Having a Baby in Canada

General Information [1]

Introduction

Many of us remember when family doctors delivered babies. Today, in large urban centres, it seems unusual to have anyone other than a specialist deliver a baby. The Canadian Institute for Health Information (CIHI) confirms this trend. It reports that in 2000, obstetricians performed 61 percent of all vaginal births and 95 percent of all Caesarean births— many more than family physicians. There is also a difference between the city and the country. In urban areas, fewer family doctors (12 percent) deliver babies than family doctors do in small towns and rural areas, where 27 percent perform this service.

Furthermore, it is becoming more frequent for a family doctor to follow the mother only for the first 32 weeks of the pregnancy before transferring her care to other practitioners, including midwives and obstetricians.

The Canadian Institute for Health Information also tells us that

• there are few obstetricians and anaesthetists in remote and rural areas,

• the number of family doctors providing obstetrical services is declining, and

• the number of northern community hospitals that offers obstetrical care has decreased over the past two decades.

A research study cited by CIHI concludes that many family doctors don’t want to deliver babies for a number of reasons, including the unpredictable lifestyle that accompanies assisting deliveries. As these doctors know only too well, babies don’t necessarily arrive during office hours! Fear of a malpractice suit is another big reason that many family doctors don’t want to assist deliveries: There is little wrath or grief to compare to that of a family whose baby has been injured during delivery.

Clearly, health system errors are not the only cause of damaged births. Errors have, in fact, lessened. Though the number of malpractice cases launched has decreased, the monetary damages awarded by a court or as a result of a settlement usually are high. It’s no surprise, then, that the malpractice insurance fees that doctors who deliver babies pay are high. However, none of this compares with the tragedy faced by a family who has been deprived of an otherwise healthy baby because of a medical error. The burden on the family both emotionally and financially will be an ever-present source of sadness during the child’s growth and development.

One American physician advocates bringing a video camera into the delivery room, not only to record what happens during birth but also to act as a powerful record for the future in case of a lawsuit. Although most centres do allow videotaping, mainly as a record of the family bonding with the new baby and to provide some early pictures for the baby album, they require the explicit permission of all health workers in the room at time of birth. However, they will not allow its use for recording monitoring devices or other labour documents such as charts.

There is one other reason that the number of family doctors practising primary-care obstetrics is declining: the absence of system supports. Over the last number of years, as a result of services being rationalized, obstetrical services have been consolidated. That means that fewer smaller hospitals provide the service and most of the care has been transferred to one site.

Dr. Michael Helewa, past president of the Society of Obstetricians and Gynecologists of Canada, notes that in his area of Winnipeg over the past 10 years, the number of hospitals offering obstetrical services has been reduced from five to two. This is a common theme across the country. Typically, when a hospital closes its obstetrical service, the family doctors practicing in the area tend to stop assisting deliveries rather than arranging to transfer their hospital privileges to another hospital, which may be much farther away.

When we consider that specialists are scarce and family doctors are reducing their obstetrical practices, we see a troubling trend, especially if you live outside an urban centre. To get the care you need, you may have to be transferred to an urban centre. Having a baby closer to home is easier for urban Canadians than it is for rural Canadians.

As you navigate your way through the channels of the health care system, remember that this journey is a very different one than it was even a few years ago, as the statis¬tics cited above suggest. To help you, we will look at the resources available to expectant parents, emerging resources, who does what, and what you can expect within the context of somewhat limited access to people who can help you deliver a healthy baby in Canada.

Let’s look at the team that will care for you throughout your pregnancy: doctors, nurses, midwives, and various technicians.

Doctors

According to data compiled by CIHI, the majority of family doctors who practise primary maternity care provide “shared care.” This means they follow the mother for a certain amount of time before the delivery and then transfer her care to a midwife, an obstetrician, or another family doctor who does obstetrics. If your doctor is part of a group practice, your baby might be delivered by a doctor from the group and not your regular doctor. Not all obstetrician/gynecologists (OBGYN) do obstetrics. The Society of Gynecology and Obstetrics estimates that only a little over 50 percent of all OBGYNs practise primary maternity care.

To assist in delivering babies, doctors must have hospital privileges. They are usually affiliated with one hospital, so you will need to deliver your baby in that hospital. Because it is important that you are as comfortable and confident with the facility as you are with your doctor, be sure you know which hospital your family doctor is affiliated with and whether that hospital promotes moral attitudes contrary to your own. For example, should your test results indicate a severe birth defect that would cause you personally to decide to terminate your pregnancy, you will need to know that your doctor or your hospital will manage your situation in a way that is acceptable to you. Although many people have argued that the doctor will defend the hospital where he or she has privileges and thus is not the best person to ask, most doctors are very ethical people. If they know a given place has particular policies or moral attitudes and you ask the question directly, you are likely to get an honest answer. More important, any ethical doctor, regardless of personal or religious beliefs, will facilitate your decisions by organizing your transfer to another facility should such a request arise. They will help navigate your care.

Choosing a doctor when you are having a baby

The comedian Jackie Mason has a most wonderful and relevant joke: “He’s terrific! Fantastic! The best doctor in New York! He’s so great (pause) you’ll never get in to see him!” In Chapter 4, we discuss some of the general considerations that go into choosing a family doctor. Two of the biggies are experience and access.

Family doctors practising primary maternity care have training and the experience required, though there is a shortage of family doctors who practise this kind of medicine. If you are under the care of an obstetrician, he or she will have the required training and experience.

It is really crucial to find a doctor who is accessible and has either a group practice or nurses in the practice to support the doctor when he or she is not available to see or speak to you. Given the shortage of doctors who practise primary maternity care, your ability to choose a doctor may be limited. And even where there is a good doctor (family or specialist), typically he or she is so booked up that you may feel a successful appointment is conducted in sound bites. Generally, though, your care provider (family doctor or nurse-practitioner) will help you navigate to someone who does primary maternity care.

If you are lucky enough to live in an area with enough doctors to offer a choice, take into account the type of facilities the doctors have and how close you are to their office. Some doctors have ultrasound facilities close by. Proximity to the doctor and to the nearest ultrasound services will be very convenient when you are pregnant. If tests are required you will not have to travel far to get to an ultrasound clinic.

Questions to ask:

• What supports does your doctor provide after hours?

• Is he or she part of an on-call group?

• Does he or she have a nurse answer the phone?

• What is the after-hours phone number?

• What supports does your doctor have during office hours?

• Does your doctor have a nurse on site in case he or she is not immediately available?

• Are there testing facilities close by (ultrasounds, for example)?

• If something goes wrong, what do you do?

• Where will you deliver and who will deliver the baby?

Dealing with doctors when you are having a baby

Here are some tips on how to maximize your visit with the doctor that you should know when you are having a baby:

• Before your first visit to your doctor to discuss your pregnancy, get a good book on the subject.

• Compile your list of questions between appointments as issues come up and take notes at your appointments. Do not wait until the night before to try to remember your questions—chances are, you won’t be able to summon them. Leaving out the details of a symptom might have significant implications on your care. Francesca’s obstetrician had a busy practice. At each appointment he had a clear agenda of the items he needed to discuss but if she didn’t also arrive with a list of questions, the interview became quite one-sided. Francesca learned quickly to tell him immediately that she had questions written down. He would listen to all questions and answer. Sometimes, he would check things out as a result of an issue that was raised. In addition, she wrote down all his answers because often the same things would worry her again and she would have trouble remembering his exact response. It was very comforting to go back and read his point-form answers.

• Manage your expectations about the amount of time a doctor will give a patient who is low risk and doing fine. Most books talk about finding a doctor you can “talk to” but what you talk about is important too. If you have a question, an issue, a problem, or a concern directly related to your condition, you do need to be able to relate well to your doctor. But if “talk” means sharing with the doctor your knowledge about the developmental phases of a fetus, for example, a doctor with a waiting room full of patients may get a little edgy. We make this point again in Chapter 4. Many obstetricians or family doctors who practise primary maternity care have nurse-practitioners who will provide support and answers to many of your questions.

Questions to ask:

What over-the-counter medicines can I still take for:

• Fever

• Upset stomach

• Headache

Nurses

Nurses can provide many services to pregnant mothers. They include the following:

• Childbirth education

• Pre-birth counselling

• Home-care services

• Assisting labour and delivery Some nurses are also qualified to provide lactation consulting.

You might also have a nurse-practitioner as part of your team. Nurse-practitioners are nurses with special additional training that allows them to undertake some clinical services that doctors normally provide. They can order certain tests, diagnose certain conditions, and prescribe some medications. In most provinces, nurse-practitioners are allowed to practise on their own without a doctor. However, the clinical services they are allowed to provide, regardless of their training, is dependent on where they practise in Canada. Nurses are often indispensable to a physician practice. Dr. Michael Helewa is a firm believer in the “team” concept of delivering care. He has nurse-practitioners, nurses, and midwives all working together at Saint Boniface Hospital in Winnipeg.

The team approach to primary maternity care is becoming more popular in Canada. By the time Dr. Helewa walks into the examining room, the expectant mother has already had a visit with a nurse, who will have answered many, if not most, of her questions. Nurses provide both clinical support and coaching and are often better than doctors at it. As Dr. Paul Wallace from Kaiser Permanente, a U.S. not-for-profit health care organization, said in a recent conference in Toronto, “Doctors like to think they are great coaches, but they are actually lousy at coaching; nurses do a much better job.”

Anaesthesiologists (and Epidurals) We know of a family doctor who, when asked by his patient whether she should have an epidural, given that she wanted to have a “natural childbirth,” responded, “All childbirth is natural. Will that be with or without pain?” Epidural anaesthesia is used in 35 percent of births in Canada to provide pain relief during labour and delivery and is administered by specialists called anaes¬thesiologists. They also may provide neonatal resuscita¬tion. Small and rural hospitals may not offer epidurals because they need to be administered by an anaesthesiologist and require specialized resuscitation equipment, which smaller hospitals may not have. Family doctors may also give epidurals. Ask your caregiver (doctor, nurse-practitioner, or midwife) whether your hospital offers epidurals.

There are many horror stories of badly administered epidurals. Some books will tell you that you are wise to ask for the staff anaesthesiologist and not a resident, who would have less experience. However, in the hospital, the wait for the staff anaesthesiologist may be long and you may never get your epidural because he or she is busy. How big a problem is this? Junior residents do not give epidurals on their own—they need supervision by a staff anaesthesiologist. Senior residents may proceed with an epidural but with the permission of the attending or staff anaesthesiologist. Still, it is wise to ask how many epidu¬rals the resident has administered. If you are in a hospital that delivers a lot of babies, there is a good chance that the senior resident is every bit as good as the staff anaes-thesiologist and has lots of experience. After all, that is what you are looking for, experience. Practice makes perfect in medical care as well as other endeavours.

If you have decided in advance that you do not want to have an epidural, ask your doctor what to do and who to speak to if you change your mind. It is also good to know whether there is a point beyond which an epidural should not be given and what that is. Ultrasound Technicians and Ultrasounds Ultrasounds have become one of the most commonplace tests undertaken during a pregnancy. The job of the ultrasound technician is to administer the test by scanning your abdomen. The technician’s job ends there. Yes, these tests are considered safe but they are tests nonetheless. The validity of the test is in the interpretation of the results. Although ultrasound technicians are incredibly well trained and know how to read an ultrasound very well, they don’t have access to certain information, nor are they trained to diagnose.

A trained person—usually your family doctor or obstetrician—must read and interpret the results. If the results are not well read or not read within the context of other tests or clinical findings, you can be given a false sense of security. An ultrasound alone does not provide for a complete diagnosis and the technician does not have access to this other relevant information. A technician can show you the heartbeat during a routine ultrasound as he or she is taking fetal measure¬ments. But if the doctor is worried about something and needs answers, a trained physician must view the film, assess other information, and report back. This is often unpopular with worried expectant mothers. Many ultrasound techs have suffered tongue lashings at the hands of mothers desperate to know the outcome of these tests. This is understandable. But it is not fair to the techni-cian and it is not good medicine.

Two things that an ultrasound clinic must have are the following:

• Certification that it meets standards in your jurisdiction

• Certified physicians to read the results Some ultrasound clinics will provide, for a fee, a 3D picture of your baby. These services are not for the purpose of diagnosing problems, though—they are basic photo ops for your unborn child. Many members of the medical profession frown on the use of these tests for reasons other than monitoring the baby. Ultrasounds use energy waves that produce heat. Subjecting the baby to any interventions for purposes other than diagnosis is generally not a good idea.

Midwives

Many women reportedly prefer midwives because they feel that these practitioners will take more time with them. Midwives have a knowledge of obstetrics and provide care for women in all stages of pregnancy, including labour, childbirth, and postpartum care up to six weeks after the baby is born. As CIHI reports, regulated midwives (and to some extent unregulated midwives) can and do help deliver babies just like a doctor. Where there are complicating factors, you will require medical help from a doctor. Until the early 1990s Canada was one of a few countries that did not have midwifery legislation. However, this service is now regulated in most parts of Canada.

What does regulation mean? Regulated midwives can prescribe certain medicines and they can order appropriate tests during pregnancy. However, regulation of midwifery does not automatically mean that these services are covered by public insurance in every province and territory. And where they are allowed to deliver babies (at home, in hospitals, or in birthing centres) also differs from coast to coast. In Canada midwives are registered with and regulated by the College of Midwives of their province. There is no national regulatory body for midwifery. As a result, there is quite a patchwork of regulation and funding for midwifery across the country. Some provinces still do not have legislation for midwives.

In some provinces, practising midwives do not have hospital privileges. In other jurisdictions, midwifery services are not funded and women who want to use a midwife must pay for it themselves. Training require¬ments also vary from province to province and, therefore, so too do the services that midwives are permitted to perform. In some provinces, they can assist births in hospitals just like doctors. In others, they provide mostly support and education throughout the pregnancy, birth, and post-birth period. It is very important that you consult the website of the Canadian Association of Midwives (CAM), listed in the Resource section, to find up-to-date information regarding the regulation, legislation, and funding of midwives in your province or territory.

Tip: If you have chosen to use the services of a regulated midwife and you want to know about a possible birth defect, make sure you request the appropriate test. Doctors will usually automatically offer you that choice. Regulated midwives may not. The chart below shows these cross-country discrepancies as they existed in 2004. Although more women are reportedly choosing midwives to deliver their babies, it would appear that the vast majority of these births are also physician assisted.

Midwifery is not supported very well in Canada. Midwives are only allowed to have 50 to 60 clients annually in some jurisdictions, making it difficult for it to be a viable profession. Furthermore, very few schools that train midwives exist in Canada. A number of Canadian and international studies suggest that there is a difference in the type of care provided by family doctors, obstetricians, and midwives. CIHI gives a detailed account of the studies in “Giving Birth in Canada” (2004).

The highlights of these studies show that women cared for by midwives generally

• had fewer tests, such as ultrasounds, genetic amniocentesis, and glucose screening;

• were less likely to be hospitalized prenatally, to undergo a Caesarean section, and to give birth to preterm babies;

• were less likely to receive an epidural;

• were less likely to have their labour induced; and

• were less likely to have an episiotomy.

Tip: Episiotomies are incisions made to the opening of the vagina during the late stages of labour. The practice was based on the belief that a clean, controlled cut will reduce tearing, which could bring on complications later. According to recent studies, episiotomies do not protect mothers from severe tears. The practice of routine episiotomy has been abolished in this country. However, this procedure may have to be done under certain circumstances. These findings are not totally surprising. Patients who are also high risk and for whom these interventions are needed are those most frequently under the care of a doctor.

Doulas

A doula is a woman who is trained and experienced in birth support and provides birth support services and/or postpartum services, though she is usually not a nurse. She is independent and self-employed. She provides support to the mother and her partner during pregnancy, labour, birth, and the postpartum period. She offers emotional support (reassurance, perspective, and encour-agement), physical comfort (breathing techniques, positioning and movement, touch and massage, relaxation techniques, etc.), and informational and interpretive support to assist her clients to make informed decisions about their care.

A doula does not offer medical choices or options. A doula is employed by you and helps promote the birth you desire. She will assist you and your partner in preparing your birth plan. A birth doula can accompany you to the hospital when you have your baby and will provide support during the birthing process. Before heading into a hospital with a doula to have your baby, try to find out if the hospital is “doula friendly.” Some doulas feel that some hospital nurses frown on their presence. A doula does not deliver babies, perform clinical tasks (blood pressures, fetal heart tones, vaginal exams), give medical advice, or interfere with the advice given by your care provider. She does not take over the role of your primary support person (unless requested) but helps to guide him or her.

Tip: Ask your doctor or midwife about the hospital in which you will deliver and whether doulas fare well in that setting. Check with some friends who had a doula and who delivered in that hospital. And check with the doula! They know when and where they are welcome.

Doulas are not midwives—their training typically consists of two- to three-day seminars provided by two certifying organizations: Doulas of North America (DONA) and the Childbirth and Postpartum Professional Association. According to some research, women who work with a doula have 26 percent less chance of a Caesarean birth; have 28 percent less need for epidurals or analgesics (when desired); have a higher success rate of Vaginal Birth After C-Section (VBAC); have 41 percent less need for assisted birth; are 33 percent less likely to have negative feelings about their birth experience; and tend to have a more nurturing attitude toward their baby.

Postpartum doulas are becoming a popular addition to doula care. This type of doula provides support to new parents in the first few days or weeks at home by

• reassurance, support, teaching, and education concerning infant care (feeding, sleeping, bathing, etc.) and the new mother’s care (eating well, getting enough rest, postpartum adjustment, etc.),

• assistance with light housekeeping (laundry, shopping, meal preparation) if required.

Tips:

• Do not hire a doula if you are hoping for help making medical, clinical, or moral decisions regarding your pregnancy or your child. A doula will obtain information to help you make informed decisions, but she will not and should not make decisions for you.

• Interview two or three doulas to find the one who best suits you and your partner—after all, you will probably be spending a fair bit of time with her!

• Request references or ask friends for referrals.

• Ask your caregiver about his or her experience with doulas and also if the hospital welcomes the presence of doulas.

• Doulas are self-employed and each offers different experience and training—ask for their contracts and fees.

Doulas will not provide decision support on clinical matters, medical matters, or moral issues. They will not answer questions such as “I am five days overdue and the doctor wants to induce me on Tuesday, which will be seven days overdue. Should I say okay?” or “They want to break my water. What do you think?” There have been cases in which doulas have resigned from a case, having been put under great pressure to answer questions or help make decisions outside their mandate. This can be traumatic for the expectant mother. What Tests Will You Be Given?

The Society of Obstetricians and Gynecologists of Canada recommends a prenatal visit every 4 to 6 weeks until about 28 to 30 weeks and then every 2 to 3 until 36 weeks. After that, the visits are recommended to take place every 1 to 2 weeks until delivery. In addition to the schedule of routine visits with the doctor, women in Canada do receive a great deal of information on a number of important topics such as nutrition, exercise and breastfeeding, labour and delivery, as well as other important information about the pregnancy, the kinds of tests that will be required and why, and optional tests.

A good resource book about pregnancy can provide you with the details on what these tests involve and what they test for. It should also provide you with a compre¬hensive description for the various conditions or risks that these tests can identify. The routine care for pregnant mothers that is covered by your provincial or territorial insurance plan includes the following:

• Pregnancy test

• Medical history (both yours and relevant family history)

• Full physical checkup and internal physical exam of the reproductive organs and pelvis (the mother’s weight and blood pressure are also taken for comparison purposes)

• Blood tests for Rh blood type CBC (complete blood count) Blood sugar level Immunity to rubella (German measles), varicella (chickenpox), syphilis, and hepatitis B

• Cultures for sexually transmitted diseases

• Multiple serum screening for trisomies and anomalies (birth defects)

• Urine tests

• Pap test

• Ultrasound scanning Depending on the circumstances of the mother, a doctor may order additional tests or examinations, all of which are covered by provincial and territorial drug plans; an example of an additional test is HIV screening in pregnancy (antiretroviral treatment can be effective in stopping the mother-to-child transmission).

Some tests that screen for birth defects can be done before a child is even conceived. When the doctor feels there is a risk that a potential mother may be a carrier for certain diseases, the expectant mother is tested at the expense of the provincial or territorial plan. Some examples of diseases that a woman can be screened for are

• Cystic fibrosis

• Sickle-cell anemia

• Tay-Sachs disease

• Thalassemia If you are worried about being a carrier of one of these disorders, you should talk to your doctor before getting pregnant.

He or she can then decide on your risk factor and test you if it is appropriate. Once you are pregnant, a number of tests can be offered to ensure that your baby does not have a birth defect. These tests differ in accuracy and risk. One test, maternal serum screening (MSS), is very safe—it is done on a blood sample—and is becoming more common in Canada. The test looks for different “markers” that are analyzed, and results determine the rate of risk for birth defect and genetic anomalies. MSS tests are made up of single, double, and triple screening; recently quadruple screening has been introduced. The more screening that is conducted on the samples, the greater the chance of reducing the false positive and thus lessening the need for invasive testing. However, MSS tests are funded to different degrees across the country.

Only British Columbia, Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador cover the “triple-screen test,” which offers a more refined estimate of risk. All jurisdictions cover the single-screen test but it is not as accurate. You can opt to pay for more screening yourself. The Society of Obstetricians and Gynaecologists of Canada estimates that the out-of-pocket cost to a woman paying for the double-screen test is about $40 and the triple-screen test is $80 (figures current in 2006). You will want to consider getting a triple-screen test done if you are concerned about birth defects, even if it isn’t covered in your jurisdiction, because of its greater accuracy. Don’t forget to find out if your employer’s benefit plan will reimburse you if it is not covered by your province or territory. Amniocentesis and chorionic villus sampling, which test for birth defects, are covered by all jurisdictions for women who are either over 35, have a history of birth defects, or have been identified as high risk due to the results of other tests like ultrasound.

These tests are not covered by provincial and territorial health plans for women who do not fit these categories. Note too that these tests carry with them their own risks such as a miscarriage or birth defect. Birth Plans During the course of your visits, members of your caregiver team (doctor, nurse, midwife, or doula) may encourage you to fill out a birth plan. This plan will give direction on what your wishes are—for example:

• Whether you want medication

• Which interventions, if any, are acceptable to you

• Who you want in the room with you Midwives, doulas, and doctors or hospitals will either provide you with a form that you fill in or work with you to create one.

Check around for ideas on what to include in your birth plan. Talk to friends about what they have included. Francesca was offered the option of having an amnio¬centesis when she was pregnant and over 35. Her concerns about the safety of the test were allayed when the doctor told her that he’d never had a patient miscarry in 10 years. No one will tell you that the test is without risk, but the experience of the people doing it and that of the place you are having it done are very important factors. Hospital Choices and Length of Stay If you are like many women in Canada, chances are you don’t have much choice regarding where you deliver your baby. But if you do have some choice, here are some things you will want to consider:

• Does the hospital have high volumes of delivery? (Higher is usually better.)

• In a low-volume hospital, is there neonatal support if there is a problem with the birth? Can you be easily transferred to a more specialized setting if there is a problem? Are the doctors and nurses on site trained in neonatal resuscitation?

• In a low-volume hospital, does your physician have access to specialists for consultation?

• What kind of facilities does the hospital have for giving birth—are there birthing rooms, birth chairs, etc.?

• Is the hospital doula friendly?

• Is the hospital “baby friendly”? “Baby friendly” is a designation created by the World Health Organization and UNICEF, and given to hospitals with practices that promote and support breast-feeding. In 2003, CIHI reported that only two hospitals in Canada had this status.

By 2006 the number had doubled, and two community health centres had been added. (See the Resources section at the end of this chapter.) Even without the designation, many hospitals do promote and provide some support for breastfeeding. The Breastfeeding Committee for Canada recommends that all staff dealing with pregnant or breastfeeding mothers should have at least 18 hours of training in this field. You may hear it referred to as the “18-hour course.” If it is important to you, ask if the hospital has adopted this practice of training its staff. The average hospital stay for a healthy woman having an uncomplicated delivery is 24 to 48 hours, but the length of stay varies across Canada.

The jurisdictions with the shortest length of stay for vaginal deliveries without any instruments are Alberta, Ontario, and Nunavut. The longest length of stay for the same type of births tends to be in eastern Canada. Clearly, if there are complications, the stay is longer. However, consider that 20 years ago, women often stayed in the hospital close to five days for an uncomplicated birth. The CIHI data show that with the shorter hospital stays, there is a higher readmission rate for newborns suffering from jaundice. The data also show that a greater number of babies in Canada are arriving either prematurely or before the due date. This trend is found not only in Canada but elsewhere and is often attributed to the increased number of twins and triplets as a consequence of advanced reproductive technology.

Earlier discharge is not necessarily a bad thing if everything is going well. However, there are situations where an extra day or two can make all the difference, as Francesca found out. When she was in hospital for the birth of her child, Ontario was in the grip of the SARS epidemic (so no visitors were allowed), her husband had been hospitalized for weeks for a serious health problem and she had not been allowed to see him (also because of SARS), and her father was dying in Sudbury, a city about 250 miles (400 km) north of Toronto, where she lived. She decided to try to stay as long as possible in the hospital, where she would have food and care and support during this difficult time. But hospitals have their timelines, and if your baby is born normally without complication and you are deemed healthy— both of which applied to Francesca—then you are out. Full stop. However, as she told her obstetrician about her situation, Francesca burst into tears.

He told her not to worry and said that he would deal with it. She was able to stay a little longer, and she found those few more days made the difference between coping and not coping. When she did request that she be discharged, she felt more confident and wasn’t feeling like someone was throwing her from a train! Tip: If you are undergoing a tough situation at home and you really need a little extra time, the best advocate in this case is not your mother, your husband, or your great-aunt Gertrude (convincing though she may be). Talk to your doctor. That is the person who can judge the situation best and, if he or she feels it warrants it, intervene on your behalf. Your doctor will have pull in the hospital, but you probably don’t. Having Baby at Home versus in the Hospital The debate over home versus hospital deliveries has been raging for a long time and is not going to go away any time soon.

There are some important issues to weigh if you are undecided about the best place for your delivery. If you are interested in having a baby at home, you should be assisted by a registered midwife to lower your risk, but you should also know that epidurals cannot be given at home. If you are sure that you want an epidural, you must deliver in a medical centre. Also, doctors do not deliver babies at home. According to Statistics Canada data reported by CIHI, 99 percent of babies in Canada are born in hospi-tals.

Recently, a large study conducted in the United States and Canada by Kenneth C. Johnson and Betty-Anne Daviss concluded that low-risk, at-home births are as safe as and more convenient than hospital births. The study compared at-home, low-risk births to low-risk hospital births (assisted by qualified practitioners— doctors and midwives) and found the following about rates of interventions:

• Five percent of the women at home needed epidurals, compared to 63 percent in hospital; in Canada, epidurals are not allowed to be given at home.

• Two percent of the home-birth women needed episiotomies, compared to 33 percent in hospital.

• Forceps were needed for 1 percent of at-home women, compared to 2 percent in hospital.

• Five times fewer at-home women delivered with Caesarean sections in the event of an emergency, compared to hospital rates.

• The rate of infant deaths was similar to those delivered in hospital.

• About 12 percent of women who wanted to give birth at home had to be taken to hospital because of complications or pain.

Co-author Betty-Anne Daviss writes that “the risk for home births is very similar to hospital birth, but you have one-tenth to one-half the intervention, so a lot of the caesareans being done, a lot of the forceps being done in hospital, are not really necessary.” The study is gaining a great deal of attention around the world on an issue that remains very controversial. On one side of the debate, many women and health care providers such as midwives have felt that home birth for low-risk cases is both natural and favourable. The study seems to support this position. However, many argue that having a baby at home is risky because something can go wrong even if mother and baby are healthy and the delivery is expected to be uncomplicated.

The Society of Obstetricians and Gynaecologists of Canada is concerned that although many births may take place without problems, when there is a problem, things can deteriorate very quickly. It also points out that a home environment, while comforting, may actually interfere with the ability of the woman to get immediate care. Bear in mind that 98 percent of the data in this study came from the United States and only 2 percent from Canada. The United States tends to have higher inter¬vention rates in hospitals than Canada, so the data may not correspond well to what is going on here, and the sample in Canada is too small to be significant. In addition, the researchers compared “low risk” in both home births and hospitals.

But on closer examination, “low risk,” as they defined it, could include a lot of women who are actually higher risk by other definitions. And these women tend to deliver in hospital. For example, according to the study, low-risk women were those who delivered the child at term (not premature), had a spontaneous birth (not induced), and had a baby that presented with its head first (not a breech). Any birth that met these three criteria was included in both hospital births and home births for the purpose of the study. But women who had hypertension or diabetes, for example, conditions that could have serious repercussions on risk during birth, would have been included in their definition of “low-risk.” Women in this category would have almost certainly been advised to give birth in a hospital rather than at home. Therefore, we believe the sample is somewhat compromised.

Epidurals cannot be administered at home. Women who prefer to give birth at home are generally women who tend not to want any external intervention, including chemical pain management. So it is not surprising that the number of epidurals needed by women giving birth at home is so low. The debate will continue for a long time to come. There are examples of increased risk on both sides. Those who argue against home delivery could present a case such as this: A baby is being delivered in a home many kilome¬tres from a hospital. The cord is prolapsed (which means that the cord starts coming out before the presenting part of the baby). The baby pushing up against the prolapsed cord can squeeze off its own supply of blood and oxygen, a very serious condition that may even lead to severe brain damage or death. The timeline for help is variable but can be terribly short.

A call to 911 will not usually be sufficient, and the results may be tragic. Those on the other side would argue that medical errors are committed in hospitals when births are rushed—something, they would say, that is much less likely at home (a claim we cannot substantiate). Both sides can present statistics to support their view. And in the end, it is a personal decision that should be based on knowledge of your own condition, the condition of your baby, your medical team, and the plans in place in case of an emergency. We believe this last concern is lessened greatly by choosing hospital deliveries. Infertility Experts consider a couple to be infertile when they are unable to conceive after trying for one year.

In 2004, Health Canada in its on-line report “Assisted Human Reproduction at Health Canada” estimated that about one in eight Canadian couples experiences infertility. CIHI reports that most jurisdictions in Canada will cover tests that can help reveal the reason that a couple may be having difficulty conceiving—for example, semen analysis. Also, many jurisdictions will cover some corrective treatment such as repairs to varicoceles and fallopian tubes or endometriosis cauterization. If you require assisted reproductive technology (ART), these methods are not fully covered by provincial or territorial health plans.

Ontario covers limited in vitro fertilization. A great debate is raging over whether assisted reproductive technologies should be publicly funded—ARTs can be very expensive. The question of whether a government should cover some of the cost of ART has resulted in Charter challenges in Ontario and Nova Scotia. However, the court decided in both cases that the provinces had the jurisdiction to choose, restrict, or deny coverage of some ARTs.

The most common reproductive technologies being used in Canada are

• In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)

• Artificial insemination As of 2006, Ontario is the only province that funds IVF, but it does so only for women with completely blocked fallopian tubes. IVF/ICSI treatment can cost thousands of dollars and the price varies depending on the clinic in which it is done.

Our Resources section lists the Canadian Fertility and Andrology Society, which will provide useful information on the subject as well as a listing of IVF clinics in Canada. A common thread to all the information provided is the following: The place where you have your baby is as important as the emotional support and medical assis¬tance you seek. A hospital may or may not have moral positions on certain matters. It may or may not be doula friendly or baby friendly. It may be a place where lots of babies are born or it may not be such a place. These things are important, some more than others.

If you are embarking on an interaction with the Canadian health care system to have a baby, you need to know yourself, and what you want. You need to manage your expectations and help yourself by being prepared when you see your doctor.

Did You Know?

• Rates for assisted delivery using forceps or vacuum extraction tend to be higher in East Coast provinces.

• “Caesarean on demand” is a recent phenomenon. This is the practice of booking a Caesarean section without any medical reason.

• Some women favour this practice rather than going through the vaginal birth process.

But, as with any intervention, there is increased risk. The Society for Obstetricians and Gynaecologists of Canada has issued a position statement against Caesarean section on demand. If you have had a Caesarean section in the past, this does not necessarily mean that you cannot give birth vaginally in subsequent deliveries.

Resources [2]

Books

Healthy Beginnings, Third Edition. A. B. Lalonde and Nan Schuurmans (Toronto: Society of Obstetricians and Gynaecologists of Canada, 2006). Healthy Beginnings is the only purely Canadian resource of its kind. At about $20, it provides great value and it is now available from www.chapters.indigo.ca. It can also be ordered through the Society of Obstetricians and Gynaecologists of Canada.

What to Expect When You’re Expecting. Heidi Murkoff and Sharon Mazel (New York: Simon & Schuster Ltd., 2006).

What to Expect: Eating Well When You’re Expecting. Heidi Murkoff and Sharon Mazel (New York: Workman Publishing Co., 2005).

1,000 Questions about Your Pregnancy. Jeffrey Thurston (Irving, Texas: Tapestry Press, 2002).

All these books are exceptional. They walk you through a great deal of information in a very readable way and are recommended by many nurses and physicians. Any of them will serve you well as your reference book throughout pregnancy. WEBSITES “Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America.” Kenneth C. Johnson and Betty-Anne Daviss: 2005. You can read the study results for this paper by going to the British Medical Journal’s website.

Web MD, www.webmd.com, This website is a terrific resource to look up general medical information on conditions. An area called Pregnancy and Family includes a week-by-week guide to your pregnancy.

Organizations and associations

Society of Obstetricians and Gynaecologists of Canada 
www.sogc.org
Telephone: 1-800-561-2416
This website provides information on women’s health, including menopause, pregnancy, and general women’s health issues. It also provides up-to-date position state¬ments from the organization on a number of issues that you may find interesting.

Canadian Fertility and Andrology Society 
www.cfas.ca
Telephone: (514) 524-9009
This organization offers a great listing of fertility clinics in Canada.

Canadian Association of Midwives 
www.canadianmidwives.org
Telephone: (514) 807-3668 
The best feature on this website for women interested in knowing about the services provided in their own province or territory is the “Across Canada” link. Click on it and then on the jurisdiction in which you live to get information on the status and regulation of programs in your jurisdiction. There is also contact information about other programs. Childbirth and Postpartum Professional Association, www.cappa.net

This organization certifies doulas and its website has a resource for finding a doula. Doula Care, www.doulacare.ca, Telephone: (905) 842-3385 (for the Greater Toronto Area) or 1-888-879-3199 (for all other areas) This organization is the Canadian association for doulas and will provide you with listings for doulas as well as information about doula care, including the questions you should ask.

DONA International 
www.dona.org
DONAInternational is the international association for doulas. It provides general information and the website allows you to access doula support in your jurisdiction.

Motherisk 
www.motherisk.org
Telephone:
1-877-327-4636: Alcohol and Substance Abuse
1-800-436-8477: Nausea and Vomiting
1-888-246-5840: HIV and HIV Treatment
(416) 813-6780: Motherisk’s Home Line
Motherisk is run from the Hospital for Sick Children in Toronto. It is a service that is available to all Canadian mothers. Motherisk provides authoritative information and guidance to pregnant or lactating patients and their health care providers regarding the fetal risks associated with infection, disease, and drug, chemical, or radiation exposure(s) during pregnancy. It can help answer questions such as “What can I safely take if I have a terrible headache?”

Baby friendly hospitals and birthing centres in Canada

For the complete list of all officially designated baby-friendly hospitals and community health centres in Canada, go to The Breastfeeding Committee for Canada website at www.breastfeedingcanada.ca

Installation Hôpital Brome-Missisquoi-Perkins du Centre de santé et de services sociaux la Pommeraie
Website: www.hopitalbmp.qc.ca/
Telephone: (450) 266-5503
950, rue Principale Cowansville, Quebec J2K 1K3

St. Joseph’s Healthcare Hamilton
Website: www.stjoes.ca/default.asp
Telephone: (905) 522-4941
50 Carlton Avenue E. Hamilton, Ontario L8N 4A6 For a more complete list of Maison de naissance in Quebec, go to www.mimosa.qc.ca/coordonnees_mdn.html

Centre hospitalier Saint-Eustache
Website: www.moncsss.com

Telephone: (450) 473-6811, ext. 2185M
520, boul. Arthur-Sauvé Saint-Eustache, Quebec J7R 5B1

Maison de naissance Mimosa du Centre de santé et de services sociaux du Grand Littoral
Website: www.mimosa.qc.ca
Telephone: (418) 839-0205
182 rue de l’Église Saint-Romuald, Quebec G6W 3G9

Baby Friendly Community Health Services in Canada Mission communautaire duCentre de santé et de services sociaux d’Argenteuil
Telephone: (450) 562-4711, ext. 8237
145, avenue de la Providence Lachute, Quebec J8H 4C7

Mission communautaire du Centre de santé et de services sociaux de CLSC La Pommeraie
Telephone: (450) 266-2522
112, rue Sud Cowansville, Quebec J2K 2X2

References

[1] Unless otherwise indicated, all text from the General Information section is taken from Navigating Canada's Health Care: A User Guide to Getting the Care You Need by Michael Decter and Francesca Grosso (Copyright © Michael Decter and Associates Inc. and The Grosso Group Inc., 2006. Reproduced by permission of the authors and Pengin Group Canada).

[2] Unless otherwise indicated, all text from the Resources section is taken from Navigating Canada's Health Care: A User Guide to Getting the Care You Need by Michael Decter and Francesca Grosso (Copyright © Michael Decter and Associates Inc. and The Grosso Group Inc., 2006. Reproduced by permission of the authors and Pengin Group Canada).

Patient experiences