Natural birth no longer the norm in Canada

A new study shows that three quarters of the nation's births involve surgical interventions, which may be overused in some regions and inaccessible in others, writes ANDRÉ PICARD

Friday, Sep 10, 2004


Five-day-old Cléo Richer and mother Gillian Brouse: Surgical induction and a fetal monitor helped an otherwise 'uneventful' delivery.
 Photo: Bill Grimshaw/The Globe and Mail
Five-day-old Cléo Richer and mother Gillian Brouse: Surgical induction and a fetal monitor helped an otherwise 'uneventful' delivery.

From Friday's Globe and Mail
When Gillian Brouse learned she was pregnant earlier this year, her obstetrician immediately suggested a scheduled cesarean section. Despite an earlier surgery to remove uterine fibroids, which placed her at higher risk of complications, she declined.

When labour began last Friday, Ms. Brouse was again offered the option of a cesarean. She said no. But she was equipped with a fetal monitor and agreed to surgical induction, the breaking of her water, to speed up the birthing process.

Two hours later, her daughter Cléo was born at the Ottawa Hospital. "In the end, it was a short, uneventful labour," Ms. Brouse said in an interview.

Cléo's arrival into the world, surrounded by technology and omnipresent surgical options, was also typical.

In fact, three in four births in Canada now involve some form of surgical intervention: C-sections, epidurals, forceps, vacuum extraction and episiotomies are all commonplace, according to a new report from the Canadian Institute for Health Information.

"The data show that we're a bit too dependent on technology," Jan Christilaw, head of specialized women's health at B.C. Women's Hospital, said in an interview. "We've kind of lost sight of the fact that the best birth is an unmedicated vaginal birth."

Yet, the data show that among the 330,000 births in Canada each year, the all-natural births are increasingly rare. According to the report, which was based on data from 2001:

almost one in two women receives epidural anesthesia during labour;

one in four women undergoes an episiotomy during delivery;

one in five births is medically induced, using either drugs or surgical techniques;

one in four births was by cesarean section, an all-time high;

one in six babies is delivered using forceps or vacuum extraction.

Even more striking than the nationwide numbers is the fact that rates for the procedures vary wildly from one jurisdiction to the next.

For example, the number of women receiving epidural ranges from a high of 75 per cent in parts of Quebec to a low of 4 per cent in parts of Nova Scotia. The rate of assisted delivery -- forceps and vacuum -- ranges from a low of 5 per cent in parts of Manitoba to almost 30 per cent of parts of Newfoundland and Labrador. The episiotomy rate varies from 4 per cent in Yukon to almost 18 per cent in Nova Scotia. And the rate of cesareans, a major operation, even varies from 14 per cent in parts of Saskatchewan to 32 per cent in parts of Newfoundland and Labrador.

"These huge regional variations in childbirth practices, something you would expect to be fairly uniform across the country, are quite surprising," said Glenda Yeates, president and CEO of CIHI. "This report clearly raises some questions that need to be answered."

Pregnancy and childbirth remain the single biggest cause of hospitalization for women in Canada, but practices are far from uniform, suggesting there may be a lot of unnecessary surgery going on in some places, and a lack of access to necessary care elsewhere.

"There are a lot of red flags that should go up in terms of how obstetrics are practised in this country today," Dr. Christilaw said.

Dr. Christilaw said, for example, that women are still undergoing far too many episiotomies, a surgery that research has shown is rarely justified. Similarly, she called the rise in cesareans, particularly elective cesareans, "troubling."

The large variation in epidurals suggests that, in some parts of the country, women may not have access to pain relief because of a lack of specialists (the procedure must be done by an anesthesiologist).

Kim Campbell, president of the Canadian Association of Midwives, shared those concerns but worried more about the overall trend toward surgical intervention.

"Labour works well most of the time if you let nature follow its course, but this is a sad reflection of our desire for convenience above all else."

Ms. Campbell said the truly skilled practitioner, whether a midwife, nurse, family physician or obstetrician, knows how to monitor a birth patiently and "pull out the tool box only when you need it."

But what the data show, she said, is an approach that is characterized by the saying: "Give a man a hammer and everything becomes a nail."

Both the doctor and the midwife said the new data also show there is a cascading effect, that if you begin with a single intervention, such as induction or an epidural, there is a much greater likelihood that others will follow.

And the two offered similar advice to women who are planning to have a baby: Discuss all the procedures with your doctor or midwife beforehand so you understand what is involved and can establish what interventions you will accept.

"It's just not possible to have a detailed, informed discussion and a rational decision between contractions," Dr. Christilaw said.

Ms. Brouse said planning is ultimately what made her birth a good one. "I knew what to expect and I told them my choices on pain relief and surgery beforehand."

A birthing glossary

Induction: Labour can be induced using drugs or special tools to artificially break the water. Induction is used for a number of reasons, including when the baby is overdue or too large, when the mother or fetus have medical issues, or when the mother's water breaks too early.

Epidurals: Epidural analgesia is a form of medicated pain relief that has become widespread. The drug is injected into the space around the membranes surrounding the spinal cord, providing pain relief to the lower body. But the procedure is not commonly offered in many hospitals because it must be done by an anesthesiologist. Epidurals tend to lengthen labour, increase the rate of assisted delivery and the risk of fetal malpositioning. The pain-

killing drugs can also cause side effects in mother and infant.

Assisted delivery: Refers to the use of forceps or vacuum extraction during delivery as an alternative to cesarean. Forceps are smooth metal instruments, similar to giant spoons, which are applied to the infant's head if the baby is stuck. With vacuum extraction, a plastic or metal cup is attached to the head to pull the baby out of the birth canal. The use of forceps can cause tearing to the mother, while vacuum extraction may hurt the baby.

Episiotomy: An incision made to enlarge the vaginal opening in the late stages of labour. Episiotomy was initially believed to be a means of avoiding vaginal tearing and, until the 1970s, it was almost routine. But studies show episiotomy does not protect against tears.

Cesarean section: The delivery of a fetus by surgical incision. The most common reasons for the procedure are a previous C-section, a slow or abnormal labour, breech position of the baby, a fetus suffering a medical problem or distress, and labour induction. A C-section is a major operation and can increase reproductive problems such as ectopic pregnancy and uterine rupture.