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An Open Letter to the G8 Summit:  Making Maternal Health a Priority

As the Executive Director of Birth Trauma Canada I congratulate Canada and the other G8 countries for their willingness to make maternal health a priority.  I fervently hope this isn’t another round of rhetoric.  For too long the health of mothers around the world – Canada included – has been neglected and dismissed.  Maternal morbidity has been considered normal and acceptable, even necessary, for too long, unfortunately often by the very professions who have been tasked with protecting maternal health.  It is clear the status quo does not work.  I am reminded, on a daily basis, of the misogyny and inhumanity in obstetrics.  Please read thoroughly for a better understanding of this statement.

Short term and long term morbidity, and mortality, among childbearing women are shockingly and inexcusably high throughout the world.  Canada, also, has much to be ashamed of in this regard, particularly with respect to maternal morbidity.   The sad fact remains that much of it is preventable if countries cared about reproductive choice and the quality of obstetrical care.  This requires comprehensive and transformational changes in attitudes and resource allocation.

The developed and developing world needs to embrace genuine evidence-based obstetrical medicine.  Other medical specialties have long since complied with this logical requirement.  Too often what passes for research in obstetrics and gynecology is scientifically illiterate and dishonest.  Propaganda and bias have no place in medical research and we can not affect change without quality information.

            The inexcusable variation between regions and hospitals in terms of maternal morbidity and adverse obstetrical events must be addressed.  Again, Canada is as guilty of substandard care as other jurisdictions.  If quality hospitals and competent medical staff can consistently provide maternal care with no or very low rates of adverse obstetrical events we need to ask “Why won’t all hospitals do this?”  It is an uncomfortable question that deserves an answer.

The practice of vilifying women for wanting, and justifiably expecting, effective pain relief during childbirth must end.  Pain relief is a quality indicator in every other medical specialty.  Why should the only medical specialty caring exclusively for females be the exception?  Denying epidurals is barbaric, regressive and sadistic yet, even today and in this country, a significant proportion of obstetrical care providers label women as abnormal failures if they labour and birth with an epidural – a medical breakthrough now close to a century old. The world needs to stop denigrating women who choose planned cesareans as a way to avoid the morbidity associated with vaginal deliveries, assisted vaginal deliveries and emergency cesareans.  We need to end the irrational notion that ‘natural’ is always good.  There are many ‘natural’ aspects of life on this planet that kill or maim humans.  Childbirth is but one of them.  Humans have always had to wrestle and subdue nature to survive.  To deny women the benefits of human ingenuity and technology, while enjoying these benefits ourselves in all aspects of our lives, is hypocrisy of the lowest order. Women are a diverse group of individuals and that individuality must be respected.  They have the right to know all the risks, assess those risks and make their own decisions concerning those risks.  Obstetrical reform can’t be a battle with modernity or humane advances.

             Medicine’s raison d’etre is to save lives, alleviate suffering and limit morbidity.  A country’s ethical mandate is to protect its citizens.  Yet, in 2010, both fail miserably when the suffering and morbidity is experienced by women and when the lives lost are women.  Why is that?  This is another uncomfortable question that deserves an answer.

             Respect for the human rights of women, reproductive choice, access to unbiased information and informed consent are the cornerstones of any meaningful improvement in maternal health.  Will the world make the necessary changes?  Will the best way to avoid negative health issues for women continue to be avoiding motherhood?  Without mothers we have no society. 

Penny Christensen

Birth Trauma Canada


Birth Trauma Canada (BTCanada) would like to state that we do not endorse the recent Joint Policy Statement on Normal Childbirth issued by the Society of Obstetricians and Gynaecologists of Canada (SOGC), the Association of Women’s Health, Obstetric and Neonatal Nurses of Canada (AWHONN Canada only), the Canadian Association of Midwives (CAM), the College of Family Physicians (CFPC) and the Society of Rural Physicians of Canada (SRPC).   [JOGC, #221, Dec 2008]

BTCanada will not support any organization, or group of organizations, that dictate to women what is ‘normal’ or ‘natural’.  It is important for women considering pregnancy to understand what the SOGC and their partners consider normal and abnormal, and to consider the contents of this submission in the light of their definition of ‘natural’.  That definition, according to the Compact Oxford English Dictionary  [3rd edit, Oxford University Press, 2005] is: 

“existing in or derived from nature; not made, caused by, or processed by humankind”

They also add that “Childbirth is considered to be natural childbirth if there is little or no human intervention”.

I struggle to understand this partnerships’ irrational notion that, because something is natural, it must be good.  The rest of the medical industry doesn’t suffer these delusions.  The idea that nature is something to wrestle with, subdue, and improve upon is as old as medicine itself.  A willingness to alleviate death and suffering – two other, undeniably natural processes – continues to improve the quality of life for millions. 

The only real, guaranteed way to ensure ‘little or no human intervention’ in obstetrics is unassisted childbirth, a growing trend where women choose to birth at home while banishing midwives and other obstetric care providers.  I have to wonder if the SOGC and their partners are endorsing this type of ‘natural’ childbirth experience.

The SOGC and their partners do not consider epidurals normal during labour.  The only pharmaceutical interventions they consider normal are opioids and nitrous oxide inhalation (both, incidentally, ‘processed by humankind’).  They now, finally, consider epidurals during delivery normal after many years spent denigrating them.  ‘Normal’ delivery can include induction, augmentation, electronic fetal monitoring, hypertension, hemorrhage, perineal trauma and surgical repair of this trauma, artificial rupture of membranes, active management of third stage and admission to the neo-natal intensive care.  BTCanada, and women around the world, do not consider any of these ‘normal’.  They are common, some often necessary to save lives and limit morbidity, traumatizing and many are often done unnecessarily and routinely by the same people endorsing this report.  They are not ‘normal’ and, using their own definition, certainly not ‘natural’.   Why do they consider these aforementioned ‘unnatural’ interventions ‘normal’ and consider other interventions (like planned caesareans and spinal anesthesia) abnormal?  Aren’t all interventions “made, caused by, or processed by humankind”?  How ‘natural’ are their own lives?  Do they live in heated homes?  Use computers? Cell phones?  Antibiotics for bacterial infections?  Pain killers for their own aches and pains?  Drive vehicles?  Watch TV?   Isn’t it sanctimonious and hypocritical to deny autonomy, progress and advancement to women while enjoying these other obvious human manipulations of nature themselves?

The SOGC and its partners consider caesarean birth ‘abnormal’.   This is a position BTCanada takes great exception to.  Planned caesarean section is a valid, legitimate and justifiable birth option in uncomplicated term pregnancies, just as spontaneous vaginal deliveries playing by the SOGC rules are.   The paper under review here states that “Vaginal birth following a normal pregnancy is safer for mother and child than a caesarean section”.  There is absolutely no credible, scientifically valid evidence to support this statement for planned, non-laboured caesareans in quality hospitals nor is this statement universally accepted by birth support groups, individual practitioners or medical associations around the world.  I challenge the SOGC and its partners to provide any credible evidence to support their statement.  They certainly haven’t provided any credible evidence source in the references they provide with this bulletin.  The only one agreeing with them is a like-minded organization from the U.K.  There is no shortage of information supporting their position but not all information is valuable.  Obstetric research has a serious problem with bias and is often of poor scientific quality.  It is easily de-constructed.  Disreputable research is not evidence; it is propaganda.

There are several rational reasons some women want a planned caesarean section over a planned vaginal delivery.  Some of these include:

  • Avoidance of genital tract trauma and the reconstructive surgery required to repair that damage
  • Avoidance of excruciating pain and the possibility they will be denied effective pain relief by those who deem such things abnormal
  • Avoidance of pelvic floor damage that results in urinary and/or anal incontinence and/or pelvic prolapse
  • Avoidance of subsequent short term or life time physiotherapy and gynaecological surgeries done to repair, or attempt to repair, the damage mentioned above
  • Avoidance of pain or loss of sensation during sex resulting from damage done to the vagina during vaginal births
  • Avoidance of loss of privacy and dignity
  • Avoid the risk of an emergency caesarean after labour
  • Avoid the risk of a vacuum extractor or forceps delivery
  • Avoid the risk of an episiotomy
  • Avoid electronic fetal monitoring
  • To reduce the chance of possible morbidity or mortality for their baby associated with vaginal birth
  • To minimize the amount of time they must remain vulnerable to medical staff and medical interventions
  • To avoid being unable to make their own decisions because of trauma and pain
  • Fear of childbirth
  • Fear of developing post traumatic stress or other psychological damage as a result of their vaginal childbirth experience

These are well known and well documented risks associated with vaginal deliveries and the SOGC and its partners are fully aware of them.  They are not trivial or uncommon and women have the right to reject these risks.  Inferring that women are ‘not normal’ for rejecting these risks or that any of these reasons are not ‘acceptable’ obstetrical indications is cruel.  No one has the ethical right to force these risks on women if they find them unacceptable.  Women have the right to informed consent about ALL the risks and short term and long term morbidity associated with ALL birth possibilities.  They have the right to decide for themselves, without bullying, which risks they are willing to accept and which they will not.  

I applaud the SOGC and its partners for working to improve maternity care.  They make many much needed, valid suggestions for improvement but I don’t think they are following the path many women want.  Certainly we agree that interventions shouldn’t be routine, that routine episiotomies are banned, that spontaneous pushing on the woman terms in a position of her choosing is sensible and that women, who want continuous labour support and non-pharmacologic comfort measures, be given that opportunity.  These improvements are not only necessary, they are long overdue.  The SOGC and its partners need to also remember that many women aren’t going to choose these options because they consider them dismissive and ridiculous solutions to bigger problems.   It is also worth noting that these improvements in maternity care are necessary in the first place because of past and present policies initiated, endorsed and practiced by the SOGC and its partners.  Misogynistic practices were practiced by them over many years, without any evidence-based justification.  It wasn’t that the evidence wasn’t there.  The facts were available if only they had bothered to look past their biases.  Remaining judgemental and biased, and refusing to listen to ALL women, is not the way to regain credibility.

Obstetrical care providers should not consider themselves, and their ideologies, the pinnacle of the obstetrical hierarchy.  It isn’t about them. That place should be reserved for the women they serve.  Forcing all women to accept their particular model of care is unacceptable and does not meet the needs of the individual.  And we need to remember that women are as individual as any other human being. 

What we need is ‘humane’ birth, as assessed by the woman herself.  Let’s forget those controversial and judgemental words ‘normal’ and ‘natural’.  As long as these outdated obstetrical attitudes persist we will continue to see pregnancy rates in this country decrease, and the SOGC and its partners will continue to see BTCanada advocate for human rights for ALL childbearing women – not just those deemed ‘normal’ by the SOGC and their partners.  We, sadly, will also continue to support those many women who have horror stories to tell us and who have life-time health problems; many of which have had birth experiences deemed ‘normal’ by the SOGC and its partners.  Many more, whose pregnancies and birth experiences resulted in complications, assisted vaginal deliveries and emergency caesareans, must also continue to deal with the artificial stigma that they are ‘unnatural’ or ‘abnormal’. 

Penny Christensen

Birth Trauma Canada



November 2, 2008
World Health Organization
Avenue Appia 20
1211 Geneva 27, Switzerland
Dear Dr. Islam;
As Executive Director of Birth Trauma Canada (BTCanada) and as a member of the Coalition for Childbirth Autonomy (CCA) I respectfully request credible evidence to support the World Health Organization’s statement that a safe cesarean limit should not exceed 10-15%. I have searched extensively through information sources (including WHO commissioned articles by Jose Villar, etal in The Lancet and BMJ in 2006 and 2007 respectively) and have not been able to locate documentation which specifically states that this rate can and should be a global target irrespective of situation and culture. I can find a great deal of other information supporting the WHO statement but none of it is credible. My position is supported by numerous scientific sources around the world that state there is no valid data to support this oft-quoted safe cesarean rate. There seems to be a preponderance of scientifically illiterate research, and worse, a deliberate lack of scientific integrity in much of the existing obstetric literature. Lumping statistics for planned vaginal deliveries that end in emergency cesareans, cesareans performed after a trial of labour, cesareans done in substandard hospitals by unskilled medical practitioners and cesareans done for serious maternal and fetal complications during pregnancy with non-labour planned cesareans in healthy mothers with term fetuses skews the truth. It is an example of deliberate deception and, along with dishonesty about all morbidity and mortality associated with vaginal childbirth, has been and continues to be, the reason obstetric research lacks credibility. This type of bogus science should have no place in medicine or in formulating health policies. Scientific dishonesty is being used to limit reproductive choices (a clear human rights violation) for women and contributes to the on-going problem of shamefully high maternal and infant morbidity and mortality rates around the world.
In my work at BTCanada, I am inundated by data and stories that strongly suggest this artificially set standard causes unnecessary short term and long term negative physical and psychological consequences for women in my country and around the world – both now and in 1985 when the World Health Organization’s position was published in The Lancet.
“Countries with some of the lowest perinatal mortality rates in the world have cesarean rates of less than 10%. There is no justification for any region to have a rate higher than 10-15%.”
I struggle to understand how one sentence can be used to support the other when cesarean rates – particularly with respect to planned primary cesarean without labour at 39+ weeks gestation – have nothing to do with increased infant and maternal mortality rates. Quality of care and the political will to actually care about women does. Countries with the highest mortality and morbidity rates for women and their children are those with the lowest rate of access to competently handled cesarean childbirth options. This is as true today as it was in 1985.
I have no doubt that you and other people within the World Health Organization and around the world are struggling with this issue as I am. It is imperative that we work to resolve this issue and I look forward to hearing from you.
Penny Christensen
Birth Trauma Canada
North Hill RPO
Box 65136 Calgary, Alberta, Canada


Rates of cesarean section: analysis of global, regional and national estimates. Betrán et al. Paediatric and Perinatal Epidemiology, vol 21, pg 98-113, 2007

The basic tenant of this statistical article is to support the authors’ assumption that maternal mortality rates increase when cesarean rates fall below 10% and exceed 15%. One would expect, if this were true, to see the lowest maternal mortality rates (MMR) in countries and regions where the cesarean rates fall between 10 – 15%. This is patently untrue. Southern Africa has a cesarean rate of 14.5% (their statistics) and a shameful MMR of 400 per 100,000 live births (UNICEF, 2005). Canada has a CS rate of 26.3% at last count and a stated MMR of 6.1 per 100,000 live births.
That cesarean rates below 10% drastically increase maternal and perinatal mortality rates is indisputable. Emergency cesareans, cesareans done for serious medical complications arising from pregnancy and pre-term labour cesareans save lives. Their own data shows that rates below their much touted 15% ‘safe’ level have the same problem.
Any study seriously looking at a correlation between cesarean rates and maternal mortality needs to exclude confounding variables like quality of care, regional differences in maternity policy, the value placed on women within their culture, lack of standardized evidence-based guidelines, anti-cesarean biases, infection control standards, substandard hospitals and obstetrical practitioners and poor reporting practices. It isn’t that these variables ‘may’ skew results and conclusions. They do – big time – and statements made without addressing these issues are never credible. I also have to question their use of statistical methodology and the lack of an independent statistical review and analysis. If I had a burning need to avoid taking responsibility for past failures with respect to ‘safe’ cesarean rates I would choose log-log analysis as well. This article can be one of two things. It is either a perfect example of how dangerous statistics are in the hands of the scientifically illiterate or it is a deliberate lack of scientific integrity.
There are hospitals with high cesarean rates and extremely low rates of maternal mortality and morbidity. This simple fact is hidden by a lack of transparency and accountability in obstetrics. It was as true in 1985 as it is today. How come some hospitals are able to accomplish this and others can not? It is clear that it isn’t cesareans to blame for high maternal and perinatal mortality and morbidity rates; it is those unskilled practitioners that perform them and those who institute policies against them armed only with their anti-cesarean biases. They can’t (or won’t) recognize what works and what doesn’t and they deliberately avoid applying sound medical practices that could save lives and reduce morbidity. Quality surgical techniques, prophylactic antibiotic use, anti-thromboembolism techniques, proper aseptic technique and access to effective pain control have been used effectively for decades to reduce mortality and morbidity in other medical specialties. Why not obstetrics? Those seriously interested in reducing maternal and perinatal mortality and morbidity need to look at what successful hospitals are doing and adopt their methods. Vilifying cesareans and blocking advancement in obstetrics is not the answer.
Dr. Amy Tateur makes an eloquent case against the conclusions arrived at in this article and the choice of statistical methodology. I reproduce her words below.
Penny Christensen, Birth Trauma Canada, Coalition for Childbirth Autonomy

SEPTEMBER 9, 2008 7:46AM

What's the right C-section rate? Higher than you think
Anti-cesarean activists love to point out that the World Health Organization has recommended that the C-section rate should be 10-15%. Unfortunately, the WHO appears to have pulled those numbers out of thin air. Its own data shows that a 15% C-section rate does not result in the lowest possible levels of either neonatal mortality or maternal mortality. Indeed, Dr. Marsden Wagner, who has probably done more than anyone to promote the idea of a 15% C-section rate as ideal, is a co-author of a study that actually demonstrates the opposite.
The paper is Rates of caesarean section: analysis of global, regional and
national estimates (Paediatric and Perinatal Epidemiology, 2007; 21:98–113.) The article explicitly acknowledges that the 15% C-section rate recommendation was made without any data to support it. This paper is actually the first paper that attempts to compare international C-section rates with maternal and neonatal mortality.
Since publication of the WHO consensus statement in 1985, debate regarding desirable levels of CS has continued; nevertheless, this paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health.
The data regarding C-section rates below 10% is stark:
...[T]he majority of countries with high mortality rates have CS rates well below the recommended range of 10–15%, and in these countries there appears to be a strong ecological association between increasing CS rates and decreasing mortality.
How about the data on C-section rates above 15%? The authors claim:
Interpretation of the relationship between CS rates and mortality in countries with low mortality rates is more ambiguous; nevertheless, the sum total of the evidence presented here supports the hypothesis that, as has been argued previously, when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits.
Not exactly. Indeed, not even close. The data show that low maternal mortality and low neonatal mortality are associated almost exclusively with high and very high C-section rates.

The article contains a variety of charts that make this clear. Of note, the charts are of an unusual kind. Rather than graphing C-section rates against mortality rates, the authors chose to graph the log (logarithm) of C-section rates against the log of mortality rates. A log-log graph has the advantage of exposing tiny differences when all the values are bunched close together, but all the values are not bunched together in this situation. C-section rates occur along a broad range, and mortality rates occur along a broad range. As a consequence, the log-log graph magnifies the effect of tiny differences and minimizes the effect of large differences. Therefore, you need to be very careful in interpreting the graphs.

This is an adaptation of the chart that appears in the paper comparing C-section rate to maternal mortality (the authors claim that graphing C-section rate against neonatal mortality produces a similar result). The area representing a C-section rate of 10-15% has been highlighted in yellow. The horizontal blue line represents a mortality rate of 15%. Lower mortality rates are below the blue line and higher mortality rates are above the blue line.

The data themselves are quite clear. There are only 2 countries in the world that have C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15% has higher than acceptable levels of maternal and neonatal mortality. There nothing ambiguous about that.

The authors claim:
Although below 15% higher CS rates are unambiguously
correlated with lower maternal mortality; above this range, higher CS rates are predominantly correlated with higher maternal mortality.
No, that's not what it shows at all. It shows that only countries with high C-section rates have low levels of maternal and neonatal mortality. A high C-section rate does not guarantee low maternal and neonatal mortality because C-section rate is not the only factor. For example, Latin America (represented on the chart by open diamonds) has a high rate of C-sections performed for social reasons, but does not have a low level of maternal mortality.
The bottom line is this: The only countries with low rates of maternal and neonatal mortality have HIGH C-section rates (except Croatia and Kuwait). The average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 36% are consistent with low rates of maternal and neonatal mortality.

The authors’ claims are not supported by their own data. There is simply no support for a C-section rate of 15%, since virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have rates that are far higher. There is also no support for the claim that "the sum total of the evidence presented here supports the hypothesis that ... when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits". When C-sections are performed for medical indications, there is no evidence that rising C-section rates lead to rising rates of maternal or neonatal mortality.

The authors own data indicate that a C-section rate of 15% is unacceptably low, and that the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality.