48. Rural Maternity Care
Increasingly, women and their families have to travel sometimes hundreds of kilometres to access quality maternity care. This travel puts tremendous strain on expectant mothers, their families and their communities, particularly in rural and Indigenous communities, where the shortage of maternity care is experienced most acutely. We know that when women have to leave their communities to receive essential maternity care, they are under increased stress, and health risks and adverse outcomes increase for both mother and baby, even when excellent care is finally provided in distant locations, leading to increased costs to families and the provincial health care system.29
Over the past twenty years, especially in rural settings, regional health authorities have relentlessly closed small maternity units. They claim such units are either too small to be safe or not economically viable, or both. The actual data shows that such units, at least in western Canada, have been shown to be safe—surprisingly, even some without immediate Caesarean section capability. This is possible because the staff at such units easily transfer high-risk women to higher levels of care before or during labour, and because they transfer early, when problems are developing—and because medical and nursing staff are determined to keep their skills up to date. Also, hospitals that receive these needed transfers from another hospital or a home birth in progress are positive in their role.
Throughout my career I have worked with local, usually rural, communities to help keep their maternity services running. It was always a politically dangerous activity, as the regional health authorities were never happy with my intervention. It has been a struggle, as the trend is for local authorities to eliminate those services, merely to save money, even when they are functioning well and have excellent safety outcomes for mother and baby. We joke that the perfect Canadian hospital has no beds, no staff and no patients. The budget is balanced every time.
When I was evaluating maternity services in northern BC communities, I also found good examples of physicians committed to those communities in which they lived. The United Church of Canada was responsible for the medical care in several northern BC communities where all the doctors were on salary. A few other communities ran with what is called alternative payments, in which all staff including doctors are on salary. Long-term stability has been achieved because doctors and all staff have the time and the needed organization to focus on the needs of their community rather than worrying about their financial requirements. Team practice is the norm. The needs of patients and the community are addressed in a collaborative enterprise. The doctors, nurses, nurse practitioners, public health nurses and others meet regularly to develop policy, plan individual patient care and think of how they can address community health issues.
Some remote locations have so few births that maintaining an unsustainable service makes no sense. But we are in a time when loss of maternity services from well-functioning units serving their communities is actually dangerous for the women who have to travel long distances to receive service. And it costs them and their families substantial dollars to uproot themselves and pay for travel costs, lost wages for the partner and support services like babysitting.
Moreover, the data shows that when healthy, low-risk women have to travel long distances to give birth to an average-sized baby, the results are less good than if they stayed in their home community. There are many reasons for this, chief among them the loss of support during labour and birth, including the loss of a cultural and ceremonial context, especially for Indigenous women.
The family doctors who provide rural maternity care are passionate about it, and they see themselves as providing full-service maternity care, including birth and often anaesthesia. If they depart, the system radically changes. If a community loses maternity care, it tends to lose child care specialists, as well as community health workers and school health workers. Finally, although the community will be served by doctors, the kind of doctor changes. When maternity and child care are no longer in place, the doctors who serve the community are not full-service doctors. They tend to refer a lot because their skills are more limited. Unlike their predecessors, the new doctors lack a commitment to the community and don’t stay long.30
Although these are the most extreme examples of a maternity system under stress, even women living in large urban centres are finding it increasingly difficult to find a maternity provider to attend them for their pregnancy and delivery. Why do we have a growing gap in maternity care? The answer involves multiple factors. First, the number of family physicians practising obstetrics in BC and nationally has greatly declined in recent years. Furthermore, more than twenty rural maternity services have closed in BC since 2000. Fewer family physicians are incorporating maternity care into their practices, and the age of obstetricians is increasing. This maternity care gap is even more troubling when you consider that the number of births per year in BC is projected to increase from around forty thousand to more than fifty thousand by 2020.
Although the number of posts for midwife trainees has recently increased, we are still not training enough midwives. Wait-lists at most midwifery practices are far outstripping supply. The point is not to produce just any type of care provider. The type of care midwives and many family physicians provide is exactly the type of care the great majority of the population needs—care that specifically addresses the needs of the low-risk population. The approach most of these primary care professionals employ will reduce unnecessary Caesarean sections and other procedures, while improving outcomes for mothers and babies at lower costs to the system.
In some (mostly rural) settings, collaboration between midwives and family physicians can save a maternity service from going under, avoiding a loss of culture that would make a community unattractive to young families.
If our governments truly understood that midwives provide a high level of care, with far fewer interventions, resulting in overall savings for our health care system, they would strongly promote midwifery while encouraging family physicians to take on and stay in maternity care.
Public policy decisions regarding health care, especially maternity care, need to be based not on the vagaries of a year-to-year budget cycle but on the needs of women and their families, supported by sound evidence and analysis. I’ve become convinced that midwives, working in innovative and collaborative models of care with other maternity care providers, are a significant part of the answer to a system under increasing stress. Midwives can increase access to maternity care in urban, rural and underserved communities and help improve health outcomes for mothers and newborns, which is why most of us involved in maternity went into this profession in the first place.
While I was chief of the department of family practice at Women’s and Children’s Hospitals, the position afforded me the opportunity to be a part of the British Columbia Reproductive Care Program (BCRCP). At the time, the program was occasionally asked to evaluate childbirth in particular cities or regions, because of an issue that had arisen in maternity and/or newborn care. I participated in several evaluations, always by the request of the CEO of a region. We went out as a team consisting of an obstetrician, a family physician, a maternity nurse and a midwife. We would study the situation and submit a report on our findings. Our report was detailed and contained recommendations that were not necessarily welcomed by the CEO who had requested the evaluation.
The stimulus for one review was the threatened closure of maternity services in Nelson, BC. In this case, under pressure from the community, the CEO of the regional health authority requested the review. The CEO planned to close all services in Nelson except emergency care, thereby turning the Nelson hospital into a triage station on the way to the town of Trail. Surprisingly, the CEO committed himself in advance to follow the recommendations of the BCRCP team.
Nelson is in the Kootenays in BC’s Interior, seventy kilometres from Trail, on a difficult mountainous road. It takes about an hour to ninety minutes to drive the distance, unless the road is icy and snow covered. At times, the road is impassable. Nelson was considered to have a model rural hospital. It had three general surgeons, a urologist, two internists, a pediatrician and an obstetrician, and two midwives used it as well. A large group of family physicians attended births and received backup from the obstetrician and pediatrician, and the general surgeons provided Caesarean section backup when the obstetrician was occupied or away. Moreover, it was one of the first small rural hospitals that embraced midwifery, and relations between the disciplines were outstanding.
The regional health authority was determined to close all in-patient services in Nelson, designating Trail as the regional centre—despite the dangerous route from Nelson to Trail and the fact that Nelson was also itself a de facto referral centre, draining a number of small communities in its natural catchment area. Before our review was completed and received by the CEO, he advised all the Nelson specialists to move to Trail. With the exception of the pediatrician (who was determined to stay in Nelson as a consultant to the GPs), all of the other specialists were making plans to move away from the area entirely, rather than move to Trail—some to the United States.
While one of the surgeons was making plans to leave but was still in Nelson, a Nelson resident ruptured his spleen. The surgeon operated and saved his life. There would have been no time for them to get to Trail. He would have died on the way. The health authority was unmoved.
The BCRCP recommendations were limited to birth, as was their mandate. The BCRCP strongly recommended that maternity care remain in Nelson. But the health authority did not immediately follow the recommendations. It was in this heated environment that the Nelson community and their doctors invited me to make a presentation. The meeting took place in the hockey arena. I was freezing as I stood on a thin piece of plywood placed on the ice.
The community members at first exhorted the town’s doctors to take the issue to the health authority and the media. This would have taken pressure off the community members, who assumed that the doctors had the power to influence the decision. When my turn to speak came, I pointed out that the doctors would be seen as feathering their own nests and ignored. I pointed out that the only way to influence the health authority was for the community of Nelson to take direct political action and leave the docs out of it.
I suggested sitting in at their MLA’s (local elected ministerial representative) office, with baby carriages and pregnant bellies. This was done. It worked for maternity care. Unfortunately, all the specialists left for parts unknown, as they said they would.
The good and bad news is that the in-patient wards vacated by the health authority’s dictum, wards that were used by all types of general and specialist admissions, were now empty. The community recruited an obstetrician who would be on salary rather than fee-for-service. The obstetrician, a recent graduate from the University of Toronto, worked with the community to save maternity care in Nelson. The vacated in-patient space became a birth centre.
The health authority prohibited the obstetrician from doing major abdominal and gynecological surgical cases. Little did they know that this well-trained obstetrician could do laparoscopically what most obstetricians could only do with open surgery. Patients operated on laparoscopically get better sooner as well. The few major elective procedures went to Trail. The obstetrician has been in Nelson for more than fifteen years and has no intention of leaving, despite the fact that when a backup GP surgeon does a Caesarean section in his usual fee-for-service mode, the cost to the BC Medical Services Plan (MSP) is deducted from the obstetrician’s salary.
In 2014, probably based on my work in Nelson and discussions on our maternity listserv, known as Maternity Care Discussion Group (MCDG), where I have been listmaster for more than thirty years, I was invited to assist Banff with their maternity care problem. Banff is a sweet community in Alberta well known for its skiing and other recreational activities. The little hospital in Banff was a full-service hospital mainly served by GPs, a few specialists and some GP surgeons, GP and specialty anaesthesiologists, and nurses with a range of skills. They had a maternity ward and a Level 1 nursery, capable of basic newborn care. Consultations and transfer to specialists were obtained from hospitals in Calgary, 130 kilometres away. The town of Canmore is 26 kilometres away, between Banff and Calgary on the Trans-Canada Highway. In good weather it is an easy car ride. Canmore has a small full-service community hospital, including maternity care and birth.
Banff hospital at various times has had two GPs doing maternity care and births. Now there is only one, in part because the Alberta regional health authority and the Banff hospital’s CEO, in a hospital governed by a faith-based organization, actively discouraged GPs interested in birth from settling in Banff. Hence, the single-handed GP has been the sole physician responsible for births, attending about fifty births per year, for many years. Her husband, a GP general surgeon, is available for Caesarean sections.
The community is greatly supportive of this single GP and passionate about retaining maternity care, even with low birth numbers, especially because the highway to Canmore can be snowy, slippery and dangerous. Rarely, it has been completely closed. Another unappreciated or ignored factor is that Banff hospital maternity and other services acts as an unofficial referral centre for patients from Lake Louise and other small communities as far away as the BC border. Patients travelling to Banff from these distant communities while in labour and approaching birth appreciate being able to stop in Banff rather than travelling on to Canmore.
This sole GP had superior relations with the maternity care nurses, who were devoted to birthing mothers and proud of their work, despite the small size of the service. The Caesarean section and episiotomy rates and use of other interventions in birth were very low. Outcomes for mother and baby were outstandingly good, especially compared to Canmore, where a group of GPs provided maternity care. The relatively poor outcomes in Canmore compared to Banff is especially interesting, because Canmore tends to transfer to Calgary many conditions retained by Banff, which ought to result in a lower Caesarean section rate in Canmore than Banff, but it is the opposite. One can appreciate why the Banff GP does not want to go to Canmore for her births.
The CEO of Banff hospital found that staffing the maternity service was expensive because birth timing is unpredictable. She was not impressed with the excellent results, compared to her plan for the facility. Astonishingly, what the CEO had in mind was to provide destination plastic surgery at Banff hospital, something the community does not need but is a big moneymaker. She advertised this service in the US, coupling the service with reduced-fee hotel accommodations in the town. Perhaps, as some joked, a ski-and-plastic-surgery package could be sold. She began promoting Banff plastic surgery in the US before she ordered the maternity service stopped, telling the sole GP to attend her births in Canmore, a decision strongly opposed by the Banff community, who knew well how excellent the maternity care and outcomes were delivered by their GP and maternity nurses.
Advertising in the US drew private-pay Americans, because plastic surgery in Banff was less expensive than comparable care in the US, and the hospital would receive US dollars to help balance its budget—with full support from the faith-based governing group in turn responsible to the Alberta regional health authority.
The plastic surgeons and anaesthesiologists, lusting after the private American dollars, fully supported the CEO and brought along a number of the other specialists to this cause. As this scenario had reached a fever pitch, I was invited to address the community, which I did after studying the many interlocking issues. Wisely, the GP attending births stayed in the background, while a variety of very sophisticated community members spoke to the issues that would affect the community. These included highway conditions, the limited bus service that was of course unresponsive to women in labour, the cost to poor and Indigenous women and families of going to Canmore, and the loss of some supports from family unable to make the trip.
It was a large and vocal meeting, with the community selling T-shirts excoriating the CEO and addressing the issues. The MLA said some waffling things and was roundly booed. He promised to look into the problem, but the community knew he would not.
I spoke to the issues I had researched, and I clearly supported the community’s position. As I did in Nelson, I gave them the data to support their cause and supported the direct community action needed.
It was uplifting but useless in the end. The CEO refused to meet with the community and closed the maternity service. As the Banff hospital was closing, one patient came to the GP’s clinic in active labour too late to transfer to Canmore. The GP wanted to assure the health of the fetus, so she borrowed a fetal monitor from the emergency room, with the permission of the emergency room staff. The CEO accused her of stealing hospital equipment and reported her to the hospital’s Medical Advisory Committee to be sanctioned. She even involved the RCMP in an investigation. The charges never went anywhere, but still…