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.