Yet another article in my local newspaper last week bemoaned the fact that the caesarean rate keeps rising and physicians are concerned not only about the high rate of surgery but also the future complications that increase after caesarean surgery. It's a well-documented fact that a caesarean can adversely affect a woman's health for the rest of her life and can lead to catastrophic complications in future births. That's one reason why, 40 years ago, doctors did everything in their power to prevent that first caesarean from being done.
- What if there was a tried method of reducing the caesarean rate within hospitals?
- What if it involved some truly innovative thinking?
- What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?
- What if it saved money, recovery time for the patient, and better health for the babies?
Would you think that method would be adopted all over North America right away? Yes, that would be a reasonable assumption. Unfortunately, this project was undertaken at B.C. Women's Hospital, it was a success, and it was dropped once the project was complete with a resulting re-increase of the caesarean rate. No reason for discontinuing the project has ever been given but i will speculate at the end of this article.
The ‘First Births Project' was undertaken at B. C. Children's & Women's Health Centre in Vancouver, British Columbia. It was the first phase of a Continuous Quality Improvement project with the aim of ‘Lowering the Caesarean Section Rate'. Start date was January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous (never given birth) women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions.
Staff from all departments of the hospital were brought together in a brainstorming session to share hypotheses on what was causing the high rate of caesareans. Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.
1. Women were being admitted to hospital too early (before reaching 4 cms dilation, active labour).
2. Fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby)
3. Too early use of epidurals (women who get an epidural before 8 cms dilation are at increased risk of surgery)
4. Inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).
Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought. The audit confirmed that these 4 areas were ones that needed attention. Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women's Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
According to published results from the hospital:
"After six periods, BC Women's had admitted and delivered 1369 nulliparous women with singleton (one baby only), cephalic (head enters pelvis first), term presentations. The caesarean section rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation."
Whats Happening Today?
At the time of writing this article in 2009, it's back to business as usual at this hospital. Women are induced, monitored, epiduralled, and admitted early. The caesarean rate is 30% and the head of obstetrics is concerned but has no action plan.
Why on Earth Would This Be?
I assert that it is because it is an "up at dawn" battle with the physicians to change their ways. The gossip that I hear from nurses is that the doctors did everything they could to undermine this project. For example, a doctor would examine his patient and state "She's 8 cms dilated, get the anaethetist." Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6cms. The doctor would smile and shrug his shoulders, "whoops". The same thing happened around the issue of monitoring, induction and admitting… trickery to subvert the project and return to their old ways of doing things.
It's interesting that, when I went to find the references for this article, the most comprehensive archiving of this material is on the website of an Australian midwife. I guess she found the project as fascinating and important as I did. Most obstetrics workers have no idea that this project ever existed. It's a low tech, novel, innovative approach that had excellent results. I'd love to see it copied everywhere but it's a bit like dieting… everyone knows how to lose weight (eat less, exercise more) but only a few get into action.
We DO know how to lower the cesarean rate, committed action is needed.