Best-feeding May Mean Less Breast-feeding

With my daughter, I breastfed pretty much exclusively for the first five or so months when she started displaying signs that she was ready for the introduction of solids (reaching for our food, no longer having the tongue ejection reflex, etc.). Her main source of liquid nutrition continued to be breastmilk until she was 10 or so months old, when it was decided that we should introduce formula into her diet in preparation for daycare. Before then, formula was very rarely used (I could probably count on my fingers the number of ounces my daughter had consumed it). That's not to say that my daughter wasn't accustomed to bottle feeding, she was, as we had introduced a bottle at around 5 days of age (I liked the idea of my husband feeding our daughter at least once a day - to give myself a break and to allow him to have those minutes with her)- but in general the contents of that bottle was pumped breast milk.

It's not that breastfeeding was difficult for me - it wasn't. I didn't have supply issues and it was not painful. My daughter gained weight and seemed to 'get' the hang of breastfeeding readily. In general, breastfeeding was convenient - there was always a meal, at the right temperature, and at the time it was needed.

However, looking back, it was also inconvenient. It meant that we had to buy a breastpump. It meant that I always had to wear clothing that would allow access to my breasts - and so after the maternity clothes served their purpose there was yet another wardrobe of nursing clothes. It meant that the child had to be with me or alternatively that I had to pump and plan for their to be a sufficient quantity of pumped milk on hand. While I pumped, I could not do whatever I pleased but had to engage in pumping compatable activities - so time wise, pumping did not so much 'save' time as it reallocated time. If feeding time happend while we were out and about, it meant I had to stop and find an appropriate place to nurse (at the very least somewhere to sit for a while). It meant that I had to watch what I ate or drank. It meant that when I couldn't nurse at the expected time, I could expect to become engorged or leak (there was a time or two when I woke up in a literal puddle).

I was quite happy when my daughter was fully weaned from breastfeeding shortly after her first birthday - I was happy to have my body back as an independent one from hers. After nearly two years (pregnancy + breast feeding) of sharing myself with her to such a physical degree, I was ready to end the breastfeeding relationship. And she really didn't seem to mind when the morning nursings ended and then when the bedtime nursings ended.

The inconveniences I experienced, are absent some of the real challenges that many women face when they choose to breastfeed. I had the luxury of a year-long maternity leave and no other children to care for while I was nursing my daughter - many women do not get maternity leave (those who are self-employed in Canada or do not have employer provided top-offs may find it financially difficult and those in the US). I did not need drugs or supplements to increase my milk supply - many women find this neccessary. I did not need to undertake an elimination diet due to food sensitivities of my daughter - many women do. Breastfeeding was not painful - it is for many women. I did not have a history of sexual abuse or eating disorders - many women are survivors. My daughter did not have problems with latching or gaining an appropriate amount of weight while she breastfed - many infants may fail to gain weight or may need assistance latching.

And yet looking back, knowing what I know now, I think I might do things a little differently this next time (even if it were under the exact same circumstances as the first time). For one, I will have another child to care for - an active toddler, albeit the plan is to keep her in her daycare full-time. But, also I am more aware that breastfeeding is not the only appropriate choice for infant feeding and that having a little more independence from my child might be good a thing. I also think that there's really no reason to believe that a mother can't have the best of both worlds and that more combo-feeding might be realistic goal this next time around. So for myself, best-feeding my next infant, very well might mean less breast-feeding.

Correlation is not Causation, a.k.a. "Look at the Confounders Batman!"

In the past week or so, a study has been making the rounds. This one claims that babies born via c-section have twice the risk of being obese as those who are born vaginally. The anti-csection brigade is using it as yet another reason to clamp down on the epidemic of unneccessary c-sections, and at the same time making moms who would willfully choose c-section, absent any medical indication, feel as though their choice is posing some risk to their child.

I've had a brief look at the study in question - and here is my conclusion:

Correlation is not causation, and "Look at the confounders, Batman!".

There are a lot of reasons why the rate of c-sections has increased over the past few decades. Moms are older by the time they have children - there are things that seem to be pre-requisites to starting a family now, many women want to be married for a while before starting a family, many women want to own a house before starting a family, many women want to have a career before starting a family, and as a result of wanting a career many women must complete post-secondary education before starting a family. At the end of a day a woman is often in her thirties before she even tries getting pregnant. As a result of being in your thirties before you even start on the "mommy track" you might be more likely to need help getting pregnant in the first place. This might mean fertility drugs. This might mean IVF. Even if it doesn't mean those things, your risk of having multiples increases with age. Many moms might only be planning on having small families. Moms also seem to be more likely to be starting their pregnancies with higher BMI's than in the past and they also seem to be having higher rates of gestational diabetes. Women also seem to becoming more aware that vaginal birth is not risk-free and may also have some unpleasant risks. And all of this is in a context of having the risk associated with having a c-section plummet - surgical methods have improved immensely over the past few decades. So in short, I'm not shocked that the use of c-sections in birth has increased - quite simply because in an increasing number of cases the benefits of surgical birth outweigh the risks and costs associated with surgical birth.

Now the question that needs to be asked, and wasn't asked by this study - is whether or not all of those things that wind up causing an increase in the c-section rate might also increase the risk of childhood obesity. In which case, it wasn't the c-section that caused the babies to be beefier - and doing things to address the rate of c-sections alone (without addressing the underlying causes of the increase) won't do anything to address the rate of childhood obesity. You might just wind up with just as many beefy kids, but more birth injured moms and babies.

I also found it quite interesting, that the risk of obesity seemed to be HIGHER among those who were having urgent or emergent c-sections than among those having planned c-sections. This would seem to indicate to me, that the causes of the c-section in the first place are probably much stronger determinants of childhood obesity than the method of delivery.

In short, this study does little but add to the hysteria around the debate surrounding childbirth and further confuses the very complex problem of childhood obesity. I can see it now, the mother in line at McDonald's with her chubby little cherub playing their PS3, saying "The kid is a c-section baby - it's got nothing to do with everything else we do."

Interesting: The Patient Voices Network of BC

I recently came across the the Patient Voices Network - an interesting initiative that seeks to facilitate patient involvement in the health care system. I must applaud the government for reaching out to patient groups, and hope that it is doing so with an open ear. I am encouraged by the existence of this organization, and think it has tremendous potential to affect change in the health system of British Columbia - particularly if it sheds light on the reality patients face as they access the system for their health care needs.

It would appear that the network has a broad scope - and is aimed at all patients who interact with the healthcare system in British Columbia.

Personally, I am interested in the maternity care system in British Columbia - as it is the part of the system that I've had the most experience with in the last two years on a personal level - and over the next 6 months will continue to be the part of the system that I am most likely to be personally touched by. I hope this network will achieve an adequate representation of mothers from accross the childbirth spectrum - and would not/will not be swamped by those who are strong proponents of natural childbirth, as proponents of access to medical intervention in childbirth also need to be heard and represented.

I hope other mothers in British Columbia who have concerns about the maternity care system will also speak up and be heard. In particular, I hope that mainstream mothers who want access to epidural pain relief, who do not want to choose between the 'niceities' of homebirth and the safety of hospital birth, those who want to be able to exercise informed choice on all available childbirth options, and those who would like to see outcomes placed ahead of process, will also speak up. If not for yourself, then for the prospect that your children might be able to bear their children in a better and more balanced system.

So I have decided to park my general skepticism and cynicism at least momentarily and I've decided to learn more about this initiative, as a maternity care patient - I hope other BC mothers will do the same.

A (very wonkish and very economics based) post on how healthcare might be better structured in Canada

Let me preface this post with the following:

This is a very wonkish health policy post - and reflects personal opinion only.

The healthcare system in Canada is incredibly complex and the challenges that will emerge over the decades to come are significant. It is clear that the current system, as it has evolved over the past several decades has many strengths to it, but also many weaknesses. It is also clear that meeting the challenges will require colloboration and mutual respect between healthcare providers, patients, and government. Facilitating those changes might be better achieved if the very structure of how healthcare in Canada is funded and organized was changed to reflect the reality of what the healthcare system is and what it sets out to achieve for Canadians.

Currently, healthcare in Canada is funded via general tax revenues (provincial and federal) and in some provinces (like BC) per-capita premiums (like MSP) that may be waived for low-income individuals. Provinces each administer their own health care system - so in effect there are 10 provincial health care systems in Canada.

As a result of this structure, there are some significant weaknesses (well-known) that result.

1. Provinces compete against each other for resources and tend to out-bid each other in sequential rounds of bargaining with health care provinces.

2. There is wide variation in terms of the health care services that are accessible to Canadians based on their province of residence. There are procedures that might be "insured services" in one province but not in another. The wait time for access varies widely across the country. In general the province with the most resources to devote to health care services has the best health services available in terms of what is covered by the public system and wait times for access.

3. Governments tend to be hesitant to raise taxes in response to rising demands for healthcare services. As a result health services are either underfunded or other areas of public services are restrained to pay for the services provided in the health care system.

4. There is no relationship between what an individual pays towards the healthcare system and their health care needs or their controllable health behaviours. If you make a lot of money, you pay high income tax and contribute high amounts towards the health care system. It is a myth that health care is "free" in Canada, income=health care premiums in Canada - it is only "free" if you happen to be so poor as to not pay any taxes at all.

5. There is limited flexibility in the types of services that can be accessed in Canada. Services that are not publicly provided as insured health services are supplied via the private health industry - these are things like cosmetic surgery, sterilization reversals, dentistry, etc. Services that are publicly insured and provided often lack choice - there are few "frills" in the Canadian system, a patient generally cannot choose to access services faster (but pay for the privledge) nor can they choose to access services that might be qualitatively different (ie. a surgical delivery versus a vaginal delivery when not medically indicated) and pay for the difference in resource use. In general, a patient also cannot "choose" a nicer facility for a price for a publically provided service. Generally, facilities do not compete against one another for market share. If a Canadian wants choice or frills for a 'publicly insured' health service, they often must pay for that service completely out of pocket and access that service abroad.

6. There is a lot of administrative duplication and inefficiency that results from the running of 10 different health systems.

7. The system tends to be prone to politicization. Decisions regarding what is or isn't covered or how resources are allocated or even what information on the system is provided to the public are often political in nature.

That's not to say the system is without it's advantages.

It is a tremendous advantage that there is no problem of "uninsured" Canadians - every Canadian has health insurance and access to health services. They might not be the best health services that are technologically feasible. They might be services in older facilities. Canadians might have to wait a long while to access those services.

So how might Canada retain the current advantages of the existing system while correcting some of the disadvantages?

While there are likely many different ways to do this, I think that one way to do it would be to do the following:

First, create a Public Health Insurance Agency of Canada (PHIAC) that provides mandatory basic health insurance to all Canadians and pays for those services via a combination of individual premiums that are based on income, age, and health behaviours that are under the control of the individual and a government grant from corporate taxes. Risk associated with genetic predispositions or accidents could and should be pooled accross the entire population. The amount of premiums needed to be paid would be based on the health services needed. Health premiums would be separate from taxes - but mandatory and collected in a similar fashion to how taxes are collected. All Canadians of legal age would be shareholders in the PHIAC.

Second, create an independent organization (the Healthcare Senate) with a fixed-term appointed board with nominations from health care providers, provincial governments, patients, and PHIAC that can make binding decisions on the insurer and facilitate collaboration between patients, health care providers and the insurer. This organization would set compensation levels and make decisions regarding resource allocation, determine which services are covered, undertake quality improvement and review initiatives, collect and analyse data on health service use and outcomes, and report to the public.

Third, open the door to optional private insurers and private payment for services not covered under PHIAC and for 'frills' such as expedited access to services, nicer facilities, and patient choice.

No doubt there would also pitfalls to this kind of system, but it does provide "some food for thought" - and I would tend to think that such a system may retain many of the advantages of the current system while remedying some of the disadvantages. I am also curious if there is any health sytem in the world that is structured in this way and if so, what are its results?

Cost Studies on Cesarean Birth versus Vaginal Birth Short-Changes Mothers and Babies

As an economist, I am often dismayed by the existing studies that compare the costs of vaginal birth with the costs of caesarean birth - and then come to the conclusion that a great deal of money could be saved by promoting "normal birth". I am further dismayed, when without question or critical thought the media then goes on to parrot the cost difference, as being $4,863 versus $2,486, as in this recent Toronto Star article . The problem with most existing cost studies and a simple parroting of cost statistics is that it over simplifies the issue of cost as it pertains to childbirth.

The first flaw in the basic statistics on the cost of mode of delivery, is that they are retrospective in nature. This means that they do not reflect the planned mode of birth but rather are the result of the actual mode of birth.

As such, the statistics on the costs of caesarean sections include the costs of both elective or planned cesarean sections as well as the costs of emergent caesarean sections. The vast majority of emergent cesarean sections are the result of planned vaginal births that do not go as expected. Emergent caesarean sections cost significantly more than their planned counterparts as many of these births involve the interventions (and their costs) that are common to vaginal births as well as the costs of caesarean births and may also involve increased costs associated with a substantially increased risk of complications. This artificially inflates the reported cost of cesarean birth.

While the basic statistics inflate the cost of caesarean birth, they also diminish the cost of vaginal birth. A "straight forward" vaginal delivery - is a delivery that does not involve the use of an epidural or augmentation, and does not involve the use of forceps or vacuum to assist with the delivery of the child. This is the type of delivery that those who subscribe to the philosophy of natural childbirth aspire to achieve. The reality is that for many women achieving this kind of delivery is simply either not possible or not desireable (it could be done, but at a great risk of harm to either the mother or the child). Many women elect or need epidural pain relief. Some women have fetuses that are simply too large or are not ideally positioned for their bodies to safely accommodate a natural delivery. Many women and babies need help with the delivery process and will require assistance by way of either forceps or vacuum (which in the absence of an epidural can be excruciatingly painful). Some who planned on a "straight forward" vaginal delivery will ultimately need an urgent or emergent caesarean. Yet, the costs associated with epidurals, forceps, vacuum, or emergent caesareans are conveniently left out of the tally associated with "straight-forward" vaginal birth - and as such do not even reflect the reality of the "average vaginal birth".

As a result, readers are erroneously left comparing the discounted costs of vaginal birth with the inflated costs of caesarean births.

If that wasn't bad enough, it should also be noted that the vast majority of existing cost studies completely ignore longer-run costs that may be associated with the mode of delivery. If the delivery results in a cost that is incurred more than 42 days after the birth, the costs are frequently not allocated to the mode of delivery. A child born with a life-long disability as a result of mode of delivery - will not have the life-long costs allocated to that mode of delivery. A mother with urinary or fecal incontinence attributable to the mode of delivery that needs to be repaired (through surgery or physiotherapy) months or years later will not have those costs allocated to the mode of delivery. A mother with PTSD or PPD associated with her mode of delivery will not have the costs of those mental health issues allocated to the mode of delivery.

Furthermore, the costs that occur as a result of mode of delivery that are incurred privately are never accounted for in cost-studies of different modes of birth. There are private costs associated with either mode of delivery - including time off work, costs of preparing for the birth, and costs of recuperating after the birth.

Lastly, the costs that are "expected" by planned mode of delivery are likely to be very different on a case-by-case basis. There are many women for whom the "expected" total cost of a planned vaginal delivery is likely to be lower than the "expected" total cost of a planned caesarean delivery. There are other women (particularly in a time when mothers are getting older, heavier and having fewer children) for whom the "expected" total cost of delivery would be cheaper by planning an elective caesarean delivery.

As a health system, the goal should be to encourage women to discuss their circumstance and options with their healthcare providers and to choose the mode of delivery that is most efficient for them in their individual circumstances with an objective to reduce unnecessary morbidity and reduce unnecessary mortality for mothers and and babies. If this were done, a reduction in the overall healthcare costs would likely follow, even if a reduction in the rates of caesarean sections did not.

Spending Money Where it Matters: Maternity Care

I fully understand that resources in the health care system are limited - and that decisions must be made with regard to resource allocation. I know that providing health care services to the population is expensive. I know that these costs are increasing over time for a wide variety of reasons, including an increasingly older population, an increasing ability to treat what once was untreatable, increasing expectations to access treatment and inflation. I know there is tremendous pressure to 'bend the cost-curve' and improve health care system sustainability and that bending the cost-curve and ensuring health system sustainability is imperative.

I also know that maternity care is not the place to 'save money' and that doing so will and does come at a tremendous cost.

I am more than a little disturbed at efforts to turn back the clock on this area of care. I am disturbed at the efforts by provincial governments to encourage home births and 'invest' in birth centres that are basically places where women give birth 'in somebody else's home', and in particular I am disturbed because the primary motivation for encouraging these things is to save money. Money indeed will be saved, but it will be saved by limiting access to medical care and services during birth. Of course homebirth and birth centre births are cheaper than hospital births - if a woman does not have access to an epidural, the system does not have to pay for one. If a woman does not have access to fetal monitoring, then again, the system does not need to pay for it. If a woman does not have immediate access to a cesarean section - there is a chance a 'normal' birth will happen instead. When technology is not available, it does not get used.

I also know that proponents of homebirth will point to the few studies, like the recent BMJ article entitled "Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study," that show that outcomes between homebirth and hospital birth are comparable. However, they will fail to examine those studies with a critical eye. A study that uses composites for perinatal outcomes and maternal morbidity completely fails to recognize the huge difference between a death or a lifelong disability, with having a cesarean section or a fractured clavicle. This study also limits its scope to the birth itself and the period immediately after the birth (42 days) and as such fails to recognize the consequence and costs of longer-run morbidity and mortality. Further the study considers "normal birth" (defined as being without induction of labour, epidural or spinal anesthesia, general anesthesia, episiotomy, use of forceps, ventouse or cesarean section) as being a "good" in and of itself - without any justification for that position.

The fundamental flaw of course is the underlying assumption that the use of technology in birth in hospitals is done so without reason or merit and that using technology in birth does not 'buy' anything of value. This strikes me as being a rather large assumption, that should be extensively tested prior to being accepted. Use of technology in birth buys reduced pain. Use of technology in birth buys reduced risk of very severe outcomes and long-term disability. Use of technology in birth may make the difference between life and death, and it may make the difference between a 'normal' life and one filled with life-long challenges. Given the nature of the population being served (typically young, and healthy) what is being 'bought' with the use of technology in birth will have benefits over a very long time horizon, potentially 80 or more years.

It should be crystal clear that the government's embrace of out-of-hospital birth has nothing to do with supporting choice and everything to do with saving money. If it was truly about choice, government would increase access to hospital-based midwifery and make hospital environments nicer to facilitate the choices of women (for example private rooms, birthing tubs, increasing the ability of partners to stay with parturients, etc.) WITHOUT sacrificing their access to medical advancements. Facilitating a choice that denies or delays access to medical technology, particularly if it is proven to be needed is not good policy. It's cheap, but should not be considered cost-effective.

Reflections on Unnecessary Things

Women who choose cesarean absent a medical indication for cesarean in North America are often portrayed in a negative light. They are deemed a drain on the medical system (at least in Canada). They are called "too posh to push". They are called vain. There are those who would even deride them as being somehow unworthy of motherhood - after all, giving birth vaginally is the way "nature intended". Some people might even declare that women who gave birth surgically, have not "given birth" and are somehow "lesser women". Any woman who has had a cesarean or is planning a cesarean, feels compelled to defend her choice or the reason for it, as there seems no bigger travesty than an "Unnecesarean". Even Canadian policy makers feel as though a worthy goal is to "reduce the rate of cesarean births" and "increase the rate of attempted VBACs".

This situation generates many Unnecessary Things, far worse than surgery among a group of women who could have had a "normal birth" if only they let "nature take its course", but freely and with informed consent opted out of "normal birth".

This situation "unnecessarily" legitimizes the denial of patient autonomy - a woman denied a cesearean absent a medical indication for it has no recourse. She often does not even have the empathy of others - after all she has only been subjected to what is considered "normal".

This situation makes finding sympathetic care providers "unnecessarily" difficult for those who would prefer an elective cesarean birth. Many women are forced into a situation that lacks continuity of care, or may have to travel to access the care they need.

This situation "unnecessarily" generates feelings of inadequacy among those who through no fault of their own were unable to "achieve" a vaginal birth.

This situation "unnecessarily" increases the risk of truly traumatic outcomes for mothers and infants. Many mothers believe that if they just push a little longer, labour more, or refuse an epidural that they can avoid a cesarean birth. Many might delay to the point of an emergent situation which then risks being "unnecessarily" unconscious for the delivery of their child, "unnecessary" complications, "unnecessary" disability, and "unnecessary" death.

Other "unnecessary" things that result from this situation are "unnecessary" pain, "unnecessary" vaginal tearing, "unnecessary" sexual dysfunction, "unnecessary" post-natal mental health problems, "unnecessary" reconstructive surgery, "unnecessary" incontinance, "unnecessary" bias in the information given to women planning on giving birth and "unnecessary" guilt.

In sum, the situation as it is today, "unnecessarily" jeopardizes quality maternity care. It puts process ahead of outcomes, and that is what necessarily needs to change.

Recollections: Crisp and Absent

There are things about the last time I gave birth that I remember very, very crisply - the bits that revisit me every now and again, in a dream or suddenly during a conversation or are triggered by something I have read. Mostly it's the emotions I remember, the terror, the pain. The conversation my doctor had with me shortly after I went into labour indicating there was no OR available, no anaesthetist available (therefor no epidural), that there were pediatric appendectomies and I would have to wait (lies!). I remember hoping that labour would progress slowly - that time might be on my side as a first timer. I remember hoping that nothing would go sideways. I remember thinking if I stayed still enough, maybe the child could wait until an OR was free and I could still have the birth I wanted. I remember as I was in great pain, asking my husband if I could sue in whispered tones...and I remember being told I was 10 centimetres and the c-section was not going to happen...I remember breaking down and sobbing at that time knowing I had no choice - or at least I had not been given any choice. I remember them breaking my water. I remember the nurse telling me that "my body was made to do this" and that "direct my screams into pushing." I remember hating my body at that time, despising it, feeling it was responsible for the betrayal, for not taking long enough to labour, for causing me such immense pain. I remember being offered a mirror to watch the birth (why on earth would I want to?) and turning it down. I remember my daughter not crying when she was born, needing to be resuscitated after birth, and again watching hoping that she would be okay. I remember being stitched up, and taken back to my room. I remember showering my bloody self after the birth, and sobbing in the shower.

That is what is crisp. It still overwhelms.

Then there's everything that seems to be absent from my memory.

I don't remember where my husband was during the pushing phase. - He indicates he was at my knees, but I do not recall.

I don't remember the name of the doctor who actually delivered my child.

I don't remember my in-laws coming to the hospital when I was actually in labour.

I don't remember having any conversations with my OB after the first conversation, shortly after labour started.

I don't remember the details...

My recollections are both crisp and absent.

There is still a sadness that this is what is there, that terror and pain are what I can recall when joy is what should be the overwhelming recollection (it is not) - it cannot be changed. I am eternally grateful for every memory of my daughter since - for every smile, for every moment of motherhood that I have been blessed with. At least those memories bring overwheling joy. I am also eternally grateful that my experience was not more negative (I am well aware that it might have been worse). But I am angry still, knowing that the ability to recall my daughter's birth - coherently, without being overwhelmed by such negative emotions, was taken from me.

Making Choices: The Definition of Being an Autonomous Human Being

There's an idea out there that says a good mother does certain things - she gives birth naturally unless there is a medical need to do otherwise. She breastfeeds unless there is a medical need to do otherwise. She stays at home with the children if possible until they are of school age.

And when she doesn't do these "ideal" things, she must explain why.

I had a cesarean section because...

We formula fed because...

I went back to work because...

And rarely is it okay for a woman to finish these sentences with "I wanted to." or "I chose to." To answer in that way is to ask to be judged - with the ultimate damnation "she must be a bad mother."

There is a certain shame in making these choices.

And oddly enough when the child does something undesireable mothers "who do all the right things" feel the need to preface their situation with, "I did everything right, I just don't understand why little Aiden won't"...and those who made other choices might be scorned "she let little Ethan watch too many violent video games and farmed out the parenting to daycare...that's why that kid is the ultimate demon spawn."

Equally, there is an urge to take credit for the child's accomplishments - "little Aiden gets straight A's because (insert parenting choice here)", or conversely the "bad mom" who happens to "have a good kid", just "got lucky".

I've come to the conclusion that, parenting isn't math or an exact science and there are no "universally right" answers because far too much depends on the context in which the choice was made. Far too much depends on the specific mother. Far too much depends on the specific child. Far too much depends on the specific context in which the family must live.

I've also come to the conclusion that there's a lot to be said for not being ashamed for making a choice that is different from what might be considered the "universally right" choice, for having confidence that regardless of the choice made, if it was based on the best information available applied to the specific context at hand, that it was "the right choice".

Like in many things in life, the focus needs to be on what is ultimately a "good outcome" - rather than on the specific processes that may or may not have been used to get there.

And ultimately, if there's an outcome I'd want for my child, it would be for my child to have the ability to make a choice, based on the best information that they have available and applied to the specific circumstances my child finds themselves in - and to be confident in whatever choice they actually make.

Guidelines for Names

Mr. W and I believe that the final addition to our family is likely to be a boy - we certainly aren't going to paint the kids' room yet but we have given some thought as to what this final addition might be called. Of course the acquisition of any additional baby gear or the finishing touches on the room will wait until we get a more definitive answer on what Little Bean definitely is or isn't. We are having to wait for a more definitive answer as to what Little Bean is or isn't because VIHA implemented a policy in March of 2010 (after we found out what our daughter was) not to inform parents of the sex of their baby at the 18-20 week ultrasound. So while we definitely think we saw a penis, we don't know that what we think we saw is actually what we saw.

We have some general guidelines on naming children that worked very well in choosing our daughter's name and we will use them again this time around:

1. The name should be easy to spell.

2. The name should be difficult to mishear.

3. The name should be clearly male or female.

4. The name should not sound silly on a grown adult.

5. The name should be difficult to make fun of. (Note: kids are kids and if they can make fun of a name they will, but at the very least this should be a challenge.)

6. The name should be different from the last name. As such Benjamin Benson would be a no, no - as would William Williamson or Gunnar Gunderson.

7. Either parent can veto a name for any reason, both parents must agree on the moniker that is to be used.

8. The name should not be exceedingly common - so anything in the top 50 is out.

9. The name should suit the child. As such, if the chosen name does not 'fit' the child once it is born, an alternate name should be chosen.

Let the list making begin!

Spotlight on Support: Stillbirthday, An Amazing Resource for Women Contending with Baby Loss

When I was pregnant with my daughter, the Serum Integrated Pregnancy Screening came back with a higher than screen cut-off risk for Trisomy 18 - Edwards Syndrome. My dear daughter's risk of this condition was somewhere in the range of 1 in 400. As I read about the implications of trisomy 18, it became clear that in many cases the condition is incompatable with life and the majority of fetuses with the syndrome die before birth. Children born alive with the syndrome have a low rate of survival as a result of abnormalities of the heart, kidney malformations and internal organ disorders. Given this risk, I needed to know whether or not my daughter was actually afflicted by this condition. I breathed a sigh of relief when I read the results from the amniocentesis that clearly stated that the fetus I was carying was a female with normal chromosomes. I was thankful to be spared from a heartbreaking diagnoses.

However, many women are not spared from the heartbreaking reality of a pregnancy loss, a stillbirth, or a newborn death. For these women the anticipation of a new arrival is replaced by immense and immeasurable sadness - for all of their hopes of parenthood are dashed before they even begin.

Finding support in the face of such tragedy can be a daunting task. Recently, through an online community - I have had the privledge of becoming acquianted with Heidi Faith. Heidi Faith is a remarkable woman, who through her own experience of loss, has created an online community of support for other women who are in the midst of their own tragedies. Stillbirthday offers support for women who have suffered from pregnancy loss, still birth and newborn death.

For offering these women and their families a place to turn to, Heidi Faith and her site Stillbirthday, does amazing work.

One of the Easiest Parenting Decisions We've Made, is also One of the Most Important

I have come to the conclusion that most parenting decisions don't really matter in terms of the "Big Picture" despite how much we may antagonize over them at the time.

Breastfeeding versus formula feeding - doesn't really matter - just ensure that whatever form of feeding you choose is done safely and meets the nutritional needs of the child.

Crying it out versus night-time parenting - again doesn't really matter - as long as your sleep needs and those of your child are being met.

Daycare versus stay-at-home parenting - again doesn't really matter - as long as whoever is watching your child is providing for their needs - emotional, physical, financial and intellectual.

None of these decisions are ones that I or my husband are likely to have any remorse over - we chose what was best for our family at the time and our decision is unlikely to have any adverse impact on anybody else.

However, when deciding whether or not to immunize and whether or not to follow the recommended schedule - the decision was not one that was overly hard. Why? Because the most credible sources of information on this subject are overwhelmingly in favour of childhood immunization according to the vaccination schedule.

Vaccines are some of the safest medical products out there - there are decades of data on the safety and effectiveness of vaccination. Vaccinating my child is safer than driving her daycare. Vaccinating my child is safer than taking her to the park to play.

Vaccines are incredibly effective at preventing disease. The vast majority of immunized children will not catch the diseases for which they have been immunized.

There was no contra-indication to my child being vaccinated. She is not allergic to any of the components in vaccines. She does not have any condition for which vaccination would be ill-advised.

The possible complications and consequences of the diseases prevented by vaccines are potentially serious. Infants who catch whooping cough stand a better than even chance of being hospitalized with it, and one percent of them will die. Chicken pox and the measles cause a week or more of misery for the kid - and having chicken pox as a child means having a risk of shingles later in life. Mumps can result in deafness or sterility. For every disease that there's a vaccine, the risks of the disease far outweigh the risks of the vaccine - without exception, I found that the data was clear - denying my child the benefits of vaccination would be a parental failing in ensuring her health and well-being.

Furthermore, I discovered that this was a decision that actually mattered. It mattered because not everyone can be vaccinated - some people have medical reasons why they cannot be immunized and others find themselves susceptible to vaccine preventable diseases due to a compromised immune system. For some of these people, coming into contact with a vaccine preventable disease can be life-threatening. Think of those too young to be immunized. Think of pregnant women. Think of those battling cancer or HIV. Think of organ transplant recipients. Not everybody is a winner in the health lottery. Think of those for whom, for whatever reason the vaccine just doesn't work. All of these people rely on the vaccination decision of everyone else. This is because, widespread vaccination establishes 'herd-immunity' - simply put a high-level of vaccination prevents the disease from circulating in the community. Further, I learned that for many of these diseases people are contagious long before any symptoms emerge. As a result, a person could unknowingly spread these diseases. I simply wasn't willing to make my child a potential biological weapon of mass destruction. She'd probably fare all-right if she did catch one of the diseases that are prevented by vaccines - but would the newborn be all right? Would the cancer victim be all right? Would the pregnant woman and her unborn child be all right? It simply wasn't a risk I'd take.

As such, I am disturbed when I read about whooping cough emerging in the Fraser Valley and Vancouver and the recent diagnosis of a case in Sooke (note Sooke is a bedroom community of Victoria). I am disturbed to read that measles cases are at a 15 year high. I am disturbed because this suggests that vaccination rates have fallen to levels where herd immunity has been compromised and the diseases are able to circulate in the community.

As such, I'd ask parents to take a look at the evidence - the real evidence on the safety and effectiveness from Health Canada, from the Centres for Disease Control, from Dr. Offit and Dr. Albietz, from medical journals and experts in the field of immunology and public health. I'd ask them to look at the information on the diseases that are prevented by vaccination - not only for themselves but also for those with compromised immune systems - those who are in their community. I'd ask them to be critical and skeptical of the information they read. I'd ask them to ask themselves whether or not the claim made has been substantiated or debunked. I'd also ask them to ask themselves whether or not the person making the claim has a stake in the claim being made - are they trying to sell a nutritional supplement? Are they credible?

I've looked at the evidence - and to me its clear, to me it's clear that if you give a whoop about your child, or your community its important to vaccinate according to the schedule that has been recommended.

This is a parenting decision that matters - and luckily, it was one of the easiest ones I've made (the evidence is that clear).

Quality Care Means Access to Adequate Pain Relief

I've previously blogged about the epidural rate in British Columbia - in short it is very low and varies fairly substantially between areas of the province. Depending on the reasons for it's lack of use in this province, it might be very concerning as failure to provide access to pain relief when requested, in my opinion, is "a bit of a failure to provide quality care."

The rate has improved somewhat between last year and this year - but it remains low. Among first time mothers in British Columbia with labour, nearly 50 percent of them had an epidural (49.7% - source BC Perinatal Services) in 2010/11. This ranged from a high of 66.2% of moms giving birth at BC Children and Women's hospital to a low of 32.5% of moms giving in the Northern Health Authority. In Vancouver Island Health Authority, 46.4% of first time moms with labour had an epidural, up from 43.8% the year before. In some jurisdictions in North America the epidural rate for first time mothers exceeds 80 percent.

According to the Canadian Institutes for Health Information - the use of epidurals for all vaginal deliveries in British Columbia in 2009/10 was 30.3%, compared to a Canadian average of 56%. This suggests that the use of epidural anaesthesia is even lower among women who have previously given birth.

Anecdotally, I know of women who gave birth in Vancouver Island Health Authority who wanted epidural anesthesia and could not get access to it - I was one of them when I gave birth in 2010.

However, much like how the specific process of giving birth (c-section versus vaginal) should not be used to judge the quality of care - neither should the specific mode of pain relief. A very low rate of epidural use tells me very little about the reasons for the low rate. Given the extreme variation regionally - I suspect that it is a matter of accessibility. However, at the end of the day, I don't care about how a woman achieves relief from her labour pain - rather I care about her right to achieve that relief from her pain if she desires to be relieved of it and her ability to access pain relief that indeed does relieve her of the pain. Unfortunately, there's a "bit of a gap" in the statistics in this regard - and at the very least the discrepency between what is observed (low epidural rates relative to some parts of BC and the rest of Canada) and what would be expected should be investigated further.

Quality care means access to adequate pain relief.

Where I Draw the Line...

I'm pretty much a live and let live kind of girl...I support an individual's right to freely make choices that impact on themselves and others for which they have the responsibility to make decisions. I hope (and largely assume) that the decisions made are ones that are based on good information and best meet the needs of those making the decision. As a result, I tend to be very pro-choice on a large array of issues - particularly those that fall into a personal domain. But I must draw the line on certain things ...

One of those things is vaccine rejection for non-medical reasons.

I believe vaccine rejection is one of the most insidious threats to public health that exists today. Furthermore, I believe that being appropriately vaccinated is part and parcel of the social contract and that everyone who can be vaccinated, should undertake to do so. Choosing not to vaccinate is sociopathic, it's based on a set of conspiracy theories and risks that pale in comparison to the risks of the diseases prevented by vaccines. Those who refuse to be vaccinated rely on everyone else who decide to vaccinate themselves to be protected from disease - as a result the benefit from the herd immunity which has been established without having to take any of the actions needed to establish that protection. Until that immunity is lost - because too many people choose not to do their own part. Then vaccine preventable diseases re-emerge and those who really have no choice due to medical reasons (a known allergy or reaction or a compromised immune system and the very young) pay the price - sometimes the ultimate price - death.

So when it comes to vaccination - I am not pro-choice, I am not pro-choice because those who don't have a choice cannot be expected to pay the price (often tragic) for somebody else's misinformed decision to forgo vaccination.

Targeting Specific Rates of C-sections and VBACs is Misguided at Best and Dangerous at Worse

One of things that really, really perturbs me is the use of rates of VBACs and rates of c-sections as performance measures. I think that these measures might have been well-intentioned but are terribly flawed indicators of maternity care. In short I think that efforts to 'keep down the rate of c-sections', or 'increase the rate of VBACs' are bad policy, for a lot of very good reasons.

1. It places a value judgement on how birth occurs - in short by having a publicly stated goal to reduce the c-section rate or increase the rate of vaginal births after c-sections - it sends a message to moms. That message is "physiological birth is superior to surgical birth" - in short many women get the message that they have failed if they have a c-section or do not attempt/succeed with a VBAC. Birth no longer is about bringing home a healthy baby and a mom who is in the best physical and emotional health as possible - it becomes about how the birth occurred. It's time to realize that a c-section is not a failure and that a vaginal birth is not an accomplishment. A healthy mom and a healthy baby is an accomplishment - as is a process that facilitates that outcome and respects the emotional and physical needs of both mother and baby.

2. The unintended consequences of this focus might be really, really ugly. When the focus shifts to how birth occurs, inevitably there are trade-offs. The trade-off of having a low c-section rate might be an increase in the number of births that are assisted by forceps and vacuum. The trade-off of having a low c-section rate might be a decrease in the rate of inductions after 40 weeks and an increase in the number of still births. The trade-off of having a low c-section rate overall might be an increase in the number of emergent c-sections that occur when delivery with 30 or 20 minutes is critical to avoiding long-term disability. The trade-off of increasing VBACs might be an increase in uterine ruptures. The trade-off having a low c-section rate might mean more 3rd and 4th degree tears. The trade-off of a low c-section rate might be an increase in the rate of severe birth traumas. The trade-off might mean putting the process of how birth occurs ahead of the genuine desires and needs of the patient.

Are these trade-offs ones that we really want to make?

3. These are not indicators that tell us anything meaningful about the quality of care or appropriateness of the care received by maternity patients. By focussing on these measures, and actively seeking to reduce c-section rates or increase the rates of VBACs - we are not measuring what matters or moving closer to achieving the goal of maternity care that is actually better. Effort needs to be made to find the measures that really reflect good quality care and to report on those things.

It's time to quit focussing on reducing the cesarean rate or increasing the rate of VBACs - these measures and goals should be immediately scrapped. Yesterday wouldn't be soon in enough in my opinion.

Mothers and babies deserve better - they deserve quality care that places genuine outcomes that matter ahead of the specific mode of delivery.