Why measuring cesarean rates misses the mark

The Canadian Institute for Health Information (CIHI) has updated its interactive tool, “Your Health System,” which reviews health-care data across all provinces and makes recommendations for the delivery of services, such as childbirth. This includes “low-risk” cesarean rates, meaning the number of low-risk women who have surgery after laboring with a single baby in their first pregnancy.

Provincial “low risk” cesarean rates are compared to the 17.9 percent national average, including Alberta’s 20.8 percent rate and British Columbia’s 24.5 percent rate, which are graded “below average.” In fact, CIHI’s message to all hospitals, physicians and patients on cesarean births in general is clear: A lower rate is “desirable.”

But is it? Challenging this inherently flawed measure of patient care is long overdue. As a standalone statistic, a “low risk” cesarean rate lacks the nuance needed to inform and improve individual clinical care. It simply tells us how many first-time mothers who went into spontaneous labor had a cesarean birth.

Clinical care counts

It does not tell us the clinical considerations behind the decision to intervene, or the relief many mothers feel when a cesarean is performed due to unforeseen complications during labor. We are not reminded that the average age of a mother giving birth in Canada has risen to 31.7 years, representing an upward trend that carries higher risks.

Nor does it consider changes in baseline rates of pre-existing medical conditions and pregnancy related medical conditions, high infant birth weights that are associated with obstructed labor and fetal distress, and modern developments in fetal monitoring that more frequently diagnose potential fetal distress.

CIHI’s indicator targets those for whom vaginal birth “is expected,” implying that many cesareans are unnecessary. However, childbirth is intrinsically unpredictable, and tolerance for poor outcomes is low. Parents expect a living and healthy baby, and cesareans are an important part of how obstetricians achieve this for Canada’s families.

Information, consent and autonomy

Outcomes for mothers matter, too. Last year, new evidence highlighted Canada’s “unacceptably high” rate of severe injuries to the pelvic floor from forceps and vacuum use, and the highest anal sphincter injury rate of 24 high-income countries.

Researchers criticized a lack of concerted effort to reduce these injuries. A province’s increasing cesarean rate could mean obstetricians are offering cesarean birth as an alternative, and that more mothers are choosing to avoid an instrumental delivery.

Especially as pelvic floor injuries increase a woman’s lifetime risk for urinary and fecal incontinence, pelvic organ prolapse, and complex surgeries that cannot always solve these issues. Any policy or practice denying choice in childbirth, or refusing and delaying cesareans on the mere presumption that rates should be lower, defies the principles of patient-centered care.

And given the United Kingdom’s landmark Montgomery Supreme Court judgment on autonomy, maternal satisfaction is a more appropriate measure of success than any cesarean rate.

Lessons to learn

CIHI could learn another valuable lesson from the U.K., too, since its stated intention “to help reduce C-section rates” in Canada is linked to concerns about “higher costs.”

For decades, U.K. hospital staff and even safety inspectors blindly supported extraneous efforts to reduce cesarean births, until outstanding multi-billion (yes, billion) dollar litigation costs for maternity services caught the attention of the government.

Demands for change by families whose babies and mothers died or were seriously injured as a result of delayed and absent cesareans, often for “low-risk” pregnancies, led to police investigations, a national safety inquiry and criticism of birth mode targets.

Litigation may be notoriously difficult for patients similarly harmed in Canada’s health-care system, but it is rising, as are the long-term costs associated with pelvic floor damage.

A patient-centered perspective

Furthermore, Canada has long faced challenges with regional health-care variations driven by diverse patient needs, physician practices and resource availability (staff and blood, for example).

Recognizing this, CIHI recommends better access to cesareans in remote areas. However, we argue it now needs to rethink its blanket position elsewhere that a “lower rate is desirable.” Especially as its recent statement inexplicably links to an obsolete national “normal childbirth” policy that warns it is for historical research only, not clinical use.

To genuinely guide health-care evolution, CIHI’s childbirth metrics must adopt a broader, patient-centered perspective. It should recognize that women’s reproductive health extends far beyond the delivery room, and incorporate data on common but often overlooked conditions, such as pelvic floor disorders, endometriosis, infertility and uterine bleeding.

Women are not merely vessels for childbirth—they are whole individuals with diverse health needs. Canadian women deserve comprehensive, thoughtful reporting of data that acknowledges and addresses these unique aspects of their health.

This article is republished from The Conversation under a Creative Commons license. Read the original article.