Author: Patricia Nicholson

The latest report from the POWER study has mostly good news for Ontario women: the province is a very safe place to give birth, for mothers and babies. Women across the province have access to high quality reproductive and gynecological care and services.

However, the data also highlight some regional variations in services. About one-quarter of babies born in Ontario hospitals are now delivered by caesarean section, with some areas of the province reporting significantly higher rates than others. Other services that varied widely by geographic location included hysterectomies – both the number of surgeries and the way they are performed.

The POWER (Project for an Ontario Women’s health Evidence-based Report) study is a multi-part, comprehensive report on women’s health in Ontario. Chapter 10 of the study, released last month, looks at gynecological and reproductive health, including maternity care, childbirth, abortion and hysterectomy rates across the province.

Dr. Sheila Dunn, physician and research director at the Family Practice Health Centre at Women’s College Hospital in Toronto, and one of the study’s authors, says that there was significant variation in findings across the province, according to geographic area. However, only two categories appeared to be affected by socio-economic status: abortion and teenage pregnancy.

‘The good news is that for most conditions care did not vary by socio-economic status,’ Dr. Dunn says. ‘It matters where you live, but it doesn’t appear to matter quite so much what your socio-economic status is.’

Regional variations

The overall rate of caesarean deliveries in Ontario was 28 per cent. Perhaps the more important number is the percentage of low-risk babies delivered by C-section: 23 per cent of full-term, single birth babies who presented in head-down position were born by caesarean. Low-risk C-sections rates varied from 17 per cent to 26 per cent in different areas of the province.

Hysterectomy rates also varied widely. The provincial rate of hysterectomies for benign gynecological conditions was 258 surgeries for every 100,000 women. However, the number was about half that in the area with the lowest hysterectomy rate (133 for every 100,000 women), and much higher in the area with the highest rate (440 for every 100,000 women).

Not only was the highest regional hysterectomy rate three times as high as the lowest, but the surgical procedures used also varied by region. Minimally invasive techniques such as vaginal or laparoscopic hysterectomy – in which the surgeon removes the uterus via the vagina, or uses small incisions in the abdomen to perform the surgery – are preferred, when possible, to open abdominal surgery. The percentage of women who had minimally invasive hysterectomies ranged from 30 per cent to 63 per cent, depending on the region.

Dr. Dunn notes that the POWER study only reports numbers, and cannot provide reasons for the differences between regions. ‘This kind of data raises questions about why there should be such a difference,’ she said. For example further research could examine whether training in less invasive hysterectomy procedures is available to gynecologists in all areas of the province.

One factor that did appear to make a difference in hysterectomy rates was education.

‘There was variation in rates of hysterectomies according to the educational attainment of the neighbourhood where the women lived,’ Dr. Dunn said. ‘For the whole province, women living in areas where there is lower educational attainment were more likely to have a hysterectomy.’

Socio-economic variations

Socioeconomic status was not a factor in most aspects of reproductive and gynecological health in Ontario. The two exceptions were abortion and teenage pregnancy.

‘I think it’s good news that socioeconomic status really doesn’t appear to affect your chances of having a caesarean section or whether or not you’re going to have a hysterectomy. But it does make a difference in terms of your likelihood of getting pregnant and delivering a baby if you’re a teen,’ Dr. Dunn said. ‘Teens living in the poorest neighbourhoods were almost six times more likely to have a birth as those living in the most affluent neighbourhoods.’

The poorest neighbourhoods also had significantly higher abortion rates than the most well-off neighbourhoods.

Again, the study results can’t explain the reason for the differences. But Dr. Dunn noted that they do highlight issues and areas where there are opportunities to develop strategies, do outreach, improve sexual health care, examine C-section rates and provide more resources for maternity care providers.

‘These kinds of questions that are raised by the data suggest opportunities to reduce those differences,’ she said.

Shared decisions

An important aspect of reproductive and gynecological health is that many procedures – including many of those with regional differences, such as caesarean section, hysterectomy for benign conditions and abortion – have a high degree of patient participation in decision-making. Dr. Dunn stressed the importance of providing women throughout the province with access to the full range of options, and information about those options.

‘The nice thing about this data is that it gives us a starting point to measure change,’ Dr. Dunn said. ‘It enables us to think about what might be done to improve the way care is provided.’