Canadian mothers face a high rate of severe, long-term injuries from the use of forceps or vacuum in childbirth, and urgent action is needed to reduce it, the authors of a new analysis paper say.
Operative vaginal delivery (OVD) refers to using forceps or vacuum in the second stage of labour when the cervix is fully dilated. Health-care professionals may need to use the instruments if labour stalls or if the fetus is at risk.
In an article published Thursday bymedical journal BMJ, epidemiologist Giulia Muraca, an assistant professor in obstetrics and gynecology at McMaster University, and her co-authors note that Canada has the highest rate of maternal trauma during forceps- and vacuum-assisted deliveries out of 24 high-income countries. Canada’s injury rate was 16 per cent, compared to an average rate of 5 per cent for the group.
The paper says that of the more than 35,000 single infants born after OVD in Canada, one in four attempted forceps deliveries and one in eight attempted vacuum deliveries resulted in obstetric trauma — most commonly, obstetric anal sphincter injury, which involves severe tearing to the perineum.
Up to 15 per cent of deliveries in Canada include the use of forceps or vacuum.
“These rates of injuries are absurdly, unacceptably high,” Muraca said in an interview. “And there’s been … no concerted effort to reduce them. Perhaps even worse, we’re not even recognizing or talking about them.”
Births using forceps have ‘absurdly high’ injury rate in Canada, research shows
Featured VideoNew research finds that Canada has the highest rate among high-income countries of maternal trauma from the use of forceps and vacuum assistance during births. Experts say it’s a taboo topic that needs more transparency and education to prevent future injuries.
‘Worried that my son might die’
When Laura Ralph of Vancouver gave birth to her son seven years ago, she recalls it was a chaotic and anxiety-provoking experience. The doctors told her the fetal heart rate was falling and they needed to use forceps to deliver him quickly.
“At one point, I was worried that my son might die and that I might die,” Ralph said through tears.
Ralph needed a blood transfusion in the operating room. The forceps also contributed to pelvic prolapse, which happens when the pelvic floor muscles weaken, she said. In her case, her bladder fell into the vaginal wall.
Long after her son’s birth, Ralph said, she was dealing with lingering mental health issues, as well as the long-term effects of pelvic prolapse, including not being able to exercise as strenuously as she would have liked.
The Current19:43Hidden trauma of birth injuries in Canada
Featured VideoAs many as one in four births using forceps is leaving Canadian women with severe injuries, according to new research. Those injuries can have a long-lasting impact on quality of life, but it’s also a hidden trauma for many women, with little help available. Matt Galloway talks to medical experts about the risks women are facing and what needs to change.
When she later became pregnant with twins, she had a planned C-section.
Episiotomy and other options
Ralph contributed to the BMJ paper as a patient partner because she hoped it might prevent others from experiencing what she did, she said.
More severe perineal tears can lead to pelvic pain, sexual dysfunction and fecal and anal incontinence, which “can have devastating effects on social, psychological and physical wellbeing,” the paper says.
Other countries like the Netherlands, Finland and Sweden have zero per cent injury rates after they abandoned use of forceps altogether because of issues with maternal trauma, Muraca said.
Dr. Modupe Tunde-Byass, an obstetrician and gynecologist, says in trained hands, forceps and vacuum are safe. (CBC)
Dr. Modupe Tunde-Byass, an obstetrician and gynecologist focused on high-risk births at North York General Hospital, said health-care providers decide whether to use forceps or vacuum on a case-by-case basis.
In trained hands, they are still safe options, said Tunde-Byass, who was not involved in the paper. But she added that women should be empowered early in their pregnancy to learn about alternatives, including C-sections and episiotomy — a surgical cut made at the opening of the vagina during childbirth, to aid in a difficult delivery and prevent tearing.
However, Canada has moved away from episiotomy since a landmark clinical trial in 1992 found that having the procedure could cause just as much trauma as going without it for vaginal deliveries that happen after the natural onset of labour.
“It’s being demonized,” Tunde-Byass said. She added that many health-care providers will avoid performing episiotomies because they can negatively affect their quality improvement ratings.
However, both she and Muraca say that when providers correctly perform an episiotomy during operative vaginal delivery, many of the injuries are prevented.
More research from other countries is beginning to back that up, the BMJ paper says, showing less risk of obstetric anal sphincter injury when an episiotomy is performed at an angle that keeps the incision from extending into the sphincter.
Focusing on prevention
Muraca suggests Canada should take a page from the playbooks of Australia and the U.K., where lowering rates of maternal trauma is a national priority. In addition to their greater acceptance of episiotomy, they put more emphasis on prevention.
For example, she says, expectant mothers in the U.K. will receive a “bundle” of care that includes pelvic floor exercises they can do before childbirth.
Dr. Amanda Black, president of the Society of Obstetricians and Gynecologists of Canada, cautions against comparing countries as the BMJ paper did, saying the comparisons may not be fully apples-to-apples.
“Having said that, I don’t think we can discount the fact that there is some concern about the fact that our rates of obstetric sphincter injury may be higher than compared to our colleagues,” she said.
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
