Should Elective Cesarean Births Be Covered By Provincial Health Plans?

The big news in the Canadian birth world this week was an article that announced Ontario is considering cutting coverage for medically unnecessary cesarean births.

On the surface, this makes total sense to me. Having an elective cesarean birth is akin to having elective surgery of any kind, and therefore it seems reasonable  for it not to be covered by provincial health plans. If we spend less money on medically unnecessary cesarean births and put that money into training more midwives and educating women about birth in a way that is supportive and positive, we might have a more cost-effective system with better birth outcomes.

However, we have created a culture where many women (and doctors!) are often scared of vaginal birth. This culture is the product of years of promoting over-medicalized birth, portraying birth as scary and painful in the media and avoiding bringing up our children with an awareness of the real process of childbirth.

The birth culture we have created is what has led to our unnecessarily high rate of cesarean births. This includes, but is not limited to, elective cesareans. If we want to reduce the cesarean rate, we need to shift our birth culture to one that promotes and supports vaginal birth, one that teaches women vaginal births are safe and provides them access to resources for having healthy vaginal births. I worry that taking away their option for cesarean births without working on our birth culture may be dangerous and unfair.

According to a counsellor who used to work for the Elective Cesarean Clinic at the Best Birth Clinic, one of the most common reasons  given for elective cesareans is having had a previously traumatic birth.

If my interactions with women who have experienced trauma during labour and birth has taught me anything, it’s that we need to give these women back their power. Why do they choose elective cesareans? Partially out of fear they will have a repeated traumatic experience, partially as a way to get control in a medical system that they feel previously let them down.

Telling these women they cannot have an elective cesarean because physically there is no medical reason to do so takes away even more of their power. Although I believe having a vaginal birth after a previously traumatic birth has the potential to be a healing experience in many circumstances with the right support and care, I think most importantly women need to feel in control of their bodies and what happens to them. 

Would women who desire elective cesareans for phsycological or emotional reasons be provided with coverage for these surgeries? Would they be provided with resources to help them cope with their previous experiences around birth and support them through a healthy and positive vaginal birth?

I absolutely agree with the article when it says “Women who give birth by C-section spend more time in hospital, often a few days, adding to costs in the health-care system. Some women opt to give birth at home with midwives, which further saves the system money and reduces the risk of mothers and babies contracting hospital-based infections.” Vaginal births are also often considered more ideal for breastfeeding success and postpartum recovery.

I do think we need to work on reducing the cesarean birth rate in Canada. Numbers for “elective” and “emergency” cesarean births are both way too high. I believe the solution mostly lies in educating doctors and the general population that birth is not a medical procedure which is inherently dangerous or leads to suffering. We need to shift our birth culture to one which provides women access to positive and accurate information about birth, so they can plan to have vaginal births with a trust in their bodies’ ability to do so.

I talk about Power to Push so much in my blog, you’d think they were paying me! But I can’t HELP mentioning them again here. The Power to Push Campaign and Best Birth Clinic at BC Women’s Hospital here in Vancouver has undertaken the goal of reducing the cesarean birth rate in BC. They are doing an amazing job of supporting vaginal births for women who would normally end up on the path to a c-section, such as women who have had previous cesareans or who’s babies are in a breech position. Their elective cesarean clinic has counsellors on staff. Their goal is to help women “push for the best birth possible.” If we really want to reduce cesarean births in Canada, we need more campaigns like this, more midwives, more access to information and support for healthy vaginal births. We need to shift the culture we have around birth to start creating real change.

You can read more about my perspectives on birth culture in the birth culture and philosophy categories on my blog. You may also want to read an article I posted earlier this week, Promoting A Gentle And Informed Birth Culture.

For more information on Cesarean Birth here in B.C., visit OptimalBirth BC.

Here are a few of things I think require some thought when considering cutting coverage for elective cesarean births:

  • Define medically unnecessary. Should women who have psychological and emotional reasons for desiring cesareans be in this category? If they are not going to plan a cesarean, should they be provided with other resources to help them cope well with a vaginal birth?
  • Would some of the financial resources for elective cesareans be redirected to increase access to midwifery care , prenatal education, and campaigns promoting vaginal birth with accurate and supportive information?
  • Is cutting funding for elective cesareans the first step in sending the message that vaginal birth is safe and generally preferrable? Or are there other steps that should be taken before we should consider cutting funding?

I agree whole-heartedly that fewer cesarean births are generally best for our women, newborns and our healthcare system. But the methods we use to achieve that goal need to be well thought out and considerate of the state of our current culture around birth.

Comments welcome below. If you have any information, research or thoughts on this subject, I’d love to hear from you!

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  11 comments for “Should Elective Cesarean Births Be Covered By Provincial Health Plans?

  1. Laurel Brant
    February 13, 2014 at 10:01 pm

    Do you have any stats from the Power to Push Campaign?

  2. jeherendeen@gmail.com
    December 27, 2013 at 8:50 am

    Better yet, put independent midwives in charge of primary maternity care, and pay your OBs a comfy flat salary to twiddle their thumbs in operating rooms, waiting for actual obstetrical emergencies to show up. Your cesarean rate would be cut in half, and you’d save pots of money.

  3. jeherendeen@gmail.com
    December 27, 2013 at 8:09 am

    Here we go again, with the LIE that there are too many cesareans because of stupid women demanding them. If you don’t want medically-unnecessary cesareans, pay all your OBs a flat salary, period.

  4. June 17, 2013 at 11:43 am

    I should add further that you seem to be confusing the term “elective” with patient choice or maternal request. Elective simply means “planned or scheduled” and the vast majority of surgeries are elective in that they are planned or scheduled – however, most that are covered by provincial medical insurance have a medical indication for the surgery.

  5. Mrs. W
    January 26, 2012 at 8:38 pm

    I greatly beg to differ – we have a culture that is so supportive of vaginal birth that women are scared of csections in a way that is far disproportionate to the actual risks. Mothers who don’t achieve vaginal deliveries often feel like failures. Women who would choose cesarean are marginaligized and often have their requests denied – some are subjected to vaginal deliveries they when they have no desire to do – often these deliveries are very traumatic for these women. Rarely do we talk of the ‘sequalae’ of natural birth – pelvic organ prolapse, urinary incontinence, fecal incontinence, and hemmorhoids. Nearly all cases of cerebral palsy would be prevented by prophylactic cesarean. The cost studies are flawed – seriously so and in all reality the cost difference between planned vaginal birth and planned cesarean birth is negligible.

    • January 27, 2012 at 8:58 am

      “some are subjected to vaginal deliveries they when they have no desire to do – often these deliveries are very traumatic for these women” I totally agree with that statement. Which is why I am saying I worry about it being dangerous to remove coverage for cesarean sections. However, I WILL argue with our culture being supportive of vaginal birth in a way that is healthy and confidence inspiring, which is the way women need to feel in order to have a positive vaginal birth.  Interesting how we have such different experiences… I FREQUENTLY hear women talk about being afraid of urinary incontinence, hemmoroids, tearing, etc. I’m also curious about your comments on the cost differences… I’ve only ever seen numbers that show cesareans cost more. I’d be interested to see some numbers that refute that if you’ve got them.

      I also will agree that sometimes women who do not birth vaginally can feel like they somehow failed. I truly hope our culture will move more and more away from our tendency to compete and judge and hold ourselves to other people’s standards. Women deserve respect and should have their births honoured, whether they were intervention-free vaginal births, medically assisted births, or cesareans.

      Thanks so much for your comments! Love getting different perspectives on such an important topic.

      • January 27, 2012 at 9:50 am

        Mrs. W. Here’s some numbers from the Optimal Birth BC website. Optimal Birth BC is made up of a team from The School of Population and Public Healthat UBC, Perinatal Services BC, The BC Women’s Hospital Cesarean Task Force as well as provincial health authorities. From their website:

        “Cesarean birth is associated with higher rates of maternal and newborn morbidity and death compared to vaginal birth, and uses considerable health care resources. A study from the Canadian Institute for Health Information reported that the average cost of cesarean birth ($4600) is 60% higher than that of vaginal birth ($2800). In Canada, a 6% absolute reduction in cesarean birth from 26% to 20% would result in a total annual cost savings of $36,640,000 Reference: Canadian Institute for Health Information. Giving Birth in Canada: The Costs. Ottawa, Ontario, 2006.”

        http://www.optimalbirthbc.ca

        • Mrs.W
          January 30, 2012 at 4:30 am

          Jessica – the problem with the cost numbers are they are not based on intention to treat and the caesarean cost numbers include a large portion of emergency c-sections. A proper comparison would be based on birth plan – so if 25% of planned vaginal births wind up being cesarean, those costs should be in the ‘vaginal’ category. A truly elective planned csection (39 weeks, healthy mom) likely costs less than $500 more than a planned vaginal birth.

          • January 30, 2012 at 3:04 pm

            Interesting. What you say about Intention to Treat makes total sense.  Although in general I prefer to see where numbers are coming from, I concede that it makes sense that “emergency” cesareans are more costly than elective cesareans, although I still wonder about elective cesareans being less financially costly than planned vaginal births. I’m sure you’re getting this from a reliable source, but it goes against everything else I’ve ever read!
            My personal belief (and hope) is that a shift in our maternal care practices could greatly reduce the number of “emergency” cesareans and increase the number of vaginal births with positive outcomes, physically and psychologically, for both mother and child. And that, ultimately, is my biggest concern! 

      • jeherendeen@gmail.com
        December 27, 2013 at 8:55 am

        OF COURSE women are afraid of urinary incontinence, etc. with vaginal birth–they’ve been listening to their OB. OBs get paid more to do cesareans. Does anyone reasonably expect OBs to encourage moms to deprive them of extra income?

    • Laurel Brant
      February 13, 2014 at 9:58 pm

      I want your references, please! Show me a good study that proves cerebral palsy is preventable, or the rates reduced significantly, by prophylactic cesareans. Where is the literature that clearly indicates birth (trauma) causes cerebral palsy? I know it has been a commonly held belief but I have been under the assumption that there is no proof. Please, I do not want to give inaccurate information to childbearing women and I cannot take your word on this important issue – I need the research.

      I don’t know if you have had cesareans or not. In my experience, women who have given birth by c/s are often defensive and, yes, feel like failures – because their bodies didn’t do what they were designed to do. Regardless of the reason for the c/s (it could very well have been to save a life), later, when they feel safe, women will often express sadness at not knowing what it’s like to push a baby out of their bodies. Let’s be clear – no one makes them feel one way or another – they have, and are entitled to, their feelings about the birth of their babies, it is their experience. I remember being told, “Don’t feel bad, you have a beautiful baby.” or, “You shouldn’t feel sad/angry/depressed/lonely, whatever – BUT, I did! I had so many feelings, regardless of what anyone said. Having someone tell me how I should or shouldn’t feel, only made it worse.

      I don’t have the numbers to compare costs between vaginal and cesarean deliveries, but I do know about the convenience of scheduling and performing surgery. That convenience needs to be factored into the costs as well.

      In the 36 years since my c/s I have learned a great deal and I’m still learning. I am always surprised when a women doesn’t question how she ended up with a c/s – usually a cascade of interventions accompanied by a belief in the medical propaganda/fears. I think the only way to move forward and make different choices is to ask questions, even the uncomfortable ones.

      There are women who have only experienced c/s’s and who have many of the same ‘sequalae’ attributed to natural/vaginal birth, such as pelvic organ prolapse, urinary incontinence, hemorrhoids, rectocyles plus they may also have, adhesions from the incisions.

      I know this discussion appeared 2 years ago but I hope we can continue it as it is as relevant today as it was then.

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