Preventable Obstetrical Interventions: How many caesarean sections can be prevented in Canada?

Public health authorities have been alarmed by the progressive rise in rates of Caesarean section in Canada, approaching one birth in three in several provinces. [editor’s note: current US Cesarean rate is 33%]

We aimed therefore to consider what were preventable obstetrical interventions in women with a low-risk pregnancy and to propose an analytic framework for the reduction of the rate of CS.

We obtained statistical variations of CS rates over time, across regions, and within professional practices from MED-ÉCHO, the Quebec hospitalization database, from 1969 to 2009.

Data were extracted from a recent systematic review of the cascade of obstetrical interventions to calculate the population-attributable fractions for each intervention associated with an increased probability of CS.

*** We thereby identified:

• expectant management (as an alternative to labour induction)
• planned vaginal birth after CS as the leading strategies for potentially reducing rates of CS in women at low risk.

An increase for vaginal birth after CS to its 1995 level could lower the current CS rate of 23.2% (2009 to 2010) to 21.0%.

Other alternatives to obstetrical interventions with a potential for lowering CS rates included:

• non-pharmacological pain control methods (such as continuous support during childbirth)
• intermittent auscultation of the fetal heart  (instead of electronic fetal monitoring)
• multidisciplinary internal quality assessment audits

We believe, therefore, that the concept of preventable CS is supported by empirical evidence, and we identified realistic strategies to maintain a CS rate in Quebec near 20%.

KEYWORDS: Caesarean section, health organization, health services, obstetrical interventions ~ PMID: 23756274[PubMed – in process]

*** Formating note and comments by FG.org’s editor:

I made minor formatting change (bulleted lists) to make reading easier, and the data more useful.

Editorial Commentary ~ faith gibson

What is both remarkable and laudable about this study is the long-overdue idea of an analytic framework for the reduction of the rate of CS.

Data analysis relative to childbirth practices and associated maternal-infant outcomes can be done in many ways. For example, available data can be used to compare vaginal birth and CS rates for all the categories of birth attendants who provide intrapartum care to low and moderate risk women — obstetricians, other physicians, and midwives — and then compare each category with the rate of mortality and serious morbidity in cohorts of healthy mothers and babies.

However, we also need the specific data to determine what (or if) certain interventions (induction, continuous EFM, epidural) directly decrease the rate of normal (spontaneous) vaginal birth, or act as triggers for a mounting cascade of interventions leading to operative vaginal births and that most extreme intervention in normal childbirth — an unscheduled Cesarean section.

Other sources of reliable data have identified optimal rates for Cesarean surgery (safest maternal-infant outcomes) to be between 5% and 10%. The national average for C-sections in the US is 32.8%. Obviously the use of an “analytical framework” is vital to our ability to provide high-value, cost-effective maternity care and should be the highest priority for American researchers.

In the meantime, I must point out that all four practce-related recommendations identified by this study as reducing Cesarean rates — expectant management (instead of induction), normalizing vaginal birth after a cesarean, non-pharmacoligical pain relief including continuous support during labor, and intermittent auscultation of FHT instead of continuous electronic monitoring — are physiological management strategies already utilized as part of the midwifery model of care. They are currently recommended and routinely used by midwives in all birth settings.

Obviously what is missing from the current  ‘obstetrical’ model, and needs now to be reintroduced, is physiologic childbirth as the science-based standard of care for healthy childbearing women. 

This normalizing of normal childbirth is to be used by all categories of birth attendants (midwives, family practice physicians and obstetricians) and in all birth settings (hospitals as well as non-medical settings such as birth centers and PHB).  

Viva la differences between the model of obstetrical interventions developed and designed to treat complications (for which we are all grateful!) and the normal, non-medicalized care provided to healthy women who don’t need or want routine medical interventions.  Many of the painful, risky and expensive medical and surgical procedures used routinely in the US became part of the medical standard of care without ever having proven their worth.  We now know from the data that the continued routine use of them do not routinely benefit a healthy population of childbearing women with normal pregnancies and are not justified either on safety or economic grounds.

The time to implement these changes is now.   The first steps include:

• Teaching the principles of physiological childbirth in all training programs for medical and nursing students 
• Utilizing physiological management as the standard of care for healthy women with normal pregnancies
• Accepting the midwifery model of care as an integral part of the healthcare system