Oh, ACOG - Say it ain't so

On facebook in the Cesarean by Choice Awareness Network group there's been a lot of discussion about the American College of Obstetrics and Gynaecologists committee opinion on cesarean delivery on maternal request. I am fairly disappointed at the new committee opinion, one that seems to take a step closer to the stance taken by the Canadian Society of Obstetricians and Gynaecologists - it does not condemn or disallow maternal request cesarean, but makes it quite clear that its members should recommend vaginal delivery in circumstances where there are no medical indications for a cesarean delivery. Which is fairly different from the stance that a physician is ethically justified in performing a maternal request cesarean if he or she believes it is in the interest of his or her patient. In many ways it is no different than the kind of approach taken to mothers who for whatever reason determine that their needs are better met by formula feeding - they are repeatedly told that "Breast is Best" and made to feel no end of guilt for needing or wanting to use formula to feed their children. ACOG has decided to tell women that Vaginas are meant for birthing children, and if you want a cesarean we might do it, but only after you are reminded that a "vaginal birth is best". Many women who are requesting a cesarean already face barriers in finding a physician who will accommodate their needs, to add the feeling that what they are asking for is something "against medical advice" - seems above and beyond what women who are requesting cesarean need.

What women who are asking for cesarean need are physicians who listen to their request, provide them with the risks and benefits of planned cesarean delivery and the risks and benefits of planned vaginal delivery, answer whatever questions they have about their treatment options AND ultimately respect, and facilitate the decision they make regarding the planned delivery of their child. They do not need to have someone else's ideology about childbirth imposed on them. What women who are choosing cesarean need is better information on their choice (much of the information that is currently available is not about "maternal choice" cesarean, but rather about cesareans that are performed as a result of medical indications for cesarean). What women who are choosing cesarean need is the confidence that their choice will be respected, even if their OB doesn't happen to be on-call when they go into labour.

Nothing is more empowering than having the confidence that you have the right to decide what to do with your own body - and nothing is more disempowering than feeling as though you do not have the right to decide what to do with your own body. Perhaps it is time that the ACOG, the SOGC, the mayor of New York and anybody else who feels that women should not have a choice about how their child is born or fed is reminded that - it is the woman's body, let her be free to decide what to do (or not do) with it.

The Beliefs of Canadian Maternity Care Providers - Who to choose when your choice is cesarean?

The Canadian Journal of Midwifery Research and Practice published a study entitled "Midwives' Belief in Normal Birth: The Canadian Survey of Maternity Care Providers' Attitudes Toward Labour and Birth", by McNiven, et al. in Volume 10, Number 2, Summer 2011. The paper examines the results of a survey conducted in 2007.

It should be noted that midwives generally believed that a vaginal birth was a more empowering experience than a cesarean birth, that those who deliver by cesarean miss an important life experience, did not believe that cesarean prevented urinary incontinence or sexual dysfunction, agreed that there should be an organized pre-cesarean section peer review of all cesarean sections to reduce the cesarean rate, and agreed that all cesareans should be subject to a peer review to reduce the cesarean rate. Further, midwives are most likely to believe that childbirth can be considered normal prospectively, that childbirth doesn't usually require medical intervention, to prefer natural methods of pain relief, and that home birth is as safe as or safer than hospital birth. Personally, I did not find my vaginal birth to be more empowering than my cesarean birth (quite the opposite), and in terms of life experiences, frankly, I wish I would have missed out on the "life experience" of vaginal birth. That being said, I always believed that having a midwife as a prenatal care provider would be a poor fit personally, and the results of this survey seem to confirm that belief.

However, midwives have a tendency to portray themselves as some kind of guardians of patient autonomy. So what did the midwives of this survey think about a woman's right to choose cesareans?

More than half (58.6 percent) did not believe a woman had a right to choose a cesarean in the absence of a medical indication. Slightly fewer than one in five (18.5 percent) believed in a woman's right to choose cesarean.

What was surprising is that the view regarding cesarean sections was largely consistent with the views held by both Registered Nurses and Family Physicians who provided prenatal care with 60.4 percent and 60.8 percent of those providers disagreeing with a woman's right to choose a cesarean even in the absence of medical indications.

With regards to the right to choose cesarean, obstetricians were the most likely to agree that a woman has a right to choose a cesarean with 42.3 percent agreeing a woman has a right to a cesarean and 15.3 percent taking a neutral position.

I find it somewhat disconcerting, that the right to choose a cesarean in Canada among those providing prenatal care is so widely disagreed with (but particularly among midwives, RN's and family physicians). It seems trite to me that a patient has the right to decide what is done with their body (among the available options, after considering the advice of care providers) - the fact that it is not trite in prenatal care in Canada is disturbing.

Hopefully the memo that was sent regarding patient autonomy more than 25 years ago in the Morgentaler case will soon be received by the majority of those providing prenatal care in Canada.

Birth Trauma and Productivity

Looking back at the year that I was back at work between maternity leaves - I hate to admit that I was not as productive as I could have been. Beyond juggling a child and work - I was also juggling a considerable psychological burden - as much as I may have wanted to focus on work, I found myself distracted. I was distracted by what had happened. I was distracted by my subsequent pregnancy and what was going to happen. I also found myself trying to deal with a degree of cognitive dissonance between what I do, and what I had experienced. I was able to get what needed to be done, done and managed to accommodate the travel back and forth to Vancouver to access care - but there was a considerable hidden cost to my birth trauma. My productivity was damaged.

The loss of productivity as a result of birth trauma is a cost that is largely hidden and difficult to quantify. Some women forego the paid labour force entirely as the demands that result from the birth trauma are too great to accommodate paid work. Other women, like myself, manage to accommodate their birth traumas and their careers, but are less productive than they would be otherwise. In both cases, there are no statistics that even attempt to get at the presence of this phenomenon or the degree of impact it has. Perhaps some of the differences that persist between men and women in the paid labour force can be attributed to the impact birth trauma has on women. After all if your coping but not thriving, you will not be promoted.

Still I must consider myself lucky. The work I do could accommodate the psychological burden I was carrying. I had four-walls and a door. I did not need to interact with the public or others on a daily basis. I could do what I needed to do (usually write a blog post on what I was thinking) to allow myself to focus enough on the work at hand. I could work longer days to accommodate days off for travel. I had an understanding supervisor. Indeed, I was lucky - and under different circumstances - arguably under most other circumstances, it probably would have been likely that my career could have been collateral damage to what had happened.

I am thankful that my son's birth went well - and I am hopeful that by the time I return to work from this maternity leave, I will not be carrying the same psychological burden and that my ability to work to capacity will be restored. Still, I can't help but wonder - in the absence of what happened, would I have been a better economist and mother?

200th Post

When I started this blog, I was pregnant with my daughter. A first time mother-to-be, who really had no idea what was about to happen. When I started this blog, I was worried about finding a doctor who would support my request for a cesarean, I was confident that I would find one or do what needed to be done to have a planned cesarean delivery - but I really did not imagine that after finding a doctor who agreed that I would be in a position where I would be delivering my child by the very way that I had sought to avoid. When I started this blog, I anticipated that it would remain just another mommy blog - a place where I would have written about the cesarean birth of my daughter and then quickly moved on to the one-hundred-and-one different things that happen as a baby becomes a toddler, a big sister, a child. I did not imagine that it would remain focussed on maternal request cesarean, maternity care and birth trauma. I did not imagine that it would become one of the main ways that I would process my experience. I did not imagine that it would help other women. I did not imagine that it would have the kind of impact it has had. I did not imagine that it would even be read much at all.

So two-hundred posts later, I cannot help but look back on the last few years (most of the posts have been within the last year and a half) - and be somewhat pleased with the work that has been done. And in the ways that this blog has exceeded my expectations - I look forward to seeing what work will be done - as it still seems clear, that there is still much work yet to be done.

Thank-you.