It comes as no surprise to Dr. George Arnold that the high rate of Caesarean births in Ontario is a loaded issue. Not only does it raise alarms among women about their choices in childbirth, but C-sections also cost money — about twice as much as a normal vaginal birth.

So last year, the chief of obstetrics at Markham Stouffville Hospital and his staff set a new goal — to safely reduce their Caesarean rate, which had climbed to nearly 30 per cent of its 3,000 annual births, to 25 per cent by the end of 2011, which works out to about 150 births.

They decided on a few key strategies, such as tightening policies on inducing childbirth in women past their due date, and educating patients about the option of aiming for a vaginal birth even after a previous Caesarean.

By year-end, the annual C-section rate was down to one in four women, saving the hospital roughly $70,000. In the month of December, it was 22 per cent.

“We’re excited about what we’ve been able to accomplish in a short time,” says Arnold. “So the trend continues.”

He says it’s proof that hospitals can target specific areas where they can be more efficient and cost-effective and make small changes that translate to large savings across the system.

Caesareans made headlines last week when Ontario Health Minister Deb Matthews suggested that curbing the procedures would help ease the soaring health care budget and hinted at the possibility that “elective” C-sections might no longer be covered by the Ontario Health Insurance Plan. She later backed off and stressed they will not be delisted.

Health care experts responded that the notion of cutting such services makes no sense because the issues are complex and it should be up to patients and their physicians.

“We should not wish for a health-care system where decisions about whether we are entitled to services are in the hands of a clerk armed with a checklist,” said Dr. Ellen Tsai, a Kingston pediatrician and medical professor at Queen’s University.

Arnold says it makes more sense for hospitals to look at their own practices and data to find potential changes that can reduce costs without jeopardizing patient safety.

According to the Canadian Institute for Health Information, Caesarean births in Ontario cost an average $4,863 versus $2,486 for a vaginal birth without interventions. When staffing and other fixed costs are considered, Markham Stouffville estimates savings of $70,000 as a result of reducing C-sections last year.

The rate had climbed gradually until it exceeded the Ontario average of 28 per cent, which is above the national average and almost twice Manitoba's rate, according to numbers from the Institute of Clinical Evaluative Sciences.

At the same time, the birth unit was facing a budget crunch that meant they could either cuts costs or reduce their deliveries.

“We looked at the rate and said, okay, is there a way of getting that back down?” says Arnold. “We got complete buy-in from the beginning.”

Also important were the hospital’s midwives, who play a strong role and advocate for natural childbirth. While caesareans are necessary in certain cases, the Association of Ontario Midwives stresses that vaginal birth is safer and that midwives have an average C-section rate of 15 per cent, which is in line with World Health Organization recommendations (though it’s important to note their clients are highly motivated to seek natural birth).

A logical place for the hospital to start looking was inductions. The numbers showed 25 to 30 per cent of women were being induced, many of them only a few days after their due dates. And when mothers don’t go into labour naturally, the chance of C-section is considerably higher.

The hospital changed its policy so that unless there is a problem with the mother or baby, physicians are encouraged to wait until 10 days after the due date before artificially trying to bring on labour. Arnold says the impact was evident within two months. Inductions were cut in half, and Caesareans started to decline.

The birth centre also launched a campaign to educate women about the benefits and risks of attempting a vaginal birth after a previous Caesarean (VBAC). They distributed literature and held information sessions twice a month. Many women don’t know VBACs are a viable option and historically many physicians have been reluctant to try.

Last month, 24 were performed at Markham Stouffville and Arnold says on average, 85 per cent of women who planned one last year were successful.

One of them was Lisa Williams-Rozario, 40, who has had four babies at the hospital. Her youngest, Carter, is 11 months old.

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Eight years ago, she gave birth to her first child Jake in an emergency Caesarean after being induced and going through 19 hours of labour that stopped progressing. She found the surgery traumatic and painful with a long period of recovery and wanted to do everything possible to avoid another one.

She was “ecstatic” after delivering Tyson, now 6, in a vaginal birth and then again for her youngest two children.

“It was very important to me,” says Williams-Rozario. “I was glad that I stood my ground, though I didn’t put anybody at risk.”