Doctors urged to re-examine C-section rates
Doctors urged to re-examine C-section rates
Specialists ask obstetricians to consider using other delivery methods to reduce high number of cesarean births at Victoria hospital
May 12, 2008 at 4:39 AM EDT
VICTORIA — A Vancouver obstetrician is urging doctors at Victoria General Hospital to retool their birthing techniques to lower the hospital’s high and rising tide of cesarean sections, approaching 40 out of 100 births.
Duncan Farquharson, who specializes in risky pregnancies, wants doctors to consider using vacuum extraction and forceps more often during deliveries and to find ways to lower the hospital’s elevated rate of induced births.
“Our province sticks out nationally as having the highest cesarean-section rate, and Victoria General sticks out even more,” said Dr. Farquharson, medical director of B.C.’s Perinatal Health Program. “The trend is likely to continue, unjustifiably.”
At Victoria General, forceps and vacuum extraction are used in about 10 per cent of births, below the national average of 16. The two interventions can injure mother and baby.
In 2006-2007, induction was used 642 times for 2,829 births. Of the 642 inductions, 197 C-sections followed.
During 2006-2007, there were 38 cesareans for every 100 births, a 50-per-cent increase from 2000 when 25 of 100 births at Victoria General were C-sections.
The Canadian average, based on 2005-2006 figures, is 26, similar to other Western countries, with a low of 21 in Saskatchewan, up to B.C.’s high of 30. (In 1990, there were 19 C-sections for every 100 births in Canada.)
Concerned about Victoria General’s rate, the Vancouver Island Health Authority launched both external and internal reviews last fall.
“Any time you’re the highest, it makes you wonder,” the authority’s chief medical officer Owen Heisler said. “We don’t want to be No. 1. We want to be a little less than No. 1.”
In March, Dr. Farquharson brought his recommendations, based on statistics collected by the B.C. Perinatal Health Program, to the hospital board. Since 2000, details on every birth in B.C. that surpassed the 20-week mark have been put into a growing database.
In addition to his suggestions concerning the forceps and vacuum deliveries and induction rates, Dr. Farquharson determined that mothers-to-be in the Victoria area, on average, weigh more and smoke more than mothers in the rest of B.C. Both factors can give rise to risky pregnancies.
Also, delaying childbirth to the late 30s results in poorer outcomes. The late teen years are the ideal time to give birth, Dr. Farquharson said.
At Victoria General, pregnant women older than the age of 35 make up about 25 per cent of the mothers, versus B.C.’s 22-per-cent average.
Melinda Stephenson, age 37, was aware of Victoria General’s C-section reputation but never expected that she would be one of the statistics.
“I feel kind of gypped that I didn’t have a natural birth,” said the Sidney resident who had her first child in March.
Healthy and not overweight, she started labour at 8 p.m. and arrived at Victoria General by 6:30 a.m. the next morning after her water broke.
The nurses were changing shifts and the result was, Ms. Stephenson says, that she was virtually ignored. Despite having contractions that were a few minutes apart and immense pain, Ms. Stephenson waited one hour before the on-call doctor examined her.
By 9:30 a.m. she saw the obstetric doctor. She asked for an epidural, which she believes would have helped her to deliver, but did not get one.
At 10:30 a.m. the doctor decided to give Ms. Stephenson a C-section because the baby was stuck. Alternative birth methods, such as forceps or vacuum extraction delivery, were not offered, she said.
“By then, I was in so much pain, I didn’t [care] how they did it,” Ms. Stephenson recalled.
Jan Christilaw, a nationally recognized cesarean expert, said that might have been an example of a doctor making a “soft call.”
“There’s safety, then there’s expediency,” said Dr. Christilaw, vice-president of medicine at B.C. Women’s Hospital.
While the health of baby and mother must be paramount, there are times when C-sections are done for less than overwhelming reasons, she said.
In the Kootenay Boundary area, 22 per cent of the births in 2005 were C-sections, B.C.’s lowest rate. Different medical philosophies and a greater acceptance of alternative birthing practices are factors, Dr. Christilaw said.
Given the variables, Victoria General wants to find ways to possibly narrow the gap that exists between it and other hospitals. “We are taking it very seriously,” Dr. Heisler said.
Over the next five months or so, all medical staff from the obstetrics ward, including midwives, will meet. Using hospital data, they will discuss what decisions are leading to C-sections.
“Let’s look at everything,” Dr. Heisler said.
If patterns become obvious, interventions will be developed. For example, if data show that 80 per cent of overweight mothers require C-sections, then an educational program, delivered by family doctors and hospital staff, could be developed to urge mothers to reach a healthy weight.
B.C.’s four remaining health authorities are being encouraged to conduct similar reviews to reduce B.C.’s C-section rate, Dr. Farquharson said.
Cesarean sections are major surgery requiring about a 12-centimetre incision through the abdomen into the uterus. Getting the baby out takes five minutes but stitching up the mother afterward can take 30 minutes. Infections, blood clots, hemorrhaging and significant postpartum pain are all risks.
Doctors are paid less, $442, to do an emergency C-section, but $517 for a vaginal delivery. The lower rate is to dissuade C-sections, Dr. Christilaw said.
But because patients undergo major surgery, they remain in the hospital at least three days. A C-section’s total cost is about twice the cost of a vaginal delivery.
Instances in which C-sections are necessary include when the baby is in breech, horizontal or sideway positions or if the placenta is blocking the baby’s passage. Also, mothers who deliver their first child by cesarean section are prone to repeat the procedure with subsequent births.
Special to The Globe and Mail
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