Canada Makes Progress on Maternal Requests

img_0012-1The Society of Obstetricians and Gynaecologists of Canada (SOGC) has announced a new Committee Opinion on maternal request caesareans from its Annual Clinical and Scientific Conference in Victoria, BC, which confirms an obstetrician’s right to support maternal request.

This is important progress.

The Opinion Abstract concludes: “After exploring the reasons behind the patient’s request, and discussing the risks and benefits, if a patient insists on her choice a physician may pursue one of the following two options:
1) Agree to perform the CS after 39+0 weeks gestation;
2) Disagree and refer the patient for a second opinion.

The Canadian position effectively merges the UK’s NICE guideline position in its last two  maternal request recommendations:

NICE CG132 in 2011: “For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.

An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.

NICE CG13 in 2004: “An individual clinician has the right to decline a request for CS in the absence of an identifiable reason. However the woman’s decision should be respected and she should be offered referral for a second opinion.

Important Progress

The SOGC says its responding to rising rates of caesareans “to avoid vaginal birth“, and also cites a 2009 study that found “42% of Canadian obstetricians supported a person’s right to choose“.

And while it’s disappointing that pelvic organ prolapse and safety of baby (lower risk of stillbirth at term) are not listed alongside urinary continence in the SOGC’s press release, this is an important step forward for a society that up until now had aligned itself more closely with FIGO and WHO (than with NICE) on the subject of maternal request.

There is evidently disagreement between its members, as there is in all countries on this issue, and the SOGC rightly provides OBGYNs who do not support maternal request with the option to refer women to someone else.

However, most importantly, those who do support this choice are now formally backed by their society, and the SOGC’s Opinionclearly states that a mutual decision on the mode of delivery should be made without bias or coercion.”

The next step (as in the UK), needs to be for women to have access to clear information outlining which obstetricians and/or hospitals support maternal request, so that they can book their risk/benefit consultation accordingly (I contacted the SOGC about this in April and May 2018).

Something similar to this Canadian clinic information for abortions, for example.

SOGC press release

IT TAKES TWO: WEIGHING THE RISKS OF CAESAREAN DELIVERY ON MATERNAL REQUEST

Victoria, B.C., June 26, 2018 – The Society of Obstetricians and Gynaecologists of Canada (SOGC) says Canadian women who opt for a planned caesarean section (CS) without medical or obstetrical indication, need to be fully briefed by their physician on the pros and cons of the procedure prior to delivery. The SOGC’s Clinical Practice Obstetrics and Guideline Management and Oversight Committees issued this Committee Opinion in light of the rising incidence of elective caesareans being performed to avoid vaginal birth.

“All maternal health care providers need to understand and hear the reasons why some women consider preplanned caesareans the best option for them. This includes understanding the person’s values, fears and concerns,” says Dr. Jennifer Blake, CEO, SOGC. “But any final decision should not be made until women are equipped with the most up-to-date and evidence-based information to help them make such an important decision about how their baby will be born.”

Risks of Caesarean section include the risks associated with major surgery and anaesthesia as well as potential longer-term risks that could complicate future pregnancies. Elective CS is also associated with a decrease in breastfeeding and an increased risk of asthma in infants.

Elective CS, however, is associated with lower rates of postpartum hemorrhage and fewer surgical complications when compared with unplanned emergency CS and intrapartum CS. CS before the onset of labour may also reduce the lifetime risk of urinary incontinence.

Elective CS is a procedure that does not have overwhelming support among Canada’s medical community. A 2009 study found that 42% of Canadian obstetricians supported a person’s right to choose CS compared to 19% of family physicians, 25% of nurses, 19% of midwives and 29% of doulas.

To address this, the Committee Opinion suggests the process of counselling and decision-making should be made over several sessions and may also include other members of the maternal health care team. The Opinion also clearly states that a mutual decision on the mode of delivery should be made without bias or coercion.

“Some physicians may not agree with the request because of ethical or medical reasons. But if a patient decides they want to go ahead with the procedure, contrary to the wishes of their doctor, that doctor has a responsibility to refer the patient for a second opinion or transfer care,” says Dr. Blake.

The Committee Opinion Abstract can be read in full here.

  • Written by author and journalist Pauline Hull

7 comments

  1. Cannot begin to express how much this means to me – to know that progress has been made and that women who are pregnant and choosing cesarean can hope to get better care than those who went before them. To know that care providers who support choice, can do so more openly. To know fewer women will be traumatized and subjected to delivering in ways they do not find acceptable.

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  2. I am so, so relieved that this opinion/recommendation has been put into black and white by the SOGC. I was told by a doctor at one point during my quest for a maternal request c-section that “there’s no such thing as a maternal request c-section in Canada.” Emphatically not true. Having this press release printed out and in my hand would have made it all so much easier when I first requested a referral to an OB. And I will add that seeing those statistics–42% of OBs supportive, 15% of GPs, etc–is really eye-opening and informative. That’s the sort of information that will help a woman continue her fight for a c-section and not be discouraged by the first GP who tries to shut her down. Thank you for reporting on this, Pauline.

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  3. This is great news. I’ve long wondered why patient autonomy is the rule in all other areas of medical practice except this one. And why a women can choose to refuse a cesarean, even if that refusal would result in injury or death to them or the fetus, but a woman can’t refuse a vaginal birth for an outcome which will provide better protection to her pelvic floor. I also can’t understand why an OB is required to discuss the risks of a cesarean but not the risks of a vaginal birth. There are many incontinent women or women with sexual dysfunction in Canada who wish their provider would have taken the time to discuss those risks. The Birth Trauma Canada website is evidence of this.

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  4. A step in the right direction. Only a small amount of midwives support autonomy in choosing your birth. Doulas and midwives need to take off their rose coloured glasses—Perhaps this is because they do not have to deal with the aftermath-they are not involved in your recovery once your under the care of an OB. As maternal morbidity takes on more transparency, narrative and data collection hopefully those approval numbers improve. Respect what mothers need to be happy and healthy. Babies need mothers. Mothers matter.

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  5. This is a great step forward! No one else but the woman herself should have the right to make decisions regarding her own body. Too many countries around the globe are belittling women with very restrictive policies for childbirth. I hope more of them will follow Canada’s example.

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  6. Overjoyed but cautiously optimistic to hear this news. The SOGC has championed its ‘normal’ birth policy for many years and Birth Trauma Canada hopes this is the first positive step towards real autonomy with respect to birth mode options and respect for the right of every woman to avoid the common, serious damage that can result from planned vaginal births.

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