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.

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.