Relevent ethics from the news!

[intouch]

In the spirit of the up and coming interviews (T- 13 days at UBC... yikes!) I have an interesting, and very relevent case from the news that could spark some interesting ethical and health policy related debate.

 

Article is here, and is worth reading, but I will summarize it below.

 

http://www.cbc.ca/health/story/2010/01/13/c-sections-world.html

 

Basically, the 2009 c-section delivery rates have been released, China is leading the pack with 46% of all deliveries by caesarean, and over 25% were deemed not medically justifiable. The USA is up again, this year sitting at 31% of all births, and Canada follows close behind with about 26%, up from 17% in 1997.

 

I'll pose this as a question, though any sort of discussion that ensues is fine:

 

Should the Canadian Government refuse to fund (i.e. basically make C-sections unavailable) c-sections for those women for whom there is no significant medical indication, as decided by the health care team? This would include clamping down on 'barely indicated' situations as well, where the risk and cost of c-section outweigh risk of natural childbirth... not knowing much about obstetrics, I would imagine this would include a lot of older childbirths, as this is one of the highest demographics among which the procedure is performed.

 

Some obvious pros:

 

Cost... c-sections are far more expensive than conventional delivery and the year-over-year climb is adding substantially to our continually ballooning helth care costs.

 

Waiting lists for other, more necessary, procedures would drop as less OR time would be dedicated to childbirth.

 

Averaged out, c-sections seems to cause more risk than they avert (see the WHO report in the article)

 

I'll leave it there for discussion...

[AndreaM]

I'm part of an online group of moms who all had babies in May of 2007, so I've explored a lot of these issues. I don't know the issues in Canada as well as I know them in the US (most of our group is from the US), but it isn't usually the mothers pushing for the c-sections, but rather the doctors. I know women who were scared into unecessary sections and inductions (that led to sections) by their doctors, possibly due to concerns over being sued.

 

Many hospitals in the US won't allow women to even try VBAC (vaginal birth after c-section), no matter what their medical history is or the reason for their first section, which means that if you had a c-section for your first child you have to have one for any subsequent children. Also, a lot of my friends were offered an induction starting from 2 weeks before they were due, just because they were really uncomfortable and wanted to be done. Not surprisingly, many of them ended up with a c-section due to failure to progress, because their body and baby weren't ready yet. Another friend had gestational diabetes and was told by her doctor that her son would be way too big if she went to term and she had to be induced 2 weeks early. She really didn't want the induction, but because she trusted her doctor she went ahead with it and her son only weighed 7lbs 12 oz and was nowhere close to the 10lbs he was predicted to be. Other friends were offered scheduled c-sections for their second babies, just because their first delivery was difficult or they had tearing (due to episiotomies, but that is another rant). Other options, such as different birthing positions were not presented and the difficulties and complications of recovering from major surgery while caring for a newborn were minimized.

 

There are also a lot of poor representations of childbirth in the media. Think of any television program you have seen that portrays childbirth and the image that comes to mind is a woman either screaming or enjoying her epidural. Also, the woman almost always says "It's time" and is then rushed to the hospital where she has her baby right away. This is a totally unreaslistic portrayal of labour and birth and causes a lot of fears for first time mothers. Fear and tension in childbirth make it difficult for a woman to relax and let the contractions do what they need to do, resulting in longer more painful labours, which leads to more interventions, complications and ultimately more c-sections.

 

Greater fear also seems to lead to more epidural usage, which in turn seems to lead to more complications, interventions and c-sections. I know several women who planned on asking for and getting an epidural as soon as they possibly could, which for many hospitals is at only 3 cm dilated. Others who wanted to labour drug free, found that every time any hospital staff checked on them they were offered drugs and finally just gave in.

 

If we want to reduce the number of c-sections in Canada and around the world we need to change how we view birth. It needs to be viewed as a normal and healthy part of life, rather than a scary and dangerous situation that women need to be rescued from.

 

In countries like the Netherlands, where woman mostly have midwives and give birth at home (for uncomplicated births), their c-section rate is low (12.9%) and yet they still have excellent outcomes (low infant mortality - 4.7/1000). These stats are common for western European countries, most of which have a similar attitude surrouding birth. Compare that with the US whose c-section rate is 31% and has a higher infant mortality rate (6.3/1000) or Canada (26% c-section, 4.8/1000 mortality).

 

I will end my rant there.

[terryann]

In the US, malpractice insurance for obstetricans is ridiculously high. If they have numerous lawsuits, I think they can lose their malpractice insurance or have the fees increased substantially. In some states, there is a shortage of doctors willing to deliver babies for this reason.

In the US, you do not need funds to sue. A lawyer will take the case and if he/she wins take a percentage of the settlement. This has given rise to unnecessary lawsuits which even if the doctor wins, money is spent going to court to defend her/himself. In saying that, perhaps the c-section rate is higher to avoid complications with vbacs or regular births.

I assume in Canada, doctors have to be accountable for their reasons for performing a c-sections because they are paid by the government. I do believe that in Canada, the patients interest in put first...just my thoughts, or what I would like to believe.

[astrogirl]

AndreaM - I've heard a lot of horror stories about things like that from my friends in the States who are moms. I have one friend down there who had an emergency c-section for her first child (I think she was actually induced early), and she's had 2 VBACs since then. The hospital closest to her doesn't allow VBACs at all, so she had to have babies 2 and 3 at a hospital that's like an hour farther away from her.

[AndreaM]

astrogirl - I kept an informal spreadsheet record of all the birth outcomes of the ~200 women in my online forum and over half of the women who were induced early ended up with an emergency c-section due to failure to progress. Most of the early inductions were for reasons such as not wanting to wait anymore, or being uncomfortable from swelling. Very few women went overdue at all, because many were offered an induction on or before their due date. Some of the inductions were for medical reasons, such as pre-eclampsia, but many were not.

 

Something else I have noticed is that the 'rules' for women who are past their due date have changed. It used to be (12 years ago when I had my first baby) that women were allowed to go 14 days past due, before induction. It was 10 days past due when I had my second baby (4 years ago) and many hospitals now only allow 7 days past due. With these changes there are more inductions, leading to more c-sections.

 

Also, with inductions it is much more difficult to go without pain relief and more women get an epidural which then stalls the induction and leads to a c-section. I was induced with my first two girls, but went into labour spontaneously with my third. With my first I had both prostin gel and oxytocin and it was horrible. Everytime I felt that I could start to cope with the contractions, the oxytocin levels would be turned up and it would be horrible again. The difference between that experience and my spontaneous labour was huge. With my third I didn't even feel a need for any relief until the last contraction of transistion and by that point I was ready to push anyway and didn't end up using pain relief at all. Yes, I realize that third babies are generally easier than first babies, but there is a huge difference between natural contractions and oxytocin augmented ones.

 

One last thing I wanted to add was a quote from a doctor in one of the books I read: "The only c-section I have ever been sued for was the one I didn't do", which sums up the cover-your-butt, avoid being sued attitude of some OBs in the US. If in doubt, cut the baby out.

[thatonekid]

astrogirl - I kept an informal spreadsheet record of all the birth outcomes of the ~200 women in my online forum and over half of the women who were induced early ended up with an emergency c-section due to failure to progress...

I just wanted to say that I know c-sections are being performed more frequently than they have been in the past, but the insight in this post was really interesting to me. Especially since I have no first hand experience in the issue. So, thanks for sharing your (informal) statistics with us!

 

(note: this post was supposed to be sincere, but it's hard to put emotion into an internet forum with the 11 smilies vBulletin had to offer.)