What am I doing?

I wrote a letter to the editor of our local paper in response to this outrageous article which appeared on Sunday. I'll post it if it gets published.

Victoria is Canada's caesarean capital
Victoria General Hospital has the highest rate of C-sections in the country

Katherine Dedyna
Times Colonist

Sunday, July 29, 2007

Nearly four labouring women in 10 -- more than 1,000 women last year -- had either an unplanned or planned C-section at the hospital, which sees more than 2,800 births a year.

The Canadian Institute for Health Information said last week that the C-section rate across the country has been climbing steadily for more than a decade. The most recent numbers from 2005-06 indicate that 89,397 babies, or 26 per cent of babies born in hospitals, were delivered by C-section, compared to 23 per cent five years earlier and 17 per cent in 1993. The reason Victoria General Hospital has the highest C-section rate in the country at 37 per cent might be a confluence of many factors, although none is peculiar to Victoria.

Doctors cite, among other reasons, older, heavier mothers; increasing numbers of women who don't want to labour long; technology that shows potential fetal problems; mothers who have had previous C-sections returning for a second; and the presence of worried fathers in the labour room.

"We don't have any good data on how much is consumer-driven versus system-driven and so on," says Dr. Jerome Dansereau, chief of obstetrics at the Vancouver Island Health Authority. "It's really difficult to dissect those numbers."

VIHA's head of family practice obstetrics at the hospital, while saying she wants the rate lower, defends it. "I've never been involved in a case where I thought that it wasn't a necessary C-section based on the evidence we have," says Dr. Deborah Bircham.

A C-section is major surgery involving an incision made through the mother's abdominal wall to remove the baby from the uterus. In healthy mothers, this leads to three times the complication rate of vaginal births, with blood-filled swellings and infections -- some life-threatening -- being the most common at VGH.

British Columbia is the province with the highest C-section rate in the country, at 30.4 per cent. Health professionals say there are many forces pushing up the rate in B.C. and across the country, and it is possible some are more common in Victoria.

For instance: Advanced maternal age is a factor in C-sections, and women over 35 make up 24.1 per cent of mothers in Victoria compared to 21.5 per cent B.C.-wide. The other explanations include:

- Patients are not as patient as they used to be, says Dansereau.

It happens weekly if not daily, that a woman is not labouring well and does not want to carry on any longer. "There is only so much as the caregiver that you can say or do to convince her to carry on, carry on, especially if you're not convinced that it's going to make any difference at the end," he says.

Luba Lyons Richardson, vice-chairwoman of midwifery at VGH, has seen the same culture shift in her 30 years of practice. "Women themselves have less tolerance for longer labours, for a baby that's a little bit in distress."

But caregivers have empathy for women with low coping skills and previous traumatic labour who don't think they can face that again, says Richardson. She knows of women who ask for elective caesarean sections and get them, depending on extenuating circumstances.

"That's another debate that rages on. If women have choice, then shouldn't they have that choice?"

- Even the mention of a one per cent risk of a negative outcome for the baby by continued labour influences mothers in favour of C-sections, Dansereau says.

Fetal monitoring is there to record every bit of risk, and that, too, has increased the C-section rate, says Bircham.

But the equipment that shows potential problems is not accurate enough to be definitive, so doctors take the cautious route.

"If you have something non-reassuring, you are obligated to deliver the baby," Bircham says.

Sometimes after a C-section, she thinks labour could have gone on another couple of hours. "But do you want to be the one that says, 'I'm sorry, we shouldn't have waited. Your baby is now going to have brain damage.' "

- Vaginal births after a previous C-section are falling. Mothers who have had previous C-sections are given the option of a scheduled C-section for their next birth because of the risk of uterine rupture. Doctors cannot force these women to try vaginal birth, even in the absence of factors that led to the prior C-section, says Bircham.

There were 301 scheduled C-sections at VGH in 2005-06, although some of those were for other complicated deliveries.

- Surgeons in Victoria will do C-sections rather than traumatic forceps delivery. Only 10 per cent or fewer of VGH births involve instruments such as forceps, far lower than the national average of 16 per cent.

"That might be a big difference and I wouldn't disagree with that," says Bircham, adding that forceps can lead to damage to the mother's perineum and to the baby.

- Doctors are seeing heavier mothers.

"There are more and more women presenting to my office with weights over 200 pounds at the beginning of a pregnancy," says Bircham, and that leads to bigger babies and reduced space in the birth canal.

- Susan Miller, an RN and prenatal educator since 1978, says protective dads in the delivery room also affect the C-section rate. "The dad will say, 'Do something, she's in pain.' " And that often means an epidural.

The epidural freezes a woman's abdomen and increases the potential for C-section because it obliges her to stay in bed, with a continuous fetal monitor, IV and blood pressure cuff, with no opportunity to help the baby change position.

Bircham would like to see a lower rate of C-sections -- and notes that if home births were factored in, the local rate would drop to 35 per cent. But she says women in Victoria get excellent maternity care.

They do not get C-sections for their first pregnancy just because they want one, she says.

But midwife Lyons Richardson won't be surprised if eventually women walk in cold with their first pregnancy and demand a C-section for any reason they want.

"Give it 10 years and I don't think it's going to be that unusual."

Dansereau doesn't rule out the rate going to 50 per cent, given the continuing upward swing.

"There is no one who could have predicted what we see today," he says, "and there is no one who can predict when it will stop."

© Times Colonist (Victoria) 2007