Health information report shows changing picture of childbirth in Canada
September 09, 2004

TORONTO (CP) - Lots of epidurals, more C-sections, but far fewer episiotomies - these are some of the factors that make up a shifting portrait of childbirth in Canada over the last decade or so, a report by the Canadian Institute for Health Information says.

The report, released Thursday, says almost half of Canadian women giving birth have epidurals. As well, caesarean-section and medically induced births are on the rise in the country, but the proportion of episiotomies - surgical cuts to prevent vaginal tearing and other post-natal complications - have fallen dramatically.

"There really is a changing picture of childbirth in Canada and we do see the situation being quite different than it was, say, 10 or 20 years ago," institute president Glenda Yeates said from Ottawa. "And the other finding is that there is significant regional variation, that the experience of child birthing is clearly quite different depending on where you are in the country."

The 80-plus-page report, the second in a series of four on birth-related statistics to be released by the institute, also shows the proportion of newborns admitted to neonatal intensive care units (NICUs) in Canada rose to 14.4 per cent in 2001-2002 from 12.6 per cent in 1994-1995. Typically, babies stayed in the unit for two days, although low-birth-weight babies tended to stay longer and were more likely to die during their stay.

The increase in NICU admissions may be related to a hike in multiple births, resulting from reproductive technologies, and the fact that more women are having babies later in life, putting them at greater risk for underweight, premature newborns, doctors say.

"It's just steadily creeped up," said Dr. Vyta Senikas, a spokeswoman for the Society of Obstetricians and Gynecologists of Canada. "For us, the best is that the longer that the baby can stay in the uterus, which is the best incubator of all, the best (it is) for that patient to avoid delivery.

"Obviously our concern is that treatment of premature labour needs to be looked at," said Senikas, including the approval of newer, more effective drugs to postpone labour.

And when it comes to labour and delivery, the institute found that epidurals - delivery of anesthetic near the spinal cord to block pain - were used in 45.4 per cent of all vaginal births in Canada in 2001-2002, compared to 59 per cent in the United States and just 12 per cent in England. A comparative figure from previous years in Canada was not available.

But epidural use can differ substantially depending on where a woman lives, ranging from a low of about four per cent in the Northwest Territories and Nunavut to 35 per cent in Alberta to a high of more than 60 per cent in Quebec.

So why is there so much variation?
"This is the first time we've put out, and I think that I've seen, this kind of data - and it poses that very question," said Yeates, speculating that the ups and downs in epidural usage may reflect cultural differences, the preference of patients or their care providers, or the availability of anesthetists, particularly in rural areas.

The report also said more Canadian women are having caesarean sections. One in six babies were born to mothers having a C-section for the first time in 2001-2001, up from one in seven in 1998-1999. Canada's rate is similar to that in much of the United Kingdom and the United States.

The C-section rate varied from a low of 9.2 per cent of births in Nunavut through about 18 per cent in Manitoba and Saskatchewan to a high of about 27 per cent in B.C., New Brunswick and P.E.I.

"It's clear that this range of variation would suggest that it's not completely predictable medically as to when a C-section would be recommended or performed in this country at this point," said Yeates. "There still seems to be significant variation depending on location."

When it came to mothers experiencing medically induced births - in which drugs are used to induce labour - the report shows a substantial jump, to one in five births in 2000-2001 from about one in eight a decade earlier.

The report also shows that in the last decade, episiotomy rates in Canada have decreased to less than a quarter of vaginal births in 2000-2001 from almost half in 1991-1992.

"There has been a real change in the standard of care," Yeates said, noting that recent studies have suggested episiotomy is not as effective as once thought.

CIHI said the proportion of assisted deliveries - using forceps and/or vacuum extraction - remained relatively stable overall at about 16 per cent of vaginal deliveries, but the method of choice has changed.

Forceps-assisted deliveries are on the decline, said the report, noting that they accounted for just over one in 20 births in 2000-2001, compared to about one in 10 in the early 1990s. Rates for vacuum extraction, in which a suction-cap device on the head helps ease the newborn into the world, have risen over the same period, to 11 per cent of vaginal births from seven per cent.

Regionally in Canada, rates of assisted delivery varied more than eleven-fold - from a low of 2.5 per cent to a high of 28 per cent of vaginal deliveries.

The Canadian Institute for Health Information is an independent, not-for-profit organization working to improve the health of Canadians.