Regional Variation in Referral Practices and Approach to CDMR

I learned something last night - something that had I known last time, I would have taken a very different approach to my pregnancy and birth plan. I learnt that the referral practices in Victoria are very different from the referral practices in Vancouver - so different that I would almost expect them to be from different provinces or different countries instead of just a short hop-skip across the Georgia Straight. Specifically, I discovered, that it is infinitely easier to get an OBGYN to look after you for your pregnancy in Vancouver than it is here. Victoria has some weird custom whereby the OBGYNs do not take low-risk pregnant women on until fairly late into their pregnancies. In contrast, in Vancouver - a woman can ask to be referred to an OB (instead of the choice of GP who does maternity care and midwife) and actually expect that request to be carried out in a timely way.

I anticipate my first meeting with my OB will be in 4-6 weeks from now - when I'll be about 12-14 weeks pregnant. That is 22-24 weeks sooner than my first meeting with the OB in my last pregnancy.

I also learnt that in Vancouver, a scheduled c-section is just that - a scheduled c-section (regardless of the reason) and that I should expect a specific time and date for my c-section at some point between 39 weeks and 40 weeks gestation and that I should not expect to be 'bumped'... apparently bumping in my new OBGYN's experience is very rare (less than 5 percent of the time) and generally of a short duration (an hour or less) when it does occur. I cannot begin to tell you the kind of piece of mind this brings - unlike my last pregnancy where I was on tanterhooks for 36 weeks fearing that my request would be denied, only to have my request granted, breathe a sigh of relief for 3 weeks and then ultimately be denied what was a very well informed and clearly communicated decision on how I wanted my child to be born.

So it looks like I will be shlepping back and forth to Vancouver over the coming months - and that's okay, I want the person who will deliver my baby to also be the person who looks after me during my pregnancy - and given that I prefer a surgical birth route, the person who will deliver my baby isn't a GP and isn't a midwife.

Logistically, financially, and emotionally - this appears to be a very workable plan. If I were drinking, I'd pop open that bubbly we didn't quite get to before seeing two lines on the pregnancy test -- but I guess some fancier potato chips and fancier ginger ale will have to do in my morning sickness induced quesy state.

Nauseously Optimistic

Morning sickness has struck - and unlike my last pregnancy its not in its mild form but rather has caused me to feel like I want to puke, and the rare times when I don't want to puke, I want to sleep. This state of being is not good for clear thought - thus the relative pause in blogging.

That being said - one of my contacts through blogging has given me the name of someone who may be able to assist me in the 'end of pregnancy' matters. I am nauseously optimistic at this lead, as it seems to be legitimate. Further, as the lead is within the confines of my province, it would be considerably more economical than the current plan A (go to Oregon to have the baby). The logistics of this potential plan are appealing.

It would still involve some travelling but that is not neccessarily a bad thing, as given my prior experience of Victoria General Hospital - I truly wish to avoid it for baby number 2.

Progress is good - and a little help from the blogosphere has gone a long way. I'm nauseously optimistic at this point.

Finding Trustworthy Prenatal Care

I met with my family doctor over 10 days ago, and asked to be referred to an OBGYN for my prenatal care. I specifically asked not to be referred to either Dr. who provided my care last time - and I told her why. I gave her a list of 3 names - she said she'd get back to me in "a few days". I've heard nothing, yet.

I fear that one of the reasons things went they did last time was because there wasn't an opportunity for me to build rapport with the OBGYN. We met once at 36 weeks (when he agreed to do the c-section, before meeting again when I was in hospital and in labour (and he was giving me the tale about pediatric appendectomies and no OR or anasthesiologist after I had already spent 2 days in hospital patiently waiting). It's a lot easier to lie to a patient when you don't really know that patient.

Perhaps it would have been different if I had been referred earlier in the pregnancy - maybe at 20-25 weeks, that's not the OBGYN's fault, but rather my primary maternity doctor's. It wasn't like I hadn't asked to be referred earlier, I had, repeatedly. But I trusted, and waited. I thought my primary maternity doctor "got me" - I thought she understood and was supportive of my wishes. At our last prenatal - she reassured me that the baby was not going to "come out that way"...

So understandably, I don't want to be referred to somebody who I will have to rely on to refer me again. It's going to be hard enough for me to trust this time around...

Why is it that only women who desire vaginal births are given any reasonable chance at continuity of care?

If you are an OBGYN (on Vancouver Island or in Vancouver) who is supportive of maternal request c-section, feel that you can actually make it happen and willing to take on a somewhat anxious pregnant woman (who likely has some degree of PTSD and trust issues) with an EDD of September 20,2011 - please drop me an email at awaitingjuno (at) gmail (dot) com.

The Attack on CDMR in Canada

The other day I wrote about Ontario's plans to make moms pay for c-sections that were "medically unneccessary". The proposed plan is frought with difficulties and opens the door to some very disturbing changes to health care - which if successful other provinces in their own quests to reign in budgets would be sure to follow suit.

Let me begin with saying getting access to a maternal request c-section in Canada is already very difficult. A woman must make her request known to her doctor, her doctor must then refer her to an OBGYN, the OBGYN must then be receptive to the request, and then after all of that she must actually secure time in an OR - which if the hospital shares its OR with all the other areas of the hospital - might be practically impossible. And unlike other 'elective' surgeries - babies do not wait forever to be born. As a result, true maternal choice (in the absence of hard or soft medical indications) of how she delivers her baby is already unjustifiably thwarted many times, unless the stars align. Add to this the fact that as soon as you mention you prefer a c-section to deliver your child people look at you as though you have antlers. And now add to this the cost.

The difficulty in accessing CDMR in Canada already causes some women to forego having children, because they don't believe they have a right to ask for a c-section. For some women, the lack of access to CDMR forces women to birth vaginally when they do not want to - as a result they may suffer severe anxiety, and be at an increased risk PTSD and PPD. It causes other women to leave the country to give birth.

Secondly, who determines what is a "medically unneccessary" c-section. Many might argue that most repeat c-sections are "medically unneccessary" - after all VBAC is successful more than half the time. What about other 'soft-indications' for c-sections, you know the things that don't rule out a vaginal birth but certainly make it more risky? A history of crohn's disease or IBS? A narrow pelvis? A large baby? Tokophobia? I mean if a woman chooses vaginal birth aware of the risks she's facing, it is one thing, but if she has no choice or must pay for her choice? How is this promoting quality care? Will the woman know before she gives birth, whether or not her c-section is covered, or might she receive a letter in the mail from some bureaucrat that says based on the evidence you have a greater than 50 percent chance of having a 'successful' vaginal birth, so if you wish to proceed with your c-section it will be $x. Will the woman be on the hook for the full cost of the c-section - or just the difference between the cost of an elective c-section and the expected cost of a planned vaginal birth? Will the government be unjustly enriched by this move?

I am also quite appalled at the public sentiment on this issue as expressed in the comments section of the news articles on this story. Overwhelmingly, the public seems to support the idea that if a woman wants a c-section in the absence of medical indications (aside from being pregnant) that she should have to pay for it. The public is not giving birth to that woman's baby - she is. It is her body, she has to live with the results of her choice on how to birth that baby.

Is a public health system based on what the general public finds acceptable what we really want in this country? Think about that long and hard, and think about what might next be on the chopping block or delisted (epidurals? care for lifestyle induced afflictions? aggressive treatment choices for cancer?) Do you really want your care decisions based on what some bureaucrat has determined is 'neccessary' or 'most efficient'- or do you want to be able to decide based on your own assessment of risks and benefits in consultation with your doctor - to choose what's best for you?

Is a Maternal Request C-Section Like Cosmetic Surgery??

No, no, no, no a thousand times over. An elective c-section is not like cosmetic surgery and claiming that it is serves no purpose other than to denigrate those who would choose it for the delivery of their child and validate delisting (not being covered under public health insurance) much as Ontario is currently considering doing (see last post).

A pregnant woman MUST deliver her child. There is a legitimate NEED for delivery to occur, and delivery can only occur one of two ways: vaginally or surgically by way of c-section. For most conditions, the patient has a right to choose what treatment they will pursue to address that condition. Generally speaking, not all courses of treatment are covered under medicare but of those that are, the patient should have a right to choose among them. Delivery by way of c-section at term is an effective and proven method of giving birth that is generally considered safe for both mothers and children with risks and benefits that are different from vaginal birth.

Now a woman who is not pregnant that asks for a c-section (absent mental health problems) - THAT is directly comparable to "cosmetic surgery" and shouldn't be covered by the public purse.

The Challenge of Finding a CDMR Friendly Doctor in Canada

Maternal request c-section in Canada is controversial - the Society of Obstetricians and Gynaecologists of Canada is explicit in its criticism of the practice and government has aggressively promoted normal birth (see The Power to Push campaign).

In all honesty, it is far easier in BC to find providers supportive of Homebirth, even for first time mothers; than it is to find providers supportive of maternal request c-section. There is no listing of maternal request c-section friendly providers (you can actually google 'home birth' Victoria, BC and get a bunch of names of providers who support this service - including the "Home Birth Association of BC"). Further, providers in Canada must operate within the constraints of the health authorities. As such a mother who requests a c-section, without any underlying medical indication, is directly at odds with aggressive attempts to lower the c-section rate - and at odds with all the other demands for the same set of resources. As such there is little to protect a woman's right to choose delivery mode and have her choice respected.

Today I go to my doctor, much as I did over two years ago - and will ask to be referred to a maternity care provider. Except, this time, I will be more blunt - this time, I will not trust blindly. I'm nervous...and rightly so - I have no confidence that if I were to give birth here, that I could expect any different of an outcome than I had last time.

A Canadian Woman's Right to Choose Delivery Method: Is a Legal Precedent Needed?

In Canada, in 2012, a woman who wants to "choose Caesarean", absent any medical indication for one, as her mode of delivery, has little reason to believe that her informed choice to do so will be respected and many reasons to believe that she will be subjected to a trial of labour and potentially a vaginal birth that she does not want.

This is why, I am planning on an elective caesarean at term in the US for my next delivery: I have no reason to fully trust that my informed choice in Canada would be respected.

Don't get me wrong, there are women in Canada who do manage to secure an elective c-section, without medical indication - but it is a bit of a roll of the dice. There is nothing here to assure a woman that she has a "right" to that choice. There is no legal precedent and the Society of Obstetricians and Gynaecologists of Canada (SOGC) are not supportive.

Absent a legal precedent, or a change in policy from the SOGC or being blessed with a medical indication such as "breech" - my next baby will very likely be born on American soil. For the record I think a legal precedent is possible (there IS a charter argument to be had), I also think a change in SOGC guidelines is possible - I just think neither are likely before the arrival of the next baby W.

On Being Canadian and Wanting a Maternal Request C-section

Despite being cultural cousins, there are significant differences between Canadians and Americans. We have gun control. They have a constitutional right to bear arms. We have universal health care. They don't yet have unversal health care. We have highly trained and regulated midwives. They have the "Certified Professional Midwife"...which is a very different critter (see The Skeptical OB for more on this).

One significant difference that I failed to appreciate while I was awaiting Juno - is the significant difference between the Society of Obstetricians and Gynecologists of Canada(SOGC) and the American Congress of Obstetricians and Gynecologists (ACOG).

The Society of Obstetricians and Gynecologists of Canada (SOGC) has produced a Joint Policy Statement on Normal Childbirth - in December of 2008. In it there are some serious contradictions, on one hand "6. All pregnant and birthing women and their families should be able to make informed choices. All candidates for normal birth should be encourage to pursue it." and on the other hand "4. Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby." and "5. A Caesarean section should not be offered to a pregnant woman when there is no obstetrical indication.". Also of interest is In short, the SOGC is supportive of informed choice, so long as that choice is "Normal Birth" wherever and whenever possible. It is clear that the SOGC is well aligned with the practice of midwifery in Canada.

Compare this with the American Congress of Obstetricians and Gynecologists who put out their stance on maternal request c-section in December 2007 and reaffirmed it in 2010. The ACOG recommends that "1. Cesarean delivery on maternal request should not be performed before gestational age of 39 weeks has been accurately determined unless there is documentation of lung maturity. 2. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. & 3. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta and gravid hysterectomy increase with each cesarean delivery." Overall, the ACOG is reasonably supportive of maternal request c-sections, provided some very reasonable conditions are met. I might argue that the unavailability of effective pain management (ie. lack of epidural access) might be considered a legitimate reason to request an elective c-section, given that unmanaged pain during labour likely predisposes a woman to post-natal PTSD.

I should note that I had heard of Canadian women successfully planning c-sections, IN CANADA, without medical indication before - I therefore thought that surely if one was clear in her request, consistent in her wishes, that this was something I too could secure. All I needed to do was ask to be referred to a doctor who was open to maternal request c-section and ask to be referred to an OB who would agree (after providing information on the relative risks and benefits) to perform the procedure. I did that, it didn't happen.

So if I were in those shoes again - a Canadian nullipara, informed on the risks and benefits of elective c-section vs. vaginal birth and intent on planning an elective c-section; knowing what I know now about the stark difference in stance between the ACOG and the SOGC; I would have bit the financial bullet and would have given birth in the USA. It is also pretty clear to me right now, that if I want #2 to be born via elective cesarean at term, I might stand a much better chance of achieving that goal south of the border.

Alternatively, if I were an American worried about the intervention happy ACOG, perhaps I would go North - in pusuit of 'normal birth'.

An Invitation to Join the Cesarean by Choice Awareness Network

The Cesarean by Choice Awareness Network is a social network for mothers who support choosing birth via cesarean. It is for women who have chosen cesarean births and for those who would choose cesearan birth. It's a place to share information and build the CDMR community.

To join, click on the following link:

http://cesareanbychoice.ning.com/?xgi=2rSnVDLbAOUL4Q

Deconstructing the Cost of Planned Cesarean Delivery

Some people claim that women should not be free to plan a cesarean delivery because cesarean deliveries cost more than vaginal deliveries, and in a publicly run health system (like in Canada), that is unacceptable as it places an unneccessary strain on the system. As a result, the violation of patient autonomy and charter rights is "justified".

This claim needs to be deconstructed because such a violation should only happen when it can be demonstrably justified in a free and democratic society.

I believe this claim can be clearly deconstructed using data from the the Canadian Institute for Health Information's Patient Cost Estimator
I note that all data is for the province of British Columbia.

For convenience, I will assume that all repeat c-sections are planned c-sections, even though many of them will include failed vaginal birth after cesarean attempts (which would be at a higher cost as they would be emergent procedures). The average cost of these in 2008/09 was $3,410. Also for convenience, I will assume that all other births were 'planned vaginal' births regardless of whether or not they resulted in an 'actual vaginal delivery'. I note that some primary c-sections would have been lower cost planned c-sections for bonefide medical reasons, however, the vast majority of them are likely emergent/urgent c-sections done as a result of complications that emerged during labour. Weighing these births by volume, the weighted average of planned vaginal delivery in BC in 2008/09 was: $2,938.45. I note that this is likely an underestimate of the cost of planned vaginal delivery.

So, according to this back-of-the-envelope calcuation, how much does the health system 'save' by denying a women the right to choose a cesarean delivery based on these rough estimations:

That's right ladies and gentlemen - violating a patient's autonomy in BC in 2008/09 saved the health system an estimated $471.55. Assuming that 2 percent of all 'planned vaginal deliveries' would have choosen a cesarean (approximately 721 women in 2008/09), the health system saved $340,091.44. That's less than 0.3% of the money spent on deliveries in the health system in 2008/09 and less than 0.0025% of the total $15 Billion health budget in 2008/09. In 2008/09, to allow all women in British Columbia who would have choosen cesarean delivery to do so would have cost less than the amount that was paid to Vancouver Island Health Authority's CEO in salary and benefits ($417,425) in 2007/08.

I note at my therapist's rate of $160 bucks per hour is less than 3 hours worth of therapy. I'm reasonably convinced that my birth experience will need more than 3 hours of therapy to deal with - so in my particular case, denying my right to choose how my child was born will likely cost the system MORE than if the pre-labour cesarean had been granted.

I also must note that this cost difference does not include the costs that are associated with correcting the impact of vaginal delivery on the pelvic floor, the cost of caring for permanently disabled children who were injured during their mothers' planned vaginal deliveries, or the cost of birth related litigation.

So to those who say that planned elective cesarean is not a valid birth choice on the basis of cost - I would say that they need to take a long, hard look at some real numbers. I would further hope that preservation of one's charter rights should be worth more than $471.55 - which is likely a gross overestimate of the actual cost difference between thes modes of delivery.