BC Minister of health makes short-sighted and inaccurate remarks…

In a piece in the Victoria Times Colonist a few days ago in relation to an increase in funding for home birth in British Columbia, the Hon. Dr. Margaret MacDiarmid, BC’s Minister of Health, made some very disturbing remarks.

MacDiarmid, the former president of the B.C. Medical Association, is encouraging women with low-risk pregnancies to plan their deliveries at home if that’s what they’d like, citing B.C. research published in the Canadian Medical Association Journal in 2009 as the safety standard.

As long as mothers were screened to be low-risk and assisted by a registered midwife, “there wasn’t any difference between the outcomes for moms and babies whether they were at home or in a hospital,” she said, adding it would also save the health system money.

(Read more: http://www.timescolonist.com/Health+minister+encourages+home+births+risk+cases/7481232/story.html#ixzz2BAYhYSqN)

The study she cites from 2009, Janssen et al., involved less than 3000 home births, was retrospective, and used registry data that defined perinatal mortality as mortality from any point after 20 weeks to 7 days of life.  They published relative risks for perinatal mortality but not actual numbers in the original paper.  After criticism the CMAJ published an on-line appendix of the actual numbers but in a sloppy manner with reversed column headings that resulted in significant edits and confusion for readers.  The difficulty is, because there is no detailed information available on the seven deaths in the study, its difficult to draw conclusions since we know nothing about the circumstances that lead to each mortality.

One of the authors of this study, is our old “friend” Dr. Michael Klein who has made it his life’s mission to convince physicians and nurses that work in LDR that natural birth is “better” and that women will do better if we deny them “elective” things like pharmacologic pain relief.

I think the Minister might look at both the NHS in the UK and the situation in the Netherlands.  Both have maternity systems where the majority of care is provided by midwives and where there is active policy to encourage home births…and in both cases, large prospective cohort studies have shown that outcomes in the home birth group are poorer than for those who chose hospital care (see the Birth place Study and the Netherlands Study).  Home birth rates in the Netherlands are falling.  Women in the UK under the NHS who are defined as “low risk” are often completely unable to access  obstetrical consultants, hospital births and pain relief in labour unless they have the personal means to pay for private care.  And by the way, they are HOPPING MAD about it.   As they should be.

So where does that leave BC women?  Well, before I get flamed too badly, let me say that I don’t think choosing a home birth after informed consent is obtained is a stupid choice or an unsafe choice or a choice that shouldn’t be tolerated.   I think it is a perfectly legitimate choice.  But I don’t think that saying “home is as safe as the hospital” meets any of the conditions of informed consent – an attempted homebirth results in increased risk even though the absolute value of the risk isn’t that impressive.  However it is certainly not the ministry’s place to encourage any one birth plan…especially one that has small but real increases in risk and poor outcomes.  That’s just irresponsible.  And if the motive for doing so is to “save money” then it’s reprehensible.  Homebirth won’t save anyone money as several commenters here have pointed out…you still have to fund all the back up systems to look after transfers, you still have to pay for all the complications and it would only take one catestrophic outcome (ie one child with hypoxic ischemic encephalopathy and major disability) that could have been avoided in hospital to knock out the “savings” from homebirth completely for years.

But lets drill a little deeper….why is the BC Ministry of Health (MOH) dropping a half million dollars on low-risk, predominantly caucasian, predominantly upper middle class pregant women who are all, by and large, going to do well anyway?  Why aren’t they directing their scarce resources (and we keep hearing how there is no more money for health care, right?) towards those for whom the dollars would do the most good…for example, marginalized populations like pregnant teens or recent immigrants or investing in a culturally sensitive aboriginal obstetrical program?

Could it be because…..*gasp*…….predominantly caucausian, predominantly upper middle class women (and their husbands/ partners) vote?  And that they generally vote Liberal?

These women don’t need extra funding.  They could be charged the $350 fee for the second homebirth midwife out of pocket (charging the patient for that fee, btw wouldn’t be in violation of Canada’s Health Act) and most of them wouldn’t blink ….this is a demographic, remember, that likely spent more than that for pregnancy belly photography, doesn’t pause before dropping $200 for pre-natal yoga classes and thinks nothing of purchasing $70 curve-revealing lululemon tank tops.

No, they don’t need extra funding.

The Liberals, however, need the votes.

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8 comments

  1. Given, though, that you are pro “choice after informed consent,” certainly it wouldn’t be fair to demand that the women who elect to have home births should pay $350 out of pocket for the second birth attendant, just because they can afford it? Otherwise, one could argue that women of the same demographic who are electing to have a pain-controlled hospital birth should pay for their narcotics and/or epidurals because they are able to afford them and it is a “choice.” Something to think about…

    1. I’m not sure I can follow your analogy. Those sitations aren’t equivalent. Suggesting that any one demographic pay out of pocket for any hospital or physician service violates the Canada Health Act. The CHA, though, was written prior to the licensing and regulation of midwifery. Midwifery services are currently only covered by provincial insurance in 8 provinces and one territory – and on a purely voluntary basis. I have a philosophical problem with the assumption you seem to make that pain relief in labour is an elective luxury. Is pain relief after surgery or trauma a luxury too? Should we ask well off patients to pay for their nacotics after hip replacement if they can’t just “tough” it out? What is the difference between someone in pain from labour and someone in pain because of an elective surgical procedure? If its merely an idea that labour pain is “natural” or somehow “beneficial” than that is a value discussion and it is fundamentally unethical to impose one’s values upon others. Relief of pain in labour has many beneficial effects on mom and potentially some for the baby. For example, PTSD and post-partum anxiety are less common after labours with pain relief. There are biochemical indications that placental perfusion improves with epidural analgesia. There are no indications that home birth is better for the baby, and some evidence that it is worse, although it may offer some psychological benefits for mothers who want that option.

      I am not “demanding” that they pay out of pocket. I merely wanted to point out that the BC MOH increased the resources offerred to a demographic of society that already has excellent outcomes and I think the money would be better spent on a demographic where the money could bring about real increases in health and well-being. I further posit that their motivation is not increasing the health and well-being of the population (which should be their vision, right?) but rather to acquire/ maintain the goodwill of their voter base.

  2. Actually, I don’t view pain relief during labour as a “luxury” and I never said that it was. I said it was a “choice” (in most cases). It is a choice that I personally made, and was grateful for. Likewise, it is also a “choice” to have pain relief during/after many other surgical/medical procedure (a choice that most sane people elect to exercise).

    A woman makes the “choice” to have pain relief in order to feel safer, more secure, more comfortable, happier, etc. with her birth process — and her wishes should be honoured. As should a woman’s choice to have her birth at home, where she feels safer, more secure, more comfortable, happier, etc. When it comes down to it, the second birth attendant is probably not going to provide much of benefit from an emergency medical standpoint, but if it makes a woman feel better — in other words, if it helps her to experience childbirth as much on her terms as possible — why on earth would you intimate that she should pay for it just because she can? Let’s look at the big picture here: funding second birth attendants to the tune of $350 per woman is a drop in the bucket as far as healthcare dollars go. I’m sure you could think of a lot more grievous inefficiencies and misallocations of resources within the system!

    My beef is that you seem to support the notion of “choice” in childbirth only insofar as it complies with your vision of what that should be, which is, well… basically the same thing the NCB advocates are doing.

    Whether or not the Liberals made this decision to curry favour with a certain demographic of voters, do you not support a woman’s right to choose — to whatever degree she can — where and how she gives birth? And if so, should women who choose to give birth at home not have access to additional resources to support their choice?

    1. I support choice. Absolutely above and beyond what I would personally choose for myself. My vision of what childbirth “should be” is that it should be safe, respectful and the care offered should be effective and fully explained including alternatives and their likely consequences (informed consent).

      There is choice in all aspects of health care. The public system pays for some of those choices, not all. With respect to childbirth health policy, it is my opinion that our dollars would be better spent on segments of the population that are currently experiencing the worst outcomes, rather than on a group that already enjoys the highest levels of health and well-being. That doesn’t mean I don’t respect the choices pregnant women make and I’m not sure how you’ve gotten that impression, perhaps I’m not expressing myself as clearly as I like to think I do. I certainly am not sitting here saying all women should give birth in a hospital with an epidural. That’s not for everybody, nor should it be.

      I have some questions…

      Do you think the MOH should be encouraging women to make any one birth plan?

      Do you think the MOH should be encouraging women to make choices on the grounds that they will “save the system money?”

      I hope we have some common ground on those two issues even if I’ve made you spitting mad with all the other stuff I wrote, because I think that those two issues could have some significant consequences for BC women.

  3. No, on both accounts. I think the MOH should support, financially and otherwise, women’s reasonable birth plan choices. (“I want to give birth on top of the Stawamus Chief. Please have a helicopter on standby in case things go awry.” would *not* be an example of a reasonable birth plan :))

    Back in the 70’s and early 80’s, women were essentially being forced to have c-sections after exceeding arbitrary labouring deadlines, or to have their babies removed by forceps after pushing for “too long,” regardless of mother’s and baby’s well-being at the time. My mom got caught up in that and ended up having two c-sections against her will (that both at the time and in retrospect she believed to be unnecessary). It wasn’t until the mid-80’s that she was finally was able to have the vaginal birth that she always wanted, but she had to find new care providers and really strongly advocate for her right to choose. I think the NCB advocacy movement sprung up as a response to that exact lack of autonomy. Unfortunately, the pendulum has swung too far in the other direction, and now women are largely being encouraged away from choices that don’t fit the NCB paradigm, the irony being, we are still dealing with the same fundamental issue: a disrespect for the woman’s right to choose.

    1. Very well said…except for the top of the chief cos that sounds like a great birthing spot 😉

      1. Hahaha, I won’t lie: the thought actually occurred to me, albeit briefly, while I was hiking there at 8 months.

        BTW, have you seen this?
        http://www.vancouversun.com/news/Burnaby+hospital+strategy+devised+gain+votes+letter+reveals/7521608/story.html

  4. You are a very wise person. That’s why ur not ob/gym like me. You said exactly what I thought when I read this comment. Right in the discussion the authors said there was no where near enough patients to show a difference why on earth did the editors allow conclusion home birth as safe as hospital. It is 2 to 10 times more dangerous to deliver at home versus hospital. Why don’t we fund home like birthing centres staffed by midwives attached by a walkway to an ob staffing birthing suite and let the patients/clients benefit of both models of care. Stop the either or situation and get along

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