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?


  1. I love your blog - I had an emergency section with my first and elective section with my second and wish I could have skipped the drama and pain with the first!

    Section rate and VBAC rate are routinely reported by hospitals - but I don't think those are actually the two major measure they use. I'm doing my masters in public health right now, and the two biggest reporters on maternal and fetal/infant outcomes in BC are PSBC (Perinatal Services BC) and CIHI (Canadian Institute for Health Information). They both use a matrix of indicators to determine quality of care - you can check out their measurements here:

    I agree though that mother's experience and happiness are still completely left out though, and they should definitely be reporting on these!

  2. Hi Anonymous - glad you like the blog - I am a health economist and am familiar with the statistics produced by CIHI and the Perinatal Services of BC, as well as the statistics used by the Ministry of Health. The Vital Statistics Agency is likely the most current set of statistics on Birth in British Columbia and they recently released the 2011 Annual Report. The thing is - once you have been around the statistics long enough, you become aware of what they measure and how, but also what they do not measure. Birth is an area where there could be substantial improvements in the data collected and the information available. For example - we know how many epidurals were given but we do not know how many were asked for nor do we know how long women waited for epidural pain relief.