Statistics about medical care and procedures can vary depending on how information is collected. Health records, research, medical billing data, and other sources all provide information. Each has its own source of error. The CIHI tried to use reliable data sources to give the most accurate picture. The reports are available at www.cihi.ca.
Data alone cannot explain why changes occur. However, some possible explanations have been included in discussion of the trends. One involves changes in society’s expectations and norms. New guidelines, based on research, have also been developed for care providers. Third, care providers now must consider risk management and legal issues (possibility of injury).
One major change in society involves women delaying childbirth until later in life, spending their youths pursuing academic and career goals. Women then try to become pregnant when they are less fertile, and may be forced to seek medical help.
Fertility treatments lead to more multiple (twins or more) pregnancies. Multiple pregnancies result in a higher rate of babies born early or with low birth weights. As well, there are more deliveries by caesarean section. This is one example of an intervention cascade. Each intervention or procedure is associated with a higher rate of further intervention, leading to increases all along the line.
For instance, induction of labour can also start an intervention cascade. Many women ask doctors to start their labours. They may be at the end of pregnancy, feeling quite uncomfortable or even miserable. Perhaps they have personal reasons, such as a husband going out of town soon. Doctors and midwives are reluctant to intervene unnecessarily. If there is not a good medical reason to start labour, induction increases the chance of other interventions. The labour is more likely to require pain relief, use continuous monitoring of the baby, or result in a caesarean section.
If the risk to the health of the baby or mother is made greater by continuing pregnancy as compared to starting labour, then labour should be started. Risks include heavy bleeding, high blood pressure conditions, the unborn baby not growing well, and being more than 41 to 42 weeks pregnant. The reports showed induction was used in 15 to 25 per cent of deliveries, with the highest rates reported in Nova Scotia and Prince Edward Island.
An epidural can be used to provide pain relief in labour. It involves inserting a small tube next to the spinal cord in the low back. Anaesthetic drugs are given through the tube to provide pain relief.
A dramatic difference is shown in the number of epidurals used across the country. There are two primary reasons for this difference. First, care providers with the skills to provide epidural anaesthesia are not available everywhere. Attitudes and beliefs of women and their caregivers towards the experience of childbirth also differ from region to region.
Epidurals are most common in large urban hospitals and least common in rural communities. Overall, 45.4 per cent of vaginal births in Canada used epidurals as compared to 59 per cent in the U.S. Regionally, the Northwest Territories had the lowest rate of epidural use at 4.0 per cent. The highest rate was found in Quebec at 60.2 per cent. In one region of New Brunswick, three out of four women having a vaginal birth used an epidural.
As far as interventions go, episiotomies are the exception. An episiotomy is a cut to the bottom of the opening of the vagina during childbirth. Episiotomy rates have declined significantly since it was recognized that routine use of this procedure does not improve the outcome for mother or baby. An episiotomy may still be needed, and they are still performed 23.8 per cent of the time. This is compared to a rate of 49.1 per cent a decade ago.
Assisted vaginal deliveries use forceps or vacuum to deliver the baby. In Canada, this occurred in 16.2 per cent of deliveries, a fairly steady rate over the previous decade. However, there has been a change in the instrument being used. In 1991, almost twice as many assisted deliveries were by forceps than by vacuum. By 2001, the opposite occurred, with almost twice as many vacuum deliveries as forceps.
The regional differences across the country were quite astounding. Women from Nunavut had a 2.5 per cent assisted vaginal delivery rate. The rate of those from the eastern region of Newfoundland and Labrador was more than ten times that, at just over 28 per cent.
Caesarean birth was first done as a way to save the life of a baby of a dead or dying mother. In the 19th century, the use of anaesthetic gas made the procedure more humane. When the caesarean delivery rate reached five per cent in the 1940s, questions arose over whether or not the rate was too high. By 1980, the caesarean rate was 15 per cent and rising. A small decrease occurred in the mid 1990s, when guidelines were developed to offer vaginal delivery to those who had previously delivered by caesarean section.
By 2002, a new high rate of 22.5 per cent was reached. There is no sign the rate will decrease in the near future. The World Health Organization recommends that caesarean section rates should remain between five and 15 per cent of all deliveries. Once again, the women of Nunavut were least likely to have a caesarean. In the Bathurst area in New Brunswick, the rate was three times as high.
Certain trends in society lead to a higher rate of caesarean deliveries. They include an older population of pregnant women, with more obesity than ever before. As well, guidelines have been developed that encourage care providers to recommend caesareans for all breech deliveries. (Breech is when the baby is bottom first rather than head first). These factors contribute to the increasing rate. Women who have had a previous caesarean section are also more likely to have a caesarean birth in following pregnancies.
With a preterm (before 37 weeks of pregnancy) birth, there is a greater chance of infant death or long-term disability. The rate of preterm birth in Canada has risen from 6.6 per cent in 1991 to 7.6 per cent in 2001. In the U.S., these rates were 10.6 per cent and 12.1 per cent over similar time periods.
There are many reasons why these rates are increasing. Older and more obese women, as well as those with multiple pregnancies are more likely to experience unfavourable events, such as preterm birth. At the same time, care of these at-risk babies has improved dramatically. As a result, care providers have become less concerned about delivering babies early.
It is wonderful that we have the variety of medical care available and the means to help families have the healthiest babies possible. Current statistics show existing trends, some of which are for the better, and some possibly for the worse. As an individual, each woman can help reduce her need for intervention in pregnancy. She can do this by living a healthy lifestyle, avoiding unnecessary interventions in pregnancy, and labouring in a supported and encouraging environment.