Wednesday, February 27, 2013

The Power of Numbers - the Math of Maternity Care

When I am working, I spend most of my time immersed in numbers and thinking about indicators that can be used to measure health and the health care system. As a result, I am acutely aware of the power of numbers and the importance of understanding what numbers are available, how the numbers used are calculated, what the numbers include or exclude, and what it might mean when the numbers change over time. As a result, I read statistics and particularly health statistics, with a different lens. Specifically, I am much more critical of the numbers I see - as I know that the story being told by the numbers depends critically on the numbers used and how they are being interpreted. I have become particularly aware and interested in the numbers used (and not used) to tell the story of maternity care, particularly in the news media. The thing is numbers have power, and by focussing on the wrong numbers or interpreting the numbers in the wrong way - there may be unintended negative consequences for women and their babies. Currently, the most commonly used statistics in the news media with respect maternity care are: infant mortality, cesarean section rates, and cost estimates - and, sadly these numbers and they way they are used are telling a story which may be leading many women, care providers, and health administrators astray.

Infant mortality is the number of babies who die from birth to one year of age relative to all babies who are born alive. As a result improvements in the rate of accidental death or access to paediatric care - perhaps as a result of better car safety, sleep safety or better health insurance coverage - will lower the rate of infant mortality. While fewer very young children dying is a very good thing, saying it is the result of better maternity care is a bit of a stretch. Unfortunately, many media reports make that stretch and equate infant mortality rates with maternity care.

With respect to cesarean section rates - little quality information can be gained by looking at the headline rate (number of c/sections as a share of all births). This is because nothing is known about how many of those cesareans are planned cesareans, how many are emergent cesareans, how many are maternal choice, how many have complications, how many are traumatic, or how many avoid much more severe complications that would have occurred in the absence of a cesarean. Given a choice between a third or fourth degree tear, an instrumental delivery, or an oxygen deprived baby - most moms are better off and would likely choose a cesarean section. Further, the cesarean section rate is not risk adjusted, and as such it is nearly impossible to say whether or not any specific rate is too high or too low without knowing the characteristics of the population being served - is it older? are the mothers of a healthy weight? are there other co-morbidities (heart problems, kidney problems, diabetes, etc.)? When the relative risks of cesarean are reported on, both emergent and planned cesareans are frequently lumped together and as a result the risks of an emergent cesarean are underestimated while the risks of an elective cesarean are overestimated. Lastly, the only thing the cesarean section rate tells us is how many cesareans were performed, the supply of cesareans, but it tells us nothing about how many cesareans should have been performed, the demand for cesareans.

Finally, the cost estimates that are available are at best flawed in that the costs included are only the immediate costs (those that occur within 30 days of the birth), and the costs of cesarean lump together emergent and elective surgeries and as a result do not reflect the costs associated with planned mode of birth. From an economics perspective, spending money on birth (including spending money on cesareans or other interventions) might be a good investment if it avoids other costs in the long run, such as those costs involved in coping with a damaged pelvic floor, birth trauma, or a birth injury.

There are better statistics that already exist - like the perinatal mortality rate. There are also better statistics that could exist - like the rate of unmet need (ie. epidurals requested but not given), the rate of adverse mental health outcomes, and patient reported outcome measures. Numbers are powerful, unfortunately it is quite possible that when it comes to maternity care, the focus is on the wrong numbers.

Thursday, February 14, 2013

Are the common practices with respect to Maternal Request Cesarean negligent?

I have been wondering if the common practices that are applied by many physicians in Canada and in many Canadian hospitals with respect to maternal request cesarean are negligent and unreasonably frustrate the rights of women to make medical decisions for themselves.

In my own case with respect to the birth of my daughter (and I do not believe this is uncommon), my maternity doctor did not refer me until I was 32 weeks pregnant. This might be common practice with respect to elective cesareans in general, but I would argue that it is negligent when it comes to maternal request cesareans. This is because under most circumstances an elective cesarean has an underlying medical need and as a result there is little doubt that the doctor who is receiving the patient will agree to undertake the procedure. In contrast - many doctors will not agree to perform a maternal request cesarean - just as many doctors will not agree to perform an abortion - and that is their prerogative (frankly, having a doctor who disagrees with treatment is probably not a good thing anyways). This may lead to the need to see more than one doctor to request the cesarean. Further, many mothers who are requesting cesareans are doing so because of anxiety over the prospect of a vaginal birth - and often that anxiety is not resolved until there is some certainty that the desired mode of birth will be realized. As such, the doctor who is referring the patient needs to be reasonably confident that the doctor that the patient is being referred to will agree to the request or at the very least it would appear prudent for the physician to refer as soon as the request is made and facilitate shared care of the maternal request cesarean patient with an OBGyn. To do otherwise seems to have a high risk of frustrating the patient's ability to direct her own medical care.

Also with respect to my birth of my daughter, it has been alleged that Vancouver Island Health Authority had no OR booking schedule for elective cesarean deliveries and as a result my case was necessarily added to the OR Slate. Failing to provide a fixed time and date leaves elective cesarean patients particularly vulnerable as they are competing with other emergent cases on the open slate. As a result, it is fairly predictable that an elective cesarean patient (unless she's in labour) is likely to be bumped by more urgent cases. This unreasonably frustrates the woman's right to choose a pre-labour cesarean - particularly in large hospitals with a high volume of emergent cases that arise. I would argue that it is negligent and discriminatory to provide for other elective surgeries on the regular slate but not elective cesarean deliveries. It is plain and obvious that a woman at 39 weeks' gestation is at high risk of going into labour, and that subjecting her to uncertain access to an OR puts her at risk of having her medical decision frustrated. Why should patients who choose tubal ligations, adult circumcisions, bladder suspensions, or any number of other elective surgeries be allowed a spot on the regular OR slate, but women in need of elective cesareans be denied space on the regular OR slate? This is particularly true when a delay in access to OR resources may result in that woman being deprived of exercising her right to make a medical decision for herself with regards to how her child is to be delivered. It is obvious that patients in need of elective cesarean deliveries deserve to have more certain access to OR resources as their conditions are arguably more time sensitive than many other elective surgeries. Again, I do not think that it is uncommon practice for hospitals to deny space on a regular OR slate to elective cesarean patients - even though it is plainly obvious that the practice of doing so poses unnecessary risks.

Women who choose cesarean section deserve to have their medical wishes respected and practices that unreasonably frustrate their ability to exercise their autonomy with respect to the delivery of their child should end. If the woman is going to need an OBGyn eventually - what purpose does delayed referral serve? If the woman is going to need OR resources for the delivery of her child - again what purpose does denying space on the regular OR slate serve? The only logical purpose these practices serve is to prevent women from obtaining the medical care they desire in a timely way - and there's something that's wrong with that.

Friday, February 8, 2013

Failing Mothers - Maternal Request Cesarean in Canada

A while ago, a mom-to-be contacted me asking if I knew an OBGYN in her area (Hamilton, Ontario) who would agree to a maternal request cesarean. I asked the grapevine, and managed to wrangle a name - and with high hopes I hoped that this mother would be able to get what she needed when she needed it. I recently got an update from that mother - and my heart sank. She went into labour the day before she was to meet with the OBGYN (she was 36 weeks pregnant) the doctor on call did not support her request and she ultimately delivered her son vaginally. His respiration was depressed, he needed to spend some time in the NICU, he had some broken blood vessels and blood pooled between his skull and his scalp, he needed a blood transfusion and has been on morphine and the mother had some tearing that required stitches.

Her story - is illustrative of the many problems that persist with respect to maternal requests cesareans in Canada. Finding an OB supportive of the request, and hoping that if you do go into labour the OB on-call will be supportive of your request is a risky proposition. You may go from OB to OB (or have you primary maternity care physician neglect to refer you until late in your pregnancy) with each having a wait of several weeks for an appointment (how is that quality care???), or you may go into labour and have someone who disagrees with your choice and withhold the care that is needed, when it is needed. Or you may find a supportive OB but run head-long into a hospital policy that makes acquiring your delivery all but impossible.

It's a situation that must be addressed - all these mothers want is to be counseled on the risks and benefits of their treatment options (planned cesarean delivery and planned vaginal delivery) - and to be free to choose the treatment that best meets their needs and to expect that whatever choice they make will be respected and facilitated to the degree possible. They are asking not to be unfairly deprived of their personal autonomy without good cause - seems perfectly reasonable to me.

There are doctors and hospitals in Canada that do accomodate the needs of these mothers - but the difficulty is that it is difficult to know which doctors and hospitals they are when the time comes.

As I do get requests from time to time from mothers looking to have their needs met (I currently know of a woman who isn't even pregnant yet who wants to find a supportive doctor in Ottawa) - if you are an OBGYN who provides maternal request cesarean or your hospital has an accomodative policy (fixed OR date and time for MRCS and assurance that CS will be accessible if it is wanted should the woman go into labour before her scheduled date/time) - email me at - as I'd like nothing more than to be able to help moms find the care they need when they need it.

Thank-you in advance.

Saturday, February 2, 2013

Improving Maternal Health and Wellbeing: Measuring what Matters

I love the story of the APGAR score and am moved how such a simple composite measure could improve the outcomes of babies by helping care providers focus on what matters. The story of APGAR demonstrates the power of good measurement.

Right now, British Columbia uses two measures - the rate of cesarean sections and the rate of attempted vaginal births after cesarean (VBAC) as performance measures for maternity care where good performance is considered to be a reduction in cesarean rates and an increase in the number of attempted vaginal births after cesarean. The use of these statistics as performance measures provides an incentive for hospitals and care providers to deny access to cesarean sections, sends a not-so-subtle message that vaginal birth is a good thing in and of itself, fails to adjust for risk, and has little or no relationship to what might be considered quality care. The problem is these measures place too much emphasis on process and not enough on outcome and may be undermining the health and well-being of women and their babies - in short driving the system towards providing care based on an ideology (natural/vaginal childbirth) and failing to provide patient centred care.

To highlight what I mean - my first birth would count positively in the measures used - it avoided a cesarean that would have otherwise been done. My second birth would count negatively in the measures used - it contributed to the cesarean section rate at the hospital I delivered. In terms of outcomes though, the second birth was by far, "the better birth" - at least from my perspective. Similarly, a vaginal birth that results in the use of forceps and yields extensive tearing and a brain damaged baby is still "good" by these measures, but a cesarean that results in a healthy baby and no post-operative complications is "bad" by these measures. Even a birth that results in a ruptured uterus and a permanently disabled baby is "good" but a repeat cesarean is "bad". These "performance measures" have the potential to drive truly Orwellian care - and should be abandoned in favour of measures that are capable of actually reflecting "good births" and "bad births" and driving care that is most likely to result in "good births".

I do not think it would be terribly difficult to come up with a better composite guage of whether or not a birth was a "good" birth - or at the very least measures that do not result in the provision of care that is not in the interests of the patient being cared for. Perhaps a composite measure that considers treatment plan compared to treatment outcome, APGAR scores, physical damage and psychological damage - would assist far more in the goal of providing care that results in "good births" than the silliness of measuring cesarean and VBAC rates. Is mom and baby healthy? Is mom happy? - those are the two questions that deserve to be answered, not how was baby delivered?