title: Preventable obstetrical interventions: how many caesarean sections can be prevented in Canada?
abstract: Public health authorities have been alarmed by the progressive rise in rates of Caesarean section in Canada, approaching one birth in three in several provinces. We aimed therefore to consider what were preventable obstetrical interventions in women with a low-risk pregnancy and to propose an analytic framework for the reduction of the rate of CS. We obtained statistical variations of CS rates over time, across regions, and within professional practices from MED-ÉCHO, the Quebec hospitalization database, from 1969 to 2009. Data were extracted from a recent systematic review of the cascade of obstetrical interventions to calculate the population-attributable fractions for each intervention associated with an increased probability of CS. We thereby identified expectant management (as an alternative to labour induction) and planned vaginal birth after CS as the leading strategies for potentially reducing rates of CS in women at low risk. For vaginal birth after CS, an increase to its 1995 level could lower the current CS rate of 23.2% (2009 to 2010) to 21.0%. Other alternatives to obstetrical interventions with a potential for lowering CS rates included non-pharmacological pain control methods (such as continuous support during childbirth) in addition to usual care, intermittent auscultation of the fetal heart (instead of electronic fetal monitoring), and multidisciplinary internal quality assessment audits. We believe, therefore, that the concept of preventable CS is supported by empirical evidence, and we identified realistic strategies to maintain a CS rate in Quebec near 20%.
authors.affiliation: department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal QC; Institut national d'excellence en santé et en services sociaux, Quebec QC.
authors.forename: Michel
authors.initials: M
authors.lastname: Rossignol
authors.affiliation: Institut national d'excellence en santé et en services sociaux, Quebec QC; Département d'obstétrique et gynécologie, Université de Sherbrooke, Quebec QC.
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Moutquin
authors.affiliation: Département d'obstétrique et gynécologie, Université de Sherbrooke, Quebec QC.
authors.forename: Faiza
authors.initials: F
authors.lastname: Boughrassa
authors.affiliation: Département d'obstétrique et gynécologie, Université de Montréal, Montreal QC.
authors.forename: Marie-Josée
authors.initials: MJ
authors.lastname: Bédard
authors.affiliation: Centre hospitalier universitaire Sainte-Justine, Université de Montréal, Montreal QC.
authors.forename: Nils
authors.initials: N
authors.lastname: Chaillet
authors.affiliation: Centre de santé et des services sociaux La Pommeraie, Cowansville, Quebec QC.
authors.forename: Christiane
authors.initials: C
authors.lastname: Charest
authors.affiliation: Canadian Association of Perinatal and Women's Health Nurses and McGill University Health Centre, Quebec QC.
authors.forename: Luisa
authors.initials: L
authors.lastname: Ciofani
authors.affiliation: Centre hospitalier de Saint-Mary, Département de médecine familiale, Université McGill, Quebec QC.
authors.forename: Maxine
authors.initials: M
authors.lastname: Dumas-Pilon
authors.affiliation: Centre hospitalier de Lasalle, Département d'obstétrique et gynécologie, Université McGill, Quebec QC.
authors.forename: Guy-Paul
authors.initials: GP
authors.lastname: Gagné
authors.affiliation: Hôpital régional de Saint-Jerôme, Centre de santé et de services sociaux de Saint-Jérôme, Quebec QC.
authors.forename: Andrée
authors.initials: A
authors.lastname: Gagnon
authors.affiliation: Programme en pratique sage-femme, Université du Québec à Trois-Rivières, Quebec QC.
authors.forename: Raymonde
authors.initials: R
authors.lastname: Gagnon
authors.affiliation: Society of Obstetricians and Gynaecologists of Canada, Ottawa ON.
authors.forename: Vyta
authors.initials: V
authors.lastname: Senikas
mesh_terms: D002170:Canada; D002585:Cesarean Section / Q000706:statistics & numerical data*; D054869:Clinical Audit; D005260:Female; D006801:Humans; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D016064:Vaginal Birth after Cesarean
keywords: Caesarean section; health organization; health services; obstetrical interventions