Systemic Barriers to Maternal Request Cesarean are Prevalent in Canada

It is difficult to be a cesarean by choice mom - most people do not understand your choice and may even think that you are nuts for wanting to choose a surgical process over a natural process. It is a choice that is stigmatized and even denigrated. It is a choice where it is still debated openly whether or not women should "have the right to choose" and the term "too posh to push" is still thrown around. Many moms have an uphill battle in Canada when they choose cesarean that extends far beyond what their friends and family may think of their choice though - there are prevalent systemic barriers that prevent many women from being able to exercise their legitimate right to choose cesarean.

Many primary care givers - family doctors and OBGyn's do not support maternal request cesarean. When women ask their doctors about it, few are receptive to the request. It is not uncommon to hear of women not being referred to an OBGyn (family physicians and midwives do not and can not perform cesareans) until their pregnancies are very advanced. When I was pregnant with my daughter, I did not get to even meet with an OBGyn until I was practically at term (referred at 32 weeks and saw the OBGyn at 36 weeks) - despite having made my desire for a cesarean known at my appointment to refer to a maternity doctor and at my first and subsequent prenatal appointments with my maternity doctor. Many women who request cesarean have anxiety about the delivery and that anxiety often is not resolved until they have confirmation from an OBGyn about the delivery plan. I found it very difficult to enjoy either of my pregnancies until I knew what the plan was regarding the delivery. Further, there tends to be significant waits to access OBGyn's and as a result it is not uncommon for a woman to wait 4 or more weeks after referral to be seen by an OBGyn.

Unfortunately, many OBGyns in Canada are also not supportive of maternal request cesarean and I do not know of many who openly offer this choice. Quite simply a woman cannot go to a phone book or even online and see that CDMR is one of the services offered by a particular OBGyn. Perhaps this is because the Society of Obstetricians and Gynaecologists of Canada does not currently support CDMR and has stated that “Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." As such, if a woman is referred late in her pregnancy to an OBGyn for the purposes of getting a cesarean, and the OBGyn she is referred to is not supportive of the request, by virtue of the time sensitive nature of pregnancy she may be unable to get a CDMR.

Then add hospital policies that might present additional challenges to women wanting maternal request cesareans. For example, at BC Children and Women's hospital - the home of the "Power to Push Campaign", women desiring maternal request cesarean are encouraged to undergo counselling at the "Best Birth Clinic" and the power to push website repeatedly reminds women that vaginal delivery is the "normal" method of childbirth. This makes women who wish to choose cesarean feel abnormal or wonder if they are in need of psychological services because they prefer surgical delivery for their children. At the time of my daughter's birth I was told by my OBGyn that an elective cesarean needed to be an "add to slate" procedure, that he could not give me a specific time and date for the surgery. What he failed to inform me, is that by not having a fixed time and day for the surgery meant that there was a very real risk the surgery quite simply would not happen at all, as it would have to compete with all the other "add to slate" surgeries and that unless he advocated and made the case that my cesarean should be a priority that it would get bumped until it was ultimately denied.

So what is the impact of these systemic barriers to maternal request cesareans? Many women who would prefer to deliver by way of cesarean cannot access timely medical care and ultimately are forced to deliver vaginally. The current system unjustifiably imposes risks on mothers who would choose cesarean - it imposes anxiety as a result of the delay in having an OBGyn "approve" the planned delivery, and it imposes increased risk that a planned elective pre-labour cesarean will need to be an urgent cesarean or emergent cesarean or may even be an unwanted vaginal delivery. At the most basic level, every pregnant woman is currently told by this system that she cannot submit to a generally safe medical procedure unless she meets criteria entirely unrelated to her own priorities and aspirations - this removal of decision making power threatens women in a physical sense and the indecision of knowing whether a maternal request cesarean will be granted inflicts emotional stress. Depriving women of their right to make medical decisions for themselves is a travesty and a grave injustice - one that I am battling to change.

Timely Access to Medical Care - Lawsuits and the Blame Game

There's a lawsuit that has been launched by Dr. Day alleging that the government has failed to provide timely access to medical care and in doing so has violated patient's charter rights to security of the person. The government has submitted in its statement of defence that it is not responsible and that it is the doctor's who failed to provide their patients with timely access.

Back when I had my daughter - I was told that by my doctors that they could not access the resources. My doctors told me that the OR was not available, that my case had been bumped by other more urgent surgeries. Then when I wrote the patient care quality office a year later to find out more about what had happened - the response I received back clearly indicated that it was not that the resources were unavailable, but rather that my doctors had failed to facilitate access to them when they were available.

As a result, I was left not knowing what happened - my doctors had said the resources were unavailable and the health authority had said that they were available. Either my doctors were lying and had committed a malpractice or the health authority/hospital was lying and had failed to ensure adequate resources were available when they were needed.

In the Day case, as in my own - it is clear that the doctors are pointing their fingers squarely at the system (the health authorities and the government) - only to find the government pointing squarely back at the doctors. Unfortunately, this leaves patients in a difficult position - in order to get accountability for being unable to get timely medical care, they must sue both the system (government/health authorities) and their own doctors.

It is a very daunting prospect - but given the realities of health care in Canada - do patients have any other choice?

Under what circumstances should women be able to "Choose Cesarean"?

In the years since I first considered having a child and the relative risks and benefits of different modes of delivery for my particular situation, I have read a lot of material on the subject - both in the mainstream media and in the scientific literature. There continues to be an active debate on the subject. There continues to be a relative paucity of research that is "on all fours". There continues to be judgement and a persistent derogation of women who elect cesarean delivery. There continues to be uncertainty regarding a woman's "right" to choose cesarean. There continues to be a lack of awareness and respect, support and empathy. There continues to be tremendous barriers to exercising the choice of cesarean delivery, including difficulties in finding supportive health care providers and unreasonable and obscure hospital policies and practices.

That being said, tremendous headway has been made in those years. The commentary that news articles and related forums attract is becoming less vitriolic and more respectful of the choice. The National Institute of Clinical Excellence in the UK confirmed in November 2011 a British woman's right to elect cesarean on the NHS. Pauline Hull and Magnus Murphy published their revolutionary book "Choosing Cesarean". There is now a Cesarean by Choice group on Facebook. A lawsuit in Canada has been filed with hopes that it might formally recognize the right of women to make this medical decision and confirm that a failure to provide reasonable access is a reprehensible violation of patient autonomy - and may constitute a form of malpractice for which hospitals and/or doctors can be held liable.

So under what circumstances should women be able to choose cesarean? Under the exact same circumstances that women or men are able to direct any medical care - that is, after they have been provided with enough information on the available treatment options for their particular medical condition and the risks and benefits associated with those options (they have met the requirements of informed consent). Further, they should expect timely access to the care that has been chosen - otherwise the right to direct one's own medical care is rendered void - after all what good is the ability to choose treatment, if time makes that treatment choice meaningless?

Forging Ahead While Looking Behind

My son's birth proved to me that birth could be an enjoyable, relatively pain free experience that affirms a woman of her ability to make medical decisions and to expect those decisions to be respected. For that I am thankful. He is healthy, I am healthy, I do not dwell on his birth and when I think about it or see pictures from it my emotional response is positive.

However, because I have been working on the litigation associated with my daughter's birth - I have been thinking about what happened then, a lot. Even when I am not wanting to. To say that it is emotionally difficult work is putting it mildly. Reading my medical file. Reading the statements of defense. Thinking about it all. The only thing positive about my daughter's birth - is my daughter. I survived the experience, I did the best I could at the time and it was enough (my daughter is fine) but it is abundantly clear that what happened did not need to happen and that my doctor's and the hospital failed me and failed my daughter.

It is trite to say that in preparing for birth, a mother should prepare not only for the birth experience that she wants, but also for the birth experience she doesn't want. I did not do antenatal classes - but I did educate myself on vaginal delivery (which was part of the reason why I wanted to avoid it), and when it was clear I did not have a choice in the matter, I did as best I could and for my daughter's sake it was enough. We survived.

And yet, in terms of coping with what happened - I still find myself, at times, overwhelmed. I cannot help but think that if what happened was truly neccessary - that if there was no way it could have been avoided, I could accept what happened (as awful as it was) as the price of admission to motherhood. However, now knowing more about what happened and what did not happen - I know that what happened was clearly not neccessary - it could have been avoided (easily). It does not make coping with what happened easier - rather it generates a profound need for accountability and justice.

Surviving the Days Before the Elective Cesarean Date

I chose cesarean because I was uncomfortable with the realities of planned vaginal delivery. I was uncomfortable with the idea of needing an emergent cesarean. I was uncomfortable with the idea of tearing. I was uncomfortable with how much pain might be involved with a vaginal delivery. I was uncomfortable with the uncertainty of the impact on my sex life. I was uncomfortable with the risk of permanent neurological damage to my child. I was uncomfortable with the idea of defecating in front of others. I was uncomfortable with the risk of urinary or fecal incontinence. I could not find peace planning a vaginal delivery - the ugliness of vaginal delivery at its worst (and even a wide range was enter than worst) was a possibility that I wanted to completely preclude even if meant giving up the chance for a vaginal delivery at its best. This was true when I was pregnant with my daughter, and more true when I was pregnant with my son.

As such, there was considerable anxiety (particularly when I was pregnant with my son) about not making it to the elective cesarean date. So how did I cope and survive those final weeks of pregnancy and what can a woman do to make that last stretch of pregnancy a little less anxiety ridden?

1. Work with a therapist. I was working with a psychologist throughout my second pregnancy and think that it helped in finding coping strategies that worked for me in my particular situation.

2. Talk to your OBGYN about your risk of going into labour and what the plan is should that happen - discuss whether or not an urgent cesarean is likely to be available if you should go into labour prior to your cesarean date. Your doctor is the person who is most informed about your particular pregnancy and your particular plans with regard to that pregnancy and is likely in the best position to advise you accordingly. If at all possible, try to arrange for the earliest safe date possible to minimize the risk of going into labour spontaneously (generally speaking this is at 39 weeks gestation - but should be discussed with your own care provider to determine what is best in your particular situation).

3. Find an appropriate activity to distract yourself and that you find enjoyable.

4. Do not over exert yourself and keep well hydrated and well nourished.

5. Avoid anxiety provoking situations. I found myself avoiding social situations in my final weeks of pregnancy.

6. Relocate if neccessary to be near to where accessing care is planned - this is particularly true if where you plan on having your baby is significantly far from where you live.

7. Arrange for the care of older children, pets, help for after the delivery, meals, etcetera.

8. Reassure yourself that even if things do not go as planned, that your primary concern is for the health of yourself and your child, and that regardless of how things unfold you will find a way to deal with it and will deal with whatever situations arise as best you can - and that is all you can do, and it will be enough because it has to be enough.

The best thing about the pregnancy with my son was his safe arrival and knowing that the worry about that arrival was behind me and that the time had come for me to enjoy my son and all the happy days that lay ahead.