How does Drummond decide which C-Sections are unnecessary?

According to the Toronto Star, the Drummond Commission will recommend a major overhaul of our health care system, including delisting of certain procedures from OHIP coverage while reducing the incidence of others.

This is a turnaround from Drummond’s earlier insistence that he wasn’t for U.S.-style privatization. If a service is delisted from OHIP, it becomes totally privatized.

There will likely be considerable debate over these procedures, given it is economist Don Drummond, and not the Ontario Medical Association, that is deciding which have value, and which don’t. And just because it is not covered, that doesn’t mean a procedure won’t be performed if someone has sufficient cash to make it happen.

Among the most controversial will be Drummond’s recommendation that fewer Cesarean-Sections be performed in Ontario.

Throughout much of the world delivery by C-Section has been on the rise. In Ontario about one in four births are delivered by C-Section, about one in three in the United States. Ontario is only a percentage point above the national average. More than 80 per cent of women who have already had one C-Section will have another. Only 1 to 2 per cent of mothers actually elect to have a C-section.

No doubt Drummond was looking at a 2010 World Health Organization paper that suggested countries below 10 per cent were likely not performing enough C-Sections, while those over 15 per cent were overusing the procedure. The WHO paper suggests 3.18 million additional C-Sections were needed globally while 6.2 million were unnecessarily performed. The cost of global “excess” according to the WHO was $2.32 billion U.S. – resources they say could be better applied elsewhere.

The WHO has since withdrawn any recommendation on optimal percentages of C-Sections claiming there was no empirical evidence to suggest a number. Further, the data in which the study is based upon has been called into question. It all makes us wonder what Don Drummond would be relying upon as a target?

Dr. Amy Tuteur, a Harvard educated obstetrician gynaecologist, says the rise in frequency may be due to legal reasons. Of the nine most common reasons for obstetric malpractice suits, six allege failure to perform a C-section or failure to perform a C-section sooner.

Nobody seems to have a definitive answer to the rise in C-Sections, but others have speculated it may be connected to the decision by mothers to have their children much later in life. Some have suggested that it may be due to improvements in technology to detect when a mother and/or fetus are placed at risk. Others have suggested that in some countries it is far more lucrative for the health care provider to perform a C-Section than natural birth.

Given most C-Sections in Ontario are performed to protect the health of the mother and/or baby, just what would a government intervention look like? Or will the idea that a necessary C-Section may be withheld prompt at-risk mothers to seek private care?

10 responses to “How does Drummond decide which C-Sections are unnecessary?

  1. I can’t believe that the medical profession would allow an economist to tell them how to practice medicine. There is way too much armchair interference in the profession already. Run Health Care like a business is the most egregious war-cry against the human condition thus far. What more is coming down the pike. Does Mr. Drummond tell engineers how to build a bridge. Where does he get the expertise to practice medicine?

  2. Good comment ,Helen.

  3. Don’t forget the hysterectomies. According to El Drummond, women are having them too often.
    I was unaware women had hysterectomies or C-sections for the fun of it….

  4. Yes, the Star reported Drummond intends to reduce the number of hysterectomies and eliminate public funding for arthroscopic knee surgery. Apparently they don’t work — just don’t tell that to the NHL players who seem to be regular recipients of such surgery.

  5. Misleading and specious headline. It is one reccomendation among many and to villify Drummond for doing what he was commissioned to do is to ignore the simple fact that Ontario has a 16 billion dollar deficit. Changes are necessary and we all have to figure it out together. Shooting the messenger is not how we figure it out.

  6. So Don — do you have an answer as to how to decide which C-Sections are valid and which aren’t? That’s the question Drummond poses with the purposeful leak of this recommendation. We agree that changes to public services are necessary and we all have to figure it out — subsequently we wonder why Drummond never held public hearings? Drummond is more than a messenger — he was the architect of Paul Martin’s 1995 budget that most economists viewed to have cut too deeply too quickly and damaged Canada’s competitiveness in the world. Now he wants to do to the same thing for Ontario, it appears. How lucky are we? By the way, Ontario’s debt to GDP ratio is far below most countries, including our neighbours immediately to the south. It is nowhere near what it was during the Martin era, either. The deficit is a concern — its not a crisis.

  7. Don the headline is neither specious or misleading. It does not villify the report or suggest that the deficit isn’t a problem. Drummond put the spotlight on C-sections himself. He categorically states that too many C-sections are being performed. If an economist tells an obstetrician to reduce the number C-sections then it is fair, indeed prudent, to ask that economist to identify which sections are unnecessary BEFORE the procedure is performed.

  8. Ontario should think long and hard before delisting c-sections that are not considered “medically neccessary” – unless they are delisting the ones that are requested by women who are not pregnant and do not have a baby to deliver.

    A baby must be delivered one of two ways – either vaginally or by cesarean – there are risks and benefits either way, and many women have valid reasons for wanting a planned cesarean over a planned vaginal birth. In truth – the numbers of women requesting to be delivered by way of cesarean are few (maybe 1-2 percent of all women). Most of these women are planning on a small family (1 or 2 children) and as such the risks and benefits of the two methods are comparable. Women who are forced to deliver vaginally when they do not want to may find the experience traumatic – and are at an increased risk for PTSD and PPD. Furthermore the cost difference between planned vaginal delivery and planned cesarean delivery is not as great as one might first suspect – particularly when you consider the costs of repairing the damage from vaginal delivery or the costs of caring for a severely disabled child who was oxygen deprived at birth.

    The cost difference between the two planned delivery methods isn’t nearly as great as one would first assume particularly once the cost associated with repairing the damage done by vaginal birth (pelvic organ prolapse, hemorrhoid, urinary and fecal incontinance), the cost of emergency c-sections when trial of labour fails, and the cost of caring for infants with brachial plexus injuries or cerebral palsy is taken into account.

    I would suspect that if Ontario does delist c-sections that are not “medically neccessary” that they would be at risk of a lawsuit on the grounds that doing so violates a woman’s charter right to life, liberty, and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice. An abortion is often not “medically neccessary” either, but I would defend the right of any woman to choose to access one if she deemed it in her own best interest, just as I defend the right of women to access an elective c-section if she deems it in her own best interest.

  9. The timing of this is interesting, since I’m the co-author of a book that is the most intensively researched volume into cesarean and specifically elective maternal request cesarean that has ever been published. The book’s title is: ‘Choosing Cesarean; A Natural Birth Plan’ and just came out this week!
    In it my co-author and I show (among many other things) that the idea that cutting access to elective cesarean will save money is not only bad economics, but even worse medicine.
    The book is available at amazon.com and will be on Canadian bookstore shelves within the next two weeks.
    M Murphy

  10. It is interesting that every jurisdiction with ‘accelerated progress’ towards the United Nations’ Millennium Goal (no 5) have one thing in common – rapidly rising cesarean section rates. The four countries who were specifically mentioned in a report looking at the progress of 181 countries, have some of the most rapidly rising – and in the case of three of them – some of the highest, rates in the entire world. These are Egypt, China, Equador and Bolivia. Only Bolivia’s number is still relatively low, but has more than doubled lately. In China it is over 50% (90% in the private sector), Egypt and Equador approaching 40% in the public sectors and much, much higher in the private sectors. Even in First World countries the relationship between rising cesarean rates and lower perinatal and maternal mortality rates are clear, from Florida and New Jersey (the highest C-section rates in the US), to Europe, where the perennially ‘natural birth nirvana’ of the Netherlands, with a low cesarean rate of about 14%, has one of the highest mortality rates in Europe, and persistently so, revealing the lie of the WHO’s now discredited 15% C/S ideal rate limit.
    The focus on getting the magic number down, is false economy, false medicine and unfortunately, because of the false perception of elective maternal request cesareans being the request of only vain, ‘too posh to push’ prima donnas, this makes for an easy target. What needs to happen is to look at UNWANTED cesareans and try to get that number down, not the WANTED ones, which at the moment anyway, is still a small overall number.

    As for economics, it is very easy to shoot holes in the argument that elective cesareans cost the state a lot of money. The problem is that the politicians are going to look at the cost of a successful vaginal delivery and compare that to an elective cesarean delivery – and predictably, will find a difference in line with their a priori belief. The problem is that the MOST expensive type of delivery also starts as a ‘planned vaginal delivery’, but up to a third of these end up as an emergency cesarean, or worse, a failed instrumental delivery and THEN an emergency delivery. Also, cost comparisons usually do NOT include the litigation costs of when things go wrong (why do you think Obstetricians carry the highest indemnity insurance premiums of all specialties), nor the down-stream costs of vaginal deliveries (damaged babies, pelvic floor surgeries for incontinence and prolapse – billion dollar costs for each of these), the business costs of vaginal birth (doulas, midwives, birthing classes, etc. etc), nor take into consideration any of the other downsides with significant cost of vaginal deliveries like the numbers of women traumatized (200,000 per year in the UK and one third of women in Australia with PTSD symptoms and a further 10,000 with a clinical diagnosis of PTSD (post-traumatic stress disorder) in the UK. Just have a look at the reports on the website of Birth Trauma CAnada. There are horrendous birth stories, but not ONE of those pertains to elective cesarean birth.

    Targeting women who CHOOSE cesarean is easy since they don’t (yet) have a voice or any political clout. It is however not fair and NOT in the population’s best interest, economically or otherwise.
    Magnus Murphy

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