The Canadian Institute for Health Information (CIHI) has updated its interactive tool, “Your Health System,” which reviews health-care data across all provinces and makes recommendations for the delivery of services, such as childbirth. This includes “low-risk” caesarean rates, meaning the number of low-risk women who have surgery after labouring with a single baby in their first pregnancy.
Provincial “low risk” caesarean rates are compared to the 17.9 per cent national average, including Alberta’s 20.8 per cent rate and British Columbia’s 24.5 per cent rate, which are graded “below average.” In fact, CIHI’s message to all hospitals, physicians and patients on caesarean births in general is clear: A lower rate is “desirable.”
But is it? Challenging this inherently flawed measure of patient care is long overdue. As a standalone statistic, a “low risk” caesarean rate lacks the nuance needed to inform and improve individual clinical care. It simply tells us how many first-time mothers who went into spontaneous labour had a caesarean birth.
Clinical care counts
It does not tell us the clinical considerations behind the decision to intervene, or the relief many mothers feel when a caesarean is performed due to unforeseen complications during labour. We are not reminded that the average age of a mother giving birth in Canada has risen to 31.7 years, representing an upward trend that carries higher risks.
Nor does it consider changes in baseline rates of pre-existing medical conditions and pregnancy related medical conditions, high infant birth weights that are associated with obstructed labour and fetal distress, and modern developments in fetal monitoring that more frequently diagnose potential fetal distress.
CIHI’s indicator targets those for whom vaginal birth “is expected,” implying that many caesareans are unnecessary. However, childbirth is intrinsically unpredictable, and tolerance for poor outcomes is low. Parents expect a living and healthy baby, and caesareans are an important part of how obstetricians achieve this for Canada’s families.
Information, consent and autonomy
Outcomes for mothers matter, too. Last year, new evidence highlighted Canada’s “unacceptably high” rate of severe injuries to the pelvic floor from forceps and vacuum use, and the highest anal sphincter injury rate of 24 high-income countries.
Researchers criticized a lack of concerted effort to reduce these injuries. A province’s increasing caesarean rate could mean obstetricians are offering caesarean birth as an alternative, and that more mothers are choosing to avoid an instrumental delivery.
Especially as pelvic floor injuries increase a woman’s lifetime risk for urinary and fecal incontinence, pelvic organ prolapse, and complex surgeries that cannot always solve these issues. Any policy or practice denying choice in childbirth, or refusing and delaying caesareans on the mere presumption that rates should be lower, defies the principles of patient-centred care.
Read more: Requests for caesarean birth brushed aside, despite guidelines to respect maternal choices
And given the United Kingdom’s landmark Montgomery Supreme Court judgment on autonomy, maternal satisfaction is a more appropriate measure of success than any caesarean rate.
Lessons to learn
CIHI could learn another valuable lesson from the U.K., too, since its stated intention “to help reduce C-section rates” in Canada is linked to concerns about “higher costs.”
For decades, U.K. hospital staff and even safety inspectors blindly supported extraneous efforts to reduce caesarean births, until outstanding multi-billion (yes, billion) dollar litigation costs for maternity services caught the attention of government.
Demands for change by families whose babies and mothers died or were seriously injured as a result of delayed and absent caesareans, often for “low-risk” pregnancies, led to police investigations, a national safety inquiry and criticism of birth mode targets.
Litigation may be notoriously difficult for patients similarly harmed in Canada’s health-care system, but it is rising, as are the long-term costs associated with pelvic floor damage.
A patient-centred perspective
Furthermore, Canada has long faced challenges with regional health-care variations driven by diverse patient needs, physician practices and resource availability (staff and blood, for example).
Recognizing this, CIHI recommends better access to caesareans in remote areas. However, we argue it now needs to rethink its blanket position elsewhere that a “lower rate is desirable.” Especially as its recent statement inexplicably links to an obsolete national “normal childbirth” policy that warns it is for historical research only, not clinical use.
To genuinely guide health-care evolution, CIHI’s childbirth metrics must adopt a broader, patient-centred perspective. It should recognize that women’s reproductive health extends far beyond the delivery room, and incorporate data on common but often overlooked conditions, such as pelvic floor disorders, endometriosis, infertility and uterine bleeding.
Women are not merely vessels for childbirth — they are whole individuals with diverse health needs. Canadian women deserve comprehensive, thoughtful reporting of data that acknowledges and addresses these unique aspects of their health.
Amity Quinn receives funding from the Canadian Institutes of Health Research.
Erin A. Brennand and Pauline McDonagh Hull do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
This article was originally published on The Conversation. Read the original article.
