Ontario plans to save money…will open two birthing centers

Oh my sisters…why do we do this to ourselves?

Dalton McGuinty announced that Ontario will provide funding to open two birthing centers, run by midwives, as a pilot project.  Ontario, as you might know, is facing a 16 billion dollar deficit and large cuts to public spending are looming.  So why agree to fund some birthing centers, now, in this age of austerity?

I think we all know the answer to that question.

Midwife assisted birth saves money.  Midwife assisted birth, according to the CBC, costs 1/3 as much as birth in the hospital.

It’s part of a plan to move “routine procedures out of hospitals” and into the community.  The government is discussing the plan with the College of Ontario Midwives and the Association of Ontario Midwives.  Shouldn’t they at least have an OB or two at the table?  What about an anesthesiologist?  What about a neonatologist?  How about an LDR nurse.  Caring for pregnant women and newborns is multidisciplinary.  I have no doubt that a birthing center could provide adequate care to the majority of low risk women that deliver there.  It’s the occasional woman who runs into a life-threatening complication or her troubled fetus that worries me.

I have participated in some high risk deliveries where the risks were known beforehand.  Multiples.  Placenta previa.  Fetal malposition.  Maternal chronic illnesses like severe autoimmune disease or heart disease.  I`ve been on alert for those deliveries.  But I haven`t been scared.  It’s hard to be scared when you have a plan…and a back-up plan…and a second runner-up to the back-up plan.  When you have an anesthesia team, an OB team, a neonatal resus team all briefed and ready to go.

Oh no, I`ve never been scared during those deliveries.

The deliveries that scare me, and that scare my colleagues, are the unanticipated disasters.  Those that unpredictably go south.

Cord prolapse.  Where a labouring woman gets wheeled on a stretcher into the OR on her hands and knees with someone`s arm up to the elbow inside her trying to hold the fetal presenting part off of the cord to preserve blood flow.  Where we flip her over and induce general anesthesia as quickly as possible knowing seconds equal fetal neurons.

Post-partum hemorrhage.  Uterine blood flow at term is 700-900 mL a minute.  The blood volume of a pregnant woman at term is around 95 ml per kg giving a woman who weighs about 170 lbs at term a blood volume of 7.3 L.  That means a post partum hemorrhage could bleed her out in 10.5 minutes.  Of course, she`ll have a cardiac arrest long before she loses every last drop of blood in her body so, in reality, she could be dead in maybe 6 minutes.  Every anesthestist, and every OB, I know has at least one story of a horrific post-partum hemorrhage.  The kind where the woman ends up with central and arterial lines and a breathing tube and you empty out the blood bank.  The kind that requires a stay in the adult ICU.  The kind that sometimes requires an emergency hysterectomy.  The kind where, just prior to the emergency hysterectomy, you might want a surgeon to clamp the aorta for a few minutes so you can fill the woman back up with blood.

Pre-eclampsia.  No one can claim that they can tell you that you`re pre-eclampsia is mild or won`t be a problem.  Pre-eclampsia is one of those things that can become severe or progress to eclampsia (seizures) unpredictably and without warning.

Venous thromboembolism.  Yeah, all pregnant women are at risk for clotting disorders…a big ol blood clot in a leg vein or a pelvic vein is really an inconvenience – until a piece of it breaks off and lodges in your lung.  Or the right side of your heart.

Amniotic fluid embolism.  Rare but a lot worse than venous thromboembolism.  There was one of these in 20 years in the province where I trained and they were still talking about it.

Placental abruption.  A double whammy as the baby becomes starved for oxygen and may die and the mother becomes at risk for disseminated intravascular coagulation (DIC), a disorder with high mortality that is difficult to treat.

Uterine rupture…which can occur even if no prior uterine scar is present.  Another double disaster whammy with a compromised, hypoxic baby and a hemorrhagic mother.

Shoulder dystocia…which can occur even if the baby doesn’t weigh in the double digits and the mom doesn’t have gestational diabetes.

Hypertensive disorders of pregnancy, embolic disorders and hemorrhage cause around 50% of maternal deaths in the developed world.  None of those three disorders can be predicted with any amount of accuracy.  A seemingly low risk woman could develop any of them at any time during labour and delivery with little warning and her only hope is astute clinicians and well-trained teams that will pick up on the problem and treat it aggressively enough to thwart death.  The chances of survival decrease with delays in diagnosis and treatment.  The chances of survival decrease if transfer is required.  The hospital is not just 10 minutes away.

Birth can be low risk, but it can only be safe in retrospect.

What really gets my gall (and my husband’s btw) about these birthing centers is that they give off an illusion of safety…like they are an intermediary between giving birth at the hospital and giving birth at home.  This poll, again at the CBC website, has shows that 57% of respondents (at least, the last time I visited it) would like to use the birthing center.  Maybe this isn’t a representative sample of all women of childbearing age.  Maybe it’s heavily geared towards women who type “natural birth” and “birthing centers Ontario” into Dr. Google.  Or maybe these women are imaging a labour and delivery unit with bigger windows and more comfortable pillows and don’t realize that there won’t be much else there.

Consider this quote from a CBC story about a birthing center that is about to open in Winnipeg (emphasis mine):

“The WRHA acknowledges the centre doesn’t have the same resources as a hospital — that it is equivalent to a home birth — and women will be told this so they can make an informed choice.”

That’s right…a birthing center is equivalent to a home birth…well not exactly.   It’s like someone else’s home, really.  You give birth there but you don’t have to clean up or do the laundry afterwards.  You don’t have to rent a birthing pool.  That stuff is all done for you.

But the convenience of not having to clean up the blood and amniotic fluid and mucous and poo doesn’t make up for the fact that in a free-standing birthing center, if something goes wrong the only thing that can be done is to call 911.

And wait.

Wait while the dispatcher finds an available EMS team.

Wait while the EMS team fights Toronto traffic.

Wait and wait and wait some more.

I think there are a few things at work here.  One, undoubtably is that modern medicine has made birth so safe that we have forgotten what it was like when moms and babies used to die with more regularity.  When the first question everyone asked was, “are they okay,” not “how much did he/she weigh?”  Secondly, I think there is a deep undercurrent of misogyny in our society.  Somehow, it`s worth the lives of a couple of women here and there to save some health care dollars.  Somehow, it`s worth leaving women without relief as they experience severe pain to save some health care dollars.

Thirdly, McGuinty said that he kept hearing from young mothers that they wanted this as an option.  Well the NCB community is a vocal minority.  They are very loud advocates for what they want.  The rest of us quietly give birth in hospital and don`t crow about how great it was on facebook or message boards.  We don`t write to our MPPs or our premiers advocating for more hospital birth.

If you look at the labour and delivery unit of any hospital with accessible anesthesia coverage, the epidural rate is 75-80%.  The majority of women want effective pain relief during labour and delivery.

Women deserve good care around the time of birth.  They don`t deserve a dressed-up homebirth in order to save money.  We are worth more than that.

Let your elected representatives know:

Dalton McGuinty: dmcguinty.mpp.co@liberal.ola.org

Deb Matthews (Minster of Health and Long Term Care): dmatthews.mpp@liberal.ola.org

Or find your MPP here.

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23 comments

  1. Gwehydd · · Reply

    I love your blog more and more with every post. I’m so glad I started learning about this stuff before I get pregnant.

  2. I love this post! I really don’t think that the NCB types get – I also think that there might be a disproportionate number of ‘first timers’ who really have no idea what they are about to get into. There’s a vast difference between a woman who has given birth, even once before, and somebody who has never done it.

    Further, I think many mothers might not realize that they are electing a lower standard of care – and that if things do go sideways, they might not have the same legal footing had they gone with a hospital birth. A hospital is expected to provide you with access to a c-section – a glorified home birth isn’t, if your kid winds up hypoxic – your care providers are measured against what is reasonable in the circumstance.

    1. That is an excellent point and not one I`d thought of myself regarding legal recourse in the event of a birthing disaster.

      I agree with you that mothers may not realize that they are electing a lower standard of care. We shouldn`t be fighting for birthing centers. We should be fighting for maternity care units with large windows and comfy beds and a homey atmosphere and excellent food where, if you choose, you can labour and birth under the care of a midwife with minimal or no `medical` interventions while at the same time having the safety net of a state of the art OR and dedicated OB and anesthesia and pediatric services just down the hall…maybe hidden behind a nice organic cotton curtain.

      What really also gets my gall, and that I didn`t mention in the above post is that there is talk of one of these birthing centers being for women of aboriginal descent. It`s not enough with the residental schools and engineered poverty and third world conditions on some reserves…no, we are now going to create a place tailor-made to provide aboriginal women with a lower standard of care….ranty rant rant!

      1. Adequate mother – I couldn’t agree more, why not improve the conditions in our hospitals so that women feel like it’s a good place to be, where their needs will be met and where choosing ‘comfort’ won’t come at the price of safety? I’d have no problems with a ‘freestanding’ birth centre, if it came fully equipped with an OR and anesthesia and a NICU across the street.

        Unfortunately, I imagine that it will take a long while for people to realize the damage done (if ever). Worse, is this the beginning of a move to make homebirth/birth centre birth the standard of care for low-risk women and restrict access to hospital birth to only those who meet the definition of being “high-risk”? Will rates of epidural use plummet, simply because women won’t have access to them (ie. BC)? Do we really want to be like the Netherlands where low risk women have outcomes that are worse than high risk women?

        1. Across the street is too far…it would still require a 911 call and an ambulance transfer. Otherwise what would they do? Help a half-naked woman walk across the street with a suspected placental abruption?

          Across the hall is ideal.

      2. Michelle · · Reply

        “What really also gets my gall, and that I didn`t mention in the above post is that there is talk of one of these birthing centers being for women of aboriginal descent.”

        There are underlying (and sometimes very, very obvious) strains of racism in many classic NCB writings. It is absolutely horrifying that we are on the verge of creating an enforced 2nd or 3rd class of women’s care at all, but to condemn women to a higher risk situation (and ultimately higher rates of death, morbidity, and malpractice) because they are native born??

        Wow.

      3. Snorkel · · Reply

        “We should be fighting for maternity care units with large windows and comfy beds and a homey atmosphere and excellent food”

        Yes yes yes! I’ve often said that this should be the goal of maternity reform.

        There is some move toward this in Australia. The hospital I had my first baby in had a ‘birthing centre’. It was ONE hotel-style double room, where the oxygen machines were hidden in a cupboard, there was a double bed and partners were allowed to stay overnight. No improvement in the food though. However you had to be a multip with no complications, and you weren’t allowed ANY pain relief if you chose that room. And you couldn’t book it – first come first served. The whole concept seemed to punish women for wanting to labour in a comfy bed.

        As a primip, I ended up in a a cold, grey room without enough blankets. My partner was sent home overnight and I fought the urge to call him and beg to be taken home, because I was terrified of this prison-like cell.

        At least I got an epidural when I asked for it, and at least there was an OB on call who could assist delivery when things went pear shaped.

  3. Mrs. W · · Reply

    I was thinking ‘a la’ Calgary downtown style with a pedway between buildings….agreed if ambulance transfer is required then it’s likely not good enough.

  4. The reason you won’t hear people advocating for more hospital birth is because the option is already available, without exception, to every single woman who wants it.

    Playing devil’s advocate here, I don’t see why we should oppose a more cost-effective birthing option (the key word being option) for those who want it. As far as I understand, nobody will be forced to use a birthing centre instead of a hospital, just as nobody is forced to use a midwife instead of an OB.

    Low-risk pregnancies are not being directed towards midwifery or community-based care. Indeed, the opposite is happening in Ontario: women who want this sort of care literally sit on months-long waitlists for a midwife!

    This is not about misogyny or denying a standard of care; it is about allowing women the freedom to make their own informed healthcare decisions, whether or not we agree with those decisions and whether or not they are the same decisions we would make for ourselves.

    I had my baby in hospital, midwife-assisted, with narcotic pain relief (hey, I’m no martyr!), and that was definitely the right decision for me. But I know lots of people who have had amazing home birth experiences and who would be thrilled with the prospect of being able to use a birthing centre instead. If that means that our health care dollars are available to be spent on other pressing needs, why not?

    1. Hey OneFitMom,

      Thanks for your comment. I love your eloquent and strongly worded statement:

      “it is about allowing women the freedom to make their own informed healthcare decisions, whether or not we agree with those decisions and whether or not they are the same decisions we would make for ourselves.”

      I know I threw that mysogyny thing in there with very little explanation. Hold on everyone, I’m about to get on my soapbox!

      I don’t oppose freestanding birthing centers because I can’t imagine deciding to personally give birth in one and I don’t oppose midwifery care. I really like and respect my Canadian midwife colleagues and I love how they are helping make maternity care more humanistic. I oppose freestanding birthing centers because I believe, as a marketing tool, that they give off a false impression: that birthing in a birthing center is somehow safer than birthing at home. The fact that they are not is not likely to be readily apparent to a lay-person and the person explaining the differences between home, birthing center and hospital should not be somene who is economically invested in the outcome of that choice.

      Hospital birth may be available for every woman that wants it, but that doesn’t mean it’s pleasant.

      I strongly believe there is mysogyny still running deep within our society and that it informs healthcare policy. You see it with delay in testing and diagnosis of heart disease in women. You see it with delay in testing and diagnosis of chronic pain in women. You even see it with cancer treatment. Men can suck up enormous healthcare dollars converting a 3 hour operation into a 6 hour one to have their prostate taken out by a robot with very little measurable benefit but we can’t seem to coordinate resources to allow women with breast cancer to have a reconstruction at the same time as their mastectomy.

      I have no doubt, none at all, that maternity care would look very different if those with the power to make decisions for the last few hundred years were those giving birth. I don’t think saving money would be an issue then. I think maternity care would be all single room, natural light, soothing beautiful decor, movement during labour, birthing pools, choice of pushing position, pain relief on demand ranging from doula support to epidural and everything in-between, delicious fresh and healthy food for the entire family, a queen sized bed for the family to sleep together in afterwards, choice of bassinet or co-sleeper, post-partum personal doula/ lactation consultant, post-partum length of stay based on the family’s needs, rooms with a second bedroom for other children with childcare and a supervised playroom down the hall etc etc. Oh, and an unobtrusive OR and NICU down the hall (probably the opposite direction from the playroom!)

      I would strongly support adding midwife units to hospitals. I would strongly support renovating existing maternity units so that they get closer to the ideal above – heck I would donate money to that kind of a project. I think throwing a small amout of money at a birthing center pilot project does very little to improve maternity care overall. I think it’s great PR. I’m not sure maternity care is where we should be saving money and I don’t think health policy decisions in general should be firstly based on frugality.

      1. You are, of course, wise to an entirely different “insider” perspective on the healthcare system. I had never considered the system to be misogynistic, but then again, I can only base my opinion on my very limited personal experience.

        I have to say that despite the fact that the hospital in which I gave birth was probably as progressive as it gets in this country (single room care; choice of lighting and music; full freedom of movement during labour; jetted tub; ability to eat and drink; etc.), it still felt like a hospital. We still had strangers (staff) wandering into our room at will when we were trying to rest. We had to turn the lights on at 8:00 A.M., only five hours after finally being able to go to sleep. The beds were uncomfortable. The food was abysmal. Actually, abysmal is an understatement 🙂

        We spent only 18 hours in hospital, and we absolutely could not wait to get out of there and back to our home at the soonest possible opportunity.

        So yes, our maternity wards need work. But will it ever be possible to integrate a home-like birthing centre environment into the medicalized environment of a hospital? I’m not so sure. Perhaps there would be value in creating birthing centres that are self-contained entities within the hospital premises?

        1. “Will it ever be possible to integrate a home-like birthing centre environment into the medicalized environment of a hospital?”

          I think so. I really do. A self-contained birthing center within the hospital would be a good stop-gap measure and, as I stated above, I would fully support that sort of an initiative. But I still think the end-game should be a homey maternity unit that integrates midwives, family docs and OBs and has them all working together. If we can make home-like units for palliative care, we can do it for partuition.

          There is no reason why a higher-risk woman shouldn’t have the same comfortable surroundings as a low risk woman. There is no reason that low-risk women should have to make a trade-off between their safety and their comfort.

  5. “What really gets my gall (and my husband’s btw) about these birthing centers is that they give off an illusion of safety…like they are an intermediary between giving birth at the hospital and giving birth at home.”

    Absolutely. Due to successes of modern obstetrics, people seem to assume that all will go well regardless of where you give birth, and hence focus increasingly on irrelevant details.

    While pregnant with #2, I accidentally did a visit to a birth centre. The instructor gave us a guided tour of the birthing suite with the tub, the neutral decor and tasteful curtains. She presented the vials of aromatherapy oils and the iPod docking station and the crowd murmured approvingly. She joked that the bed is not for lying down, as ‘now we know better than that’. She pointed to the tub and said that “water is officially classified as pain relief”. The other attendees seemed impressed. However, what I saw in that room was this: lack of OB care, lack of adequate pain relief, and lack of NICU care.

    …. And as it turned out, the hospital where I had my #2 had pretty curtains too (as well as a tub, excellent midwives, an anesthesiologist, OB/NICU down the hall, and a cafe with good coffees for my husband.

    1. Michelle · · Reply

      “She presented the vials of aromatherapy oils and the iPod docking station and the crowd murmured approvingly.”

      Snake oil is always well packaged, isn’t it? *snark*

  6. Sounds like bribing mothers with non-medical frills to forego medical services that might be of benefit to themselves or their children and accept an increased risk of a catastrophic outcome (still birth, severe birth trauma, etc.). Can you imagine if they started saying to cancer patients – the cost of treatment is $x – we are willing to send you on a lovely vacation (saves the system $y compared to actually treating the patient) if you decide to forego treatment – just sign away your right to receive the medical services and get the trip! What’s seriously not funny is that somehow doing this to women and their children is A-OK!

    How about allowing a place with privately paid for frills that has publicly paid for medical services?

  7. BeckyA · · Reply

    This last Friday I had my daughter via emergency C. It was cord prolapse, the team was so good and had her out in four minutes. ( I was having my cervix checked when my water broke and the cord slipped out.) Her apgars were 7 and 10 at one and five. The nicu team leader told my husband that we had made their day. The work they did was truly miraculous.

    1. Congratulations!

  8. Tessa Tewksbury · · Reply

    I was treated very badly in my first birth experience. My doctor was awful, the L&D nurses were mostly awful. They were cold, insensitive, and some even mocked me for being a patient that cares to take an active role in my healthcare, ask questions, and even be informed ahead of time and have specific, evidence based preferences. I was coerced into an unnecessary induction by the csection happy doctor. After 14 hours of labor, conveniently around 8pm and the doctor wanting to go home, and no complications in labor besides what could have been a physiologically normal and acceptable stall in labor (no progress in 1 hour – no, we are not all text books that dilate 1 cm per hour), I was then coerced into an unnecessary cesarean. I was given no emotional support, and even told insensitive, rude things because I was crying. One nurse even insinuated that I did not care about the health of my baby and ONLY cared about a vaginal birth, when in fact, I was traumatized by the way I had been treated, had a very normal fear of surgery, and suddenly everything was spiraling out of my control. Word from the wise: “Healthy baby is the only thing that matters” Is a phrase that should DIE! No, the correct choice of language is that a healthy baby AND mom are the most important, but no, they are not the only thing that matters, because a csection is more than just another surgery or another day at your job, it is a life changing event in a mother’s life that she will remember until the day she dies. Baby and mom’s health are the most important, but her feelings, her emotional health, should not be ignored, and hospitals and care providers would do themselves a favor if they recognized this fact, and started treated birth as the hugely special, once, twice, three times in a lifetime experience that matters very, very, very much to an expectant mother.

    The fact is, if I could birth easily and vaginally, I’d likely be choosing to do it at home because of the experiences I’ve had and the very reasonable lack of trust I have for hospitals and OBGYNs that see me as nothing but as money signs and a cadaver to cut into. For far too many, things are done for convenience or due to ignorance, such as inducting at 40 or 41 weeks when there are no medical indications, or inducing for fears of “big baby”. Women that do not want to interfere with the natural process without a medical indication are coerced with lines like “do you want to kill your baby?” and “I’m the doctor, I went to school”. However, it doesn’t take a doctorate degree to know when a doctor is coercing a woman into an unnecessary intervention for reasons of convenience. I know many women who have had midwifery care, and the care they received was outstanding. By far, the prenatal care and dietary counseling they received far surpassed that of the typical 15 minute, hear the hearbeat, pee in a cup, and shew you out the door OB appointment. I absolutely see the logic that in serious, life threatening situations that cannot always be predicted, how a birthing center or homebirth can be worrisome for those that have perhaps dealt with those complications… but the fact is, women are demanding evidence based care, and are just not getting that in the hospital, but are finding it with midwives. They are finding a better atmosphere in which the women that delivers them is the person who sees them throughout the pregnancy, labor, and even the aftercare, instead of the onslought of new nurses who you do not know, you do not trust, you do not have a close, personal relationship with, and will never remember their name or face. Birth is a very special time for some women, and hospitals quite simply are not respecting or honoring the special time that this is.

    1. I’m sorry that you had a bad experience. I agree with you…a healthy baby is NOT the only thing that matters. We need healthy mothers too and psychological health and the absence of distress is an important outcome that is not well measured or appreciated in maternity care (and much of hospital care I might add).

      Good and bad providers exist no matter if they are OBs, midwives, family doctors or nurses. I found compassionate evidenced based care with an OB and with the LDR nurses in hospital where I chose to give birth.

      Tarring all of one type of provider with broad generalizations (ie OBs = bad while midwives = wonderful) does not help in the quest to improve maternity care and something I myself need to be mindful of as I continue to blog.

  9. Tessa I agree you had a terrible experience that should not happen. But we shouldn’t throw out the baby with the bath water. Build birthing centres staffed with midwives next to hospitals not 5 miles away in busy downtown toronto traffic. Thanks dalton.

  10. While my personal preference (at this point, for my daughter in future, not for myself) would be birth with a midwife in a hospital, I am sort of sceptical about the idea of the Ontario government’s plan for birthing centres as part of some nefarious anti-female plot. I would agree with one of your posters, of course, that the use of such a centre should be a choice, and not all women will choose to use such a centre. On the other hand, I’m sort of reminded about the debate on divorce when countries like Italy and Ireland were thinking of legalizing it (which they ultimately did). Women were told how bad legal divorce would be because it would give men carte blanche to abandon their wives (one refrain was, ‘A woman voting for divorce is like a turkey voting for Christmas’ – I guess here in Canada we’d say a turkey voting for Thanksgiving). Well, guess what? In the end, most divorces are initiated by women. So I find it a bit infantilizing to say that women aren’t capable of choosing where they want to give birth.

    1. Please provide a quote where I stated women couldn’t be trusted to choose what they want. I did speculate that many of those surveyed saying they would like to use a birthing center were likely not aware of what a birthing Center is like and the resources available…heck in the last birth month club I was part of in babycenter a woman was relating how her midwife had told her epidurals would be available in these free standing birth centers (?!). And please stop emailing me demanding that I reply to your comment. Your comment is premised on a strawman not any of the arguments I made in this quite ancient blog post.

  11. Give your poor mom a break! How can she handle two little crying babies when she’s already got a big whining baby?

    theadequatemother • 5 months ago
    When I was born my grandmother flew in from another province, stayed two months and looked after my older sibling and my mother.

    When my children were born my mother, who lives 20 minutes away, came by now and again between Pilates classes and lunches out to hold the baby, coo over the baby and ask me to make her a cup of tea.

    Then she left her teacup on the end table and went home. Many of my generation have similar stories about the complete self centredness and lack of help displayed by their parents.

    I’m not sure what is behind this but it’s something bigger than NCB and hospital cost cutting.

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