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C section rate rises in Canada; Newfoundland and Labrador has second highest rate

This is the area (to left of photo) on Warner’s Road off Clinch Crescent near the Health Sciences Centre in St. John’s where the province will construct a new mental health facility to replace the aging Waterford Hospital. Work on the site could start in 2019.
The Health Sciences Centre in St. John’s. - Joe Gibbons

TORONTO — A higher proportion of Canadian women are giving birth by caesarean section, even while the overall rate of in-hospital births across the country is declining, says a report released Thursday.

The report from the Canadian Institute for Health Information (CIHI) shows there were more than 103,000 C-sections in 2016-2017, making them the most commonly performed in-patient surgical procedure, followed by knee- and hip-replacement operations.

So what's behind the rise in C-section rates, given that there's been a push over the years to pare back the number of these procedures whenever possible?

"We don't know for certain, there are a number of factors that can contribute to the increasing rates, one being that the average age of mothers giving birth is going up,'' said Greg Webster, CIHI's director of acute and ambulatory care information services.

Overall, the proportion of births in Canadian hospitals performed by C-section rose to 28.2 per cent in 2016-2017, from 26.7 per cent in 2007-2008, said CIHI. At the same time, the hospital birth rate continued to decline, dropping to 102 per 10,000 population in 2016_2017 from 112 per 10,000 population in 2007_2008.

Giving birth was the most common reason for hospitalization in Canada, with about 366,000 births in 2016-2017. The average length of hospital stay for a vaginal birth was just under two days, with an average cost of $2,569, while women who had C-sections were admitted for about three days, with that stay costing $4,033 on average.

CIHI found there were dramatic variations in C-section rates across the country.

British Columbia topped the list with 35.3 per cent of deliveries being done by caesarean, followed by Newfoundland and Labrador at 30 per cent. The Northwest Territories had the lowest C-section rate at 18.5 per cent, with Manitoba and Saskatchewan next-lowest at 23 per cent each.

Webster said the significant variation in C-section rates across Canada has been noted for a number of years ``and we also see C-section rates increasing moderately over time as well.''

The CIHI study cannot explain why B.C.'s rate is so high, but "the data provide an opportunity to see variations so regions and provinces and territories know where they are relative to their neighbouring provinces and territories,'' he said.

"And then with a concerted effort the data can be analyzed in more detail to try to tease out what are the factors that make sense clinically for higher and lower rates in different regions.''

There are a number of reasons why doctors might perform a caesarean, including pregnancies where the mother or baby are at risk for complications. Pre-term infants and those small for their gestational age can lead to a C-section, as can a woman's preference for how she wants to give birth.

"In some cases, some caesareans are done when there was an equally appropriate natural birth opportunity as well,'' said Webster. "But again, each province and territory is different in terms of its rural and urban nature, how services are organized and the needs of the individual patients.''

Dr. Jennifer Blake, CEO of the Society of Obstetricians and Gynaecologists of Canada, said each hospital needs to understand the contributing factors to caesarean-sections in its population, ``but the ultimate goal will always be to have a healthy mother and baby.''

For Dr. Brenda Wagner, an ob-gyn who sits on the Perinatal Services BC steering committee, said a major factor driving C-section rates is what kind of "maternity culture'' exists in any given hospital.

When Wagner took over as head of obstetrics at the Richmond Hospital some years ago, she said it had the highest C-section rate in B.C.

But she and her team set a goal of improving the culture by taking a multidisciplinary approach to improve quality of care and safety for mothers and babies _ and now the hospital has one of the lowest caesarean rates in the province, Wagner said from Richmond, B.C.

"When we did that, we inadvertently significantly impacted our vaginal birth rate and our caesarean-section rate,'' she said. ``It's the culture of 'how do you support women to have vaginal births?'''

Nurses on the team encourage patients to be up out of bed, to use non-pharmaceutical methods for pain control, and to employ other measures that can lead to a vaginal birth, she said, noting that the maternity ward was also remodelled to include a private circuit, where women can walk with the aid of a nurse during labour.

Wagner said there is an effort going on in B.C. to bring together practitioners at hospitals with high vaginal delivery rates and low C-section rates to help their counterparts across the province try to duplicate their success.

"There's a lot of work happening to try to shift the culture but we've got a long way to go, and the CIHI data show we've got to continue to work on this,'' she said. "I'm hoping that the CIHI data will spur this work on.''

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