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By George D. Carson
and Wendy Levinson
SASKATOON, Sask. – Birth is the most common reason that Canadian women are hospitalized each year. It’s also the root of unnecessary care.
More than 350,000 babies were born in hospitals across the country last year. And the most common in-hospital surgery is caesarean section delivery, with approximately 100,000 performed annually. So obstetricians and gynecologists provide a lot of patient care, for pregnancies and other aspects of women’s health.
A recently-released report from the Canadian Institute of Health Information found that up to 30 per cent of all health care provided offers no value to patients. Knowing this, it’s time to ask if women are being given unnecessary care, not only during pregnancy and labour, but throughout their lives.
The Society of Obstetricians and Gynecologists of Canada (SOGC) recently joined Choosing Wisely Canada, a clinician-led campaign to reduce unnecessary care, and in consultation with their membership developed an evidence-based list of recommendations: Ten Things Physicians and Patients Should Question.
The list includes unnecessary tests and procedures in labour, delivery and gynecological care that offer no value to patients and may cause harm. Unnecessary care is also costly to the Canadian health-care system.
Such guidelines would have helped Tracey and her care providers. Tracey was pregnant with her second child after a successful, healthy first pregnancy. A care provider recommended a Doppler study of the umbilical arteries. But evidence shows that Doppler studies are helpful only for high-risk pregnancies. In low-risk pregnancies, this intervention most often leads to false positives.
This is exactly what happened with Tracey. Abnormal flow in the umbilical arteries was seen on the ultrasound and so she underwent multiple ultrasounds and blood tests to ensure that the growing baby was safe.
She lived in a rural location and had to make several trips to the referral hospital for assessments. This caused her a great deal of unneeded anxiety and wasted resources.
It turned out that all was normal and Tracey had a healthy baby. The Doppler study was inappropriately applied at a cost to the patient and the health-care system. This is why the SOGC recommends Doppler studies be reserved for high-risk patients only.
Another item on the list of 10 cautions for unnecessary routine care is a routine episiotomy.
Episiotomy is when a cut is made right before a baby is delivered to try to widen the vaginal opening and reduce potential tearing. But evidence shows this pre-emptive cut can lead to increased pain, longer periods of healing and complications down the road. Sometimes, in an emergency, an episiotomy is needed but it should not be done routinely.
Another of the 10 cautions is continuous electronic fetal monitoring. Fetal heart rate monitoring has been done to ensure that babies aren’t in distress during labour. But evidence now shows that sometimes during labour and delivery, there are changes in the heart rate that can be misinterpreted by even the most seasoned clinician as a baby in distress.
Research has shown that increased monitoring doesn’t reduce birth complications, but does increase potentially unnecessary interventions in labour and increases the rate of C-sections. Obstetricians do need to follow the well-being of the fetus in labour but most deliveries are low-risk so listening to the heart rate intermittently is effective.
For gynecological health throughout life, there have been tremendous advances in screening for diseases such as cancer, but certain screening tests can do more harm than good. This is why the list includes not doing pap smears to detect cervical cancer for women under the age of 21 and over age 70.
Routine cervical cancer screening for women in these age groups hasn’t been shown to provide any benefit and high false positive rates lead to more investigations and potential harms.
Screening for ovarian cancer in low-risk women has also been shown to cause more harm than good. Studies show such screening results in a high number of false positives, causing overtreatment and complications – with no lives saved.
In medicine, as in life, more is not always better. The best medicine is based on evidence, and Choosing Wisely lists are a good reminder of how we can continue to improve the quality of care we provide to Canadian women.
George D. Carson is a clinical professor of Obstetrics, Gynecology and Reproductive Sciences at the University of Saskatchewan. He is the president of the Society of Obstetricians and Gynecologists of Canada. Wendy Levinson is an expert adviser with EvidenceNetwork.ca and a professor of Medicine at the University of Toronto. She is the chair of Choosing Wisely Canada.
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