - this is nearly guaranteed. Either a medical need will then arise for a cesarean - in which case an urgent/emergent one will hopefully be provided - or medical need won't arise and at some point the woman will be fully dilated, and given no choice as to what she will have to do whether she wants to or not. She will deliver vaginally. The experience of which is foreseeably traumatic - or at least should be - as the patient will have been subjected to what can only be considered a Forced Vaginal Delivery or an urgent/emergent cesarean where either her life or her baby's is put at risk.

And the thing with traumatic experiences is that they don't just go away - and sometimes they don't ever go away. The physician will have avoided doing what he/she saw as a medically unneccessary procedure - but in so doing will have likely inflicted a rather large emotional toll on a woman as she is entering a very significant life transition.

I can speak to the experience of forced vaginal delivery as it is my own lived experience. I can speak to the toll it has taken on me, and how it has changed me and how having had that lived experience - I would not wish it on any other woman because it is it's own kind of hell.

That is the real choice facing health care providers when women come to them asking for a patient choice cesarean: Do you facilitate the request after having provided informed consent, or do you subject your patient to a Forced Vaginal Delivery or an urgent/emergent cesarean after medical need arises?

A Doctor who Listens: Worth Their Weight in Gold

I appreciate that my experience with the medical system has changed what I expect of it, and has sensitized me to certain things. In particular, I blame part of what happened with my pregnancy and birth of my daughter as a failure of my health care providers to listen and understand what my needs were as a patient, and to facilitate those needs as best they could. I communicated my wishes clearly, and expected them to be respected.

As I've blogged about before, also as a result of what happened, I needed to find a new family doctor. It took nearly a year, but I found one. It is a new relationship - and like any new realationship, it is particularly fragile. We've had a few encounters - and while I think the new Dr. is a good person, I think that it just is not going to work out.

Advocating for oneself in the health system is already a challenge. Recently (now a month ago), I had some female oddness happen - I emailed an OB I knew and asked what I should do about it. I made an appointment with the GP - and the GP's answer was basically to just do another appointment for a pap (no physical was done at that time). I asked for a referral to an OB and that it seemed like a good idea for a pelvic ultrasound to be done. He ordered the ultrasound but refused to do the referral at that time. We did the ultrasound, and I had another appointment with him to discuss the results. My Mirena is partially imbedded in my myometrium. I decided to ask for the referral to the OB I prefer to determine what should be done. My GP is refusing to refer and insists on removing the Mirena himself (a. I'm not sure removal is fully neccessary and I'd like a second opinion on that, and b. if it does need to be removed, I'd prefer to have an OB (and preferably the OB in Vancouver) remove it because if there are any complications the last place in the world, I want to go is Victoria General Hospital). Last Monday his receptionist called - and told me that he'd prefer to remove it - I reiterated the request for the referral. I called today (10 days later) to see if the referral had been put through. It hasn't. This is the last time I'm asking for it - and frankly, this experience has demonstrated that he is not listening to me and makes me question whether or not he would listen to me in the future with any issues that may arise. I am frustrated and annoyed.

I think the hunt for a family physician for the W family is back on - and I foresee going to a walk-in clinic in the interim to get the referral I need to access the care I need.

If anyone knows of (or is!) a family physician in Victoria who is accepting new patients and who listens to their patients - I promise a low-maintenance and grateful young family.

For Spouses of Women Struggling with Birth Trauma

Birth Trauma is hard on women - but its also hard on their spouses and on marriages and partnerships. A post done by the Good Men Project for spouses of those with depression has inspired me to think about what partners of women traumatized by birth can or should do for the women they love as many of the things mentioned in the post resonated with me and my experience. Nobody tells the partners of birth trauma victims how to cope or what to do - and for the most part how can they be expected to know what to do? This post is intended to try and offer some advice to those loved ones, who desperately want to do something, but just don't know what.

Birth Trauma is devastating for women - when a woman is traumatized by her birth, her entire notion of herself as a woman and her role as a mother have been shattered. It can be a massive struggle for a woman just to make it through the day - many moms continually relive their birth experience and accompanied with the demands of motherhood, they feel overwhelmed. Spouses of women might try a gentle approach, they might try a firm approach, they might try to get them to open up, they might suggest things they think will help, they might buy presents and say encouraging things, they might get frustrated and argue. It seems as nothing a spouse does for a birth traumatized woman makes any difference - she just will not move-on. She seems unable to be grateful for all the good that remains.

Spouses of those traumatized by birth need to know, that birth trauma is not about women being in a "bad mood", or being upset because things during the birth didn't go "their way". Birth trauma is serious and debilitating. It is not about women "playing the victim" - or being trapped in "pity parties" - or being "selfish". Having a traumatic birth experience is like being in a car accident, or having your home destroyed by a flood. There might have been things that could have been done (or there might not be anything that could have been done) to avoid what happened - but the traumatized woman never asked for what happened to happen. The circumstances were entirely beyond her control - and if she could go back in time and have things happen differently, she would.

If your wife was injured in a car accident and had several broken bones - you wouldn't tell her to brush it off and continue as though nothing happened. If your wife was car-jacked and assaulted - you wouldn't tell her that sometimes that happens, and she was just unlucky but that she should be grateful to be alive. You would be patient, you would understand that she might be shaken from the experience - that she will likely need time (maybe a lot of time) and rehabilitation. Depending on how bad the experience was you might even have to come to terms with the idea that your wife might never be the same again. She might have to find ways to cope with the lingering injuries, she might not be able to do the same things she used to do, she might not ever be as social or as unguarded as she once was.

This is what birth trauma is.

Just because your wife made it through the birth physically, doesn't mean she wasn't injured psychologically. And just because you can't see the injury, does not mean that it does not exist, does not mean she is not debilitated.

After my daughter's birth, I was left reeling. It has taken years and a lot of therapy and self-care to get where I am. Three and a half-years on and I am not the same as I was and I doubt I ever will be. I won't seek care from Victoria General Hospital if I can avoid it. I am sensitive to feeling like my care providers are not listening to me. I am far more territorial of my person. I avoid movies with birth scenes in them. I am far more critical of those who judge personal decisions. I am less tolerant of intolerance and injustice. I am more skeptical and cynical. I am more angry. There are friendships I have had to discontinue - and other ones that have begun because of what happened. Birth trauma completely changed my outlook on life and who I am as a person.

When a woman is battling Birth Trauma - it is like she is in the deepest, darkest ocean - being crushed by the pressure of the water, and unable to determine the direction in which she should swim to reach the surface. All a woman wants to do is not feel the way she does, to not feel as though the day their child was born was also the worst one of their lives. They want to reach the surface and breathe -they want to swim to shore.

The natural reaction is to throw them a rope and pull them up to safety - to make them "see" how wonderful things are, to not focus on what happened, but on all the good that is. To make them move forward.

The problem is, that trying to pull women from the depths of Birth Trauma - might make things worse. Telling her to be grateful for her healthy baby. Telling her that what happened to her has happened countless times to countless other women. Telling her that she can not let what happened impact her mothering. Telling her to snap out of it and move on. Telling her that she should be happy as other women have it far worse. All these things are just as likely to drive the woman deeper into the trauma - and might add a dose of depression to go with it. Not only will she be unable to swim to the surface for air, the pressure to deny her feelings and needs for the sake of others might well crush her as she becomes a means to an end, rather than an end in and of herself.

For mothers, there is already tremendous pressure to sacrifice and put aside your needs for those of your family. Mothers already fear harming their children in some way by failing to do things the "right way". Mothers fear being labelled, they fear being seen as ungrateful. Mothers fear being judged as being weak - motherhood and birth are a kind of female machismo - and to admit that birth defeated you in some ways, is almost like admitting you are a lesser woman. There is tremendous stigma attached to mothers who are not blissful in their births and motherhood. We have been told from the time we are little girls, that being mothers is what women do and that good mothers are self-sacrificing. It does not matter that by accepting the stereotype of the good mother, we restrict women to biological essentialism - and that the sentiment is decades out of date and harms many women. The instinctual reaction for a mother is to sacrifice herself and her needs - to insist on soldiering on as a good mother does, personal needs be damned! Mothers will revert into themselves, put emotional barriers up and they will shut down. Trying to force a woman to move on, at what is likely the most emotionally challenging time of her life creates far more problems than it solves.

What spouses of the birth traumatized need to do - is to be there for their wives. If and when they talk, listen - refrain from giving opinions, just really listen. Women who are traumatized by their experiences need to be heard - they don't need your opinion about why everything is or should be okay (your body did not give birth). The thing I wanted more than anything, and the times when I felt my husband was really there for me, are the times when I felt validated and heard and sometimes just held. Your wife needs you to not be angry with her. Your wife needs you to be patient while she finds her own way out of the awful - she needs to feel and be safe when talking about it with you. However awful, the things your wife has to say - listen, and when you are done listening reaffirm that you love them still, reaffirm that you will be there for them, however long it takes and wait until they are strong enough to swim to the surface and the shore. Tell her it is okay for her to do what she needs to do for herself. It probably will be hard, you might need some help, but do not give up on your wife. Support her, love her, and be there for her until she gets to shore - she's the mother of your child, it is the right thing to do.

Forced Homebirth in a Hotel Takes BC Maternity Care to a New Low

I believe in access to adequate and timely healthcare to facilitate the needs of patients - and in particular the needs of mothers and their babies. I believe in informed consent. I believe in the prevention of birth trauma. I believe that when moms want access to medical care during pregnancy and childbirth - we owe it to them to provide that access.

Which is why I am scraping my jaw off my desk this today - I am shocked and appalled. I am also incredibly thankful, that for this mom and baby that the circumstances in which they were forced to give birth did not result in any physical harm.

A 17-year, first time mother was 8 days overdue and needed to be induced. They travelled to the Vernon Jubilee Hospital for the induction at 9 am on November 15. They needed to book a hotel room to wait for labour to begin - they returned to the hospital at 3:30 am and despite being unable to walk, the mother wasn't dilated enough and was turned away. They returned to the hotel and sometime after 4:30 am active labour began and progressed so quickly that they could not go back to the hospital. The aunt and grand-mother delivered the baby in the hotel room.

How is this acceptable care? How is this safe care? How does this respect the needs of pregnant women for informed consent and timely access to care?

This is wrong on so many levels. This apparently happened a year ago - I wonder if anything in Vernon has changed since it did?

On Causes

The other week we were flying back from a weekend vacation (a whole weekend of uninterrupted sleep and adult time with my husband) - and I did not have alot of reading material on my iPad and I was tired of scrabble, so I was reading the case law I had pulled sometime ago in support of my case. I was reading the Morgentaler decision - the decision that struck down Canada's abortion law in 1988 - there are so many striking parallels between a woman's access to abortion and a woman's access to planned cesarean. I was thinking how sad it is - how clear the law seems to be on the issues, yet at the same time - how insurmountable the challenge ahead is seeming. I was also thinking about how my experience changed me and mourning the loss of the wife and mother my husband and kids deserved to have - the woman who, had things unfolded differently, would be thinking and doing so many other things - a woman who would not be burdened by a cause.

Having a cause is a lot like having a chronic illness. A cause isn't something you give passing attention to - nor is it something you fully choose - it is the choice you make when the alternative is for whatever reason, unacceptable. It is what is done, when nothing else can be done and doing nothing is reprehensive.

The cause is also a life-preserver - a coping mechanism...it holds out hope that change is possible. That what is and what was, doesn't have to be what will be. Remaining committed to it, means that hope has not yet departed. It means that what happened to me does not have to happen to other women.

I have no doubt with respect to the right of women to expect the same rights as other patients with respect to their healthcare and their abilities to make medical decisions for themselves. There are tremendous barriers to exercising those rights and asserting those rights when they are violated - and those barriers need to be eliminated. That's not a small task - and it will require many who are committed to the changes that matter - mothers, doctors, OBGYN's, midwives, nurses, lawyers, judges and administrators. It will require a certain bravery and tenacity - and those who see the value beyond their own individual experience. It will require research and awareness. It will require resources and organizational capacity.

But none of these things should be seen as unattainable for far more has been found for things that matter far less.

Bad Evidence Drives Bad Decisions

Before I ever was a mom (and even now), I spent a lot of time with health statistics. Health statistics are experiences that have been reduced to numbers - they represent what happens to real people and describe how often specific things happen. Statistical analysis is a tool that is used to help figure out why those things happen - but it is far from perfect and far too often correlation is confused for causation. Equally problematic - the things that are not measured, often go unaddressed. When health statistics are done well - they shine a light on a problem and motivate positive change. When health statistics are done poorly - they keep real problems in the dark and hinder progress. Often, ideology colours the research that is undertaken and the result is a body of evidence that is at best poorly understood, and at worst used to make policy that does far more harm to those who it was meant to benefit.

I have come to the terrible and tragic realization that health statistics done poorly and obscured by ideology are endemic when it comes to pregnancy and childbirth.

It is the only way I can possibly understand the widespread propaganda that is largely focussed on promoting a specific kind of birth (normal birth) and a specific kind of infant feeding (breastfeeding) - even at the cost of the physical and emotional health and well-being of mothers and their children.

It is the only way I can explain Ottawa's and Toronto's public health stance on breastfeeding.

It is the only way I can explain the BC Minister of Health encouraging homebirth last year.

It is the only way I can explain all the "failure" felt by women who do not manage to have a normal birth or to breastfeed - all the while ignoring whether or not it really matters in the first place.

It is the only way I can explain why cesareans and VBACs are used as system measures, but rates of psychological trauma are not - it is also the only way I can explain why the costs associated with birth seem to end 6 weeks post-partum.

If health statistics and research in this area were being done well - the things that really mattered would be measured and better understood. If that was the case, maybe I wouldn't get the feeling that we are being penny wise and pound foolish, and short-changing the health and well-being of women and their children in the process.

Baby, I'd like My Boobs back - Thanks, Love, Mom

I've breastfed my son far longer and far more than I thought I would. I got a little lazy around Christmas last year and neglected to bottlefeed him for a few weeks. At the end - he wouldn't take a bottle. No way, no how. Not of formula, not of pumped boob juice. If it wasn't my boob, he didn't want it. I have been booby-trapped ever since.

It's kind of worked for us though. Aside from the night shift, where my now 14 month old toddler still insists on waking several times a night for some snuggles and some evening nourishment. I mean what's a little sleep deprivation - who really needs more than 3 hours at stretch anyways?

But the Mr. and I would like to go away for a weekend...and well...the boobs cannot be left behind. Furthermore I am ready to move on and would really like to get maybe a 6 or 7 hour stretch of sleep on a consistent basis. So, there's weaning ahead. And if my experience of weaning his big sister from the bottle is anything to go by, well, I don't imagine it'll get any easier - so I may as well bite the bullet and get done with it. That and leaving my mom with a baby who isn't yet weaned for a weekend seems kind of cruel...so best to get a start on it before that happens.

I get the sense that the wee little W won't be happy - I also know he'll get over it, and he'll still love me, because I'm mom and that has a lot of sway - even if it doesn't come with an all you can eat boob-fet.

But the WHO and their 2 year recommendation can go find a different boob to suck as mine are retiring in the very near future!

Ottawa Public Health Responds

I'll leave the following response from Ottawa Public Health with my readers:

Hello Ms. Williams,

Thank you for your valuable feedback on the Ottawa Public Health Make An Informed Decision About Feeding Your Baby web-page.

In 2013, Ottawa Public Health met the provincial requirement to qualify as a World Health Organization designated Baby-Friendly Initiative health facility. Our website was reviewed by assessors experienced in infant feeding to ensure quality and currency of the information. Our information sources include the World Health Organization, Health Canada, the Best Start Resource Centre.

We wish to reassure you that OPH strives to support all families regardless of the infant feeding decisions they make. Support is available for mothers who are breast-feeding, bottle-feeding with breast milk, or formula feeding. Avenues for offering information and support include prenatal education, Baby Express drop-ins and the Ottawa Public Health Information Line.

We are committed to meeting the needs of our community. The way in which information is presented on our web-site is being reviewed with your concerns in mind.

Many thanks for your interest in this most important subject.

Regards,

Tania

Tania O'Connor, RN, B.Sc.N

Supervisor (A)

Ottawa Public Health

Health Promotion and Disease Prevention

If that is what assessors experienced in infant feeding consider "quality and current" information - we have to ask ourselves, who are these people and why do they hate mothers who do not breastfeed so much?

Dear City of Ottawa: Lactavism is NOT Public Health

The other day, I was outraged by something a friend in Ottawa had pointed out on one of the discussion boards I participate in - I was shocked that a body of government would stoop to such a low level of unabashed fear-mongering and outright lactavism. It is one thing to find such things on biased webpages (The Alpha Parent, The Feminist Breeder, Natural News, etc.), but quite another to find something on the Public Health page of a major Canadian city. I always believed that such organization would hold themselves to a much higher standard - that they would have people employed who were actually committed to the health and well-being of women and as a result would be more immune from this kind of garbage.

This is not about making an informed choice - that would mean encouraging women to have a discussion with their doctor about what is best for themselves and their babies in their particular circumstance. This is about fear-mongering and bullying moms into breastfeeding and that is wrong. The information on this page is exclusively about the benefits of breastfeeding and the risks of formula feeding. There are no sources provided or even statistics on what the actual relative risks are. According to this page, breastfeeding is the magic bullet that is the golden brick road to good health, and formula feeding is plagued with illness, obesity, tooth decay, cancer and death.

I can only imagine how such information would be received by a new mother - who like all mothers, only wants to do the best for her child. How this information might drive such a mother to make truly bad choices with regards to her own health and that of her child - including buying unscreeened breast milk from donors over the internet rather than feeding her child formula, or waiting until there is a health crisis to switch to formula - and then feeling terrible about it.

That is not good Public Health.

So I emailed the City of Ottawa (and would encourage you to do the same - they can be reached at healthsante@ottawa.ca ) the following:

Dear City of Ottawa -

I am a mother and I write out of concern about the following webpage: http://ottawa.ca/... that purports to encourage women to make an "informed decision" regarding infant feeding. I am disappointed that the City of Ottawa would consider such a webpage appropriate or helpful to mothers.

Many mothers, for whatever reason, find that breastfeeding is not appropriate for themselves in their particular situation. Some mothers do not make enough milk. Some mothers are survivors of childhood sexual abuse and find breastfeeding psychologically difficult. Some mothers must return to work in order to economically provide for their children and cannot accommodate breastfeeding. Some mothers are on medications that are not compatible with breastfeeding and pose risks to the infant. Some mothers find breastfeeding painful and inconvenient.

These women need to know that formula feeding is a safe and appropriate option for meeting the nutritional needs of their babies and they need clear instructions on how to formula feed appropriately.

The webpage by the City of Ottawa is nothing less than fear-mongering and does little to provide for the informational needs of mothers. Worse, the information provided by the City of Ottawa may inflict emotional harm on many women - as they are lead to believe that the choice to formula feed will lead to tooth decay, obesity, cancer and death.

All women deserve to be supported during pregnancy, childbirth, and the year post-partum - and the City of Ottawa has determined that it should make women who for whatever reason need to formula feed to feel worse than they already do. Please revise the information on your website to be more balanced and sensitive to the the emotional and informational needs of mothers.

Sincerely,

Janice Williams

Perhaps if more women take a stand against this kind of garbage - it can be treated as the toxic trash it truly is.

Canaries in a Coal Mine: Birth Trauma Survivors

The experience of the birth of my daughter has been by far, the most negative experience of my life - it was the most terrifying, most painful, most disempowering, most psychologically wounding and dehumanizing thing that I have ever known. The only saving feature is that my daughter emerged from that experience, ultimately unscathed - and for that I will always be grateful. It was the kind of experience, that having had it - knowing it first hand - you would do anything to prevent any other human from experiencing the same. Indeed - I expect that I never will be the same, that I never will look at things in the way I would have had I never known Birth Trauma.

Much as veterans look upon war with different eyes than civilians, or, those who have never known war - survivors of Birth Trauma look upon birth much differently. They see the destructive potential of birth, they know it can decimate the lives of women and their families. Their struggles in the aftermath are often silent - the stigma of admitting that birth was not what you thought it should be, that birth was negative - is often too great. Their pain is often dismissed (this is particularly true if the child born of the birth is ultimately healthy). So rather than learn from them, rather than honour them, rather than help them in whatever ways are possible: we expect them to get on with the business of mothering.

And that is shameful, because these mothers see what others can not: the toxicity of the system and the culture that is prevailing. Birth Trauma victims are the literal canaries in a coal mine. Furthermore, by empowering these women, to speak up and speak out about their experiences AND just as importantly, to HEAR what they have to say and to LEARN from them- it is possible that the system could change. That other women might avoid the same suffering - or that when such suffering happens, that maybe it doesn't have to be as damaging.

The experiences of Birth Trauma victims are awful - worse is to fail to take the opportunity to learn from them and to prevent others from enduring the same harm.

Supporting Maternal Request Cesarean - Legal Action

Fingers crossed - I'm hoping a more personal touch to fundraising might increase the amount of support we have available to move forward with the case. Today, I launched a GoFundMe campaign - it provides a good background of the case and the amount of money that might be needed to move forward and mitigate the risk of a loss. I note that any monies raised in excess of what is actually needed will go towards establishing a Community Contribution Company that will support projects aimed at improving the health and well-being of women who are pregnant, childbearing or new moms - and will take over the Maternity Legal Action Fund once established.

Wish me Luck.

Feedback on Ontario's Report "Caesarean Section Rate Review: An Evidence-Based Analysis (DRAFT)" by N. Degani and N. Sikich

Health Quality Ontario is asking for feedback until October 24, 2013 on one of their reports. Here is what I have submitted to them via email:

October 23, 2013

Feedback on: “Caesarean Section Rate Review: An Evidence-Based Analysis (DRAFT)”, N Degani, N Sikich.

Dear Health Quality Ontario –

I am a caesarean by choice mom, a birth trauma survivor, and founder of the facebook group, “Cesarean by Choice Awareness Network” – furthermore, I am a health economist with more than 10 years experience. I am writing to provide feedback on your recent report entitled, “Caesarean Section Rate Review: An Evidence-Based Analysis” from a Caesarean by Choice perspective.

First – let me express that many mothers with a caesarean birth preference are concerned about over-zealous policies aimed at limiting access to caesarean section as they feel that their right to make a medical decision in conjunction with their health care provider about how their baby is to be born will be disregarded. Many mothers with a caesarean birth preference in Ontario (and the rest of Canada) already have a difficult time accessing compassionate care that meets their needs. Those that do find compassionate care – often fear going into labour prior to their caesarean date and having to contend with an on-call OB who does not agree with their treatment plan. Some women are forced into unwanted vaginal deliveries that have significant ramifications both physically and psychologically. Some women who cannot access maternal request caesarean either forego having children that they want or choose to terminate pregnancies rather than face the prospect of an unwanted vaginal delivery.

In terms of the economic impact of caesarean delivery on the system (page 13) – I would urge caution. There is a great deal of variation in the expected costs of caesarean delivery with emergent caesarean deliveries costing significantly more than elective caesarean deliveries. I would also suggest that the expected cost of a planned vaginal delivery is underestimated if it does not include the cost of emergent caesarean deliveries as the vast majority of emergent caesarean deliveries are the result of failed planned vaginal deliveries. Further – I would urge the economic evaluation of caesarean delivery to include the downstream cost savings/expense and that limiting the cost component to the birth and a limited time post-partum likely gives a very inaccurate picture. There are grave and expensive consequences to a vaginal birth that departs from a healthy outcome for both mother and child. In the fall of 2011, the National Institute for Clinical Excellence (NICE) in the UK, updated its clinical guidance on the use of caesarean (CG132) and found that the cost difference between planned vaginal delivery and planned caesarean delivery was just £84 after considering the increased risk of urinary incontinence associated with vaginal delivery .

Lastly, let me express my concern that maternal health policy that is focussed on achieving specific rates of types of deliveries is ideologically based, misguided and undermines the health and well-being of many women and their children. If reducing caesareans results in an increase in the number of late-term still births due to a reluctance to offer a timely induction – that is a worse outcome than a caesarean section. If reducing caesareans results in additional third and fourth degree tears or extensive damage to the pelvic floor – that is a worse outcome than a caesarean section. If reducing caesareans means limiting access to those who would choose it, and that results in traumatic deliveries – that is a worse outcome than a caesarean section. If reducing caesareans results in larger numbers of children grappling with life-long severe disability, such as those that result from intra-partum asphyxia and brachial plexus injuries, those are worse outcomes than caesarean sections.

Further – efforts to reduce caesarean sections often focus on the safest caesareans, planned caesarean sections. These are also likely to be the least traumatic and expensive caesareans. As such – such efforts are unlikely to have the economic impact that is desired.

Maternal health policy needs to shift to focus on the outcomes that matter – physically and emotionally healthy mothers and babies. Policy that is focussed on caesarean rates and managing them does little to address the health needs of mothers and babies and substitutes ideology for quality care.

Sincerely,

Janice Williams, MA (Econ)

Mommy War Criminals and Heroes

I have a real disdain for the "Mommy Wars" - they have turned mothers against one another, and have distracted women from working together to identify and solve the very real problems with which modern women and families must contend. As a result of the "Mommy Wars", motherhood has become a polarized battleground with women arguing and criticizing the specific choices that other mothers make. There's been a whole lot of yelling, and not a whole lot of listening - many mothers have become caricatures and even more have become casualties. Worse yet - the focus on what really matters has been lost and opportunities to realize progress on the issues faced by women who happen to be mothers have been foregone.

This is not to say I do not think that there is not a war to be fought - there most certainly is, but it should not be women waging war on one another, but rather women waging war on the substantive problems faced by women as they contend with motherhood.

I think that the emotional health and wellness of mothers is worth fighting for - this means that resources need to be directed into better understanding and addressing the mental health needs of mothers. There is a lot about modern motherhood that is emotionally toxic to women - from unreasonable expectations about what being a "good mother" is to the stigma associated with admitting difficulty in coping with the circumstances in which a woman finds herself.

I think the physical health and wellness of mothers is worth fighting for - this means enabling women to have timely access to adequate healthcare that promotes and maintains health and wellness. This also means that mothers need to be full partners in their health care and given evidence based information on their choices and empowered to make the choices that best meet their needs and those of their families. It also means that more research on the physical health and wellness of mothers needs to be undertaken - including research on the impacts of pregnancy and childbirth that goes beyond pregnancy and the 6 weeks post-partum.

I think the economic health and wellness of mothers is worth fighting for - many mothers face substantive challenges with regards to being economically healthy. Mothers need tools and support to address the economic challenges they face constructively and to make positive steps towards economic adequacy.

People who blindly promote an ideology and make mothers feel bad about their choices in order to feel better about their own choices - should be considered mommy-war criminals.

In contrast, people who work to support the emotional, physical or economic health and wellbeing of women who happen to be mothers should be celebrated as heroes.

Four Score and Four Years Ago

Four score and four years ago today, the Supreme Court of Canada decided that women were "persons" under the law, after a group of brave women fought to be recognized as such. It was one of the first steps towards women asserting their rights under the law. It paved the way for women to own property and to vote. It paved the way for many of things that women take for granted now. It also highlights how much work there is still to be done, particularly when I think of the treatment of pregnant women in Canada today.

So happy persons day - might we get to a place someday where it is recognized that pregnant women are persons too - persons entitled to informed consent and patient autonomy.

What motivates me?

I view what happened to me as a deprivation of my human rights as a patient and as a woman to make a medical decision for myself and expect that decision to be reasonably respected and facilitated. I gave informed consent for a specific medical procedure (cesarean - or if labour commenced an urgent cesarean) - I knew the risks and benefits of both planned vaginal delivery and planned cesarean delivery and I chose cesarean. When I was deprived of that choice, without warning and without consultation - and a wholly different procedure was imposed upon me (vaginal delivery) - it is difficult to convey how disruptive that was. When I later discovered that such deprivation was without just cause, I was shattered. All my life, I was raised to believe that I had dominion over my own body. I had the right to consent what happened to it. I had the right to not have that right interfered with - and I believed that that right was protected by the Canadian Constitution via the Canadian Charter of Rights and Freedoms. I never believed that choosing to be pregnant would be adequate cause to deprive me of my human rights.

Yet, there I was - stripped of a fundamental human right. There I was, a well-educated, well-informed, confident woman - believing I was entitled to informed consent and respect for my medical decisions and being deprived of both. I never believed it could happen to me, until it did. And, if it could happen to me - then what is to stop it from happening to any other woman? What is to stop it from happening to my daughter?

And after it happened, came the hard questions - What was I going to do about it? What could I do about it? It is all well and good to think that you have rights, but unless you can hold others meaningfully accountable for violations of those rights, did you ever really have the rights to begin with? If I wasn't willing to find some way to hold those who deprived me of my rights accountable - could I expect other women to? If those responsible for depriving pregnant women of their rights to informed consent and autonomy were never held to account, how is it possible for such violations to stop, for the system to change? How is it possible for victims of those violations to move on with their lives without any recourse or acknowledgement that they were wronged in a most serious way?

It is sad when those who find themselves deprived of their rights are left bereft of meaningful recourse - it adds insult to injury. Yet, the way the system currently is, recourse remains tremendously risky and out of reach for many patients who have been deprived of their right to informed consent and autonomy - including pregnant women. In Canada - the healthcare system is structured in such a way that deprivations of rights are almost certain to be free of meaningful consequence. In Canada, defendents (doctors and hospitals) have the full resources of the Canadian Medical Protective Association at their disposal to defend against any patient brave enough to bring forward a claim. Meanwhile patients are left struggling to find access to justice, struggling to find a lawyer to take on their claims, and struggling with the risks that pursuing a claim might involve. In Canada - if a patient brings forward a claim and fails at trial, not only will they bear the costs of their own litigation, but the defendents may also be awarded costs adding further insult to injury. In Canada - damages tend to be so limited that many cases involving deprivations of patient rights, absent catastrophic injury or loss, are simply uneconomic to pursue. In Canada, access to justice for patients wanting to assert their rights is effectively barred.

It is a vicious cycle of human rights violations that will continue. The system will continue to operate as it does, unless it becomes uneconomic to violate patient rights to informed consent and autonomy. It won't become uneconomic to violate those rights, unless patients demand accountability when those rights are violated. Patients will not can not demand accountability, unless they are enabled to do so.

I am determined to assert my human rights and demand accountability for the violation of those rights - the question is, will I (and others) be enabled to do so? Will those who can help make this happen, step forward?

That is what motivates me.

#ForMiriam

Miriam was a mother who paid the ultimate price for having a post-partum mood disorder - she was killed the other week in Washington, D.C.

I do not know the specifics in Miriam's case - I do not know if she had sought help or if she was screened for mental health problems. I do not know if she hid her issues.

What I know is that a young mother is dead - she is not the first, and sadly, tragically - she will not be the last; because of a post-partum mental health issue.

What I also know is that we need to do a better job when it comes to maternal mental health. We need to do a better job of understanding the reasons some mothers face mental health challenges in the months and years following birth. We need to do a better job of identifying mothers at risk. We need to do a better job of treating mothers who face mental health challenges. We need to do a better job of making sure that when a mother faces a mental health challenge - she can access the resources she needs in a timely way. We need to do a better job, when possible, of preventing psychological damage as result of childbirth.

The fact that another mother has lost her life to a post-partum mental health issue is sad and tragic - if we continue to not do anything to do better - that is a travesty.

#ForMiriam

Post-Traumatic Growth after Childbirth Trauma

It has now been more than three years since my daughter was born - and while my recollections of her birth remain highly negative (I suspect they always will be) and at times intrusive and disruptive (thank-you post-natal PTSD) a lot has happened in the time since, that has been and has the potential to be tremendously positive. I am currently at a place where I am more focussed on how to move forward in a positive and meaningful way - rather than being mired in the past. I believe, as a result of the efforts I have made to understand and heal from the experience - I have been fortunate to benefit from what is known as Post-Traumatic Growth.

In the immediate aftermath of the birth - I was over whelmed and distressed. I believed, that I did not matter - that I had no right to decide what to do with my body, that I was not even entitled to feel badly about the birth because I had a healthy baby and there were countless women who would happily trade places with my circumstances. My beliefs about who I was and what my rights were, and how the health care system worked were completely rended asunder. My trust both in the system, and in my own doctors was decimated. I did not feel I could share my thoughts and feelings, with even my husband - for fear of being labeled ungrateful for all that I did have, for fear of being labeled or thought of as a "bad mother". I quickly learned that few would understand and that many would hear my complaints as trivial whining. My initial response was to just try harder at being a "good mother" - after all, I had been told that I was "good at birth" - so why not repress the fact I hated it, that it felt like such a violation, an extreme cruelty. I dove into a mother's group - and tried to see the benefits of natural birth - the thing that most of the women there had aspired to. I suffered silently, often breaking down in the shower or in other fleeting moments that I had to myself and put on a brave and stoic face.

The thing I've learned about trauma, is that repressing it and suffering silently does not work - or at least it wasn't working for me. It bred cynicism. It bred anger. It bred flashbacks. It bred distraction. It bred shame. It bred isolation. It bred depression and anxiety. It bred resentment. It bred helplessness, and hopelessness. When I returned to work - I was marginally functional, and the ample amounts of time in front of a computer looking at health statistics did me very few favours. I needed to do something, so that at the very least, I would not lose my job.

That was when the real work of trying to address and heal from the experience began. I could not continue doing what I was doing (repressing the experience and trying to accept what had happened) - it was making me angry, and cyncial, and negative. If I did not do something that worked - I would risk losing my job, losing my husband, losing everything that mattered in my life - including myself. I owed it to my family and to myself to at least try to not let what happened to me - consume every last part of who I once was.

It was then that I started to really blog. I needed to get what I was thinking, out of my head. I needed to really think about things, I needed to process them.

I also needed to know what really happened (I still do) - and to do what I could to prevent the same thing from happening to others.

I wasn't really expecting everything that has happened as a result of blogging. I wasn't expecting the blog to even be read all that much (we are now at nearly 70,000 hits). I wasn't expecting to change minds on the issue. I wasn't expecting to help other women. I wasn't expecting to meet other women who were as passionate and concerned about the issues facing childbearing women as I was. I wasn't expecting to learn as much as I have learned. I wasn't expecting to create a facebook community of likeminded women "Cesarean by Choice Awareness Network" or be instrumental in the creation of a legal action fund that is focussed on protecting the rights of childbearing women to informed consent and timely access to care (the Maternity Legal Action Fund). Yet - that is exactly what has happened.

Looking ahead, my goals are clear: keep going, keep growing - there is still much work to do.

Value Women and Children: Medicalize Birth!

There has been a real push to normalize pregnancy and childbirth - a real rebellion against the "medicalization" of childbirth by governments, midwives and some doctors. Some patients have also bought into the idea that pregnancy and childbirth are not diseases, and should not be treated as such. Unfortunately - in the drive to save money and preserve market share - the reality that pregnancy and childbirth is a condition that brings with it significant health vulnerability for both women and their children, seems to have been forgotten. The idea that the choices a woman makes during pregnancy and childbirth are medical decisions that are deserving of informed consent and respect, also seems elusive.

Pregnancy and childbirth, in modern developed countries - are not normal states of being for the vast majority of women. The normal state of being for an average Canadian woman is not pregnant or breastfeeding - these are brief diversions from normalcy that typically occur 2 or 3 times during a woman's lifespan - assuming a breastfeeding duration of a year, this accounts for a mere 4-6 years out of the 30 years that are considered "childbearing". It is not normal to gain - and lose 35 or more pounds in the space of two years. It is not normal to be nauseaous for months on end. It is not normal to be winded after ascending a few flights of stairs or to be in immense pain from activities that in a non-pregnant state are of no-consequence (ie. a shopping trip to costco with a full cart, mowing the lawn). It is not normal get all kinds of unsolicitated advice on how you should conduct yourself. Further, it is not normal to be at such a heightened risk of death or long-term disability as is the case with pregnancy, childbirth, and the year post-partum. Indeed - there is little about the state of pregnancy, childbirth and the year post-partum that should be considered "normal".

Indeed, it is the degree of health vulnerability while pregnant, childbearing and the year post-partum that makes it ideally suited for "medicalization" - after all there are few conditions where the application of intervention can have such a profound impact on the ultimate outcome for both mothers and their children. As such, the choices during pregnancy, childbirth and the year post-partum, should be considered medical decisions and given the same degree of deference -in terms of informed consent and respect- as decisions that are made with respect to any other medical condition (many of which are far more benign than pregnancy and childbirth).

Indeed, neglecting to recognize the profound need to medicalize pregnancy and childbirth can have profound consequences. Neglecting to recognize the need for folic acid supplementation leads to preventable cases of neural tube defects (they range from relatively minor cases of Spina Biffida to profound disabilities that are incompatable with life such as Anencephaly). Neglecting to identify gestational diabetes and respond accordingly leads to over-sized babies that are at risk of delivery complications (ie. shoulder dystocia) and other adverse events including stillbirth. Failing to identify and respond to pre-eclampsia (abnormally high blood pressure) can result in maternal death. Neglecting to address the potential for a severe tear, and the adverse consequences of a severe tear or to improperly repair a severe tear can lead to urinary and or fecal incontinence, pelvic organ prolapse, and sexual dysfunction. Failure to provide access to effective pain relief (ie. epidural), leads to profound suffering which may be associated with longer-term psychological problems such as post-natal PTSD. Failure to provide timely access to cesarean delivery may also inflict considerable harm to both mother and child - and the choice of planned delivery method is a significant one.

In closing, I believe that the greatest disservice we can do to women and children is to demedicalize birth - decisions that are not “medical decisions” do not demand informed consent. Conditions that are not “medical conditions” do not merit research or the scientific process – and do not benefit from the improvements that result. If we value women and children, as humans – the very least we can do, is medicalize an event that has a profound impact on their health and well-being over their lifespans.

This isn't the third world - so why adopt maternal health policies that pretend it is?

I think the level of health care access and health outcomes for mothers in developing countries is nothing short of atrocious. It is a tremendous tragedy when women and children die preventable deaths every day while giving birth. It is heartbreaking to think of conditions that have been obliterated in the developed world, being common place in the developing world (ie. obstetric fistula). Access to safe cesarean section and epidural pain relief, is simply beyond the reach of what can be offered to those mothers - the resources are simply not there. When thinking of the stark reality of birth, for many women who truly have no choice in the matter, what we have access to here - IS amazing. There is nothing romantic or empowering about the situation. It needs to be addressed - and I applaud the many organizations that are working on addressing and improving maternal health in developing countries.

However, it is a real shame that the deplorable conditions in developing countries are used as some kind of excuse for denying and ignoring the needs of mothers in developed countries. This is because failing to address the needs of Canadian mothers does nothing to address the needs of mothers in developing countries (newsflash: the government won't be sending the money they didn't spend on your healthcare to a provider in a developing country) and it also ignores the responsibility and desireability of actually meeting the needs of mothers in developed countries. The mentality that one should be grateful for what they have, ignores the need for improving upon the status quo. It's great that we do better than the developing world - but is that really the comparator that we want to use?

Setting health policy according to the lowest common denominator - particularly with regards to women and their health issues should be deplored. We don't set health policy for diabetes care or cancer care according to what is accessible in the developing world - so why are we keen to do so when it comes to issues around pregnancy and childbirth? Why are we keen to oversell vaginal unmedicated delivery and breastfeeding to mothers in the developed world while ignoring the valid choice of cesarean delivery and formula feeding? Why are we so keen to discount the value of being free to make such decisions in the first place? Policies to discourage cesareans absent medical neccessity and to encourage breastfeeding -might make a lot of sense in the developing world, but we should be strongly questioning such policies in the developed world as they may be costing many mothers very dearly in terms of their health and wellbeing.

Mothers are not lesser Women

I am severely disturbed by the prevailing attitudes with respect to mothers – in short I think that there is far too much enthusiasm for telling women who happen to be mothers, what to do with their bodies, and that the person to whom the body belongs has long ago become an afterthought. In short, I fear that we have let an entire group of women (and a rather large one at that), become a lesser class of people because they have taken it upon themselves to reproduce – to ensure that there is a future generation. We have allowed these women, to be reduced to their breasts, vaginas and uteri – and that is wrong – because it neglects the most important body part a woman has, her brain.

Yes, having a healthy baby matters – it matters a lot, and it particularly matters to mothers. However, having a healthy mother also matters – and that is where extolling the virtues of specific choices – like vaginal delivery and breastfeeding, neglects the person who must undertake those activities. That is where having performance measures that reflect these choices is doing a huge disservice to the health (and particularly the mental health) of mothers.

We have come to a place, where rather than informing the individual woman of the risks and benefits of her choices and allowing her to make the decisions that best meet her needs (and those of her family) and respecting those choices – we have told her what choices to make. By extolling specific choices, we tell certain mothers that they have succeeded, but we have also told certain other mothers that they have failed. What is sad, is that many of the women who we have told are failures – haven’t failed at all, rather they have made the choices that best meet their needs and those of their family best. Yet, there is a lot of stigma and shame that attaches to things like having a caesarean section or formula feeding a child.

There has been a lot of lip service to caring about the needs of mothers – but very little recognition of a mother’s need for bodily autonomy. Is it any wonder that many mothers find themselves depressed?

Mothers Matter - Thoughts on Maternal Suicide and Suffering in Canada

The Canadian Medical Association Journal editor – Kirsten Patrick - believes that maternal suicide needs more attention - I agree, however, why wait until mothers are dead to examine what is wrong and do what needs to be done to prevent harm?

When a mother decides to take her own life it is an outright tragedy – a family is shattered, and often times the lives of her children are also in jeopardy. The fact that Canada does little in comparison to other countries to better understand and address the issue is a shameful reflection on Canada and its commitment to those who decide to bear children. In the UK and in several other countries, there is a case-by-case analysis of maternal deaths. If we bothered to do the same we might learn a lot about what can be done to prevent such a tragic outcome.

That being said, why wait until a mother is dead to examine whether or not the needs of those bearing children are being met? Those who ultimately take their lives are likely a very small portion of the mothers who suffer as a result of childbirth. We need to better understand the impact of childbirth on women in Canada – and we need to go beyond what we currently use as performance measures of our maternity care system (whether or not a caesarean was performed, or a VBAC was attempted IS very superficial). We need to go beyond the period of pregnancy and the 6 weeks’ following birth. We need to go beyond administrative data - data that reflects only on what was actually done and does not reflect at all on what SHOULD have been done. We need to invest in mothers by investing in better information – information that could actually be used to improve the system of care and prevent the most tragic outcomes. We need to invest in mothers by investing in better care in the first place. We also need to invest in supporting mothers and demanding accountability for when mothers are failed either by the system or those who care for them.

In the aftermath of my daughter’s birth – I experienced the most negative emotions I had ever felt in my life and have had some of the darkest thoughts. Anger. Betrayal. Pain. Inability to concentrate. Terror. Isolation. Shame. Disempowerment. Disillusionment. Feeling as though I no longer mattered and that I did not even have the right to be angry about it all (I had a healthy baby, after all). Feeling as though asking for accountability for what happened was asking too much. Feeling as though the only thing I could do was suck-it-up and move on, and at the same time being completely unable to actually move on. Feeling as though others were at risk for the same thing to happen to them. These thoughts that absent the hope that things will get better, that things can get better and that I still had much to be very thankful for -are likely not much different from those that plague the mothers who take their lives. I am very thankful, that hope never left – even with what had happened and the damage it had done. However, I remain very angry as I see that what happened to me was entirely preventable.

Yes, there is a pressing need to better understand why mothers commit suicide – but it is just the tip of the iceberg. There is a pressing need to understand the whole toll of having children on Canadian mothers – and doing what can and should be done to minimize that toll. A superficial examination will continue to fail to address the real needs Canadian mothers as it will fail to enable an understanding of what is wrong in the first place. Looking only at mothers who eventually kill themselves, is still a superficial examination of the broader problem. Further, unlike Kirsten Patrick – I believe that we may even have to (and should – for in some cases the mothers are the last people who are “at fault”) lay some blame and demand accountability in order for things to actually change – particularly if part of the reason mothers are suffering is a result of glaring violations of patient rights and negligence in care that have gone undetected and unaddressed for far too long.

A Good Cause – Protecting Every Woman’s Right to Informed Consent

In recent weeks, I have been busy – preparing to return to work, and figuring out how to move forward in a way that recognizes the needs of my family and my own personal needs. I have a personal need to know exactly what happened with respect to my daughter’s birth. I have a personal need for accountability for what happened. I have a personal need to gain some confidence that the same thing will not continue to happen to other women. My family needs me to meet my personal needs in a way that does not put at risk our financial and emotional well-being.

This has posed a tremendous problem – on one hand, the only way to get answers and accountability for what happened AND to ensure that the same thing does not continue to happen is to litigate. On the other hand, litigation is tremendously expensive and risky. There are many, very good, reasons why very few women ever sue as a result of their birth experiences in Canada – and now, I can say I am familiar with all of them. The problem is that because women do not, or rather cannot – assert their rights, those same rights are at risk of being disregarded.

I do not believe that I am alone in my experience. Far from it. Nor do I believe that anything will ever really change, unless the incentive structure in maternity care is changed. I believe women are entitled to informed consent and that they should be reasonably entitled to make choices in childbirth. They should be able to choose to pursue a vaginal delivery or a caesarean delivery. They should be able to choose to have an epidural or to forego pain relief. They should be able to have a discussion regarding the risks and benefits of their choices and to expect reasonable access to care to facilitate their choices.

This is not about natural or normal childbirth versus medicalized childbirth – this is about informed consent, timely access to care and minimizing the very negative consequences that can result when a woman is deprived of informed consent and timely access to care.

At this moment – I am hopeful, because in recent weeks an amazing group of women have established what could be capable of transforming maternity care in Canada.

I am overjoyed at the launch of the Birth Trauma Canada Maternity Legal Action Fund – and I look forward to the difference it will make.

Being "Open" about "Cesarean by Choice"

It is not easy being a cesarean by choice mom - either, you are open about your views on how you prefer your child is born or you keep them private with a very tight circle of "need to knows", with only your doctor, your husband and yourself knowing about your choice. In the worst scenario you repress doing what you really want to do and subject yourself to a process that you find, well kind of horrifying, all because a bunch of people who may not even be in the delivery room or changing the dirty diapers afterwards think it is what you "should" do.

I have come to the conclusion, that how women prefer to birth, is a part of "who" we are - and maybe women should not be so quick to hide or repress that part of ourselves - or at the very least women should should not hide it anymore than women would hide any other aspect of ourselves. That is not to say that women should not discuss the available delivery options with our care providers - along with their respective risks and benefits. That is also not to say that women should make choices based on misconceptions about the options available - if it is purely the pain of vaginal delivery that is the problem, then there might be appropriate alternatives to address that. But rather - we should be free to make a *medical decision* for ourselves, and to be comfortable with those choices, regardless of what they happen to be.

I think there is a lot of damage done, when how women prefer to birth is some kind of taboo, where only the dominant choice is seen as being socially acceptable. I think it is awful, that many women who prefer to birth by cesarean - feel the need to be ashamed of that choice. I think it is awful, that women cannot respectfully discuss their preferences with respect to birth. I believe women who prefer cesarean are just as deserving of a supportive community as those who prefer natural unmedicated childbirth, or medicated vaginal delivery. I believe women who prefer cesarean are just as deserving of access to care that respects that choice. I think that by failing to recognize cesarean by choice as valid - myths about cesarean and vaginal birth are allowed to remain, and instead of supporting each other to make the best choices for ourselves, many women either make a personally wrong choice or feel isolated by the choice that they have made.

Being cesarean by choice, is as much a part of me as being a mother, being an economist, being an agnostic, being a liberal, being a wife, being thirty-something - and I am not ashamed of that.

What is a Good Birth?

I recently read an article interviewing a doctor who had conducted a large study "The Good Birth Project" and then had written a book A Good Birth: Finding the Positive and Profound in Your Birth Experiencewritten by a doctor, Anne Lyerly, MD. In the interview, Dr. Lyerly summarizes 5 characteristics that make. Those characteristics are described as being:

1. Agency: a good birth is one in which we have a hand in shaping, that is informed by the things we value – a birth in which we feel involved and present.

2. Personal security: a good birth is one in which we feel safe and secure, in trustworthy hands.

3. Connectedness: the degree to which we feel meaningfully connected to our loved ones, our care providers, and of course our baby.

4. Respect: a good birth is one in which we feel others respect us, our newborn, and more broadly birth as a meaningful event in our lives.

5. Knowledge: a good birth is one in which we have enough information before and during the event that we have a sense of what is happening and why; but it also depends on the wisdom we garner by virtue of going through it.

Dr. Lyerly goes on to say that

these things can all be cultivated no matter where you give birth (home, birth center, or hospital) and no matter how (vaginally or by cesarean).

What Dr. Lyerly had to say about what makes for a good birth truly resonated with me - and I feel that many women who choose cesareans are wanting "Good Births", births that meet their individual needs for agency, personal security, connectedness, respect, and knowledge. I know that my planned cesarean with my son was truly "A Good Birth" - and I can conclude that it met all of Dr. Lyerly's criterion for a good birth.

Applying the same lens to my daughter's birth, only highlights the unnecessary challenges that many cesarean by choice moms face - and in my own case highlights how big of a chasm there is between the "Good Birth" I sought and the one I was ultimately left to reconcile.

If the interview is anything to go by - I have a new book on my reading list.

Feminism: It's About Having Choices and the Freedom to Make Them, Not the Choices Themselves

I'm an economist, as such, I have spent a lot of time in my career thinking about choices, and how people make them and trying to understand the conditions that lead to good choices - and conversely the conditions that lead to bad choices, and what can be done to get to a place where better choices are made more often. Any good economist understands that all people try to maximize their own satisfaction - but that because all people are different - with different preferences, not all people will make the same choices. And that is okay, actually, it's better than okay - it is absolutely critical!

I have come to the conclusion, that the true meaning of feminism - is about having choices and being free to make them - being free to lead a life that is most satisfying to the individual woman in her individual reality. Feminism is not, and should not be about the specific choices that individual women make - and much damage is done when biological essentialism is passed off as feminism. Much damage is done when women sit in judgement about the specific choices that other women make. Much damage is done when women fail to focus on making the best choices in their own life. Much damage is done when women fail to support other women in making their own choices.

Something wonderful happens when women shift from thinking that everyone needs to make the same choices to understanding the importance of having choice and facilitating choice. Women become more compassionate. Women become more confident in their own choices. Women become more tolerant of choices that are different from their own. Women are better able to help other women discover the choices that are best in their own individual lives, without judgement.

When the focus is on having choices, and the process of making choices - it is okay to breastfeed - it is okay to formula feed - it is okay to have children - it is okay to remain child-free - it is okay to plan a vaginal delivery - it is okay to plan a cesarean delivery - it is okay to stay at home - it is okay to work out of the home - it is okay to get a degree - it is okay not to get a degree - it is okay to get married - it is okay to stay single - it is okay to cloth diaper - it is okay to use disposables - it is okay to baby wear - it is okay to use a stroller - it is okay to send the kid to daycare - it is okay to home school - it is okay to use public schools - it is okay to use private schools - it is okay eat organic - it is okay to not eat organic - it is okay to circumcise - it is okay to not circumcise - it is okay to cry-it-out - it is okay to not cry-it-out. And none of those things make one woman a better woman than another woman who happened to make a different choice.

When the focus is on having choices and the process of making and facilitating choice - Women become empowered and empower other women - the mommy wars end and the focus shifts to what is really important - leading satisfying and fulfilling lives as individuals.

Getting There From Here

It's too early to blog about details - but it looks like there is a way to get there from here. I'm excited. It is early days - not unlike first seeing two much wanted lines appear on a pregnancy test - there's a lot of hope and potential, but just a bit of hesitation. I'll blog about details after we are through the proverbial "First Trimester" with this project. (Note: just to avoid any confusion, the W household is not expecting a baby...)

The Reality of a Traumatic Birth

The reality of having the day my child entered the world also be the day in which I had the worse experience of my life - a severe deprivation of personal autonomy - is that it has not faded from the forefront of my mind. It has been more than three years and very rarely does a day go by when I do not think about that day. On a good day, it is just there. On a bad day, it brings with it all the negative emotions - the terror, the anger, the abandonment, the pain, the helplessness. On a bad day, there is little reprieve and I find my mood sinking like a lead weight in an overwhelming ocean. The upside is that the good days, the days when it just is what it is, are growing in frequency, while the truly bad days - the days when the thoughts come with all the baggage of the negative emotions associated with it are diminishing.

I have come to the conclusion that this is the reality of my traumatic birth experience. There will always be a psychological scar - it'll fade, sometimes it may not be painful - but it will always be there. The negative experience cannot be reframed as being a necessary evil. Which is why I feel compelled to do something about what happened to me - something concrete, something that might make a difference for another woman. It is why I blog. It is why I am holding my care providers, the hospital, and the health authority to account - in the only way I truly can. It is why I can't just move on - because moving on when things still need to change, means that what happened to me will always just suck, for no good reason - and in some way feels as though it would be accepting that the way things are is somehow acceptable. There will not be closure until I feel like I have done what I could to change what is wrong with maternity care - I do not believe I can move on until I am done doing what I can to make it better for other women, other moms, like myself.

I hope that those who love me, can support me in what I need to do - in order to reclaim the woman I once was. The woman who was confident that what she thought, felt and did - actually mattered. I hope that they do not see what I am trying to do as being the actions of a "selfish bitch" - and see that what I am trying to do, needs to be done. I hope that they can be proud of what I do accomplish - and I hope they might understand a little about why I cannot just move on. I hope that I can make a difference. I hope that I can be the mother my children and husband deserve.

How to get there from here?

I want to live in a world where women are empowered to make medical decisions for themselves and can be assured of timely access to medical care to facilitate those decisions. I want to live in a world where access to epidurals and maternal request cesarean is not a matter of luck. I want to live in a world, where no woman chooses to give birth at home because she thinks her right to make medical decisions will be violated in the hospital. I want to live in a world where being psychologically scarred from the experience of birth is better understood and a far rarer event. I want to live in a world, where the information provided on birth is balanced and reflects current evidence. I want to live in a world where women do not feel the need to justify having had a cesarean or having chosen to formula feed. I want to live in a world where there is a lot less focus on the things that do not really matter (mode of birth, type of feeding), a lot more focus on the things that do matter (physical and psychological well being), and a whole lot less mommy guilt.

I want to live in a world where the voices of moms like me are not drowned out by voices of advocates of natural birth or home birth. I want to live in a world where maternal request cesarean is as understood and as researched as home birth. I want to live in a world of truly informed choice - where women are not "sold" on what they should do, but rather are given the information they need on the choices available to them and are free to make the decisions that best meet their needs and those of their family.

The reality is, that the world as it exists now - is still distant from the world as I wish it were. That's the challenge - getting there from here. Improving pre-natal education and the information available to pregnant women. Improving access to reasonable choices. Improving the hospital environment. Improving the legal context. Improving access to resources for those who have been through a traumatic birth or for those who are grappling with difficult pregnancies. Improving the knowledge base through research. Giving voice to the women who have no desire to buy into the ideology of Natural Childbirth. It seems as though there is still a lot of work to be done.

So how can we get the work that needs to be done, underway? What is the next logical step?

This side of the spectrum has no Lamaze. This side of the spectrum has no Childbirth Connection. This side of the spectrum has no mothering.com. This side of the spectrum has no International Cesarean Awareness Network. This side of the spectrum has no National Childbirth Trust. This side of the spectrum has no Power to Push Campaign. This side of the spectrum has no Business of Being Born. In short - this side of the spectrum has no large organization that is advocating for the interests of it's members and undertaking the work that needs to be done to improve maternity care for women who want to avail themselves of the advantages that modern medical technology can provide to make birth less painful and safer for themselves and their children.

That's not to say that this side of the spectrum is completely bereft of resources and advocates. This side of the spectrum includes Birth Trauma Canada. This side of the spectrum includes the Fearless Formula Feeder, Suzanne Barston. This side of the spectrum includes The Adequate Mother, a Canadian Anesthesiologist. This side of the spectrum has published a very well researched book by Dr. Magnus Murphy and Pauline MacDonagh-Hull "Choosing Cesarean: A natural birth plan". This side of the spectrum also includes Cesarean Debate. This side of the spectrum includes Dr. Amy Tutuer, the Skeptical OB. This side of the spectrum includes the facebook group the "Cesarean by Choice Awareness Network". This side of the spectrum includes me. This side of the spectrum has tremendously educated women who are working as best they can to facilitate change - to improve maternity care for mothers and their families. However, it remains under-organized and as a result is not meeting the potential to make maternity better for a large number of women. It needs to be better organized and better resourced in order to facilitate the work that needs to be done - there is a large mandate that is waiting to be met.

So how do we become better organized and better resourced? How do we catapult ourselves to compete with the well organized and well resourced Natural Childbirth industry? How do we harness what is a group of intelligent and motivated women and interested others to make change happen?

Those are the questions I am trying to grapple with. There must be answers. There is a will, there must be a way.

Penny Wisdom and Pound Foolishness in Maternity Care

It is fashionable to bemoan the high cost of health care - it does not matter if you live in Canada or the United States - and that extends to the costs associated with maternity care. Never mind that comparing the costs of maternity care between countries is fraught with difficulties - different countries have wholly different population health statuses, wholly different litigation systems, wholly different health care systems - all of which might contribute to differences in the price paid for maternity care. Unfortunately, what gets forgotten is what is bought with the money spent on health care during pregnancy and childbirth - and the value of those things, in terms of improved outcomes and satisfaction with the care received. It is not unlike bemoaning the high-cost of pursuing a university education that is likely to lead to a much higher paying job AND completely ignoring the likely increase in income (and productivity) that will be realized after graduation. Unfortunately, the economics of pregnancy and birth, for whatever reason, seems to be done rather poorly - with a focus on very broad measures of outcomes (mortality) and very limited timeframes (sometimes only counting costs that accrue within 30 days of birth).

It is often forgotten that countries that have realized a lower cost of care for pregnancy and birth, may have done so by cutting corners on the quality of care available to women and their children - limiting reasonable access to options and sacrificing the lives and well-being of some women and children. Examples of the sort of tragedies that can result fill the pages of the Action to Improve Maternity (AIM) website a New Zealand based organization that has tried to bring some accountability and improvements to the midwife led system that is focussed on promoting normal birth. It is also not uncommon to hear tales of epidurals being denied or delayed in the UK or parts of Canada - again both countries where integrating midwifery into the system of care and promoting "normal birth" is the norm. A birth that does not involve an epidural is cheaper than one that does, but that does not mean that quality care was provided - particularly if the woman wanted an epidural and endured a painful and traumatic delivery as a result. A birth that results in a vaginal delivery is not necessarily quality care either - particularly if it leaves the woman traumatized, or herself or her child disabled.

I would not be surprised if well done economic studies on birth and intervention in birth would show that an ideologically driven system focussed on promoting and facilitating normal birth actually comes at a tremendous cost.

Sweet and Sour

Recently, a friend pointed me in the direction of a blogpost - one where the author was excited about having a date for her elective cesarean. Of course, such a post will draw some criticism, typically from a Natural Child Birth True Believer - the following is just such a comment on the original post.

Anonymous - June 26, 2013 at 9:20 AM

Every mother has the choice to schedule a C- section. I understand that it may be right for you but I also very much believe that women need to be informed about the ways to have an empowering birth. Women need to trust in their bodies and research midwifery and the benefits of having natural birth. The birthing process begins the bond betweek mother and child. If both are on drugs and unable to have that immediate bond, it starts a life and a relationship out with stress and disconnect. With thousands of readers, I find that you have an amazing platform to discuss empowering birth options and educate women and pregnant mothers everywhere. I find that the rate of C-sections IS an issue, an important one to talk about. While you may not want to appear apologetic, I still feel that talking about it would continue a conversation that needs to be brought up again and again. I am a long time reader of your blog and I really do respect all mother's decisions. I just feel strongly about the casual nature of this post and the casual nature of all the women commenting about planned C- sections.

It's these kinds of comments that continue to astound me - how can women be so ignorant and judgemental of other women's choices? I found myself responding with the following comment.

Mrs. W. June 26, 2013 at 10:58 PM

Danielle - you are so much more gracious than I would be.

Anonymous - Danielle or anyone else does not need to justify their choice to have a cesarean to you - you are not their doctor, you are not their spouse and you are not their child. Please start with the assumption that women who choose cesarean are doing so from a position of choosing the birth that is best for themselves in their own particular circumstance. After all, most mothers who choose cesarean are capable of assuming that your choice to pursue a natural birth is an informed choice that you have made after having determined that it is best for you and your family in your particular situation.

I understand you are concerned about the rate of cesareans - however, I would argue that such concern is woefully misplaced and the focus on a specific procedure or process (normal birth), results in a complete blindness to what really matters. What really matters is getting through birth healthy and happy - what really matters is avoiding trauma and life long disability or death. Having a normal birth is not and should not be the goal - it forgets all the days that follow. If it can be achieved (and the mother wants it) safely, then great - but if the mother doesn't want it or it puts her life or the life of her child at risk, then is it worth being able to say that you pushed a baby through your vagina? Isn't being a woman about more than what you can do with your body, isn't it time that biological essentialism be laid to rest? Further, it's a rather cheap shot to declare that cesarean mothers don't or can't bond with their children as well as mothers who gave birth naturally - as a mother who ADORES her 3 year old, I can say that bonding with her was far more difficult than bonding with my 9 month old - I love them both but the PTSD her unwanted normal birth resulted presented specific challenges.

We don't measure the rates of women denied informed consent during birth. We don't measure the rates of women unable to access adequately trained and qualified care providers for prenatal care and birth. We don't measure the rates of births that result in post-natal PTSD. All of these things matter far more than whether or not the birth was a result of a cesarean.

I challenge you to become more informed on the issue of Cesarean by Choice. A good place to start might be Pauline Hull and Magnus Murphy's book "Choosing Cesarean: A Natural Birth Plan". Also look at the blogs Cesarean Debate and Awaiting Juno. And though you may hate me for it - browse through Dr. Tuteur's blog (the Skeptical OB) for a look at the seedier and far less respectable side of natural birth.

A Cesarean by any other name

There seems to be some confusion when cesareans are discussed, with elective cesareans often being confused as all being maternal request or patient choice cesareans. While the vast majority of maternal request or patient choice cesarean are elective, not all elective cesareans are patient choice or maternal request cesareans and the vast majority of elective cesareans have clear medical indications for being performed. The term "elective" simply means that the procedure was scheduled in advance - and given that maternal choice cesareans account for maybe 2 percent of all deliveries - it is very likely that the elective cesarean in question had a medical indication for being performed (breech, big baby (macrocosmic), etc.).

Maternal request or patient choice cesareans are those that are performed because the mother has decided that she prefers cesarean delivery over an attempt to deliver vaginally. And for some reason, many people get all hot and bothered when a woman who potentially could deliver vaginally chooses not to. It is almost as though they see a woman making a choice that is different from the one that they would make as being some kind of criticism of the choice they would make. It is very similar to those who are up in arms about a man or a woman's right to marry a partner of the same sex - even though giving a person the right to marry who they want to has absolutely no impact on their own ability to marry who they want to.

To be fair the terminology in discussing maternal request and patient choice cesareans does leave a little to be desired. I find request to be a really weak word - it paints the woman as almost having to "beg" for the treatment of choice. Similarly I find the word demand - as in "patient demanded cesarean delivery" to be really aggressive. I have come to prefer "patient choice cesarean delivery", but even that seems to negate the very real need for a cesarean delivery to occur once a patient has decided that it is her preferred mode of delivery. After all, we do not call patient chosen cancer treatment, patient choice chemo or patient choice radiotherapy. That being said, I am not sure what better terminology could be used.

Regardless, patient choice cesareans are not worthy of the disdain they seem to attract - particularly from those with absolutely no medical training.

Congratulations Kanye and Kim - Wishing You the Best of Luck

Kim Kardashian gave birth today - and invariably there was reports it was an elective cesarean. And then a while later it was reported that she delivered "naturally".

The comments section on the elective cesarean story is like NCB (Natural Child Birth) activists greatest hits. With such tried and true statements like, "a cesarean is major surgery", "recovery from a vaginal delivery is so much easier", "our bodies were designed to do this", "how selfish", "cesareans should be reserved for those who need them", "cesareans are more dangerous for the baby", etc.. It seems as though almost everyone is an armchair OB, and if they could have a natural delivery - why couldn't Kim suck it up and have a natural delivery too?

I'm a little tired of the armchair OB's in this world and would like to put out the following:

1. Yes, cesarean is surgery it has risks, but vaginal delivery is a major medical event that also has risks. Discuss both options and their associated risks and benefits with your care provider - ideally someone with a real qualification for childbirth that was earned at an accredited post-secondary institution and not Google U or Anecdote High.

2. Recovery from a vaginal delivery is not always easier than recovery from a cesarean delivery.

3. Our bodies weren't designed. They evolved - somewhat awkwardly with tradeoffs made between head size and pelvic girth. Birth is not an easy process for many women. Many women historically died. Many babies historically died. Some were disabled. Birth is incredibly painful for many women. If this is something we're "designed" to do - would someone please fire the designer, or at least start a class action for negligent design.

4. Cesareans have some serious risk avoidance benefits for the baby and for the mother and may in many cases be safer for the baby and comparably safe for the mother - again discuss this with a qualified care provider.

5. Choosing a cesarean is often the anti-thesis of "selfish", mothers who choose cesarean often knowingly increase some of their risks in order to reduce the risks of delivery to their child. That seems pretty unselfish to me. Or at the very least not more selfish than mothers who choose vaginal deliveries for the sake of "easier recoveries".

I do not really care whether or not Kim had a natural delivery (maybe she did) or elected to have a cesarean (maybe she did) for the birth of her child. I care that she was able to have an open and honest discussion with her care providers about the options available to her, that she was empowered to make a decision and have that decision respected, and that she and new baby are happy and healthy at the end of the day. It's what I hope every pregnant women is able to do - have access to appropriately trained care providers who can advise accordingly, retain the right to make medical decisions, have access to timely care and go home at the end of the day with a healthy baby in her arms being mentally and physically ready to start parenthood.

I partly wonder if reporting one mode of delivery and then the other mode of delivery is strategic - a way of keeping the actual mode of delivery between the mother and her care providers confidential. If so - that is not such a bad thing, but wouldn't it be even better if they were straight up with it and take a few notes from a commenter here a few days ago who offered something along the lines of the following "We'd like to maintain the confidentiality of the medical care received, but we assure you that the baby and the mother will be receiving the best care possible."

It is rather sad though, that such a personal decision can spark such derision. But given the derision that is associated with other personal mothering choices right now (formula versus breast-feeding, cry-it-out versus never cry, stay at home versus work out of the home, cloth versus disposables) that it is not really overly surprising.

I guess we're still a ways off from a world where the majority of comments following a celebrity birth announcement manage to ignore the mode of delivery and focus on what really matters - a healthy and happy mother and baby!

In closing, "Congratulations Kanye and Kim and Little Baby Girl K - wishing you a long, healthy and happy life together as a family!"

Why do women choose cesarean?

I still get annoyed when those who just don't get it attempt to speculate why women choose a cesarean delivery for their child, particularly in the absence of a medical indication for one. They continue to speculate that it is because some celebrities have chosen it. Or because they need to choose a particular day for their child to be born. Or because they need to schedule the rest of their lives to accommodate the arrival of their child. Or that women who choose cesarean are just uneducated and ignorant of the wonders of vaginal birth. The paradoxical bemoaning of cesarean being "major surgery that is much harder to recover from", while at the same time being "the easy way out" continues to boggle my mind.

The reality is that the women who choose cesarean are among the most informed women I have ever encountered - not only on the specifics of delivery by planned cesarean, but also the realities of planned vaginal deliveries. They have seriously considered both options and have decided that they prefer the risks and benefits of cesarean delivery over the risks and benefits of vaginal delivery for themselves in their own circumstances. Most of them have encountered significant resistance and challenge to their choice from family, friends and their own care providers. Few women who choose cesarean (particularly among primiparous women), simply choose an elective cesarean delivery and then have that choice respected and facilitated without challenge throughout their pregnancy. Women who choose cesarean, particularly without a medical indication for one, have to be strong advocates for themselves in order to survive the inevitable criticism of their choice and to overcome barriers to realizing that choice.

The reality is that women who choose cesarean, are not doing it to emulate some celebrity idol.

The reality is that women who choose cesarean, are not generally doing it to achieve some favourable birth day for their child as most women who choose cesarean also choose a delivery that is at 39 weeks gestation unless there is a medical indication for an earlier delivery.

Some women who choose cesarean are doing it out of an unreasoning dread of vaginal delivery. Sometimes this can be addressed with counselling, sometimes it cannot. For these women, a planned cesarean provides a tremendous amount of psychological relief and enables them to enjoy their pregnancies.

Some women who choose cesarean are doing it to avoid the vagaries of vaginal delivery. It's generally accepted that an uncomplicated vaginal delivery is easier to recover from and considered better for both mother and baby - but knowing that an uncomplicated vaginal delivery will actually materialize is something that can only be known retrospectively. Many women who choose cesarean are knowingly sacrificing a chance at the ideal outcome, in the hopes of maximizing the chance of a good outcome.

Some women who choose cesarean are doing so to protect the integrity of their pelvic floors and to reduce the risk of urinary and/or fecal incontinence later in life. It is true that pregnancy on it's own poses a significant challenge to the pelvic floor - but a vaginal delivery further increases the risk of damage. Often the solution to pelvic floor problems is surgery but unfortunately surgery often fails - incontinence products and pessaries are also an option to manage the symptoms. To some women, a cesarean is a fair price to pay to minimize the risk.

Some women choose cesarean because of serious doubts about the availability of effective epidural pain relief at their planned facility of delivery. For facilities that do not have dedicated obstetric anaesthesiology - there might be delays or complete lack of availability of epidural pain relief. Sometimes this can be addressed with a planned induction, sometimes it cannot.

Some women choose cesarean because of prior birth experiences that were traumatic. Birth experiences that resulted in extensive tearing. Birth experiences that had unmanaged and intolerable amounts of pain. Birth experiences that might have lead to urinary or fecal incontinance. Birth experiences that might have resulted in long term or permanent injury to their children (HIE, brachial plexus injuries). Birth experiences that might have resulted in PTSD.

Saying that women who choose cesarean do so because celebrities choose cesarean, or to fit a child into their busy schedules, trivializes what is a very serious choice for many women. It discounts the real reasons women choose cesareans and it makes life that much more challenging for those who are wanting to choose cesarean for the delivery of their child.

We don't say women choose vaginal delivery just because "they want an easier recovery" and go on to decry the choice of planned vaginal delivery as being selfish - so why do we trivialize and disparage moms who choose cesarean, after all for many moms who are choosing cesarean, their reasons for doing so are just as valid as the moms who are choosing a vaginal delivery?