Vaginal Birth Roulette (Part 2): Data From the BC Perinatal Services 2007/08

Another source of information on birth in BC is the Perinatal Services Annual Report. The most recent report is for fiscal 2007/08. According to this report, among women giving birth for the first time, fewer than 1 in 2 (49.7 percent) had a spontaneous vaginal delivery, fewer than 1 in 2 (47.5 percent) had epidural anesthesia and more than 1 in 6 (17.3 percent) had an instrument assisted delivery. More than 1 in 3 first time mothers (33 percent) delivered by caesarean.

It is interesting to note that of the 53.2 percent of women considered "normal" at the onset of labour (spontaneous onset of labour, singleton in vertex presentation, no previous caesarean, term gestation of 37-42 weeks), 3 in 4 had a "spontaneous vaginal delivery", with 12.4 percent having an assisted vaginal delivery and 11.3 percent having a cesarean section. Among nulliparous moms meeting this criteria 60.2 percent had a "spontaneous vaginal delivery", while nearly 1 in 5 had either an assisted vaginal delivery or a caesearean section. Among women who have previously given birth meeting the definition of "normal" at the onset of labour, nearly 93 percent go on to have "spontaneous vaginal delivery" while 1 in 20 (4.8 percent) have assisted vaginal deliveries and about 1 in 39 (2.6 percent) have caesarean sections.

Only 38 percent (neraly 2 out of 5) of all caesesareans in British Columbia in 2007/08 were elective caesareans (and of that the vast majority of these had a 'medical indication'). The BC perinatal services annual report lumps in maternal request with VBAC declined indicates that 4.1 percent of births fall into this categoy. Assuming all of those are planned c-sections 543 maternal request/VBAC declined caesareans were undertaken in 2007/08 - accounting for 10.5 percent of all elective caesareans. I note that the vast majority of these are likely to be VBACs that were declined - and I personally would not consider declining a VBAC to be a "maternal request c-section". Sixty-two percent (more than 3 out of 5) of all caesareans in BC in 2007/07 were urgent or emergent.

As a percentage of all vaginal deliveries - the risk of a 3rd or 4th degree laceration was 4 percent. Episiotomies happend in 9 percent of cases. Slightly less than half of all vaginal births in first-time moms involved use of an epidural and around 30 percent of all vaginal births involved use of an epidural. As stated in a previous blog post - there is a large discrepancy in epidural use in BC compared to other provinces - which suggests to me that there may be some issues related to accessing this form of pain relief in BC.

The Canadian Referral Process

I had my appointment with my GP today to get a referral - I spent more than half the time crying. I told her that I do not want to be referred to Dr. X or Dr. Y because of what happend last time - that I did not want a vaginal birth last time and after being bumped for 2 days wound up with an epidural free vaginal birth. Under no circumstances do I want a vaginal birth this time. I gave her the names of 3 OBGYNs that I'd prefer to be referred to - the problem is that in Canada OBGYNs generally don't handle uncomplicated pregnancies. The practice in BC is to refer to a general practitioner who does maternity care or a midwife - then have that person refer to an OBGYN at 33-35 weeks. My problem with this, is that waiting until 33-35 weeks is cutting things just a little bit close. How do you establish a relationship at that point? How do you trust that they'll go to bat for you at that point? Worse, if you don't like who you're referred to, is there enough time to get a referral somewhere else?

Why is it that only women who desire vaginal births, deserve continuity of care?

I'm hoping one of the OBGYNs on the list will take me on...sooner as opposed to later. If it's not possible, I should just firm up my plan to deliver in the US - and consider it the price to pay for piece of mind.

A Note to Little Bean

Dear Little Bean:

I am sorry, I have not been able to greet news of your pending arrival with the unfettered joy that accompanied news of your sister's pending arrival. I did not pee on three pregnancy tests, as I did with your sister, just to make sure it is real...I peed on one. I peed on one - and greeted the news with a combination of happiness, but also a great deal of anxiety. I did not call every one who needed to know within mere moments of seeing the news - I've told a few people, first your daddy - we drove by daddy's office and had your sister hand him the pregnancy test. And a couple of days later your Grandma J and Grandpa G, your aunts T and W and uncle M and a few close friends - your Grandmas P and B still don't know. I did not immediately call my doctor to get a referral to a maternity care provider - rather I only just placed that call today, a week after 'seeing' the news. Since seeing the news, my sleep has been less than stellar - in part because of your big sister, but also in part because of my own worries and anxieties. My worry that my trust and confidence will be betrayed again. My worry that despite having a plan (albeit a rather pricey one) - that something will happen to frustrate that plan. My utter terror of being again in the worst pain of my life, out of control, and without choices that I thought I had...knowing that this is possible, is very frightening to me.

I am sorry, that I am unable to confidently welcome the news of your pending arrival, I wish that was different - but little bean, please know - that you are very wanted and your mother's anxiety and fears have nothing to do with you, and everything to do with the context in which you are coming to be. You are loved and wanted, and I will deal with it as best I can.

Forgive me little bean - my response to your pending arrival, is just another unfortunate consequence of what happend when your sister came into this world. It's not your fault, it's not hers - but it sucks. It sucks that I can't greet this news with the unfettered joy that it deserves to be greeted with. You are wanted and loved, and I will do everything to ensure your safe arrival into this world.

Love,
Mommy

A Retrospective Reason for Wanting an Elective C-section

It has dawned on me that another reason for wanting a c-section with #1, would be to actually have a respected choice with #2. In Canada, and in British Columbia particularly, women who want to have vaginal births after c-sections (VBAC) are actually encouraged to do so. This is despite the relative risks of repeat c-sections compared to VBACs. It actually is a preformance indicator of the health care system, and those in the ministry of health (whoever they are who decide these things) actually want to see the number of women who attempt VBACs in BC increase. It's a bit mind-boggling (to me) in a province where only 1 hospital in BC currently has DOBA - but at any rate it is what it is.

I have a friend who is currently pregnant, and if she decided to go for a VBAC she would be free to do so. She is currently planning a RCS (repeat c-section) - but without a doubt, knows that the final decision of c-section or VBAC is hers and hers alone to make. I am somewhat envious of her freedom to choose at this point in time.

So I can add to the reasons for wanting an elective c-section: The Right to Choose Mode of Birth with subsequent births (all be it that vaginal births subsequent to a c-section do have higher risks).

The Serious Side of Funny

I'm hoping those of you who read my blog will appreciate my sometimes off sense of humour. In a semi-departure from the serious, I came accross this thought-provoking video featuring the "Completely Honest OBGyn".

A couple, obviously expecting their first are meeting with their OBGyn. They confess to him their desire for a "natural birth", the OBGyn then tells them how such an event would likely 'go down'. At the end he asks "So when can I schedule you for a c-section - does 3 or 4 work?" And the couple agrees that 3 is good.

My first thought was "where was that OBGyn when I had my first?".

My second thought was "some of that honesty about birth could be really refreshing."

My third thought was "this couple's experience is not at all unlike women who try to access elective c-sections when the prevailing culture is to attempt a natural birth".

I could entirely re-write the script and it would reflect the experience of many women who attempt to get the birth they want (c-section), only to be talked into something else entirely (natural) without any deference to the reasons behind the request in the first place. It could even be written in the delivery room itself as a woman is denied her request for an epidural.

The video highlights why many women self-select to the care provider who they feel will align most closely with their own philosophies on childbirth. Women who are highly desirous of a 'natural experience' tend to select care providers who are most likely to facilitate that experience (a midwife), meanwhile, women who are open to (or may even desire) a medicalized birth tend to choose a traditional medical provider (an OBGyn or MD). (I note that this is pure speculation, I have no actual survey data or study data to back up this hypothesis - but it makes sense to me so I'm going to run with it).

This video also highlights the information that women may be missing out on depending on which care provider they select. Those care providers most supportive of 'natural birth' tend to minimize the downsides to it and accentuate the upsides, meanwhile, those most supportive of 'medicalized birth' might share a similar bias in the other direction. (Again, this is mere speculation as I have no hard data to support this theory). As result of that kind of bias and self-selection, I can imagine the sort of trauma that might be inflicted should expectations not match up with experience (yet another theory without data, but again, I'm going to run with it).

Of course, if it was an example of what care in maternity SHOULD be like it wouldn't be funny at all...the really, really funny part (actually more sad now that I think of it) is - that the video might actually be a fairly accurate protrayal of what maternity care is like for many women. That needs to change.

I'm not a Feminist, I'm a Humanist

I never took a "Women's Studies" course in university - actually the whole idea of there being a "Women's Studies" department somewhat baffled me at the time. It seemed to me to be a bit odd, that there would be a Women's Studies department but no Men's Studies department. Of course anybody actually enrolled in Women's Studies would say that a Men's Studies department would be completely unnecessary because all the rest of everything was done from a male dominated perspective.

I rarely gave a thought to the idea of feminism, beyond the idea that women were mentally on par with men and just as capable as human beings in terms of what they could do with their lives. In fact, it has only been recently that I've been labelled a feminist and that my feminist leanings had clouded my critical thinking abilities. This in reference to my stance on elective c-sections in the absence of a traditional medical indication for one. It seems that the area of birth is the last frontier of misogyny, and even more odd is that much of the criticism is levelled at women by other women.

Go to any media article on the topic of elective c-section and you will find a litany of misguided and abusive commentary with respect to the topic. The idea that somebody else should restrict how a woman does or does not approach a medical condition (birth) is still very alive and well in Canada today.

Is it not clear that when it comes to medical decisions with regard to a medical condition that the decision about how to treat or not treat that condition should rest with an informed patient and their medical caregiver? After all is it not that particular patient who must live with the consequences of their decisions? Is the patient not entitled to informed consent, and security of the person, and respectful care?

Never before in my life, have I thought so critically about something, as I have thought about birth. In part, because never before in my life have I had to defend an opinion as vigorously as I have had to defend my opinions on birth, and in defence of that position, I have had to do an extensive amount of research.

The only funny thing is, that my opinion on birth really boils down to a very simple idea, "That a patient and her medical caregiver have the right to decide on the best course of action for that individual patient with respect to that patients particular medical condition." As a result of this idea, it is clear that I would defend a woman's informed right to choose a natural birth as rigorously as a woman's informed right to choose a c-section. To me this really doesn't seem like such a contentious proposition, what is ridiculous is that it is a contentious proposition.

Further, such a position doesn't make me a feminist, it makes me a humanist.

Dear Materniy Care Providers

Found this on Birthing Beautiful Ideas and thought it was worth reposting.


Dear Maternity Care Providers of the World:

On behalf of all women who are, or have been, or ever will be pregnant, I wish to make the following requests and pleas and clarifications.
I make these requests and pleas and clarifications to you not because I think that you are callous or unwise or deficient in your skills.  In fact, I don’t think you, on the whole, are any one thing at all.
You are not a homogenous group, and we are not a homogenous group, and we all come from places and perspectives that are radically unique and individual.
But still.
But still.
I make the following requests of you because, in addition to the quality prenatal care that we all deserve, regardless of our social and economic backgrounds, I also think that we pregnant women–we who have been pregnant, or who are pregnant, or who will be pregnant–deserve a special and robust sort of respect from our care providers.
And I think that too many of us are not receiving this respect.
Perhaps, you might argue, this is because we don’t know  how to properly engage with you.  Perhaps our own advocacy for ourselves and our babies seems disrespectful to you.
For sometimes we state our cases inelegantly.  We use medical terms incorrectly.  We print out pages upon pages of information gleaned from internet sources of varying repute.  We make requests that seem ridiculous or useless or even harmful to you.
And sometimes you find us to be annoying or petulant or curious or infuriating or stupid.
But what many of us really are is desperate.
We’re desperate to find a care provider who respects our autonomy, and not just theoretical respect for our theoretical autonomy but a real, earnest respect for the actual exercise of our autonomy.
We’re desperate to find a care provider to listens to us, and who responds to us without condescension.
We’re desperate to find a care provider who is willing to admit when they don’t know the answer to one of our questions.
We’re desperate to find a care provider who avoids exaggeration and coercion and manipulation in conversation with us.
We’re desperate to find a care provider who supports our active engagement in our pregnancy and birth.
And we’re desperate to find a care provider who simply sees us as persons.  Who treats us as persons.
Not as ticking time bombs.  Not as potential lawsuits.  Not as fetus carriers.  As persons.
And this is regardless of whether we want to give birth in a home or birth center or hospital.
Notably, to expect this from you–to want this, and even demand it from you–we know that we have responsibilities too.
We have a responsibility to treat you with the same courtesy that we expect from you.
We have a responsibility to research our options with care and discretion.
We too have a responsibility to appreciate the differences in your perspectives and values and practices.
We have a responsibility care for ourselves and our babies as best as we are able to (though please note that these abilities vary widely).
Yet despite how well or how badly we manage these responsibilities, we still have a right to your respect.
All your years of training–the blood, the sweat, the tears, the money spent on education, the hours sacrificed to your profession–give you extraordinary skills and abilities and knowledge, but they do not give you  the knowledge of what it’s like to be any one of us.
To inhabit our bodies, to know our bodies as we do, to have the exact and unique values and perspectives and preferences and commitments and plans and dedications that we have.
And all your years of experience do not give you infallibility, nor do they grant you the right to approach us with domination and paternalism instead of mutual respect and partnership.
So we ask you to grant us this respect.  To treat us as partners in our maternity care.
Even those of us who don’t yet have the skills or knowledge or resources to act on these rights.
For we all deserve it.
Every single one of us.
 
Sincerely,
A pregnant woman, who also wants and deserves this respect from you.

*image credit seanmcgrath on flickr
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Pushing for Better Access to Maternity Care in BC

BC Children's and Women's hospital continues to be the only level 3 hospital in BC with Dedicated Obstetric Anaesthesiology to provide anesthesia services to women who are in labour and delivery. Royal Columbian, Surrey Memorial, and Victoria General Hospital are also level 3 hospitals. Both the government and the health authorities have known (or ought to have known) that failing to have anesthesiologists to meet the needs of pregnant and labouring women would result in delayed and denied access to epidurals, delayed and denied access to elective c-sections, delayed access to urgent c-sections and delayed access to emergency c-sections.

As a result of these delays and denials women have been harmed. Those who had their access to epidurals unreasonably delayed have had to endure unneccessary labour pain. Those who have had their access to epidurals denied have faced unneccessary labour pain and have faced the risk of general anesthesia in the event of an urgent or emergent c-section, the risk of inadequate pain management in the event of an instrumental delivery, and an increased risk of their child needing to be resuscitated due to exposure to intrapartum narcotics. Those who have had elective c-sections delayed have faced increased risk including the increased risk of going into labour prior to the c-section and an increased risk of an unwanted vaginal delivery, and for those who did go into labour awaiting their elective c-section they endured unneccessary labour pain and increased surgical risks. For those who had their c-sections denied, they endured an unwanted vaginal delivery, unneccessary labour pain, and all the sequalae and risks of vaginal delivery that would have been avoided if the planned c-section had taken place. For some their husbands and loved ones have had to watch as they suffered unneccessarily. For some they continue to experience increased levels of anxiety and may have PTSD and PDD as a result of their poor birth experiences. Some are hesitant to trust the health system and some are choosing to forego having additional children out of fear that the medical services that they need won't be there when they need them.

Thankfully for vast majority of these women who have been impacted there have been no long-run damage to their health or the health of their child, but unfortunately for some there have been disasterous consequences.

Women who have been impacted need to take a stand and demand better from their government and the health authorities. They need to write to the Patient Care Quality Offices of their respective health authorities. They need to write to their MLAs. They need to take a stand and say that it is wrong to unreasonably delay or deny access to epidurals and c-sections to women at level 3 hospitals. It is particularly wrong when women and their care providers have determined that access to these services are in the woman's and her infant's best medical interest (both physical and psychological).

Government needs to be held accountable for this apalling breach - or nothing will change.

Email me at qualitycareforbcmothers@gmail.com if you have been impacted by this issue and are interested in making a difference in BC.

The Disservice of Biased Information

I skipped out on the prenatal childbirth preparation classes - not to say that I didn't prepare myself for childbirth, I did - but I focussed my attention and education on surgical childbirth, as that was what I had planned on doing. I skimmed the other stuff (I went to the meet the doctor night at the hospital) - but mostly found that it confirmed what I did not want to do - give birth the 'normal' way. One of the reasons I opted out was that I perceived that I would be a poor fit in the traditional class - the maternal request c-section mom - no doubt I'd be singled out and potential ridiculed for my choice. I wasn't going to put myself in that position. This was a perception of bias (on my part) about the information that would be given in the class. Of the moms who did attend pre-natal class, they confirmed for me that indeed there was a 'natural childbirth' bias in the information given. Thanks, but, no thanks.

Unfortunately this left me somewhat flat-footed when I was faced with no other choice but to give birth 'naturally'.

I don't think biased information is limited to the 'natural childbirth community', I think the medicalised birth also has some degree of bias and perhaps an over emphasis on the avoidance of risk at all costs.

My problem is that I don't think there's much of a middle ground, and as a result women are left trying to decipher the information they receive about childbirth. For some women, likely those with higher levels of information literacy, they can sift through the information and make decisions that work best for them. Unfortunately for many women, they are ill-equipped to sift through the information in a way that identifies the bias (and corrects for it) and may make decisions that are less than ideal for themselves and their babies.

Good decisions that meet the needs of women and their babies would allow women to determine what matters most to them and which course of action is most likely to result in the most satisfaction when the job of parenting begins. I think this is the underlying problem with birth plans and can explain the sometimes large gap between what women expect of childbirth (and after) and what women actually experience of childbirth (and after).

The other big problem with bias, is that it tends to generate a paradigm where there is only one right way to give birth or parent. It generates the "if I didn't do it this way, I'm a failure" feeling and provides fertile ground for the development of "sanctimommies" and that is also damaging. Every woman should be able to stand by her decisions and say with conviction "I looked at the information available, and I made the choice that works for me and my child" with pride and with knowledge that it's okay to make a decision that is different from somebody else's decision.

Bias in information is bad, informed choice is good - but good choices rely on good (unbiased) information - a difficult challenge for any pregnant or birthing woman or parent today.

Elective c-section at 39 weeks, could prevent some very unpleasant consequences of vaginal delivery

Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise.
Semin Perinatol. 2006; 30(5):276-87 (ISSN: 0146-0005)
Hankins GD; Clark SM; Munn MB
The University of Texas Medical Branch, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Galveston, TX 77555-0587, USA. ghankins@utmb.edu

PURPOSE: The purpose of this analysis was to determine the impact on specific forms of neonatal morbidity and mortality by allowing women to opt for delivery by elective cesarean section at 39 weeks of gestation (EGA). According to the National Vital Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational ages>or=39 weeks EGA. Estimating that over 4 million deliveries occur annually in the United States, this would yield approximately 3 million pregnancies wherein the woman may exercise her choice for either primary or repeat cesarean section at 39 weeks EGA or at the point when labor is established. METHODS: A search was conducted using Ovid Medline spanning the past 10 years using the following key words: fetal trauma, shoulder dystocia, brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal encephalopathy. Using this search technique, over 2100 articles were identified. The abstracts were reviewed and pertinent articles were chosen for further consideration. The identified articles and their applicable references were obtained for inclusion in this review. Preference was given to publications on or after the year 2000 with the exception of classical or sentinel articles, which were included without regard to year of publication. RESULTS: Four major categories of neonatal morbidity and mortality are discussed: Shoulder dystocia: Accepting that we do not have a successful method for the prediction or prevention of shoulder dystocia, the question becomes, "What is the chance that a baby will sustain a permanent brachial plexus injury at delivery?" Additionally, is there a significant protective effect of cesarean section in reducing the risk of such injury? Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a composite estimate of the risk of 0.15% for vaginal deliveries and applying it to the 3 million deliveries>or=39 weeks EGA, approximately 4500 cases of brachial plexus palsy would occur. If only 15% of these injuries were permanent, 675 permanent brachial plexus palsies would occur annually. If the risk of permanent injury is 1 in 10,000 as reported by Chauhan, 300 permanent brachial plexus palsies would occur annually in the United States. The range then for permanent brachial plexus injury that could be avoided with cesarean section on request would appear to vary between 1 in 5000 and 1 in 10,000 vaginal births. Fetal trauma: The incidence of significant birth trauma varies from 0.2 to 1 to 2 per 1000 births. The use of sequential instruments, for example, vacuum followed by forceps or vice versa, is specifically associated with an unacceptably high injury rate. Intrapartum-related neonatal deaths of vertex singleton fetuses with birthweights>2500 g from traumatic cranial or cervical spine injury secondary to vacuum- or forceps-assisted vaginal delivery are still occurring. Overall, the frequency of significant fetal injury is significantly greater with vaginal delivery, especially operative vaginal delivery, than with cesarean section for the nonlaboring woman at 39 weeks EGA or near term when early labor has been established. Neonatal encephalopathy: The prevalence of moderate to severe neonatal encephalopathy is 3.8/1000 term live births with a neonatal fatality rate of 9.1%. In 4% to 10% of cases, the etiology appears to be pure intrapartum hypoxia. Intrapartum hypoxia superimposed on antepartum risk factors may account for up to 25% of the moderate to severe encephalopathies, according to one cohort. A paradox in the data thus far is that infants born to nonlaboring women delivered by cesarean section had an 83% reduction in the occurrence of moderate or severe encephalopathy. Considering a prevalence of moderate or severe neonatal encephalopathy of 0.38% and applying it to the 3 million deliveries occurring at >or=39 weeks EGA in the United States annually, 11,400 cases of moderate to severe encephalopathy would occur. The rate of encephalopathy observed in infants delivered by cesarean section would yield approximately 1938 cases. This net difference in moderate to severe encephalopathy would represent 9462 cases annually in the United States that could be prevented with elective cesarean section. Although cesarean delivery may be protective for the development of neonatal encephalopathy, to date it has not proven to be protective of long-term neurologic injury in the form of cerebral palsy with or without mental retardation and/or seizure disorders. Intrauterine fetal demise: Copper reported that the rate of stillbirth is consistent from 23 to 40 weeks EGA with about 5% of all stillbirths occurring at each week of gestation. Yudkin reported a rate of 0.6 stillbirths per 1000 live births from 33 to 39 weeks EGA. After 39 weeks EGA, a significant increase in the stillbirth rate was reported (1.9 per 1000 live births). Fretts reported on fetal deaths per 1000 live births from 37 to 41 weeks of gestational age, showing that the rate progressively increased from 1.3 to 4.6 with each week of gestation. It can be estimated that delivery at 39 weeks EGA would prevent 2 fetal deaths per 1000 living fetuses. This would translate into the prevention of as many as 6000 intrauterine fetal demises in the United States annually-an impact that far exceeds any other strategy implemented for stillbirth reduction thus far. CONCLUSION: It is reasonable to inform the pregnant woman of the risk of each of the above categories, in addition to counseling her regarding the potential risks of a cesarean section for the current and any subsequent pregnancies. The clinician's role should be to provide the best evidence-based counseling possible to the pregnant woman and to respect her autonomy and decision-making capabilities when considering route of delivery.

Major Subject Heading(s) Minor Subject Heading(s)
Birth Injuries [epidemiology] [prevention & control]
Brachial Plexus Neuropathies [prevention & control]
Brain Diseases [etiology] [prevention & control]
Cesarean Section [trends]
Dystocia [etiology] [prevention & control]
Female
Fetal Death [epidemiology] [prevention & control]
Fetal Diseases [epidemiology] [prevention & control]
Fetal Hypoxia [prevention & control]
Gestational Age
Humans
Infant, Newborn
Patient Participation
Pregnancy
Stillbirth [epidemiology]
Surgical Procedures, Elective
United States [epidemiology]


PreMedline Identifier: 17011400

Inadequate Resources to Support Maternal Choice in Birth in BC is Unreasonable

The numbers of women who give birth in British Columbia have been fairly stable with the rate per 1,000 population being aroun 10 since 1999 (ranging from a high of 10.4 in 1999 to a low of 9.69 in 2005 - source BC Vital Statistics Agency 2009 annual report). As such, the demand for services related to childbirth and pregnancy should be fairly well known. Further, many women make decisions regarding the birth of their children well in advance of labour - choices about whether or not to have an epidural and in some cases about how to deliver their child (ie. planned c-sections). As such, when women go to give birth and cannot access epidurals and c-sections in a timely way, is it really excusable to blame a lack of resources?

Is the 'Power to Push' campaign dangerous?

In BC there is a well known campaign that is called the Power to Push, and while at first glance it appears to support woman's choices in childbirth, it is decidedly "Pushy" about pushing natural child birth. This is particularly true of it's facebook page.

I have several concerns about the campaign. First, it's intended purpose is to 'push' down the Caesarean section rate in BC. Second, when discussing birth options, very few statistics are given about the relative risks of the options. Third, the benefits of medical intervention are downplayed. Fourth, the risks of natural birth are downplayed.

In short I think the campaign is irresponsible and I'm somewhat concerned that a major hospital (BC Children and Women's - the only hospital in BC with dedicated obstetric anaesthesiology) would support such a biased campaign.

Women need to be empowered to make decisions regarding birth - decisions that are safe and informed. Further, women need access to the services that support those decisions. Failing to provide unbiased and complete information (like real statistics on the risks and benefits) is irresponsible and dangerous.

Why doing something is important

Nothing I do now can change the past experience I have had of childbirth, it will always be what it was. However, knowing that what it was and what it should have been are two very different things, remaining silent about it sends the message that somehow that is okay. Burrying it in the past will not help me move forward. What happend was wrong on many different levels. Knowing that I am not alone in my experience of being unable to access appropriate care, makes it more wrong not less...

Which is why I am finding that doing something about it is helpful. It is why speaking out, is important. It is why talking to other moms matters - because mothers matter and they deserve better. I hope that what I do today will reduce the chance of the same wrong continuing to be done. I want my daughter to get the care that she deserves when she decides (if she decides) to be a mom.

I can't change the past - but I might be able to change the future, but only if I refuse to be silent. What happened to me was wrong, if it happens to my daughter and I could have prevented that in some way - then I will have truly failed.

Letter Sent to VIHA's Patient Care Quality Office

Today I sent the following to the Patient Care Quality Office of the Vancouver Island Health Authority:

Dear Vancouver Island Health Authority, Patient Care Quality Office;

I write more than a year after I gave birth on July 11, 2010 - because I feel that the care I received failed to meet an acceptable standard.

I was supposed to give birth by way of a scheduled c-section on July 9, 2010. I recieved the call from the hospital, fasted accordingly and arrived as directed and waited. As I was a gestational diabetic, the lack of food eventually caused my blood sugar to drop into a hypoglycemic range and a glucose drip was started. We continued to wait. Surgery did not happen that day and I spent the night in the hospital hoping it would happen the next day. Again we fasted and waited, and again surgery did not happen and again I prepared to spend another night in the hospital - with the promise that surgery would occur first thing the next morning. Unfortunately, I went into labour at quarter to midnight, at which point I was informed that there was no anaesthesiologist available. There was no access to an epidural. My daughter was born vaginally at 4:42 am and needed to be resuscitated. I sustained 2nd degree tears and experience a minor degree of stress urinary incontinance. My labour was terrifying and painful. To this day I have difficulty reflecting upon the experience without feeling stress and anxiety. My autonomy as a woman was violated that day as I was subjected to a natural vaginal delivery, despite having planned for an elective pre-labour c-section.

I am apalled at the level of care I received and am further apalled that VIHA was aware or should have been aware that reducing the level of anaesthesia access to labouring women would result in access to c-sections and epidurals being unreasonably delayed or denied.

Sincerely,
Mrs.W

The Cost of Cheap Healthcare

Before I was a mom, I would have never believed that a woman living in Canada, in an urban centre, in the 2000's would be denied an informed choice about where and how to give birth. In my pre-mom naivete I believed that birth plans carried weight and were a critical element of quality, patient-centred care. I knew that birth had all kinds of twists and turns - that often those planning vaginal birth had a need for c-section or found the pain of labour too great and needed pain medications. However, I believed (wrongly!) that such flexibility was reserved for the exceptional circumstance. I mistakenly thought that the phenomenon of waitlists and care rationing was absent from maternity care - after all it seems absurd that such things would apply in this area of care. As anyone with any experience with babies knows - babies do not wait! Further, the care needs of pregnant woman are known largely in advance - there are a good 7 to 8 months of advance notice...

I certainly did not just show up at the hospital one day and say - I'd like my c-section now please. Rather from the first prenatal appointment, I let it be known that that was my preferred method of birth.

The decision to inadequately resource labour and delivery services has undoubtedly saved the system money - but at what cost? Would I be sitting here more than 15 months after the event still thinking about it, if I had gotten the care that was appropriate in a timely way? Would I be so trepiditous about venturing towards having another baby? How many other women in BC feel as I do?

Forcing women to endure the pain of childbirth against their will when there is medical technology available that is on a whole, safe, to alleviate the pain of childbirth seems really misogynistic and antiquated. Doing so to save money, is just cheap!

Does Morgentaler set a precedent for a woman's right to timely access to medical care?

More than 20 years ago on January 28, 1988, the Supreme Court of Canada handed down the decision in R. v. Morgentaler. Despite being a criminal case, the case examined a women's rights in the context of the Charter of Rights and Freedoms. The Morgentaler case found that the criminal legislation governing abortions in Canada was unconstitutional. The reasoning for the unconstitutionality of Canada's abortion laws was that it interfered with section 7 of the Charter which states that "Everyone has the right to life, liberty and security of the person and the right not to be deprieved thereof except in accordance with the princples of fundamental justice". Part of the reasoning for striking down Canada's abortion laws was the delay in obtaining therapeutic abortions that the was caused by the mandatory procedures for procuring an abortion at the time - the delay resulted in a higher probability of complications and greater risk which infringed upon a woman's section 7 charter right. (Judges Dicson and Lamer). Judges Beetz and Estey reasoned that section 7 of the Charter must include a right of access to medical treatment for a condition that represents a danger to life or health without fear of criminal sanction. Judge Wilson also agreed that the abortion laws were uncontitutional as it "takes a personal and private decision away from the woman and gives it to a committee which bases its decision on "criteria entirely unrelated to the pregnant woman's own priorities and aspirations." Judge Wilson also found that s.7 of the Charter should protect both the physical and psycological integrity of the individual and that section 251 was deeply flawed by subjecting women to considerable emotional stress and unnecessary physical risk and that putting woman's capacity to reproduce in the control of the state was a direct interference with the woman's physical person. (Note: Information on the Morgantaler case is from the University of Alberta's law website: http://www.law.ualberta.ca/centres/ccs/rulings/rvmorgentaler.php.

A woman who cannot procure an abortion in a timely way without fear of criminal sanctions, has been deprived of her right to life, liberty and security of the person. This is settled law.

Yet, in British Columbia women who are giving birth may have their access to medical intervention limited because of decisions made by the BC Government, the Health Authorities, the BCMA and BC Anaesthesiologist Society. Have these women been deprived of their section 7 charter rights?

I'll take my own personal experience as an example. I wished to procure a c-section without medical reason. My motivations were primarily psychological and included a desire to avoid an emergency c-section, desire to avoid damage to my pelvic floor, desire to avoid the pain of labour, desire to avoid serious harm to my child including the risk of brachial plexus injury, and cerebral palsy. I had throughly researched the issue, I was aware of the risks and benefits of both modes of delivery and I had made a choice. I found a care provider who was supportive of that choice and we booked a delivery date (July 9, 2010). Due to resource limitations (that the government and health authorities were well aware of) - I could not access timely medical care (a pre-labour c-section) and was for all intents and purposes - forced to give birth vaginally.

Similarly, access to epidurals is also constrained in BC.

Inability to access c-sections and epidurals in a timely way (39 weeks for elective, scheduled c-section, 2 hours for urgent c-sections, 30 minutes for emergency c-section and 2 hours for epidural) strikes me as a violation to a woman's section 7 rights, particularly when the only choice a woman has for giving birth is the public health system.

Wrapping my head around...everything

I spend a lot of time in the space between my ears. Thinking about my last pregnancy and birth (mostly birth). Thinking about the health care system in BC - often as it pertains to maternity care. Thinking about whether or not any of it really matters...and if it does matter thinking about what I can do about it. Thinking about the future, and the next pregnancy. Thinking about what kind of health system my daughter will face when she is approaching motherhood.

The only conclusion I have come to is that my experience can not be without value or purpose - which is more of a beginning than a conclusion.

I have started in motion what I hope will be an effective way of making my experience (and those of others) matter. Only time will tell if that is truly the result of my actions. I hope for courage and strength...and to repair some of the damage done.

Am I nuts to consider trying for #2 when nothing in the system has changed??

My husband is on board with the idea that we should begin to try for number 2...that active efforts to prevent pregnancy should cease in the hopes that my daughter will have a little sibling.

Am I nuts for even considering this, NOW? Nothing in Victoria has changed, I am not overly convinced that it will change before the end of the as yet to commence next pregnancy. I'm fairly certain that I will again request a c-section...but am I confident that I'd be able to attain such a birth plan? Not in the slightest. The OBGYN I had last time has decided to go into oncology...so I'd even have to find another OBGYN who would be sympathetic to the request, and then I'd have to hope (and pray, and hope some more) that the actual resources would be there when I needed them.

What are my options? A private birth, isn't an option in BC - there simply isn't anywhere where I could even 'pay' to ensure that I'd have access to an epidural/c-section....Perhaps birthing in Alberta? But again that might not be entirely realistic....

And what if its just a replay of the show I've already seen...is the happy ending good enough? Do I just lay back and let my autonomy as a woman be violated again? --there goes my jaw, it's clenched again.

Is it time for a 'counter-revolution' in Birth?

There's another voice in the birth debate that has been squelched in the last couple of decades by those who view a 100% natural birth experience as being superior to the medical alternatives. There's a bias in childbirth education classes. There's a bias on the web. It's not a scientific bias - despite what Ina M. Gaskin and Rikki Lake might have you believe. Worse - it harms women and babies by restricting their choices and leading them to make decisions that wind up making them (and their babies) worse off. It makes women who do not subscribe to their beliefs feel as though they've failed in mothering or parenting.

The voice of the 'Natural Child Birth' (NCB) movement is exceptionally loud - they have their figureheads and their documentaries ("The Business of Being Born").

The counter-voice is quiet and must be sought out - it exists but it seems less charged. Where is the anti-NCB documentary "Beyond Reason: The Religion of Being Born"??.

Are women who fear childbirth given a fair deal by the health system?

The Globe and Mail today published that women who fear child birth were more likely to have c-sections (both elective and emergency) compared to those who do not fear birth.

What I found remarkable were the comments after the story. In particular there is a stark contrast between those from women who 'get' the fear of childbirth, and those who are hard core natural birth advocates. Those who get it would never denigrate the choice of a woman to opt for an elective c-section (or a natural birth if that is what she desires). Meanwhile the natural birth advocates are hellbent on enforcing their views on other women and would actively ban informed choice.