Wednesday, October 23, 2013

Feedback on Ontario's Report "Caesarean Section Rate Review: An Evidence-Based Analysis (DRAFT)" by N. Degani and N. Sikich

Health Quality Ontario is asking for feedback until October 24, 2013 on one of their reports. Here is what I have submitted to them via email:

October 23, 2013

Feedback on: “Caesarean Section Rate Review: An Evidence-Based Analysis (DRAFT)”, N Degani, N Sikich.

Dear Health Quality Ontario –

I am a caesarean by choice mom, a birth trauma survivor, and founder of the facebook group, “Cesarean by Choice Awareness Network” – furthermore, I am a health economist with more than 10 years experience. I am writing to provide feedback on your recent report entitled, “Caesarean Section Rate Review: An Evidence-Based Analysis” from a Caesarean by Choice perspective.

First – let me express that many mothers with a caesarean birth preference are concerned about over-zealous policies aimed at limiting access to caesarean section as they feel that their right to make a medical decision in conjunction with their health care provider about how their baby is to be born will be disregarded. Many mothers with a caesarean birth preference in Ontario (and the rest of Canada) already have a difficult time accessing compassionate care that meets their needs. Those that do find compassionate care – often fear going into labour prior to their caesarean date and having to contend with an on-call OB who does not agree with their treatment plan. Some women are forced into unwanted vaginal deliveries that have significant ramifications both physically and psychologically. Some women who cannot access maternal request caesarean either forego having children that they want or choose to terminate pregnancies rather than face the prospect of an unwanted vaginal delivery.

In terms of the economic impact of caesarean delivery on the system (page 13) – I would urge caution. There is a great deal of variation in the expected costs of caesarean delivery with emergent caesarean deliveries costing significantly more than elective caesarean deliveries. I would also suggest that the expected cost of a planned vaginal delivery is underestimated if it does not include the cost of emergent caesarean deliveries as the vast majority of emergent caesarean deliveries are the result of failed planned vaginal deliveries. Further – I would urge the economic evaluation of caesarean delivery to include the downstream cost savings/expense and that limiting the cost component to the birth and a limited time post-partum likely gives a very inaccurate picture. There are grave and expensive consequences to a vaginal birth that departs from a healthy outcome for both mother and child. In the fall of 2011, the National Institute for Clinical Excellence (NICE) in the UK, updated its clinical guidance on the use of caesarean (CG132) and found that the cost difference between planned vaginal delivery and planned caesarean delivery was just £84 after considering the increased risk of urinary incontinence associated with vaginal delivery .

Lastly, let me express my concern that maternal health policy that is focussed on achieving specific rates of types of deliveries is ideologically based, misguided and undermines the health and well-being of many women and their children. If reducing caesareans results in an increase in the number of late-term still births due to a reluctance to offer a timely induction – that is a worse outcome than a caesarean section. If reducing caesareans results in additional third and fourth degree tears or extensive damage to the pelvic floor – that is a worse outcome than a caesarean section. If reducing caesareans means limiting access to those who would choose it, and that results in traumatic deliveries – that is a worse outcome than a caesarean section. If reducing caesareans results in larger numbers of children grappling with life-long severe disability, such as those that result from intra-partum asphyxia and brachial plexus injuries, those are worse outcomes than caesarean sections.

Further – efforts to reduce caesarean sections often focus on the safest caesareans, planned caesarean sections. These are also likely to be the least traumatic and expensive caesareans. As such – such efforts are unlikely to have the economic impact that is desired.

Maternal health policy needs to shift to focus on the outcomes that matter – physically and emotionally healthy mothers and babies. Policy that is focussed on caesarean rates and managing them does little to address the health needs of mothers and babies and substitutes ideology for quality care.


Janice Williams, MA (Econ)

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