Canada
It’s time to stop treating (normal) pregnancy (in healthy women) like a disease
ANDRÉ PICARD
THE GLOBE AND MAIL
Last updated Monday, Jun. 16 2014, 6:13 AM EDT
All too often, the miracle of birth – such as the arrival of Zoe Marina, with mom Amy Brillon at a home in Richmond, B.C. – becomes a costly hospital stay. (John Lehmann/The Globe and Mail)
The No. 1 reason for hospitalization in Canada is childbirth.
The most commonly performed surgery in this country is the cesarean section.
Those facts should give us all a case of morning sickness. And they should prompt a lot of hard questions.
Is pregnancy a disease? Is a hospital really the best place to give birth? Are women ending up there by choice or by default? Is surgery actually required to deliver one in every five babies?
There were 389,822 live births in Canada in 2012-13, according to Statistics Canada; there were 369,454 births in hospitals, according to the Canadian Institute for Health Information (CIHI).
The balance were home births or babies born in birthing centres not located in a hospital. (Also, Statscan counts actual babies; for CIHI, multiple births – twins and up – count as a single birth.)
All that to say that roughly 98 per cent of Canadian babies are born in hospitals.
And virtually every baby in this country is still delivered under the supervision of a physician – either a specialist obstetrician-gynecologist or a general practitioner. Fewer than 5 per cent of births involve a midwife.
Let’s face it, the vast majority of births are uncomplicated. That doesn’t mean easy – it means not requiring medical intervention.
Where and how you give birth matters.
It’s worth recalling the old adage: “If all you have is a hammer, everything looks like a nail.” Similarly, put a perfectly healthy pregnant woman in a hospital and she becomes a patient – someone to be monitored, sedated, drugged, “assisted,” operated on and so on.
When someone is placed in an institutional setting, there is often a cascade of dubious and not-always useful interventions that occur: Shaving of pubic hair, fetal monitoring, IV drips, inducement, epidurals, forceps, episiotomy and, of course, a cesarean section. (Again, this is not to suggest that epidurals are unnecessary, and 58 per cent of women opt for one during delivery, but pain relief can be done outside the hospital, too.)
There were 100,636 C-sections performed in Canada in 2012-13.
Fully 23 per cent of women over 35 and 17 per cent of women under 35 delivered their babies through a surgical intervention.
Does anyone seriously believe that level is justified?
The World Health Organization suggests that the optimum rate is somewhere between 5 and 15 per cent.
Too many C-sections are done for the sake of convenience (of the physician, rarely the patient) and out of fear.
Don’t buy the “too posh to push” nonsense. Yes, an increasing number of women are “choosing” a cesarean, but when you medicalize pregnancy and labour, and don’t offer reasonable alternatives, you create uncertainty and fear.
Just as troubling as the high rate of C-sections over all is the wide variability in rates around the country, ranging from 15 per cent in Quebec to 22 per cent in British Columbia. (The C-section rate in Nunavut is only 6 per cent, but high-risk pregnancies are handled out-of-territory so it’s not a fair comparison.)
Yes, surgery can be lifesaving. But too much surgery is harmful.
Physicians should be handling the complex, high-risk cases – women with conditions such as obesity and heart disease that compromise the pregnancy, mothers over 35 (though the risks to “older” women are debatable) etc.
Most births should be handled by midwives, preferably in a home-like setting, such as a birthing centre.
This is not an attempt to romanticize “natural” childbirth or a call to return to the “good old days” – because they weren’t so good. Until the last century, babies were born at home with little support, and many tragic complications for moms and babies alike.
Maternal mortality fell precipitously in the 20th century, but only a small portion of those improvements were due to obstetrical interventions.
We have a much higher standard of living (hence healthier mothers), we have contraception and emancipation (so the days of 17 children are mercifully behind us) and, most of all, we have better infection control, including vaccination and antiseptic environments.
The greatest risks to our foremothers were infectious diseases and excessive bleeding. Those are still the biggest risks today. But they are manageable risks.
In a bid to totally remove risk (which is not possible), we have made pregnancy and birth unnecessarily tedious and costly and created new risks to boot.
To make our health system patient-centred, efficient and cost-effective, the aim should be to deliver appropriate care in the right place at the right time with the right health professional.
Profound cultural change is required – and what better place to start than by tackling the leading cause of hospitalization and in-patient surgery.
Pregnancy and birthing are part of a normal physiological process that should be celebrated. Bringing a child into the world should be beautiful and memorable, messy and magical.
Why have we reduced it to a series of billable acts where moms-to-be are institutionalized and the process is unnecessarily medicalized?
Mothers and their babies deserve better.
Follow André Picard on Twitter: @picardonhealth
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