PERINATAL OUTCOMES FOR BELLA COOLA GENERAL HOSPITAL: 1940 TO 2001 by Tara Mackenzie BSN., University of Northern British Columbia, 1997 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in COMMUNITY HEALTH SCIENCE THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2004 © Tara Mackenzie, 2004 1^1 Library and Archives Canada Bibliothèque et Archives Canada Published Heritage Branch Direction du Patrimoine de l'édition 395 W ellington Street Ottawa ON K 1A 0N 4 Canada 395, rue W ellington Ottawa ON K 1A 0N 4 Canada Your file Votre référence ISBN: 0-494-04681-3 Our file Notre référence ISBN: 0-494-04681-3 NOTICE: The author has granted a non­ exclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or non­ commercial purposes, in microform, paper, electronic and/or any other formats. AVIS: L'auteur a accordé une licence non exclusive permettant à la Bibliothèque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par télécommunication ou par l'Internet, prêter, distribuer et vendre des thèses partout dans le monde, à des fins commerciales ou autres, sur support microforme, papier, électronique et/ou autres formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. L'auteur conserve la propriété du droit d'auteur et des droits moraux qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. Conformément à la loi canadienne sur la protection de la vie privée, quelques formulaires secondaires ont été enlevés de cette thèse. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. Canada ABSTRACT Objective: To describe obstetric procedures (episiotomy, forceps, vacuum extraction, caesarean section), maternal outcomes, and perinatal outcomes (mortality, low birth weight, condition at birth) for an isolated, rural hospital. Design: A retrospective descriptive study. Study Population: Women beyond 20 weeks gestation who gave birth between M arch 7, 1940 and June 9, 2001 and their newborns (inclusive) at the Bella Coola General Hospital (BCGH). Main outcome measures: Data collected included aboriginal status, date of delivery, mode of delivery (vaginal delivery vs cesarean section), birth weight, whether there was an episiotomy or not, forceps or vacuum extraction, whether analgesia, sedation, or anesthesia was used, maternal morbidity / complications, and newborn morbidity / complications. Results: There were 2373 deliveries that included 12 sets of twins. There were no maternal mortalities. Starting in the 1970’s there has been an increase in cesarean section rates; an increase in the 1950’s through the 1980’s followed by a recent sharp decrease in episiotomy rates in the 1990’s; an increase from the 1940’s to the to the 1980’s in the use of forceps followed by a remarkable decline in the 1990’s; and a recent increase in use of vacuum extraction in the 1980’s and 1990’s. The changes in procedure rates appear to reflect best practice guidelines of the times; and for the case of episiotomies, the data suggests mral physicians are capable of rapid incorporation of recent recommendations. Rates of episiotomies, cesarean section, and forceps tended to be lower than those reported elsewhere in Canada and the United States. Over the study period, there has been a decrease in perinatal mortality; and the rates are comparable to those reported elsewhere in North Ameriea and the rest of the world. Conclusions; W omen giving birth in the low technology environment of the Bella Coola General Hospital experienced relatively low obstetric procedural rates with excellent maternal and neonatal outcomes. 11 Key Words: Rural obstetrics, rural hospital, obstetrical maternal outcomes, episiotomy rates, cesarean section rates, forceps rates, neonatal outcomes, perinatal outcomes, newborn mortality 111 TA BLE OF CONTENTS Abstract ii K eyw ords iii Table of Contents iv-v List of Tables vi List of Figures vii List of Graphs viii Acknowledgements 1 CHAPTER 1: Introduction and Justification for the Study 1.1 Introduction 2-3 CHAPTER 2: Literature Review 2.1 Literature Review 2.2 Study Questions 3-9 9 CHAPTER 3: Research Design and Methods 3.1 Description of the Community 3.2 Study Population 3.3 Vital Statistics Information (1986-2001) 3.4 Ethics 3.5 Methods 9-10 10-11 11-12 12 12-13 CHAPTER 4: Descriptive Statistics 4.1 Births Trends 4.2 Maternal Mortality Rates (MMR) 4.3 Episiotomies 4.4 Operative Deliveries (Forceps / Vacuum Extraction) 4.5 Cesarean Sections 4.6 Twin Data 4.7 Perinatal Mortality 4.8 Newborn Condition at Birth 4.9 Newborn Weight 4.10 Low Birth Weight 4.11 Inferential Statistical Analysis 13 14 15-16 16 16-17 17 17-18 19 19 20 21 CHAPTER 5: Discussion 5.1 Episiotomies 5.2 Operative Deliveries (Forceps / Vacuum Extraction) 5.3 Cesarean Section 21-23 23-25 25-26 26-28 IV 5.4 Perinatal Mortality Rate (PMR) 28-29 CHAPTER 6: Research Implications 6.1 Limitations 29-32 C O NCLUSION 33 R EFER EN C ES 34-40 D EFIN ITIO N S 41 LIST OF TABLES Table 1 Newborn Condition 11 Table 2 Summary of Deliveries 13 Table 3 Mean Gravida Number over Time 14 Table 4 Analgesia Given to Labouring Women 14 Table 5 Regional Anesthetics Given Over Time 15 Table 6 Maternal Obstetric Complications 15 Table 7 Obstetric Procedure Usage Rates 16 Table 8 Obstetric Procedure Usage Rates (%) 16 Table 9 Reasons for Cesarean Section Per Decade 17 Table 10 Summary of Twin Data 17 Table 11 Newborn Mortality (Total Population) 18 Table 12 Bella Coola General Hospital Mortality Summary 18 Table 13 Condition of Newborn Per Decade 19 Table 14 Low Birth Weight (<2500 gms) 20 Table 15 Perinatal Mortality 29 Table 16 Summary of Results (%) for all BCV Women in Both Cohorts from 1986-2000 31 VI LIST OF FIGURES Figure 1 Location of Bella Coola Valley 43 Figure 2 Bella Coola Region 44 Vll LIST OF GRAPHS Graph 1 Newborn Weight 20 Graph 2 Average Proportion of Non-C-Section Births that Involved Episiotomy 42 V lll ACKNOWLEDGMENTS Without the help o f many hands the completion o f this tremendous task would never have transpired. It takes an enormous amount o f time and energy and patience to get through a thesis, to all o f those who helped me through this your time, energy, patience, critique, feedback and encouragement was immensely appreciated. In particular, I would like to say thank you to m y committee Dr. Harvey Thommasen, Dr. Stefan Grzybowski and Lela Zimmer. For Harvey Thommasen w ho’s encouragement, assistance, feedback and patience made this all possible. To Stefan Grzybowski for his assistance from near and afar throughout the process, his feedback and support was extremely valuable. Finally, Lela Zimmer who offered her feedback and assistance especially in the final moments and to Nancy Lynch for going first and contributing to the data that was used in this thesis. A heartfelt thank you to those who reviewed the manuscript and data and offered their insightful feedback including John Cutcliffe, Dr. Michael Klein, Nancy Anderson, Don Watt, and Carol Thommasen. A sincere thank you to Samara Berger for assisting with the reviewing and critiquing o f the statistics and to Romina Reyes and Andy Bottomley for helping with the inputting o f the massive amounts o f data. To Anne Allgier for her help in the searches and finds, a sincere thank you. Special thanks goes out to m y family and friends for their encouragement that kept me going even when I was sure I was never going to finish. This thesis is dedicated to everyone mentioned above and to those who I may have forgotten to thank along the way. A sincere thank you. CHAPTER 1: INTRODUCTION AND JUSTIFICATION FOR THF STUDY 1.1 Introduction and Justification for the Study The practice o f obstetrics in rural Canadian communities is undergoing profound change (Hutten-Czapski, 1999; & Levitt & Kaczorowski, 1999). The age o f practicing physicians and obstetricians is nearing retirement with new doctors not incorporating obstetrics into their practice (Levitt & Kaczorowski, 1999). A result is some remote and rural communities have no local access to maternity care services (Johnson, 2002). Indeed rural women are particularly affected by losses in local obstetric services as they must travel and be separated from family and friends when they give birth (SOGC, 1996; Klein, et al. 1984; Buckle, 1994; and College o f Family Physicians o f Canada, 1998). Among the reasons given for the discontinuation o f obstetrical services in rural hospitals is ‘safety’ with the thought being secondary and tertiary care centers have specialists who are better skilled in administering analgesia / anesthesia and better skilled in performing obstetric procedures including forceps deliveries and cesarean sections (Levitt & Kaczorowski, 1999; Buckle, 1994; Special Committee on Obstetrical Care 1987, Iglesias, 1999; Hutten-Czapski & Iglesias, 1998; Shapiro, 1999; Rourke, 1998, and Webb, & Kantor, 1992). Intuitively, one would speculate that being managed by highly skilled obstetrics team would result in lower maternal and neonatal mortality and morbidity. However, it is suggested that ‘low risk’ women living in rural communities have just as good maternal and neonatal outcomes if they choose to deliver their babies in local primary care facilities even if cesarean section capabilities do not exist (British Columbia Reproductive Care Program, 2000). In fact, this counter intuitive finding is more common when maternity care is not available locally where women must travel for that care, negative outcomes are more common (Nesbitt et al., 1990; Gagne et al., 1998; Nesbit, 1996; Deutchman, 2001; Black, & Fyfe, 1984; Larimore, & Davis, 1995). However, there tends to be an inerease in infant mortality when local physicians are absent in rural communities (Johnson, 2002). Admittedly, a limitation of these studies is their relatively small sample size and the short time periods they cover (Grzybowski, Cadesky, & Hogg, 1991; Grzybowski, 1998). Initial assumptions assumed rural perinatal outcomes would be worse than urban centers. The literature however indicates rural maternity care is not only safe but perinatal outcomes are similar to urban centers even when cesarean section capabilities do not exist. This study will look to examine whether perinatal outcomes are comparable to provincial and urban centers throughout a 60 year period for a small rural community in British Columbia. This will fill a gap in the literature from both a rural and historical perspective. CHAPTER 2: LITERATURE REVIEW 2.1 Literature Review Perinatal and Maternal Mortality Perinatal mortality is used as a measurement o f birth outcomes and can be defined as the number o f fetal deaths at 28 or more weeks’ gestation plus infant deaths at under 7 days o f age, per 1000 births (Special Committee on Obstetrical Care, 1987). In 1950, the perinatal mortality rate (PMR) in Canada was 38/1000 births; and in 1985, it was 9/1000 births (Special Committee on Obstetrical Care, 1987). The maternal mortality from the same years was 1.1/1,000 and 0.04/1000 respectively (Special Committee on Obstetrical Care, 1987). These reductions are attributed to the improved health o f mothers, better parity distribution, and cooperation between physicians and obstetricians within effective regionalization (Klein, M. 1988). Canadian statistics from 1993 to 1997 show the perinatal mortality excluding stillbirths to be consistent at about 4 per 1,000 o f the population (Statistics Canada, 2002). These rates may reflect consistent and relatively stable levels o f obstetrical care in Canada. While the National rates appear relatively stable in recent years, there are noteable provincial variations in Perinatal Mortality Rate (PMR). In 1995, Prince Edward Island had the highest PMR, New Brunswick had the lowest at 10.2 and 5.6 respectively (Nault, 1997). British Columbia was in the middle range with a rate o f 7.5 (Nault, 1997). The differences between provinces may reflect technological differences, lower or higher provider to patient ratios or differences in obstetrical practices; as well as differences in population characteristics that may affect perinatal mortality. For instance, in Toronto in the 1960’s the PMR in the 16 census tracts with the lowest income was 36.9 and the 23 tracts with the highest income was I6.1(Ohlsson, & Fohlin, 1983). This illustrates the possible disparity between soeio-eeonomie groups that may refleet population differenees including ability or knowledge for accessing care, level o f care available, perception o f care, alcohol and drug intake, poverty issues and education levels within the different socio-economic groups or census tracts. Perinatal mortality is associated with low birth weight which, in turn, is associated with a great number o f variables (Thompson, Goodman, & Little, 2002). Identified maternal risk factors for low birth weight babies include: age under 18 or over 35, primiparity or parity o f more than three, being in manual or non-manual work, being less than 158 cm tall, attending antenatal care after 18 weeks’ gestation, having diabetes, urinary tract infection, pre-eelamptic toxemia, antepartum hemorrhage, being a smoker, being o f Asian origin, and having a history o f infertility (Clark et al., 1993). Other risk factors include bacterial vaginosis, high perceived stress, cocaine use, women living without partners, women with uterine or cervical anomalies, and asymptomatic bacteriuria (Finestone, 1998). A number o f these risk factors can be modifiable if women at risk are identified early and / or the woman makes changes in lifestyle. Birth weight, on the other hand, is thought to be a reflection o f socioeconomic status as well as the quality o f medical care before birth (Thompson, Goodman, & Little, 2002). It is believed that communities with high rates o f low birth weight babies can benefit from interventions and referrals to appropriate community resources. Aboriginal Status The Medical Health Officer recently reviewed the health and well being o f aboriginal people in British Columbia (British Columbia: Provincial Health Officer, 2002). The overall health o f aboriginal people lags behind that o f other people; for example. Status Indians live on average 7.5 years less than other British Columbians. There are, however, certain health indicators for which aboriginal people have achieved levels o f health comparable to other British Columbians. Among these is neonatal mortality. For the years 1998 to 2000, the neonatal death rate for Status Indians was 1.8 per 1,000 live births, which was actually lower than the 2.7 neonatal deaths per 1,000 live births for other British Columbians (British Columbia: Provincial Health Officer, 2002). Studies of birth weights reveal higher average birth weight for North American native populations compared to other North American populations. According to B.C. Vital Statistics Agency (2001), the low birthweight rate for aboriginal people in 2000 was 5.2% and for other British Columbians in 2000 it was 5.1%. For the years 1991-1999, early neonatal mortality rate for British Columbia Status Indians was 3.0 deaths per 1,000 live births as compared to a rate o f 2.9 for other British Columbia Residents (British Columbia Vital Statisties Agency, 2001). A limitation o f studies on aboriginal verses other people is their small numbers, and the short time periods they cover. For example, B.C. Vital Statistics has information on low birth weight births among Status Indians only back to 1991. Before 1991, Vital Statistics did not routinely collect information on a newborn’s aboriginal status. Episiotomies Episiotomies were introduced in the eighteenth century with the intent on improving maternal outcomes (Lede, Belizan, & Caroll, 1996). In the 1920’s an episiotomy (cut or incision into the perineum), was introduced as a routine procedure to shorten the second stage o f labour, lower perinatal mortality and morbidity, reduce severity o f maternal trauma and pelvic floor relaxation (Reynolds, 1995). In the 1980’s a review o f the literature indicated the disadvantages o f episiotomies and they were subsequently removed as a routine gynecological procedure (Graham, & Graham, 1997; Reynolds, 1995). Even though they are not recommended as routine they can still be a necessary component in modem day obstetrical practices. The debate is to when their use is justified. Clinical indications for used include speeding up the later part o f the second stage o f labour in the presence o f fetal distress; to open up posterior areas to allow the correct line o f traction for forceps or vacuum extraction; to overcome a perineum that is rigid and delaying the last part o f delivery; and if there is likely to be a major perineal tear, an episiotomy may prevent it and be easier to repair (Chamberlain, & Steer, 1999; WHO, 1997). Since episiotomies were introduced without strong scientific evidence there use remains debated. The indications for use are still largely open for debate as fetal distress is grossly misdiagnosed and episiotomies themselves may extend to a fourth degree tear during a vaginal or operative vaginal delivery resulting in major maternal morbidity. Forceps / Vacuum Extraction The medicalization o f childbirth on one account was initiated by the introduction o f forceps in the mid 1600's by Peter Chamberlen (Hosmer, 2001). The invention o f forceps was important in advancing the physician’s role in childbirth. Their use comes with several prerequisites including ‘forceps should never be applied through a non­ dilated cervix or with an unengaged presenting part’ (Steinitz, & Osmun, 2001). Although considered a modem device there was a description o f an attempted vaginal delivery using a cupping glass in 1705, and in 1848 there was a bell-shaped device called an ‘air tractor vacuum extractor’ (Putta, & Spencer, 2000). In modem day obstetrics there seems to be a decrease in the use o f forceps and vacuum extraction with cesarean sections being the operative delivery o f choice. When you compare forceps to vacuum extractors, vacuum extractors seem to be the recommended instmment o f choice. However in a recent review the risks and benefits o f forceps and vacuum extractors appeared comparable and selected based on physician training and experience (Putta, & Spencer, 2000). Forceps or vacuum extractors are often necessary to speed up delivery in times o f fetal or matemal distress but require careful documentation as to their use (Steinitz, & Osmun, 2001). Analgesics / Anesthesia Anesthesia was first introduced to medical practice in 1847 by James Young Simpson, his use o f ether was seen as a needle some intmsion to a place where the medical professional at the time felt birth was better managed with the least possible interference (Caton, et al. 2002). The most popular method o f intervention for management o f pain continues to be systemic medications (Stamer, et al. 1999). With the increase in cesarean sections there is an increase in the use o f regional anesthesia from 55% in 1981 to 90% in 1997 (Stamer, et al. 1999). In a 1990 study o f residency programs, epidural anesthesia was used by 46% o f residency programs for operative vaginal deliveries, pudendal anesthesia by 14%, and spinal anesthesia by 2% and 3% reported no anesthesia for forceps operations (Ramin, et al. 1993). There seems to be differences in pain management and use o f anesthetics dependent on the location (Radomsky, 1995; Webb, &Kantor, 1992). There are apparent rural and urban differences in the availability o f anesthetics for a variety o f reasons including staffing and training o f local practitioners. Cesarean Sections In its early days the cesarean was performed by restraining the women, incising and removing the baby without pain control which normally resulted in matemal and fetal demise (Hosmer, 2001). There is controversy and debate over who performed the first cesarean section with some saying it was in 1500 by a Swill sow gilder named Jacob Nufer; and others who note it was Francois Rousset who called the operation a ‘hysterotomotokie’ (Drife, 2002; Murphy, 2002). There are other people labeled as performing the first and it appears somewhat debatable and potentially culturally reflective. To look at the cesarean sections today they are labeled as the most common major operation performed in America (ICAN, 2002). There is much controversy over its use with it being offered for medical indications as well as an elective choice to natural childbirth. In Canada the cesarean section rate increased from 4.8 per 100 in 1968 to 12.1 per 100 in 1977 (Wadhera, & Nair, 1982). Klein (1988) concludes that all studies indicate a rising cesarean section rate in Canada, whether it is associated with decrease in family physicians or not, they are not associated with improved fetal health. From 1989 to 1994, Canada had the second highest cesarean rate in the Western developed world (Menticoglou, 1997). The increase in cesareans is thought to be related to technologic advances, increase in the age o f childbearing, and tbe belief in its safety for both the mother and the fetus, however, perinatal mortality has been declining for decades and incidence o f long-term neurological defects has not been conclusively demonstrated with its use (Mindell, Vayda, & Cardillo, 1982). Litigation seems to be a contribution factor to the cesareans high rates o f use even when best practices are now calling for an overall population rate o f 10 percent. Wagner (2000), stated that if a cesarean is perfored the woman and child take the risk but if not performed the doctor takes the risk. In a society o f perfect expectations, increasing age o f childbirth, litigation threats, and women having to travel out o f communities for care there is no realistic end in sight to the high cesarean section rates. Bella Coola Valley The Bella Coola Valley is a rural, remote eommunity located on the Central Coast region o f British Columbia. Women have been delivering babies in the Bella Coola Valley for thousands o f years, and they have been delivering babies in the Bella Coola General Hospital since the first one was built in 1908 (Thommasen, 1999; Thommasen, Newbery, & Watt, 1999; & Mcllwain, & Smith, 2000) Locked away in a safe located in the Bella Coola General Hospital (BCGH) were Case Room Record Books which document the details surrounding births which took place between March 7, 1940 and June 9, 2001. This data represents one o f the longest rural hospital data sets available on the topic o f obstetrical outcomes and procedural usage rates. It has been established by the College o f Family Physicians o f Canada, the Society of Obstetricians and Gynaecologists o f Canada, and the Society o f Rural Physicians o f Canada that there is a need for rural obstetrics and rural practicing physicians and gynaecologists. There is evidence to support the claim that rural obstetrical facilities produce good matemal and perinatal outcomes. However, there is a lack o f practicing rural physicians and gynecologists. A position paper on mral matemity care supports women giving birth within their community and points out the need to develop public policy and clinical care guidelines to support mral matemity care programmes in mral Canada (Gagne, et al. 1998). Current gaps in the literature include the lack o f empirical evidence for mral obstetrics within British Columbia. Also with the variety o f practice settings and capabilities o f these mral facilities there is a need to compare and contrast the facilities outcomes with their obstetrical capabilities. The literature tells us little about historical practices and outcomes and current studies focus only on specific years or points in time (Hutten-Czapski, 1999; Grzybowski, 1998). Research in these areas is a necessary component in assessing the safety and outcomes o f mral obstetrical practice. In order to identify this gap, this study explores perinatal outeomes in the mral eommunity o f Bella Coola over a 60 year time period. This will contribute to the historical knowledge base o f obstetrical practices in mral communities. Key concepts for this study include outcomes, best practices, and evidenced based medicine. Outcomes in this study refers to perinatal and matemal labour and delivery results including mortality and morbidity outcomes. Best Practices refers to the planning and/or operational practices that have proven successful in particular circumstances and arc used to demonstrate what works and what docs not and to accumulate and apply knowledge about how and why they work in different situations and contexts (Definitions o f Best Practices on the Web, 2004). Whereas, evidenced based medicine refers to practicing medicine by using a set o f evolving principles, strategies, and tactics, and is based on the premise that practitioners are aware o f the evidence to support their clinical practice (Kaczorowski, 1998). Although the concepts o f best practices and evidence based medicine are similar the first refers to the overall practice recommendations whereas the second would be more or less illustrating the inclusion o f recommendations into practice. 2.2 Study Questions This paper reviews and summarizes the information in the Bella Coola Hospital’s birth registry in an attempt to answer the question(s): 1) What procedures were being done by the rural physicians over this time period? 2) How do Bella Coola’s obstetrical outcomes and procedural usage rates over time compare to provincial, national and international trends? 3) What was the perinatal mortality for Bella Coola births over this period? 4) What were the low birth weight rates for Bella Coola over this period? 5) Has the description o f newborn condition changed significantly over this period? 6) How do Bella Coola’s newborn outcome rates compare to provincial, national and international trends? CHAPTER 3: RESEARCH DESIGN AND METHODS 3.1 Description of the Community The Bella Coola Valley is located within the rugged coastal mountains o f northwestern British Columbia (Fig 1,2). According to the 2001 Census, 2,289 people live in the Bella Coola Valley (British Columbia Vital Statistics Agency, 2001 ; British Columbia Vital Statistics Agency, 2003). Approximately 40% o f the population (1100 people) are aboriginal, most o f these people being o f Nuxalk decent. The Nuxalk Indians are a tribe o f Salish-speaking Coastal Indians who settled in the Bella Coola Valley, but formerly lived throughout the surrounding British Columbia Central Coast area (Thommasen, Loewen, & Mclnnes, 1995; & Thommasen, 1999). Highway 20 provides the main access to the Bella Coola Valley. It extends 465 km west from Williams Lake across the Chilcotin plateau through communities o f Alexis Creek, Tatla Lake, Nimpo Lake and Anahim Lake and down the infamous Bella Coola hill to the floor o f the Bella Coola Valley. The paved highway then winds along the Atnarko and Bella Coola rivers for roughly 100 km, to the wharf at the mouth o f the Bella Coola River. One passes through the small communities o f Stuie, Firvale, Hagensborg, before reaching the town o f Bella Coola, which is situated next to the estuary at the mouth o f the Bella Coola River. The Bella Coola General Hospital is located in the town o f Bella Coola and serves a geographic region, which includes the communities o f Bella Coola, Hagensborg, Firvale, Stuie, Anaheim Lake, and Nimpo Lake (figure 2). Bella Coola Hospital is one of the most isolated health care facilities in British Columbia. The closest referral hospital is over 450 km by road to Williams Lake or a two-hour flight by air to Vancouver. Three physicians service Bella Coola at any given time. Each year the Bella Coola physicians see over 8,000 patients in the clinic, 2,500 patients in the emergency department, admit approximately 400 patients to the hospital and deliver up to 40 babies (Thommasen, Newbery, & Watt, 1999). Over the past 30 years, there has been a 46% increase in the total population o f the Bella Coola Valley from 1568 in 1971 to 2289 in 2001 (British Columbia Vital Statistics Agency, 2001; & British Columbia Vital Statistics Agency, 2003). The valley population showed a slight drop in Census 2001 for the first time in 30 years. 3.2 Study Population The study population consisted o f women beyond 20 weeks gestation who delivered in the Bella Coola General Hospital between March 7, 1940 and June 9, 2001. Specific information on matemal age, aboriginal status, date o f delivery, gravid status prior to delivery, matemal mortality/morbidity, analgesia, anesthesia, sedation, episiotomies, forceps and vacuum deliveries, and cesarean sections were extracted from labour and delivery case room record books. Matemal morbidities noted included retained placenta, placenta previa, placental abruption, hemorrhage, need for blood 10 transfusion, hypertensive disease, shoulder dystocia, precipitous or prolonged labour, uterine rupture, uterine prolapse/version, amnionitis, or cord prolepses. The author did not check the accuracy o f these morbidities, if any o f these were mentioned it was noted on the data spreadsheet. Birth weight, newborn mortality, and newborn condition, morbidity / complications were also recorded. Newborn Condition: Activity, Pulse, Grimace, Appearance, and Respiration (APGAR) scores were not used until September 11, 1971. Before 1971, the physician would describe condition and color o f infant. A scoring system was therefore set up to describe the condition o f infant in a simple manner over the entire study period (see Table 1). Table 1: Newborn Condition Physician Description APGAR score Morbidity Score Good or excellent 8,9,10 1 Fair, slow to breath, or cyanosed 6,7 2 Poor, Difficult breathing or resuscitated <5 3 Stillbirth 0 4 m.d. m.d. Missing data 3.3 Vital Statistics Information (1986 to 2000) Vital Statistics Information from BC Vital Stats is available for women who delivered 1986 to 2000 (inclusive) and listed Bella Coola Valley as their residence. Their data includes women who delivered locally and those who delivered elsewhere. BC Vital Statistics also provided data on Status Indian women for the years 1991 to 2000. The data was entered into an electronic EXCEL spreadsheet and later transferred to a statistical program (SPSS) for statistical analyses. The results were summarized into graphs and tables, which were then reviewed with fourteen Bella Coola Valley residents who were young adults in the 1940’s, and with four nurses and one doctor who worked in the valley in the 1950’s and 1960’s. All were asked specifically if they recalled any matemal deaths dating back to 1941. The five health care professionals were speeifically asked if the procedure usage rates seem to fit with what they recalled. This was 11 conducted only to assess whether practice and experience coincided with the statistics and not as a subject for review. Review o f the literature was exhaustive and included all known sources o f information available. These included all published journal articles through PubMed and research sites as well as Statistics Canada, BC Vital Stats, National and provincial bodies such as medical associations (GP and OBGYN), research associations (CIHR) several sites and vested interest groups such as the BC Reproductive Care Program data and reports and many, many more. Reviews and searches were conducted through some o f the following data hanks Historical Statistics o f Canada through Statistics Canada at http://www.statcan.ca/english/freepub/l 1-516-XIE/free.htm. various list serves such as Pub Med, and library searches at UNBC, UBC, PGRH databanks and on line list serves. Others included British Medical Journal website, OBG Management, BC Vital Statistics Websites and searches. The various searches resulted in large amounts o f articles and reviews on the topics o f interest with the biggest gap being the historical documentation o f the topics o f interest before the 1980’s with relatively few articles or submissions found for the study period between the 1940’s to the 1970’s. Therefore statistics and information were extracted from published literature that may not be critical reviews or study based but rather historical articles o f interest and personal journals were utilized. 3.4 Ethics The University o f British Columbia’s Clinical Research Ethics Board granted ethics approval for this project prior to start o f data collection on July 13, 2000. Before entering the data names o f subjects were removed to ensure privacy and maintain confidentiality. All data used was summarized by decade which would also ensure privacy and maintain confidentiality. The principle o f beneficenee was maintained as this descriptive study would not appear to cause harm to the population under study. 3.5 Methods The main outcome variables included aboriginal status, date o f delivery, mode o f delivery (vaginal versus cesarean birth), birth weight, episotomy or not, forceps / vacuum extraction, whether analgesia, sedation or anesthesia was used, matemal morbidity / complications, and newborn morbidity / complications. 12 The study variables were nominal indicating the use o f descriptive statistics. Chisquare was therefore used to assess frequency and significance between variables. Crosstabs were used to illustrate whether an intervention such as episiotomy, anesthesia, forceps and / or vacuum extraction, and cesarean section was performed over time by using a value o f yes or no. The Pearson Chi-Square with the level o f significance set at 0.05 was then calculated using SPSS software to see if the interventions being used varied significantly with the decade o f birth. CHAPTER 4: DESCRIPTIVE STATISTICS 4,1 Birth Trends There were 2373 deliveries involving 2361 women between March 7, 1940 and June 9, 2001 within the Bella Coola Hospital. This included 12 twin deliveries. There was a steady increase in births until the early 1960’s and then a decline throughout the 60’s and 70’s with another increase in the early 80’s followed by a gradual decline thereafter. The years with the highest birth rates appear in 1960, 1963, 1983, and 1992 with over 60 births a year, and lows in 1945, 1971, and 1995 with under 30 births per year. Data was missing for the time period March 21, 1967 through to January 7, 1969, inclusive. The summary of deliveries is illustrated in Table 2. Table 2: Summary of Deliveries Race 1940-1954 1955-1969 1970-1984 1985-2001 Aboriginal 221 317 271 316 Non-aboriginal 229 359 346 314 Total 450 676 617 630 Gravida status was available for the majority o f women (2318/2361). From the 1940’s to 1960’s, average gravid score was between 3.6 and 3.8 for the entire population; and this dropped to 2.4 to 2.6 between the 1970’s to the present time period (Table 3). Aboriginal women had higher gravida scores compared to other women, though this difference is notably declining over time. 13 Table 3: Mean Gravida Number Over Time 1940-1954 1955-1969 1970-1984 1985-2001 Total Population 3.62 3.77 2.40 2.54 Aboriginal Women 4.49 4.81 2.66 2.73 Non-aboriginal Women 2.78 2.85 2.19 2.36 Time Period 4.2 Maternal Mortality Rates (MMR) There were no reported matemal deaths in the Bella Coola Hospital during the entire study period. Narcotics, sedatives, inhalation agents, and regional anesthetics were all used to relieve the pain o f labour and delivery. A descriptive summary o f the inhalation agents, narcotics, and sedatives used are presented in table 4. The use o f regional anesthetics over time is summarized in table 5. A variety o f maternal morbidities was mentioned over the years and these are summarized in table 6. TABLE 4: ANALGESIA GIVEN TO LABOURING WOMEN Total # Women Inhalation Agents Chloroform Ether Trilene Cyclopropane Nitrous Oxide Entonox Narcotic Heroin Morphine Codeine Demerol Sedatives Benzodiazepines Sodium Amytal Nembutol Seconal Pentothal 2361 Number of Women Receiving Years Mentioned 246 413 215 34 69 145 1940-1953 1940-1953 1956-1977 1959-1964 1958-1981 1984-2001 24 36 13 869 1940-1945 1941-1961 1942-1967 1946-2001 5 206 95 216 22 1960-1992 1940-1957 1941-1955 1946-1964 1959-1964 14 TABLE 5: REGIONAL ANESTHETICS GIVEN OVER TIME Decade Spinal Anesthesia Pudendal Nerve Block Epidural Anesthesia Cesarean-section Regional and Cesareansection 1940’s 0 0 0 0 0 1950’s 2 4 0 1 0 1960’s 0 9 12 0 0 1970’s 6 17 19 13 8 1980’s 0 21 88 42 39 1990’s 24 2 55 44 39 Total 32 53 174 100 86 TABLE 6: MATERNAL OBSTETRIC COMPLICATIONS BCGH 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s Total # Women 251 443 425 368 475 399 2361 #Births 253 447 426 370 478 399 2373 Maternal Deaths 0 0 0 0 0 0 0 Retained Placentae 1 3 11 8 5 4 32 Placenta Previa 1 0 2 0 0 1 4 Placental Abruption 0 1 1 0 3 1 6 Hemorrhage 19 14 4 2 18 57 114 Blood Transfusion 1 2 1 1 0 2 7 Hypertensive 3 2 2 0 7 1 15 Shoulder Dystocia 0 0 0 0 3 3 6 Prolonged Labour 0 3 0 11 32 40 86 Uterine Rupture 0 1 1 0 1 0 3 Uterine Prolapse 0 0 0 0 1 0 1 Uterine Inversion 0 0 0 0 1 0 1 Amnionitis 0 0 0 0 2 2 4 Prolapsed Cord 0 2 0 0 0 0 2 4.3 Episiotomies The number o f episiotomies performed per decade during the study period is summarized in tables 7 & 8. The data show a gradually increasing episiotomy rate into the 1970’s after which it dropped to less than 5% in the 1990’s. The highest episiotomy 15 rates occurred during 1978 through 1980; thereafter, episiotomy rates fell to less than 5% during 1993 to 1995 time period (Table 8). TABLE 7: OBSTETRIC PROCEDURE USAGE RATES BCGH 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s Total # Women 251 443 425 368 475 399 2361 # Births 253 447 426 370 478 399 2373 18 0 18 69 0 27 0 27 146 1 34 0 34 152 0 37 0 37 175 13 43 32 75 166 42 10 36 46 16 44 169 68 237 724 100 Operative Delivery: Forceps (#) Vacuum (#) Forceps + Vacuum (#) Episiotomy (#) C-section (#) TABLE 8: OBSTETRIC PROCEDURE USAGE RATES (%) BCGH 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s # Women 251 443 425 368 475 399 Forceps (%) 7.2% 6.1% 8% 10% 9% 2.5% Vacuum (%) 0% 0% 0% 0% 6.7% 9% Forceps + Vacuum (%) 7.2% 6.1% 8% 10% 15.7% 11.5% Episiotomy (%) C-section (%) 27.5% 0% 33% 0.2% 35.8% 0% 47.3% 3.5% 34.9% 8.8% 4.0% 11% 4.4 Operative Deliveries (Forceps/Vacuum Extraction) Bella Coola’s forceps and vacuum rates indicate a reduction in the rates o f forceps use from the 1960’s to the 1980’s with a marked decrease from the 1980’s to the 1990’s (Tables 7&8). Vacuum deliveries were not used in Bella Coola prior to the 1980’s. Operative deliveries before that time denote the exclusive use o f forceps. 4.5 Cesarean Sections Up until the 1970’s there was only one Cesarean section done in the Bella Coola General Hospital. That one was done in 1959, and it was an emergency Cesarean section because a woman was hemorrhaging from a ruptured uterus. From the 1970’s onwards there has been a gradual rise in the rates o f eesareans (Tables 7&8). Reasons for cesarean 16 sections over time are summarized in table 9. Failure to progress, repeat C-sections, breech, and fetal distress were the main reasons listed for having a cesarean section. TABLE 9: REASONS FOR CESAREAN SECTION PER DECADE Decade 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s Total Failure to Progress 0 0 0 8 14 24 46 Breech 0 0 0 3 7 7 17 Repeat C-section 0 0 0 0 9 10 19 Fetal Distress 0 0 0 0 3 5 8 Miscellaneous 0 1 0 0 6 1 8 No information 0 0 0 2 3 1 6 4.6 Twin Data There were 12 sets o f twins, 9 to non-Ahoriginal women and 3 to Aboriginal women (Table 10). Five o f the 24 twin newborns died, all during the 1955 to 1969 timeperiod - one aboriginal female, three non-Aboriginal females, and a non-Aboriginal male. Two o f these deaths (non-Aboriginal male and female) were from one twin delivery. These two were described as being premature and both died a few hours after birth. Another twin death was a non-Aboriginal female stillbirth; and the last twin death was a female described as being a premature female who died 7days after delivery. Table 10: Summary of Twin Data 1940-1954 1955-1969 1970-1984 1985-2001 Total Aboriginal Twins 1 1 0 1 3 Non-aboriginal Twins 2 3 4 0 9 Total 3 4 4 1 12 Time Period 4.7 Perinatal Mortality Perinatal mortalities over time are summarized below (Table 11). Total newborn mortality rates declined from around 4.7% in the 1940-1954-time-period to 0.7% in the 1970-1984 time-period and have remained around that level since. 17 Table 11: Newborn Mortality (Total Population) Year 1940-1954 1955-1969 1970-1984 1985-2001 Total Number of Births 450(100%^ 676 617 630 Stillbirth 13 (2.9%) 13(1.9%) 4(0J% ) 5 (0.8%) Died < 24 hours 4 (0.9%) 12(1.8%) 0(0%^ 2 (0.3%) Died 1 day to 30 days 4 (0.9%) 2 (0.3%) 0(0%) 0(0% ) Total Deaths 21 (4.7%) 27 (4.0%) 4 (0.7%) 7(T1%0 Review o f aboriginal vs non-aboriginal newborn death rates reveals that total mortality for aboriginal newborns has dropped dramatically from rates o f around 6.3% during the 1940 to 1954 time period to 0.3% during the 1985 to 2001 time period. Total newborn mortality also fell from 3.1% to 0.3% over this time period. Since Bella Coola lacks the numbers to calculate a true perinatal mortality rate a calculation was made by dividing the number o f perinatal deaths by the number o f live births (including twin births), and then multiplying that number by 1000 to get the perinatal mortality rate for Bella Coola during the study period. Perinatal mortality included stillbirths, antenatal deaths, intrauterine deaths and deaths up to a week after birth (see table 12). Table 12: Bella Coola General Hospital (BCGH) Mortality Summary BCGH 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s # Women 251 443 425 368 475 399 # Births 253 447 426 370 478 399 # Maternal deaths 0 0 0 0 0 0 # newborn deaths 11 22 14 4 6 2 PMR (#71000 births) 4Ta 4&2 32.9 10.8 12.6 5 18 4.8 Newborn Condition at Birth Information on condition o f newborn at birth is summarized in table 13 below. The data below shows that the condition o f the vast majority of newborns is described as being ‘good’ at birth (approximately 90%). Table 13: Condition of Newborn Per Decade Newborn Condition (%) 1940’s 1950’s 1960’s 1970’s 1980’s 1990’s # Births 253 447 426 370 478 399 Good 91% 90% 90% 84% 92.5% 96% Fair 2% 3% 3% 8% 5% 3% Poor 2% 3% 25% 2% &4% 1% Deceased 3.5% 2,5% L4% 0,5% 1% 0% Missing L5% 1.5% 1.9% 6% 1% 0.25% 4.9 Newborn Weight Mean weights for newborns are summarized in graph 1 below. The data shows that mean weight has not really changed much over time. Mean weights for non­ aboriginal and aboriginal newborns also seem comparable over time. 19 Graph 1: Newborn Weight NB Weight - Aboriginal/Non-Aboriginal ^ 3600.00 3400.00 3200.00 3000.00 2800.00 2600.00 2400.00 m 2200.00 ^ 2000.00 Aboriginal £ 1800.00 O) 1600.00 1400.00 I Non-Aboriginal 1200.00 1000.00 800.00 600.00 400.00 200.00 0.00 1951-1962 1963-1978 1984-2001 Dates 4.10 Low Birth Weight Low Birth Weight Rate is defined as the proportion o f live births with a birth weight less than 2500g. Birth weight data is available for 1793 newborns starting around 1951, and except for the period from 1978 to 1984 it is more or less continuous. About 5% of newborns have birth weights less than 2500 grams and this has not changed much over the years. Aboriginal women appeared to have a higher percentage o f infants with birth weight o f < 2500 grams but this percentage has declined over time to the point where the rate is similar to non-aboriginals at around 5%. Table 14: Low Birth Weight (< 2500 gms) Year Total Aboriginal Number Aboriginal Number < 2500 gms (%) 1951-1962 254 21 (8%) 1963-1978 285 16(6%0 1984-2001 334 15(5%0 Total Non-aboriginal Number Non-aboriginal Number < 2500 gms (%) 300 14(5%0 275 13(5%0 345 15(4% ) 20 4.11 Inferential Statistical Analyses Pearson Chi-Square statistical analyses reveals that the likelihood o f any o f the interventions - episiotomy, operative delivery (forceps and vacuum extraction), and cesarean section - being used, varied significantly with the decade o f birth (p < 0.05). Due to the nominal level o f data the Chi-Square was the test used to denote significant difference between the proportion o f births that included various interventions over time. The results o f the analysis included the following significant results with a pvalue o f 0.05. The proportion of births that involved anesthetic peaked in the 1980’s, and the proportion o f births that involved episiotomy peaked in the 1970’s. The proportion o f births that involved forceps and / or vacuum peaked in the 1980’s. Finally the proportion o f deliveries by cesarean section increased across all o f the decades being highest in the 1990’s. All other variables and frequencies tested did not illustrate significant results. CHAPTERS: DISCUSSION The Bella Coola General Hospital is located in the isolated, rural, remote community o f Bella Coola. The data described in this paper covers a 60-year time period from 1940 to 2001, and the results support the joint position o f the SOGC, SRPC, and College o f Family Physicians o f Canada. The information presented in this paper reveals excellent maternal and perinatal outcomes are possible when an isolated rural community offers obstetric services and capabilities including cesarean section and anesthesia (regional and general). There were no reported maternal deaths in the Bella Coola Hospital during the entire study period. Fourteen Bella Coola Valley residents who were young adults in the 1940’s, and four nurses and one doctor who worked in the valley in the 1950’s and 1960’s confirmed that they were not aware o f any women dying during our study period. To their knowledge and recollection, a woman died giving birth in 1906; and several people mentioned the deaths o f two women several days after they gave birth before 1940 from what sounded like toxemia o f pregnancy. 21 Maternal mortality rate (MMR) can be defined as the number o f maternal deaths due to complications o f pregnancy, childbirth and the puerpérium, per 10,000 live births (Special Committee on Obstetrical Care, 1987). Maternal mortality has decreased throughout the decades. The maternal mortality rate was 31 per 10,000 live births in British Columbia compared to 40 per 10,000 in Canada for 1940 (Strong-Boag, & McPherson, 1986). Current maternal mortality rates in Canada are in the order o f 0.3 to 0.5 per 10,000. MMR in a Report from the United Kingdom titled “Why Mothers Die,” documented trends in maternal mortality from the 80’s to the 90’s. For the 1994-96 period there was a rate o f 9.9 per 10,000 mortalities (direct and indirect causes), with the major causes o f death being thrombosis and thromboembolism (Department o f Health, 1998). Amniotie fluid embolism, sepsis, uterine rupture, pregnancy induced hypertension, anesthesia related deaths, and haemorrhage are other causes o f pregnancy associated maternal mortalities. Maternal mortality in Canada is less than 1% o f all deaths o f women, whereas it accounts for 25 to 30 percent o f deaths o f women in developing countries (Lalonde, 1998). Another source states the maternal mortality rate in developing countries is as high as 1%, and one woman dies in pregnancy every minute o f every day due to sepsis, haemorrhage, hypertensive disease, and unsafe abortion (Drife, 2002). There is an estimated worldwide maternal mortality o f 500,000 a year; 25% due to hemorrhage, 15 % related to sepsis, 12 % due to hypertensive disorders, 8% related to obstructed labour, and 13 % due to abortion (WHO, 1994). The disproportionate rates between developing and developed countries is astronomical. Worldwide health organizations are looking at ways o f decreasing this largely preventable cause o f mortality for women across the globe. During the entire study period there were no reported maternal mortalities. This may reflect good nutrition and health for the population o f Bella Coola as well as good health care provided by the physicians over the study period. Since there was no maternal deaths there is no way to illustrate similarities or differences between aboriginal or non-aboriginal maternal mortalities. In Bella Coola the most commonly mentioned maternal morbidity was hemorrhage but despite this, relatively few women actually received a blood transfusion 22 for the problem (7/2361 women). Prolonged labour was the next most commonly mentioned maternal morbidity. It is interesting to note physicians rarely mentioned the term prolonged labour before the I970’s. This sudden shift may be related to changes in defining, diagnosing, and treatment o f a long labour. Or in light o f the subsequent increase in cesarean sections during the same time period a diagnosis o f prolonged labour may have been a justification for initiating this mode o f delivery. Other issues happening in the 1970’s included major strides in the women’s movement and wom en’s rights that also may have impacted on physicians diagnosing a prolonged labour due to women wanting their labour shortened. Data from the Bella Coola Hospital obstetrics casebook reveal that women have been receiving narcotics, sedatives, inhalation anesthetics, and regional anesthetics since the 1940’s. The specific agents used have changed over the years but the broad category o f medicine has not - for example, demerol is given these days instead o f heroin, entonox gas instead o f ether gas, and benzodiazepines are given instead o f barbiturates (Caton, Froiioh, & Euliano, 2002). A review o f the literature suggests wide variations in use o f pain management when you compare different cities in Canada in the 1990’s. In a study o f anesthesia availability in cities across Canada, epidural anesthesia was unavailable in Edmonton whereas in Toronto 58.7% were managed using epidural anesthesia (Radomsky, 1995). Epidural anesthesia was offered routinely in Bella Coola during the 1990’s but this practice may not be representative o f other rural communities. The literature suggests use o f epidural anesthesia in rural and remote areas seems to be rather low and may be related to fewer deliveries, and fewer personnel resources to perform the procedure (Stammer, et al, 1999). 5.1 Episiotomies Episiotomies were introduced in the eighteenth century with the intent o f improving maternal outcomes (Lede, Belizan, & Caroll, 1996). In the 1920’s the episiotomy was introduced as a routine procedure to shorten the second stage o f labour, lower perinatal mortality and morbidity, reduce severity o f perineal tears, improve sexual function, and reduce the possibility o f urine and fecal incontinence (Lede, Belizan, & Caroll, 1996; & Reynolds, 1995). The routine use o f episiotomies was introduced 23 without strong scientific evidence o f its benefits. There is no justification for the routine use although episiotomies remain a necessary component in modem obstetrical practices to facilitate or expedite delivery in times o f fetal distress. Recent studies indicate the use o f episiotomies may result i n i ) a decrease in muscle strength o f vaginal muscles; 2) slower wound healing; 3) more pain when resuming sexual intercourse; and 4) higher rates o f urinary and feeal ineontinenee (Lede, Belizan, & Caroll, 1996; & Signorello, et al., 2000). As a result o f these studies, and since an initial review o f the literature in 1983 illustrating the disadvantages o f episiotomies and the laek o f advantages, there has been a noticeable deeline in prevalence o f episiotomies in Canada (Reynolds, 1995; & Graham, & Graham, 1997). One Canadian study revealed the episiotomy rate declined from 66.8 in 1981/1982 to 37.7 percent o f all women giving birth vaginally in 1993/1994 (Graham, & Graham, 1997). Another study reports episotomy rates in the 1990’s at 41.8% for mutiparas and 62.7% for primiparas in Canadian hospitals (Kaczorowski, et al., 1998). Other studies reveal episiotomy rates o f 45% in Red Deer, Alberta; 55.2% in Toronto; and 62% in Edmonton (Radomsky, 1995; & Lede, Belizan, & Caroll, 1996). In the United States (US) in 1983, 69.6% o f vaginal births had an episiotomy (ACOG, 2002). In the 1990’s the episiotomy rate in the US had fallen to around 52.5%. A recent US data analysis from nulliparous women in Philadelphia hospitals shows episiotomy rates o f 42 percent overall with 7.7 percent o f women having a third or fourth degree tear during childbirth (Webb, & Culhane, 2002). The European episiotomy rate in the 1990’s is reported to be around 30% (Radomsky, 1995; & Lede, Belizan, & Caroll, 1996); and between 15-40% dependent upon the hospital (Chamberlain, & Steer, 1999). In China, episiotomies are still routine with rates above 85% in 3 hospitals (Qian et al., 2001). In the Netherlands midwives have an episiotomy rate o f 24.5% (WHO, 1995). Such wide variations in rates hints at possible institutional or physician factors that may influence episiotomy rates. Klein et al (1995) illustrate that if a physician views episiotomies favorably or unfavorably affects patient outcomes. In this study those physicians favoring episiotomies not only had difficulty limiting their episiotomy use in the restricted-arm 24 group of the study but also diagnosed fetal distress and perineal inadequacy more often and had decreased patient satisfaction and increased perineal trauma (Klein et al., 1995). This suggests the physician has a major impact on obstetrical procedures and outcomes. The World Health Organization (WHO) recognizes the reasons for performing an episiotomy but also recognizes that they are frequently used inappropriately (WHO, 1995). WHO (1995), recommends an overall episiotomy rate o f around 10% because o f the evidence suggesting liberal use o f episiotomies causes more harm than good. Restrictive use o f episiotomies is seen as a positive initiative in relation to evidencebased recommendations (Graham, & Graham, 1997). Rates o f episiotomies use in the Bella Coola Valley seem to follow best practice guidelines. Bella Coola’s episiotomy rate o f less than 5% in the 1990’s is significantly lower than other provincial, national, and international rates making this hospital one o f the few health care facilities in the world actually meeting and exceeding best practice guidelines. 5.2 Operative Deliveries (Forceps/Vacuum Extraction) Trends in forceps delivery rates in Bella Coola concur with other Canadian and International studies reporting decreases in forceps usage since the 1970’s with subsequent increases in vacuum extraction rates (Gagne, et ah, 1998; Hankins, & Rowe, 1996; Ramin, Little, & Gilstrap, 1993; & Bofill, et ah, 1996). Bella Coola’s rate of forceps when compared to BC and Canadian data, indicate Bella Coola has a rate that falls far below the national and provincial averages for both the 1980’s and the 1990’s. Reported forceps usage rates in Canada range from 6.5% to 21%. In British Columbia forceps delivery declined from 13% in 1987 to 7.4% in 1995 and vacuum deliveries increased fi-om 0.8% in 1987 to 4.9% in 1995 (MacNab, 1996). Canadian forceps rates are far lower than Australia’s, far higher than Sweden’s, and on par with British forceps usage rates. In Sweden forceps deliveries are rare with a rate o f 0.2%; whereas vacuum delivery rates are around 6.9% Sweden is viewed as a leader in obstetrical intervention guidelines as they defined forceps and vacuum extraction best practice guidelines almost a decade before Canada. Britain’s rate o f forceps usage was 5-10% in the 1990’s (Chamberlain, & Steer, 1999). In New South Wales, Australia, the forceps usage rate in 1990 was 58.1% and declined to 33.8 % in 25 1997 (Ohlsson, & Fohlin, 1983). During the same time period the vacuum extraction rates rose from 9.6 to 26.5 percent respectively (Roberts, et ah, 2002). Since Austrailia, Sweden, and Britian have similar health care systems and training these countries were used to compare and contrast with Canada. 5.3 Cesarean Section In some ways, the cesarean section has become an icon o f all the medical advances made in obstetrics. Currently cesarean section is used as both a medical intervention and an option for women who prefer it as an alternative to vaginal birth. According to American Statistics, the caesarean section is now the most common major operation performed in America with the US having a rate o f 22.9% in 2000, an increase o f 4% from 1999 (ICAN, 2002). As with other centers around the world, the Bella Coola data show there has been a gradual rise in the rate o f cesareans since the 1970’s from zero to less than 15%. Comparatively, Bella Coola has cesarean section rates that are lower than provincial, national, and international rates (Mindell, Vayda, & Cardilla, 1982). The World Health Organizations recommends a cesarean rate o f 10-15%, within which the rate reported for Bella Coola falls. In Canada, the cesarean rate increased from 4.8 per 100 in 1968 to 12.1 per 100 in 1977 (Wadhera, & Nair, 1982). The Canadian experience shows provincial variations in 1988 from Manitoba’s low o f 15.5 per 100, and Alberta’s 17.1 per 100 deliveries to British Columbia’s and Newfoundland’s highs o f 22.2 and 23.3 per 100 respectively (Richman, 1999). Another study reported cesarean rates for British Columbia for 1987 and 1995 o f 21% and 19.8%, respectively (MacNab, 1996). Klein concludes that all studies indicate a rising cesarean section rate in Canada, and notes this rising cesarean section rate is not associated with improved fetal health (Klein, 1988). Earlier Canadian data from the 60’s, 70’s and 80’s show an increasing cesarean trend. The rate in 1967-1969 was 5.8% and 1977-79 the rate was 16.9%; major factors contributing to this have been the change in approach to the breech presentation. However, there has not been a subsequent drop in perinatal mortality with this increased use o f cesarean section that would seem to adequately justify its current use (Baskett, & McMillen, 1981). 26 Worldwide trends illustrate marked differenees in eesarean rates. These studies show the Americas as having the highest cesarean section rates in the world compared to their European and Asian eounterparts. Among developed countries, the US and Canada have relatively high cesarean section rates (19 to 23%) (Menticoglou, 1997). In contrast, some Eastern European (e.g. former Czechoslovakia and Hungary), some Western European (e.g. Netherlands) countries, Scandinavian countries (e.g. Iceland and Sweden) and Japan report relatively low rates o f cesarean sections (5 to 10%) (Klein, 1988; Notzon, 1990). In Britain the frequency o f cesarean sections has increased from 5% in 1930 to 16% in 1999; 6.5% o f all deliveries are elective cesarean sections with 9% o f all births being emergency cesarean sections (Chamberlain, & Steer, 1999). The main reason cited for the rise in cesarean sections in Britain was litigation. In New South Wales, Australia the cesarean rate increased from 32.3 percent in 1990 to 39.8 percent in 1997 (Roberts, et a l,2 0 0 2 y In developing countries, cesarean section rates have soared. International data from 1981 to 1986 show Brazil with a 31 to 37% cesarean rate, Mexico City with a 27% cesarean rate and Puerto Rico with a 24 to 27% cesarean rate (Notzon, 1990; & Notzon, Placek, & Taffel, 1987). In Rio de Janeiro the caesarean section rate is around 90% (Drife, 2002). In China, county hospitals had rates o f 30%, whereas district hospitals had rates o f 73% (Qiân, et al., 2001). Such worldwide differences in rates indicates cesareans are not related as much to maternal or fetal factors as much as cultural, technological, geographical and social factors (Klein, 1988; Menticoglou, 1997; & Wagner, 2000). The indications for cesarean sections are vast. One account states that a cesarean section is indicated whenever a practitioner makes the judgment that “the risk o f vaginal delivery exceeds the risk o f the operation or that the mother’s perception is that it does” (Chamberlain, & Steer, 1999). The main indications for cesarean sections in Canada and the US are 1) previous cesarean section, 2) dystocia, and 3) fetal distress (Holmes, Oppenheimer, & Wu Wen, 2001). According to Ontario data from 1979 to 1982, the main indications for cesarean section were previous cesarean at 68%, followed by 11% for breech, dystocia, and fetal distress combined (Anderson, & Lomas, 1984). In Bella 27 Coola the main indications for cesarean section were dystocia, previous cesarean section, breech, and fetal distress. 5.4 Perinatal Mortality Rate Bella Coola’s perinatal mortality rate (PMR) was between 44 and 50 per 1000 live births in the 1940’s to 1950’s; the PMR was 10.8 per 1000 live births in the 1970’s, and for the last 10-15 years the PMR has been approximately 5 per 1000. The trends in perinatal mortality and low birth rates reported for Bella Coola are comparable to provincial, federal and international rates reported elsewhere. From 19401960, Bella Coola’s PMR is higher than Canada’s, it is lower than Canada’s in the 1970’s, and again higher in the 1980’s and about the same for the 1990’s. Because o f the relatively small number o f births per year and within a decade, fluctuations in the perinatal mortality rate are to be expected. Some authors believe such fluctuations make perinatal mortality rate a poor indicator o f rural obstetrical care or safety (Grzybowski, Cadesky, & Hogg, 1991). North American perinatal mortality rates are in the order o f 10 per 1000 births (Nault, 1997). Sweden has maintained one o f the lower perinatal mortality rates among international countries and had a PMR o f 9.4 in 1978 compared to 14.0 in Alberta in 1974 (Ohlsson, & Fohlin, 1983). Although there is a certain rate o f expected intrauterine deaths, there appears to be a decline in stillbirths in the Bella Coola Valley (BCV) from the 1940’s to the 1990’s. This may be attributed to an increase in the level o f prenatal care, nutrition, and general living conditions that have changed over time or may be related to increased knowledge o f obstetrical practices and referrals o f high-risk women to other facilities that impact Bella Coola’s statistics. Whatever the reasons, Bella Coola Hospital illustrates apparently improved perinatal outcomes overtime regardless o f the extenuating faetors. 28 Table 15: Perinatal Mortality PMR (WIOOO) 1940's 1950’s 1960’s US 1970’s 1980’s 1990’s 7.5 2& 22^.3** Canada British Columbia Bella Coola 32. P 8* 72.& &7- 2L&*** 10.9*** 77.3* 70.0* 7.3* 70.g 72j) 3 *Nault, F. **Baskett, T.F. an d M cMillen, R M . ***Special Com m ittee on O bstetrical Care(1987) The current trend towards centralization o f obstetric services is difficult to justify based on the data presented in this paper. Forcing rural women to give birth away from fidends and support systems, in high technology ‘baby delivering’ factories, under the wing o f health care strangers may not actually be in their best interests (Grzybowski, 1998; & Royal College O f Obstetricians and Gynaecologists, 2002). The data presented in this paper support the position(s) that 1) rural obstetrical care is safe, 2) rural family physicians can practice obstetrics without an obstetrician, and 3) maternity and neonatal care should be provided as close as possible to the rural patient’s home location (Iglesias, 1999; Gagne, et al., 1998; Iglesias, S., et al. 1998; Iglesias, Klein, Gagne, & Lalonde, 1998). CHAPTER 6: RESEARCH IMPLICATIONS 6.1 Limitations The data presented in this thesis provides detailed insights into the practice o f rural obstetrics in one rural community over a 60-year period. As with most data sets, this data set is not perfect. First o f all, the study population size o f 2373 deliveries may not be large enough to capture significant differenees involving rarely occurring events such as maternal mortality; that is, certain variables studied are at risk o f suffering a type II statistical error - false negative finding. Maternal mortality rates for Canadian women are presently in the order o f I in 10,000 births (Hoyert, Danel, & Tully,). We do believe 29 the population studied was large enough for the study variable o f episiotomy, cesarean section rates, and perinatal mortality. A second limitation o f the data relates to the fact that since the late 1970’s an increasing number o f women have been choosing to deliver their babies out o f the Bella Coola Valley. Local residents and health professionals who worked in Bella Coola during the 1950’s, 1960’s, and 1970’s state that very few women went out to deliver their babies prior to the start o f the 1980’s. The Bella Coola airstrip was paved and extended in 1977 and this allowed for medical evacuations by provincial ambulance jet. Therefore it is unknown as to whether the outcomes were better or worse for women who delivered outside o f the community. The development o f a rapid medical evacuation system is an important factor in more and more women being transferred elsewhere to deliver, and more and more women being told that they should deliver elsewhere because o f the possibility there would be no cesarean section coverage during the time o f their delivery. Nevertheless, Vital Statistics information reveals that over the past 15 years, over 80% o f women living in the Bella Coola Valley were still giving birth at the Bella Coola General Hospital. Lynch et al. reviewed obstetric outcome data obtained from British Columbia Vital Statistics for women who listed the Bella Coola Valley as their home residence. Obstetric outcomes for women who gave birth at the Bella Coola General Hospital were also compared to outcomes reported for women who delivered elsewhere over the time period January 1, 1986 to December 31, 2000 (Lyneh, Thommasen, & Grzybowsky, currently submitted to CMAJ). A finding was that more o f the women who delivered elsewhere had a cesarean section (31% vs 12%). Other results seem comparable. Statistical analyses revealed no significant differences in obstetrical outcomes between native and non-native women. A summary o f that data is presented in table 16. 30 Table 16: Summary of results (%) for all BCV women in both cohorts from 1986 2000 Variable Local (BCGH) Elsewhere Population 570 247 Vaginal Delivery 88% 69% Cesarean Section 12% 31% Epidural 16% NA Episiotomy NA 9% VBAC* NA 4% Forceps / Vacuum 10% 6% Maternal Mortality 0 0 NA = data not available *VBAC = vaginal birth after cesarean section Total 817 82% 18% NA NA NA 9% 0 A third limitation o f the data is that definitions and perceptions o f perinatal conditions may have changed over time. For example, the definition o f perinatal mortality has changed over time based on weight, whereas some institutions may calculate or classify according to older literature (Nault, 1997). Since there is no way o f knowing in what week o f gestation a stillbirth occurred it has been simply listed as ‘stillbirth’ on the labour and delivery sheets, all stillbirths listed in the data were included in the calculations. It was assumed medical staff were basing the diagnosis on the proper medical definitions o f the time but there is no way o f knowing if some “stillbirths” were omitted and if some “spontaneous abortions” were included as a stillbirth. A fourth limitation pertains to mortalities that may have occurred beyond the early post partum period. There were probably perinatal deaths occurring after the first few days o f delivery that were not recorded on the labour and delivery forms. There were some neonatal deaths recorded in the labour and delivery book that occurred a few weeks post delivery but we do not know how comprehensive or uniform the recording o f these later deaths was. Lastly, the data reported here were for only one rural, remote, hospital and it is not clear how applicable these results are to other rural, remote hospitals. Even though the transfer rate o f women would have been probably limited, prior to the airstrip, the hospital based nature o f the data does not allow for comparisons to other populations or population based cohorts. 31 Implications for Practice Bella Coola appears to use a low intervention philosophy to obstetrical interventions. Other practice implications include how to shift fi-om best practice guidelines into actual practice. Recommendations to decrease cesarean sections rates has not made a dramatic impact on the rates as best practice recommendations did the forcep use and episiotomy rates. This implies that there are other factors other than knowledge o f guidelines that impact on this procedure such as the fear o f litigation, the normalization o f cesarean section, and the expectations o f perfect birth outcomes. Implications for Future Research Perhaps people working in other rural hospitals could look in their old safes to see if they too, have similar obstetric data sets that could also be summarized and compared to the results presented in this thesis. Future research into what factors influence decision making in physicians in rural verses urban is warranted in order to understand what would impact or assist in decreasing forcep, episiotomy, and cesarean section rates to meet the current recommendations. As well, it would be o f interest to research physician characteristics how other factors such as culture, education, personality, experience and others influence low versus high intervention approaches in obstetrical practices. Implications for Health Policy This study illustrates that to increase physicians practicing rural obstetrics there needs to be changes made to the education o f physicians. There is a need to provide appropriate training for rural practice as well as offering educational opportunities for practicing physicians (The College o f Family Physicians o f Canada, 2002). As well in order to decrease certain interventions there needs to be better evaluation and critique o f current rural and urban obstetrical procedures and a way o f encouraging facilities to lower their rates without disciplinary actions. Decreasing cesarean sections and encouraging vaginal birth after cesarean is a logical model with a sound body o f research with positive economical and patient outcomes. 32 CONCLUSION The data presented in this research thesis supports the position that rural hospitals like the Bella Coola General Hospital have been offering, and continue to offer relatively safe obstetric services to local residents. The absence o f immediate specialist backup and advanced technological support has not resulted in an obvious substandard level o f maternity or obstetrical care. Trends in maternal mortality, perinatal mortality, as well as in use o f episiotomy, forceps, vacuum extraction, and cesarean section mirror that recorded for British Columbia, Canada, and the United States. Episiotomy, forceps, and cesarean section rates were, however, lower than rates reported for British Columbia, Canada, and the United States suggesting the physicians in Bella Coola had a low interventionist philosophy. The newborn condition data is unique and there is nothing with which to compare it at this time. The results in this thesis are relevant to both health care planners and to women struggling to deeide whether they should stay or leave their isolated rural eommunities to give birth. Local residents can be reassured that choosing to stay home does not expose them to greater perinatal risk. Being able to stay in their home community for delivery has many benefits including 1) a avoidance o f travel and accommodation risk and costs; 2) the avoidance o f unnecessary specialist consultation; and 3) statistically lower rates o f adverse perinatal outcomes. The obstetric literature strongly suggests that there are worse outcomes associated with delivering low risk mothers in large tertiary care centers. With Canada’s vast geographic area and large rural base, there is an obvious need for rural obstetrical care. Studies report better labour and delivery outcomes if ‘low risk’ rural woman give birth in their own community surrounded by family and friends (Gagne et ah, 1998). There is also ample evidence to support the claim that rural obstetrical care is safe and that rural family physicians can practice obstetrics without an obstetrician (Hutten-Czapski, 1998). 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Retrieved 12/22/02 from www.who.int/reproduetivehealth/publieations/MSM. 40 Definitions Best Practices: Planning and/or operational practices that have proven successful in particular circumstances. Best practices arc used to demonstrate what works and what docs not and to accumulate and apply knowledge about how and why they work in different situations and contexts (Definitions o f Best Practices on the web, 2004). Caesarean Section: removal o f the fetus by means o f an incision into the uterus, usually by way o f the abdominal wall (Thomas, 1989). Episiotomy: Incision of perineum at end o f second stage o f labor to avoid spontaneous laceration o f perineum and to facilitate delivery (Thomas, 1989). Evidenced Based Medicine: Practicing medicine by using a set o f evolving principles, strategies, and tactics, and is based on the premise that practitioners are aware o f the evidence to support their clinical practice (Kaczorowski, 1998). Forceps: A tool used in expediting vaginal delivery in times o f fetal or maternal complications (Steinitz, & Osmun, 2001). Low Birth W eight (LBW): A birth weight o f less than 2.5 kilograms (Unicef, 2004). Maternal Mortality Rate (MMR): The number o f maternal deaths due to delivery and complications o f pregnancy, childbirth and the puerperium, per 10,000 live births (Special Committee on Obstetrical Care, 1987). Operative Delivery: Refers to cesarean sections. Perinatal Mortality Rate (PMR): The number o f stillbirths of 500 grams or more (28 or more weeks gestation), plus infant deaths at under 7 days o f age, per 1000 total births (Special Committee on Obstetrical Care, 1987). Rural Hospital/Obstetrics: “Rural remote” as communities ranging from 80 to 400 km from a major regional hospital and “rural isolated” as communities more than 400 km away or about 4 hours transport time in good weather and “rural close” as widely dispersed population that are serviced by a hospital that is within 80 km o f small urban centers (Iglesias, 1998). Vacuum Extractor: Device, using a suction cup attached to the fetal head, for applying traction to the fetus during delivery (Thomas, 1989). 41 Graph 2 A v erag e P ro p o rtio n of N on-C -S ectlon B irths th a t Involved E p isio to m y 70 60 50 40 30 20 10 1941- 1944 - 1947 - 1950- 1953 - 1956- 1959 - 1962 - 1965 - 1969 - 1972 - 1975- 1978 - 1981 - 1984 - 1987 - 1990 - 1993 - 1996 - 1999 1943 1946 1949 1952 1955 1958 1961 1964 1967 1971 1974 1977 1980 1983 1986 1989 1992 1995 Years Graph 2: Average Proportion of non-C-section births involving Episiotomy 42 1998 2001 Figure 1: Location o f the Bella Coola Valley BRITISH COLUMBIA Queen Charlotte City Bella Coola V Vancouver 43 Figure 2: Bella Coola Region IM" 126“W BELLA C O O L A R EG IO N D sa 100 Ûotîfl L r[cïti;j u'iacAur L ICilInpr . ♦ \ K / Kimsquit j _ stuio 4tCi . B v lljfip llJ Falk 'Tr/. ^Alndili€ *SH w \ r \ éj Rivf M inael F o rt R u p c rI * , A ie a o n la ri» 3 VANCOUVER ISLAND si ,%rw 44