Pushing Back for the Best Choice - Cesarean by Choice in Canada Deserves Respect, Compassion - Not Mocking

Canadians, and Cesarean by Choice moms in particular, should be outraged at what is considered to be appropriate behaviour by research institutions and hospitals in Ontario. A website has been created - www.pushingforthebestchoice.ca - and supported by the University of Ottawa, McMaster University, the Canadian Institute for Health Research, the Canadian Health Services Policy Research Foundation, Markham Stoufville Hospital, and Queensway Carleton Hospital. It is deeply offensive and mocks patients while purporting to "Push for the Best Choice".

The content of the webpage is as follows:

Caesarean section (CS) is an efficacious option for birth, but is not without risks to mothers and their babies, including maternal mortality, infection, hemorrhage, maternal or fetal injury, increased recovery time postpartum and difficulty breastfeeding. Given these risks, it is problematic that CS birth currently accounts for more than 28% of all births in Ontario in 2010/11, which is nearly double the 15% target recommended by the World Health Organization.

I should note that vaginal birth (VB) is also an efficacious option for birth, but is not without risks to mothers and their babies, including maternal mortality, infection, hemorrhage, maternal or fetal injury, increased recovery time postpartum and difficulty in a wide variety of areas. But this article completely neglects the risks of vaginal delivery - and then proceeds to declare the prevailing rate of cesareans as problematic, while trotting out the WHO's zombie statistic that was quietly retracted in 2009 as having no evidence to support it only to be brought back to life this past year, despite having questionable evidence to support it. There is no "ideal cesarean rate" - and despite wide criticism this number continues to pervade popular media and policy circles alike.

The common perception that this large and increasing proportion of CS births is attributable to maternal requests for CS does not reflect the available evidence, particularly in a Canadian context. Maternal factors that are more likely to contribute to the increase in CS birth include increased maternal age, use of assisted reproductive technology, incidence of obesity and gestational diabetes. While these maternal factors are likely attributable to changes in sociodemographic and health status in developed countries, of particular concern are the obstetrical practice changes that have led to an increased use of technological intervention during birth. Such interventions (including increased use of labour induction, augmentation, epidural analgesia, and electronic fetal monitoring) are associated with an increased risk CS, even in cases of otherwise low-risk birth.

I agree that maternal factors (changes in the incidence of medical indications for CS) likely contribute to the higher rates that are observed in Canada. However, the article then goes on to criticize the use of technology in birth. What the article fails to consider is what happens in the absence of that technological intervention. More stillbirths (rare, but the incidence of still birth increases after 39 weeks), more neonatal asphyxia, more 3rd and 4th degree tears (and likely more pelvic organ prolapses subsequently), more PTSD as a result of extreme and uncontrolled pain... but, I guess all of that is justified to achieve a higher rate of vaginal delivery. Given the choice between many of these outcomes and undergoing a cesarean - many women would choose the cesarean and the use of technology as it best meets their needs.

Despite evidence of effective individual strategies to curb inappropriate childbirth interventions that focus on either patients, maternity care providers, or hospital policies, little is known about the cumulative effect of a multifaceted strategy to reduce CS birth.

Inappropriate by whose standard? Is it inappropriate to respect patient autonomy? Is it inappropriate to avoid the worse set of outcomes by minimizing their risk and increasing the risk of cesarean? Inappropriate to provide adequate pain relief? Little is known about the cumulative effect of a multifaceted strategy to reduce CS birth - but it is absolute foolishness to think that such a strategy is going to come without some harm. Maternity care needs to focus on what really matters, and that is not "mode of delivery" - it is healthy and happy outcomes that best meet the needs of individual mothers and babies.

As a final slap in the face, a cartoon accompanies the article (below) - a complete caricature of a doctor and a patient making a medical decision. Under the cartoon is the disturbing statistic - 10 percent of mothers (without prior cesarean) would choose it, fewer than 2 percent of mothers actually have a cesarean as a result of maternal choice.