BTCanada


Question:  I had a baby and an episiotomy 20 years ago and I still have problems with that.  I have a scar and intercourse hurts.  No one told me this would happen.  I went to a gynaecologist about this and he made me feel it was my fault and it was all in my head.  Do you think if I was allowed to tear naturally instead of being cut I would still be having these problems?

Answer:  There is no shortage of insensitive, monumentally stupid jerks who work in women’s health.  I am truly sorry you had to run into one of them.  Of course, none of the problems you are having are ‘in your head’ or your fault.  What you are describing is a very common problem with women who have had vaginal deliveries.  Unfortunately, your problems would not be diminished if you tore naturally.  Spontaneous obstetrical lacerations also scar and make intercourse painful, whether they are left un-sutured or whether they are surgically repaired.   Un-sutured damage results in asymmetrical healing, flesh tags and poor healing with even more scarring.  Episiotomies cause more third and fourth degree perineal lacerations – those that involve the rectum and anal sphincters.  A surgical laceration is easier for the practitioner to re-approximate and repair than jagged lacerations.  When skin, connective tissue, muscle and nerves (whether they are part of the genital tract or whether they are anywhere else on the body) are exposed to forces beyond their capacity – and that is what all obstetrical lacerations are regardless of the degree of severity– the damage is permanent and the area is weaker.  You are not the only woman not told about this.  A lack of informed consent for women is a shameful problem in obstetrics.  Sometimes the uterine lining is sutured into the lacerations or episiotomy repair where it becomes transplanted.  Women with this problem have endometriosis of the old laceration that causes problems (bleeding, pain, opening up) during their subsequent menstrual cycles.

Sometimes more surgery can reduce the amount of scar tissue in your episiotomy scar but, of course, this would mean seeing another, hopefully more competent, gynaecologist and enduring that surgery.  There is no guarantee it will work.  You already know that not all gynaecologists are created equal and it is also true that surgical skills among OB/Gyns vary considerably.  Some are very skilled surgeons and some aren’t.  Unfortunately, in Canada, there no way for the patient to sort the wheat from the chafe in this respect as there isn’t any public accountability or transparency about doctors competency you can refer to.  (Except doctor rating websites like www.ratemds.com which doesn’t adjust for risk, is strictly anecdotal, some doctors/staff send in positive reviews to boost their image but it is still the best we have) . I wish I could tell you there was a simple answer to your problem and I apologize for not being able to do that.


Question:  Please tell me about new cesarean techniques.  My doctor doesn’t know about them.

Answer:  No doubt about it – cesarean techniques have changed through the decades.  The newest techniques aren’t exactly ‘new’ though.  They have been around for about 15 years now in some form or other.  The older technique is called ‘Pfannenstiel’ and it involves bladder dissection and forming a bladder flap, usually removing the uterus from the abdominal cavity (exteriorizing) to repair it after delivery, routine swabbing of the uterine cavity and manual removal of the placenta.  Food and drink for the mother is often withheld for several hours – sometimes a day or two after surgery.  The incision is made very low on the torso.  Techniques older than the Pfannenstiel involved vertical incisions through the skin and/or uterus.  The newer techniques (again, I want to highlight that they aren’t very new) don’t involve bladder dissection.  The incision is made slightly higher than the Pfannenstiel incision.  The uterus is repaired in situ (without taking it out of the mother’s body) and the placenta spontaneously detaches.  If the placenta is whole the interior of the uterus is left alone as well.  Newer techniques involve way less rummaging about, cutting and stitching which means less surgical trauma for the mother.  The result is less blood loss, less infection, less post-operative analgesia use and quicker recovery times.  Mothers can get up and walk as soon as the analgesia wears off and their legs work again.  They can drink fluids in the recovery room and resume eating in about four hours.  Their babies are with them in the recovery room.  The best of these surgeries today take about 20 – 25 minutes and hospital discharge is less than 72 hours.  Some practitioners use urinary catheters; some don’t.   There are a number of names used for these ‘new’ techniques.  ‘Pelosi’, ‘modified Pelosi’, ‘Misgav Ladach’, ‘modified Misgav Ladach’ are some examples.  They have been used around the world for close to two decades.  (the Pelosi technique was developed in the US, the Misgav Ladach was developed in Israel).

Is this doctor who doesn’t know about this an obstetrician??!!  If so s/he is a liar.  As experts in obstetrics it is their job to know this.  Same goes for midwives.

Question:  Can midwives do cesareans?  Or epidurals?

Answer:  Not in this country.  Not in most countries.  There are African countries where they do, though.  They undergo surgical training just like a doctor would. 

Question: Have you heard about the Maternal Experiences Survey? I’d like to know what you think about it.


Answer: Yes, we have heard about it and thank you for asking us about it. I have to admit when I first heard that such a survey was being considered I didn’t have very high expectations. I didn’t set the bar very high. I haven’t seen the full report so I can’t give an in-depth analysis until it is released. They keep pushing back the release date. The last time I checked it was slated for release Fall 2009.  I can comment on the brief initial release, the questionnaire itself and the methodology now. I was expecting positive spin with the initial and final release. The initial release met those expectations.
Before I talk further about the questionnaire and methodology I do want to say how happy I was to see maternal experience on the radar of the Public Health Agency of Canada. This is the first time – ever – that anyone in this country (Canada is among the last of developed nations to do this) has bothered to consider obstetrics from the mother’s perspective. To do so in 2006 was a huge step forward and I commend all involved for doing this. That it took until 2006 is inexcusable but change has to start somewhere.
What I have seen so far has flaws but it doesn’t suck nearly as bad as I initially thought it would. Many of the questions are concise and relevant but some aren’t. The inquisition about smoking, alcohol and drugs was out of line in my opinion. It was an unnecessary invasion of privacy. It also has nothing to do with a mother’s childbirth experience and the survey would have been better without those questions.
If you want honest answers to personal questions you need a survey that is private, anonymous, and confidential and it must be devoid of any human bias, judgment and stigma. This survey was none of those things. It could have been but wasn’t. I can’t help think that was deliberate. If you do not address these issues you will accentuate positive answers and under-represent negative ones. The women were picked using information from their 2006 census forms and therefore the personal identifying information of each woman (and baby) surveyed was known in advance and the interviewer had much of that information. There was an interviewer (primarily by telephone although there were a few face-to-face interviews) and whenever you have an interviewer you introduce judgment and bias. It doesn’t necessarily have to be how a question is worded. Voice inflection does the trick just as nicely. Women were told their participation was voluntary but there were several ‘persuasion’ techniques* used to garner their cooperation. Despite these techniques they still had a high non-responder rate. About 25% refused to cooperate. This doesn’t surprise me given the level of mistrust, anger and skepticism of hospitals, healthcare providers and anyone who aligns themselves with them that I hear about on a near daily basis. Statistics Canada and the Public Health Agency of Canada (PHAC) knew this would be a problem and used statistical weighting to compensate. Weighting is a statistical weirdness (in this case anyways) where one assumes that the answers of the ones not responding would have been the same as the answers given by those who did respond. When they get a non-responder they simply give more credibility (or weight) to the answers they were given by the women who did respond. I would say that the overwhelming majority of women within the group who refused to participate did so because they wanted to avoid the medical profession and because they did not want to be reminded of their experience, especially with a nosey stranger. Their answers would not be reflective of other responders’ answers. Their answers would have been negative.
The one area that I was most disappointed with is the assessment of psychological damage after childbirth. If they were genuinely interested in addressing this issue they would have used a method designed to screen for post traumatic stress – and there are several good ones. Instead they used the Edinburgh Post Natal Depression Scale (EPNDS) to determine the level of depression several months after the birth. PPD is a serious and common complication of traumatic childbirth and should be addressed but screening for depression (especially long after birth) does not give an accurate picture of all the psychological damage done by any traumatic event, childbirth included. Depression is only one possible trauma symptom. The failure to address this issue will understate negative psychological effects. I also think there are better, less wishy-washy and vague ways to assess adult depression – which is what post natal depression is – than EPNDS.
I would like to see a survey that is anonymous and confidential and that doesn’t rely on humans to gather or input raw data. They could identify new mothers using census information. I can’t think of a better way of doing this that doesn’t involve the medical community – and it can’t involve them if you want honest answers. They could contact these new mothers by phone to ensure they had the right person and to ask for their participation beforehand. They would also take the time to explain how no one would have access to their answers or have any identifying information. The survey package could be downloaded from a website or mailed. The package would include a survey booklet and answer keys without any identifying features (like the kind you used in school where you darken a circle corresponding to the answer you pick). These are tabulated by machine and this would be the only thing sent in by the mother. Participants would never be asked to identify themselves, their babies or give their postal code. Any open-ended questions (like what province you live in, what was the name of the hospital or birth centre, what was the name of the doctor, nurse or midwife) would have to be seen by a human but they shouldn’t be overly personal and must be non-identifying and done on a separate piece of paper.
You can find the MES at http://www.phac-aspc.gc.ca/rhs-ssg/pdf/question07_e.pdf You can also find other information about the MES on the PHAC website.

July 2009

We’ve already talked about some of the flaws and limitations from the initial release of MES data – statistical weighting, aggressive ‘persuasion’ techniques, human intervention in data collection, interviewers given far too much identifying information about the mother, unnecessarily intrusive questions (interrogation about smoking, drug use, and alcohol have nothing to do with their childbirth experience), not including refusals to answer in calculations, the EPDS. With the release of more data we would like to expand on this critique. There is no doubt that the report suffers from positive spin and dishonesty. Some of the questions were irrelevant or of dubious worth [Its just a pacifier, folks, and those health care workers who offer formula samples are not the spawn of Satan]. The data that was released was incomplete. For instance, where is the data on how ethnic groups fare in obstetrics? Is racism a problem as much as misogyny is?
There is also praise worthy information and we will give a brief overview of both. You will likely find the data raises more questions than it answers.

You can read the data tables and overview of the information that has been publicly released here and here.

Positive Spin and Dishonesty:

1) Only live, singleton births were included. All other mothers were excluded. Those who had multiple births, those living on reserves and those whose babies died were censored. Censoring some maternal experiences does not give an accurate measurement of maternal experiences.
2) A psychological technique used to soften negative perceptions is to link words of phrases you know will illicit a positive response with ones you know will illicit a negative response. Used car salesmen do it all the time. [It’s a barely-used, mint condition BMW convertible? All new tires? Well maintained! It costs $50,000. What a deal! How can you resist?] It’s weaselly and unethical and it’s done because it works. The experience of pregnancy, labour, birth and postpartum recovery is separate from the baby. This was not made clear. Instead they consistently reminded the mother of her baby’s name or referred to her ‘selected’ baby (it elicits positive feelings) when questions about her experiences were asked. They did this 149 times throughout the 45 minute interview. It wasn’t necessary. How many live, singleton births do they think a woman is going to have in the three months from Nov 1, 2005 – Feb 1, 2006 (for mothers in the Territories) and for the three months from Feb 15 – May 15, 2006 for the Provinces? A simple statement at the beginning of the survey that the birth in question occurred during that time frame would have sufficed.
3) They did not give an honest portrayal of damage done by vaginal births. They deliberately only asked questions about episiotomies and perineal suturing. The damage they refused to ask about is still serious damage and whether the damage is sutured or not is a factor determined more by practitioner ideology than evidence-based need. Reducing the numerator in percentage calculations will give a lower percentage. They used statistics from women who had vaginal births and those who attempted to give birth vaginally (most would not have) in their calculations and conclusions. Increasing the denominator in percentage calculations will also lower percentages. Severity of morbidity was not assessed.
They refused to separate planned cesareans from emergency cesareans in their conclusions about cesarean births. The two are not comparable.
For these reasons the conclusions arrived at comparing vaginal and cesarean births are useless.

These are not rooky mistakes nor was there a lack of expertise concerning obstetrical or statistical matters among the many people involved in this MES since 1999. This was deliberate deception. They were honest about some of their limitations which begs the question, “If you know it was dishonest why do it in the first place?” Being honest about prior dishonesty doesn’t condone the initial lie.

Praise:

1) They did courageously point out the high incidence of procedures done to women that are not supported by clinical evidence.
• More than one ultrasound (only 15.8% had only one. The majority had three.)
• Continuous EFM instead of intermittent auscultation for those giving birth vaginally or attempting to give birth vaginally (90.8% had some type of EFM, 62.9% had continuous EFM, only 6.5% had auscultation with a stethoscope, Doppler or fetoscope only)
• Episiotomies (27.1% of primiparous women were given episiotomies, 15% of multiparous) Quebec was the worst offender with an average of 24.1%. Alberta had the highest rate of 3rd degree perineal lacerations.
• Supine position for birth (50%)
• Stirrups ( 57%)
• Enemas (5.4% of those who had a vaginal birth or attempted to give birth vaginally) Manitoba and Saskatchewan were the worst offenders.
• Shaving (19.1% of those who had a vaginal birth or attempted vaginal birth) Ontario, Newfoundland/Labrador, New Brunswick and Yukon were the worst offenders.
• Pushing on the mother’s abdomen to deliver a baby vaginally or attempt to deliver a baby vaginally (13.2% of all mothers surveyed with a range from 10.9% to a high of 19.3% in Nunavut)

2) They acknowledged the marked regional variations across Canada. They know which hospitals and birth centres had the worst records but that information wasn’t made public.
3) The MES committee, the PHAC and StatsCan get a thumbs up for understanding that maternal experiences matter. Hopefully the next MES will be done better and won’t take so darned long

Some Interesting Stats:
• 42.3% of all women reported having ‘a great deal of a problem’ with at least one postpartum health issue during the first three months after birth.
• 41% of women were not involved in the decision to test them for HIV, yet it is supposed to be the woman’s choice.
• 61.8% were satisfied with the information given by their health care provider. This rate dropped to 58.7% for primiparous women. In Nunavut this rate dropped to 39.1%, in Quebec it was 51.8%.
• 44% of women who had a vaginal delivery or attempted to give birth vaginally had their labour induced. 37.3% had their labour augmented.
• 53.8% of women stated their experience was ‘very positive’.


On that note we are going to leave the last word to the wise person who penned this paragraph:

“Reports have cautioned against regarding women’s ratings of satisfaction with their care as a reflection of quality of care, best practice, or good outcomes. For example, it has frequently been reported that women evaluate whatever pregnancy and birth experience they have as positive: the so-called ‘what is, must be best” phenomenon.”

The Canadian Maternity Experiences Survey: An Overview of
Findings, Chalmers, B. et al JOGC March 2008 217-228

Sonja Dabos, Meredith Jensen
Birth Trauma Canada


* If you don’t respond to the first interviewer they have a second ‘more senior’ interviewer contact you. They will call 25 times and they will call in the mornings, afternoons and evenings both on weekdays and weekends. They wait until the end of the interview to ask you to ‘share’ your personal information. They used guilt as a tactic to garner ‘voluntary’ participation.

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Question:  There are only two people who deliver babies in my town.  One is a family doctor and the other is a midwife.  The doctor is a silver-tongued pervert and the midwife is a new age wacko.  Both of them make me uncomfortable.  Do I have to go to them?

Answer:  No woman should allow medical personnel to involve themselves in any aspect of her pregnancy, delivery or postpartum recovery if they give her the creeps, if she is uncomfortable with them or if she doesn’t trust them.  This goes for midwives, doctors, nurses, ultrasound technicians, whoever.  It is often hard for women to vote with their feet or to request/find another care provider but it is essential.  Don’t ignore your conscience on these matters.  I know that going down the road to another centre, major city or another country to find the right maternity care for you is costly and unfair in terms of travel, accommodations and paperwork but the cost associated with staying with someone you don’t trust is far greater.  You’ve also touched on a problematic situation in obstetrics and that is the lack of choice, standardization and quality of care between rural and urban centres.  You will also find ‘silver-tongued perverts’ and ‘new age wackos’ in urban centres (and certainly not all rural practitioners are like this) but, given the increased number of obstetrical care providers in a major urban centre, your chances of finding the right one is better.

 

Question:  My doctor says they are just learning about the long term consequences of vaginal deliveries.  Is that true?

Answer:  No.  Midwives and doctors have known this since there was such a thing as midwives and doctors.

 

Question:  Does being pregnant make you more likely to die from H1N1?

Answer:  Yes.  Being pregnant and giving birth suppresses the immune system and anything that suppresses the immune system increases your risk of infection.  H1N1 is particularly virulent in pregnant women and new mothers.  There seems to be something about this virus that turns some people’s immune systems against them.   If H1N1 is diagnosed properly and promptly early administration with anti-viral medication appears to limit the risk of maternal respiratory failure and mortality.  Being vaccinated is your best defence.  The WHO first released a recommendation that pregnant women should get non-adjuvanted H1N1 vaccine; now they are saying the adjuvanted vaccine is safe and are recommending that for pregnant women.  There has been a great deal of mis-information and mind-changing with respect to this vaccine by the WHO and by federal and provincial health systems in Canada and I don’t know who to believe right now. 

 

Question:  I could not bond with my baby for months.  I stuck a smile on my face and pretended to the world.  I was so ashamed of my failure to be a good mom so I didn’t talk about it.  My world changed when you told me I was a traumatized mom not a bad mom.  You told me my feelings were common among traumatized mothers and I finally knew I wasn’t crazy.  Do you know how many others are like me?

Answer:  I don’t have any figures that give an idea of how widespread this is, although I know it is.    Most women, like you, can’t talk about it openly because they don’t want to be further stigmatized and ostracized from society (and they would be, sadly) and they are afraid (justifiably) that authorities would take away their children or treat them like imbeciles.  I can tell you there are three ways women react with their children after being traumatized by their childbirth experiences. 

When women are traumatized and made to feel like failures they often dive heart and soul into being super moms – pushing themselves to extreme limits to prove to themselves and others that they are a good mother.  Other traumatized mothers react as you did where their children are triggers to the horrific experience they had.  The third way is a combination of both at various stages for months or years postpartum.  I can’t emphasize enough that these are expected reactions and they are trauma symptoms seen in ALL trauma victims.  You aren’t crazy and any of the other traumatized mothers aren’t either. 

 

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