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.
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: email@example.com
Deb Matthews (Minster of Health and Long Term Care): firstname.lastname@example.org
Or find your MPP here.