Giving Birth in Canada: Providers of Maternity and Infant Care

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Giving Birth in Canada Providers of Maternity and Infant Care Contents of this publication may be reproduced in whole or in part provided the intended use is for non-commercial purposes and full acknowledgement is given to the Canadian Institute for Health Information.

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Telephone: (613) 241-7860 Fax: (613) 241-8120 www.cihi.ca

ISBN 1-55392-395-2

Cette publication est aussi disponible en français sous le titre : Donner naissance au Canada : Les dispensateurs de soins à la mère et à l’enfant, ISBN 1-55392-397-9 Giving Birth in Canada Providers of Maternity and Infant Care

Table of Contents

About the Canadian Institute for Health Information ...... v Acknowledgements ...... vii About This Report ...... ix

Birthing Trends in Canada ...... 1

Pregnancy and Delivery: Who Provides Care? ...... 3 Family Physicians ...... 5 Obstetricians/Gyneacologists ...... 8 Midwives ...... 10 Anaesthesiologists ...... 13 Nurses ...... 13 Shared Care ...... 13

Other Professionals Involved in Supportive Maternity Care ...... 15 Prenatal Educators ...... 15 Doulas ...... 15

Screening and Diagnostic Testing ...... 17

Special Challenges for Care Providers ...... 19 High-Risk Pregnancies ...... 19 Childbirth in Rural and Remote Areas ...... 20 Birthing in Canada’s Far North ...... 20 Birthing in Rural Canada ...... 21

Care in the First Weeks of Life ...... 23 Paediatricians ...... 23 Public Health Nurses ...... 24 Getting Care Over the Phone ...... 26 Lactation Consultants ...... 26

Conclusion ...... 29

What We Know ...... 31 What We Don’t Know ...... 31 What’s Happenning ...... 31 Fast Facts ...... 32 For More Information ...... 35

About the Canadian Institute for Health Information

Since 1994, the Canadian Institute for Health Information (CIHI), a pan-Canadian, independent, not-for profit organization, has been working to improve the health of the health system and the health of Canadians by providing reliable and timely health information. The Institute’s mandate, as established by Canada’s health ministers, is to develop and maintain a common approach for health information in this country. To this end, CIHI provides information to advance Canada’s health policies, improve the health of the population, strengthen our health system, and assist leaders in the health sector to make informed decisions.

As of April 1, 2004, the following individuals are on CIHI’s Board of Directors:

• Mr. Graham Scott (Chair), Managing • Mr. Phil Hassen, Deputy Minister, Partner, McMillan Binch LLP Ontario Ministry of Health and Long-Term Care • Mr. Bruce Petrie (Ex-officio), Interim President and CEO, CIHI • Mr. David Levine (Observer Status), President and Director General, Régie • Dr. Penny Ballem, Deputy Minister, régionale de la santé et des services British Columbia Ministry of sociaux de Montréal-Centre Health Services • Dr. Cameron Mustard, President • Dr. Peter Barrett, University and Senior Scientist, Institute for of Saskatchewan Work & Health • Dr. Laurent Boisvert, Director • Dr. Brian Postl, Chief Executive of Clinical-Administrative Affairs, Officer, Winnipeg Regional Health Association des hôpitaux du Québec Authority • Ms. Roberta Ellis, Vice President, • Mr. Rick Roger, Chief Executive Workers’ Compensation Board Officer, Vancouver Island Health of British Columbia Authority • Mr. Kevin Empey, Vice President, • Dr. Tom Ward, Deputy Minister, Finance and CFO, University Nova Scotia Department of Health Health Network • Ms. Sheila Weatherill, President • Dr. Ivan Fellegi, Chief Statistician and CEO, Capital Health of Canada, Statistics Canada Authority, Edmonton • Mr. Ian Green, Deputy Minister, Health Canada

Acknowledgements

The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that have contributed to the development of the report.

Particularly, we would like to express our appreciation to the members of the Expert Group who provided invaluable advice throughout the process. Members included:

• Dr. Elizabeth Whynot (Chair), • Dr. André B. Lalonde, Executive President, British Columbia’s Women’s Vice President, Society of Obstetricians Hospital & Health Centre and Gynaecologists of Canada • Mr. Jack Bingham (Ex-officio), • Dr. Carolyn Lane, Family Physician, Director, Health Reports The Low Risk Maternity Clinic, and Analysis, CIHI Calgary, Alberta • Dr. Beverley Chalmers, International • Dr. Kyong-Soon Lee, Neonatologist, Health Consultant, Centre for Research McMaster University in Women’s Health, Sunnybrook and • Dr. Miriam Levitt, Research Facilitator, Women’s College Health Science University of Ottawa, Faculty of Centre, University of Toronto Medicine • Dr. Jan Christalaw, British Columbia’s • Dr. Hajnal Molnar-Szakács, Women’s Hospital & Health Centre Chief, Maternal and Infant Health • Dr. K. S. Joseph, Associate Section, Health Surveillance and Professor, Departments of Obstetrics Epidemiology Division, Population and and Gynecology and Pediatrics, Public Health Branch, Health Canada Dalhousie University • Ms. Rachel Munday, Primary • Dr. Terry P. Klassen, Professor Health Care Nursing Consultant, and Chair, Department of Pediatrics, Government of the Northwest University of Alberta Hospital Territories, Department of Health and Social Services • Dr. Michael S. Kramer, Scientific Director, CIHR Institute of Human Development and Child and Youth Health

It should be noted that the analyses and conclusions in the report do not necessarily reflect those of the individual members of the Expert Group or their affiliated organizations.

The editorial committee for this report included: Kira Leeb, Geneviève Martin, Susan Swanson (The Alder Group), Cheryl Gula, Patricia Finlay, Jennifer Zelmer, and Jack Bingham. Other core members of the team included Nadia Ciampa, Thi Ho, Nicole Howe, Jeanie Lacroix, Vanita Sahni, and Steve Slade.

This report could not have been completed without the generous support and assistance of many others who compiled data; undertook research; worked on the print and Web design, translation and distribution; and provided ongoing support to the core team. Special thanks are also extended to CIHI staff and their families for providing the baby pictures used in this report. vii

About This Report

This report is the first in a series of four special reports prepared by the Canadian Institute for Health Information (CIHI) on the health of and health care for Canada’s mothers and infants. These reports will focus on the following topics:

• Giving Birth in Canada: Providers of Maternity and Infant Care Trends in birthing and maternity care and a look at the changing scope of practice for maternal and infant care providers. • Giving Birth in Canada: Regional Indicators Regional profiles of selected indicators of the health care and health status of Canada’s mothers and infants. • Giving Birth in Canada: The Costs Expenditures on maternal and infant care. • Giving Birth in Canada: A Profile of Canada’s Mothers What we know and don’t know about the changing demographics of mothers in Canada and about their experiences in the health care system.

Each of these special reports presents a fact-based compilation of current research, historical trends, and new data and findings to assist care providers and decision makers in planning health services in maternity and infant care. These reports complement CIHI’s ongoing reporting process and the initiatives of partners such as the Canadian Perinatal Surveillance System (see below).

1 Where the Data Come From The figure below shows the most recent completed data year for pan-Canadian health data holdings at CIHI, Statistics Canada, and the College of Family Physicians of Canada (as of

FIGURE January 2004) used in this report. CIHI data from previous years are also generally available.

2000 or 2000–2001 2001 or 2001–2002 2002 or 2002–2003 National Longitudinal National Physician Registered Nurses Database† † Survey of Children Database † ‡ Health Personnel Database and Youth † Hospital Morbidity Database Southam Medical Database† National Family Physician Discharge Abstract Database† Workforce Survey*

† Collected by CIHI. ‡ Collected by Statistics Canada. * College of Family Physicians of Canada. This report includes a Fast Facts section, to provide an expanded range of comparative data across the country. Whenever the icon to the right appears FF beside the text, it indicates that related data can be found at the back of this report.

ix x Giving Birth in Canada: Providers of Maternity and Infant Care ing link:www.hc-sc.gc.ca/pphb-dgspsp/publicat/cphr-rspc03. year forwhichdataareavailable.Itcanbedownloadedfreeofchargefromthefollow- trends atthenationallevelandprovincial/territorialcomparisonsformostrecent nal, fetal,andinfanthealth.Statisticsforeachindicatorconsistmainlyoftemporal information on27perinatalhealthindicatorsdeterminantsandoutcomesofmater- Recently, theCPSSreleasedits interpretation, andcommunicationofinformationforaction. ing cycleofdatacollectionandacquisition,expertanalysis perinatal healthdeterminantsandoutcomesthroughanongo- and EpidemiologyDivision.TheCPSSmonitorsreportson surveillance capacity,deliveredthroughtheHealthSurveillance of HealthCanada’sinitiativetostrengthennationalhealth The CanadianPerinatalSurveillanceSystem(CPSS)ispart Perinatal HealthReport2003 Building ontheCanadian Canadian PerinatalHealthReport2003 , whichincludes Highlights of This Report • Most Canadian babies are born in hospital. Obstetricians are performing an increasing proportion of both vaginal and caesarean births. In 2000 they attended 61% of vaginal births and 95% of all caesarean sections—up from 56% and 93% in 1996, respectively. The majority of obstetricians (64%) attended between 101 and 300 deliveries in 1999, whereas family physicians attended, on average, 41 births in 2000. • Most family physicians provide some maternity care, but fewer deliver babies than in the past. In addition, they are now less likely to deliver multiple births or perform caesarean sections. Instead, more family physicians are sharing care with other providers, providing maternity care for up to 32 weeks before transferring care to other family physicians, obstetricians, or midwives for the rest of the pregnancy and delivery. • Ontario researchers recently asked new family physicians who do not deliver babies about the reasons behind their decision. They tended to attribute it to concerns about their personal lives, confidence with their obstetrical skills, fee structures, and the perceived threat of malpractice suits. • The number of jurisdictions regulating and funding midwifery services is increasing. So is the number of trained midwives, and more expecting mothers are choosing midwives to deliver their babies either in hospital or at home. • Childbirth in rural and remote areas presents unique challenges. Rural family physicians are far more likely to provide obstetrical care than their urban counterparts (27% reported delivering babies in 2000, compared with 12% in urban areas). The number of northern community hospitals offering obstetrical care has decreased over the past two decades, but new birthing centres are now available in some communities. • There is a relative scarcity of anaesthesiologists and obstetricians practising in rural and remote areas, compared to urban centres. Similarly, there are lower rates of caesarean section births and vaginal deliveries with epidural anaesthesia in rural areas. • Twenty years ago, women often stayed in hospital for close to five days with an uncomplicated birth, and even longer if there were complications. Today, healthy mothers and their infants are typically discharged 24 to 48 hours after delivery. Some research indicates that readmission rates of newborns suffering from jaundice have increased following the move to earlier discharge.

Birthing Trends in Canada

Popularized through Hans Christian Andersen’s 19th-century fairy tales, the image of storks delivering babies endures today in stories and cartoons. In reality, however, babies need human help to arrive into this world.

2 In 21st-century Canada, Some Providers of Maternity and Newborn Care that help may come from in Canada any of several kinds of Many different professions provide care for pregnant care providers, all of whom

FIGURE women and their children. The graph below shows have been trained to the number of selected health care providers per some degree to assist with 100,000 Canadians in 2002. the common miracles of pregnancy and birth. Paediatric Cardiologists* 0.06 Much of this care occurs outside of hospitals, Paediatric General Surgeons* 0.18 although pregnancy and childbirth are the leading Birth Doulas**** 0.6 causes of hospitalization among Canadian women, Midwives*** 1.3 accounting for 24% Obstetricians/Gynaecologists* 5 of acute care stays in 2001–2002.1The Paediatricians* 7 continuum of care includes prenatal care and educa- Maternal/Newborn Nurses** 39 tion, screening and diagnostics, home Family Physicians* 96 deliveries, postpartum 020406080100120home support, and newborn and infant Number per 100,000 Population care during the first weeks of life. Note:Not all family physicians and obstetricians/gynaecologists provide care for expectant mothers and infants. Sources:*Southam Medical Database, CIHI; **Registered Nurses Database, CIHI;***Health Personnel Database, CIHI; ****Doulas of North America Web site (www.dona.org) This report focuses on the changing profile of the people who provide care to Canada’s mothers and infants, set within the context of overall birth and population trends. These changes are implicitly part of a larger context, and of the current debate about the future care needs of Canadians and the capacity of our health care system. Explicitly, they raise questions about how maternity care is and will continue to be provided across the country. Giving Birth in Canada: Providers of Maternity and Infant Care

2 Pregnancy and Delivery: Who Provides Care?

For centuries, most births took place in the home, with help from local midwives, friends, or family. Today, patterns of care for mothers and their babies differ around the world and are evolving over time. Internationally, the World Health Organization declared in 2000 that nurses and midwives continue to play a key role in “society’s efforts to tackle the public health challenges of our time.”2 In England and New Zealand, midwives attend seven in 10 births.3 The rate in Holland is even higher (90%), 3 Prenatal Care Choices Among Canadian Women where one third of According to Statistics Canada’s 2000–2001 National Longitudinal Survey of Children and Youth, 97% of new all babies are born in the home.4 FIGURE mothers had prenatal care. Most saw a physician (88%). However, 3% received their prenatal care from midwives. Canada’s experience is different. In a 2000–2001 Doctor survey, the vast majority Nurse (88%) of mothers reported receiving prenatal care 5 Other from physicians. Most

Provider babies are born in hospital Midwife with a physician as the attending clinical profes- Nobody sional. These patterns have been in place for 0102030405060708090100 some time, although they are evolving gradually. % Received Prenatal Care

Note: “Other” includes carers not elsewhere specified, such as holistic practitioners or friends and relatives with prenatal experience. Mothers that responded “nobody” did not have prenatal care from a person; however they may have consulted other resources, such as books, television shows, or the Internet. The percentages add up to more than 100% as respondents could have multiple sources of care. Source: National Longitudinal Survey of Children and Youth, Statistics Canada 4 Giving Birth in Canada: Providers of Maternity and Infant Care

FIGURE 4 and postpartumcare.In1994,StatisticsCanada babies today—before,during, andafterbirth. This reportprofilesthehealthprofessionalswhocareforCanada’s mothersandtheir 85%wouldacceptpostpartumcarefromanurseormidwifeinsteadofdoctor. • 21%werereceptivetotheideaofhavinganurseormidwifedelivertheirbaby • 31%ofwomensaidtheywouldbewillingtogoabirthingcentreratherthan • colleagues reportedthat: pregnancy anddelivery, andpostpartum.Usingtheirresponsestothissurvey, Wen and willingness toreceivecarefromhealthprofessionalsotherthandoctorsduringtheir Results fromearliersurveysindicatethatwomen Ottawa: StatisticsCanada Source: Note: a dropof28%. 10.5 from14.5per1,000populationin1990–1991, ratehaddeclinedto By 2000–2001,Canada’sbirth Rates Declining Birth Births per 1,000 Population instead ofadoctor;and a hospitaltohavebaby; 10 12 14 16 Time periodsare July1toJune30foreachyear. 0 2 4 6 8 Statistics Canada.(2003). 1986–1987 1987–1988

1988–1989 needs forcareandmixesofproviders. changes. Similarly, shiftsintypesofbirthsmayimplychanging infant care?Asfewerbabiesareborn,theneedforcaregivers How dobirthtrendsaffectthosewhoareprovidingmaternityand Birth Trends 1989–1990 1990–1991

1991–1992 6 Annual DemographicStatistics 1992–1993 1993–1994 1994–1995 1995–1996 1996–1997 1997–1998 1998–1999 , 2002. 1999–2000 asked Canadian are opentoother 2000–2001 2001–2002 decline varies. the magnitudeof (except Nunavut), provinces andterritories rate babies born.Thebirth lates to75,737fewer population. fallen to10.5per1,000 11 yearslaterithad 1,000 population; rate was14.5per the 1990–1991birth to StatisticsCanada, declining. According has Canadian birthrate Since 1990,the women about been steadily has droppedinmost patterns That trans- of birth but their 5 Canada’s Moms are Getting Older Like multiple births, births by women over 35 are often considered high-risk, because of their increased risk While the overall birth rate has declined, the rate of multiple Pregnancy and Delivery: Who Provides Care?

FIGURE for birth defects and other pregnancy complications. births has been increasing steadily In 1991, 34% of babies in Canada (excluding Ontario) for at least the last 10 years. were born to women age 30 and over. By 2000, this However, the percentage increase had increased to 42%. in multiple births—of which most 30 are twins—amounts to less than a 1% increase in the birth rate 25 during this time.8 Because all 20 multiple births are considered to be high-risk given their increased 15 risk for such things as miscarriage, premature birth, gestational % of% all Births 10 diabetes, pre-eclampsia, and 5 other health issues, more frequent monitoring and specialized birthing 0 skills may be required, placing 30–34 35–39 40+ higher demands on health 1991 Age care providers. 2000

Note: This excludes live births where maternal age is unknown. Source: Health Canada. (2003). Canadian Perinatal Health Report, 2003. Ottawa: Health Canada

Family Physicians† Most mothers receive care from family physicians before, during, and/or after child- F birth. The 30,258 practising family physicians in Canada in 2002 accounted for just F over half (51%) of all 6 Average Number of Deliveries per Year physicians in the country. While fewer family doctors are billing for obstetrical On average, there were care, the ones who do are attending more deliveries. 96 family physicians per

FIGURE In 2000, these family physicians attended an average 100,000 population, but of 41 deliveries, up from 30 in 1986. this rate varied greatly from one region to another. 45 40 Family physicians can be 35 involved in all stages of 30 maternity and infant care—from preconception 25 to prenatal to postpartum 20 and beyond. Almost two- 15 thirds (64%) said that they were involved in 10 some aspect of maternity Average Number Deliveriesof per Year 5 care in 2001, up from 9 0 53% in 1998. However, 1986 1990 1995 1998 2000 not all family physicians provide the full range of Source: Canadian Medical Association Physician Resource Questionnaire maternity care. In 2001,

† Throughout this report references to “family physicians” includes both physicians practising family medicine and those practising general medicine. The term “family physician” has been used in recognition of the fact that, in Canada, family physicians and not general practitioners are most likely to be providing maternity and infant care. 5 6 Giving Birth in Canada: Providers of Maternity and Infant Care ‡ under 3%. this haddeclinedto in 1994.Butby2000, by familyphysicians 1996. down from7%in tion birthsin2000, 5% ofcaesareansec- responsible doctorfor They werethemost more complicated. which tendtobe tiple births—bothof attending atfewermul- caesarean sectionsand also performingfewer Family physiciansare or Atlantic Canada. than thosein to attenddeliveries ries weremorelikely provinces andterrito- cians inthewestern territory. Family physi- on theprovinceor 2001, depending from 8% to varied acrossCanada— attending deliveries family The proportionof in 1986,comparedto412000. Questionnaire, familyphysiciansattendedanaverageofabout30deliveries than before.According totheCanadianMedicalAssociationPhysician those familyphysiciansstillprovidingthisservicearedoingso fallen. In2000,theyattended39%ofvaginalbirths,downfrom44%in1996.However, health insuranceplansalsosuggestthatfamilyphysicians’shareofbirthsattended billingdatafromprovincial maternity care,fewerareattendingbirths.Fee-for-service While ahigherpercentageoffamilydoctorsthaninthemid-1990sreport and rotationdeliveries. skilled atvacuumextractions, 44%didlow-forceps deliveries,and4%didmid-forceps care (attendedbirths).Ofthe19%whoreportedattendingbirths,85%being less thanoneinfive(19%)familyphysiciansprovidingsomeservicesdidintrapartum births just over6%ofthese change wasgreater: of multiplebirths,the Excluding births inManitobaand Quebec. Excluding births 10 ‡ physicians were attended In thecase 69% in central 9 7 • • • • FIGURE C a 3 A I N O 1 4 t n payment plans. providedunderalternate They donotincludeservices basis. cial healthinsuranceplansonafee-for-service These dataincludeonlyfamilyphysicianswhobillprovin- in1989,comparedwithfewerthan19%1999. services Just over31%offamilyphysiciansbilledforobstetrical Fewer Family PhysiciansProviding ObstetricalServices Source: 6 h 5 n c e 7

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According to the National Family Physician Workforce Survey, family physicians living outside urban and suburban areas were more likely to provide maternity care—particularly attending deliveries—than those living in urban areas. Specifically, 27% of family

physicians working in small towns or rural areas provided intrapartum care as part of Pregnancy and Delivery: Who Provides Care? their practice, compared with 12% of those in urban and suburban areas (including inner city physicians). The level of maternity care (e.g. prenatal, intrapartum, postpartum, or newborn care) provided by family physicians also varied by the age and sex of family physicians, as well as their practice setting. For example, a higher percentage of female than male physicians under 40 reported delivering babies, but for those over 40 the reverse was true. Physicians working in group practices were also more likely to deliver babies compared to those working in solo practice (23% compared to 11%).

When and why are 8 What Maternity and Newborn Care family physicians Do Family Physicians Provide? deciding not to deliver In Canada, most family physicians involved in maternity babies? Evidence

FIGURE and newborn care provide “shared care.” This means that suggests that these they provide prenatal care up to a certain number of weeks decisions are made, of pregnancy (often between 24 and 32 weeks) and then at least in part, during transfer care to another provider, such as an obstetrician, residency.11 An Ontario a midwife, or another family physician who delivers babies. study tracked family Some family physicians also attend deliveries, but the practice residents proportion varies across the country. In a 2001 survey, 66% throughout their train- of family physicians providing some care for pregnant women ing and for two years and/or newborns in the Yukon and Northwest Territories afterwards. While 52% said that they delivered babies, compared to 7% and 12% of residents planned respectively in Quebec and Ontario. to practise obstetrics 70 initially, by the time they completed the 60 program, this had 50 fallen to 17%. Only 40 16% were still delivering babies two years 30 later. The authors 20

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Canada about personal lives, Only Postpartum or Newborn Care Y.T./N.W.T. confidence with Shared Care obstetrical skills, fee Intrapartum Care (i.e. Delivering Babies, Postpartum Care, and Newborn Care) structures, and the Note: Data on “only postpartum or newborn” care were not available for the Yukon perceived threat of Territory and Northwest Territories. Data from Nunavut were not available. malpractice suits. Source: 2001 National Family Physician Workforce Survey, part of the JANUS Project, College of Family Physicians of Canada Those who were planning to provide intrapartum care at the end of their residencies, who did not feel it would greatly impact their personal life, and who practised in smaller communities, were significantly more likely to be attending births two years after the end of their residency.11

7 8 Giving Birth in Canada: Providers of Maternity and Infant Care F F 96%ofallmultiplebirthsinCanada2000,upfromalmost92%1994 • 95%ofallcaesareansectionsin2000,upfrom93%1996 • 61%ofvaginalbirthsinCanada’s provincesin2000,upfrom56% 1996 • with medicalschoolswerelesslikely. 35 weremorelikely toprovidesuchcare,whilefemalesandthosepractisingincities tors arerelatedtoparticipationinobstetricalcare:obstetricians/gynaecologistsunder obstetrics andgynaecology, only29%spentmorethanhalftheirtimeonobstetrics. share ofdeliveries the mid-1990s.With birthratesfalling, thismeans thattheyareattendingalarger The totalnumberofbirthsattendedbyobstetricianshasbeenrelativelystablesince 18% hadnotbilledforanyobstetricalservices. gists Recent billinginformationsupportsthesefindings.Ofthoseobstetricians/gynaecolo- 17% ofrespondentsdonotpractiseobstetricsatall. by theSocietyofObstetriciansandGynaecologistsCanada(SOGC)foundthat Not allobstetricians/gynaecologistsinCanadaprovideobstetricalcare.A1999survey Saskatchewan, andAlbertahadthelowestrate,atfour. population (sixin2002),andNewfoundland,PrinceEdwardIsland,NewBrunswick, provinces, Ontariohadthehighestrateofobstetricians/gynaecologistsper100,000 population. Asforfamilyphysicians,theirnumbersvarybyregion.Amongthe 1,592 obstetricians/gynaecologistspractisinginCanada,anaverageoffiveper100,000 als arefillingthegap?Theanswer, inlargepart,isobstetricians.In2002,therewere If familyphysiciansareprovidinglessintrapartumcare,whichhealthcareprofession- Obstetricians/Gynaecologists § Thesurveyincluded 668obstetricians/gynaecologists,41% ofallobstetricians/gynaecologistsin Canada. • • • • C i n

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12 Results of a 1999 SOGC survey indicated that the majority (64%) of obstetricians Caesarean Section Trends attend between 101 and 300 deliveries In Canada, a significant percentage of 12 a year. births occur by caesarean section. Pregnancy and Delivery: Who Provides Care?

9 Canadian Caesarean Section Rates Except for a dip in the early 1990s, Canada’s caesarean section rate has increased in the last two decades. It reached an all-time high of 22.5% of in-hospital deliveries in 2001–2002. FIGURE 25

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0 7 8 9 0 1 2 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 9 19 9 19 9 20 0 20 0 20 0 19 8 19 8 19 8 19 8 19 8 19 8 19 8 19 8 19 8 19 8 19 9 19 9 19 9 19 9 19 9 19 9 19 9 – – – – – – – – – – – – – – – – – – – – – – –1 199 7 199 8 199 9 200 0 200 1 197 9 198 0 198 1 198 2 198 3 198 4 198 5 198 6 198 7 198 8 198 9 199 0 199 1 199 2 199 3 199 4 199 5 199 6

Sources:Statistics Canada (1979–1980 to 1993–1994); Hospital Morbidity Database, CIHI (1994–1995 to 2001–2002)

10 Learning Obstetrics and Gynaecology Each year, graduating medical students choose specialties. According to the Canadian Resident Matching Service, Looking Ahead the number of positions offered in obstetrics and gynae- FIGURE In 1999, the SOGC asked cology has been greater than the number of positions its members about their filled in the past seven years. Data from Quebec is pre- plans for retirement. Thirty- sented separately, as Quebec training facilities do not four percent of obstetri- participate in the Canadian Resident Matching Service. cians/gynaecologists said that they were planning to 70 retire in the next five years 60 (1999–2004). According to CIHI, between 1999 and 50 2002, there were 114 retired 40 obstetricians/gynaecolo- 30 gists and 27 who were 20 semi-retired. If recent enrol- 10 ment trends continue, # o f G r a du t e s P i ons about 250 new physicians 0 would enter residency 1997199819992000200120022003 programs in obstetrics/ gynaecology over the Graduates Choosing Obstetrics/Gynaecology as First Choice same period. Obstetrics and Gynaecology Residency Positions Offered Obstetrics and Gynaecology Residency Positions Filled Obstetric and Gynaecology Positions in Quebec

Sources: Canada outside of Quebec: Canadian Resident Matching Service, www.carms.ca/stats/stats_index.htm; Quebec data: Conférence des recteurs et des principaux des universités du Québec 9 10 Giving Birth in Canada: Providers of Maternity and Infant Care 11 FIGURE course ofcareinout-of-pocket expenses. purse (aswilltheNorthwestTerritories), families inAlbertapayabout$2,500per Quebec, Manitoba,andBritishColumbiafundmidwifery servicesfromthepublic care midwivesprovideiscoveredbyprovincialhealth insurance Although regulationofmidwiferyisincreasing, itdoesnotnecessarily meanthatthe prescribe appropriatedrugsandorderrequiredtestsduringpregnancy. birthingcentres.Regulated midwivescanalso women givingbirthinfree-standing babies bothinthehomeandhospital,except inQuebec, wheretheycarefor the sameway. Regulated(andtosomeextent unregulated)midwiveshelpdeliver Midwives mayalsoworkinotherjurisdictions,buttheirpracticeisnotregulated acts, Saskatchewan hasyettobeproclaimed. and theNorthwestTerritories havealsopassedmidwifery Alberta, Manitoba,Ontario,andQuebec.Saskatchewan these servicesarenowregulatedinBritishColumbia, Canada, didnothavemidwiferylegislation. Until theearly1990s,onlyafewcountries,including and uptosixweekspostpartum. for womeninallstagesofpregnancy, labour, childbirth, with traditionalmidwiferypracticeandprovidecare Modern midwivescombineknowledgeofobstetrics Midwives Source: a two-yeartothree-year program. * first classesin2004and2005respectively. at theUniversityofBritishColumbiabeganinfall2002.Theywillgraduatetheir in2001,andtheprogram program atl’UniversitéduQuébecàTrois-Rivières started and Quebec).Thefollowingtableshowsthenumberofgraduatessince1996. Midwives cantrainatfiveuniversitiesinthreeprovinces(Ontario,BritishColumbia, Programs Number ofGraduatesFrom Canada'sMidwifery The smallnumberofgraduatesinthisyearmaybeduetoachangethe length oftheOntarioprograms in1998from oa 92 42 133 21 7 0 28 8 N/A 24 18 11 7 N/A 0 22 8 N/A 5 2 0 19 N/A 1 12 N/A 2002 1 N/A 2001 11 N/A 3 N/A 5 2000* N/A 1999 11 6 10 Total 1998 N/A 10 British Columbia 1997 8 University of 6 N/A 1996 à Trois-Rivières 6 L’Université duQuébec 5 University Ryerson McMaster University Laurentian University School Health Personnel Database,CIHI 4 4 However, plans. WhileOntario, 12 Midwifery Across Canada Midwives are primary health care providers for women in all stages of pregnancy, from

the prenatal phase to six weeks postpartum. Some provinces and territories have regu- Pregnancy and Delivery: Who Provides Care?

FIGURE lated midwifery. This means that midwives practising in these jurisdictions must have formal training and be licensed to practise. Regulation does not necessarily mean that their services are publicly funded. Jurisdictions also differ in the settings in which they allow midwifery to be practised.

Home, Province/ Legislation Out-of-Pocket Hospital, Midwifery Territory (Year) Funded Payment or Birth Centre School

B.C. Yes (1998) Yes No Home/hospital Yes Alta. Yes (1998) No Yes Home/hospital/ No birth centre Sask. Yes No Yes Home No (act not yet proclaimed) Man. Yes (2000) Yes No Home/hospital No Ont. Yes (1994) Yes No Home/hospital Yes Que. Yes (1999) Yes No Birth centre Yes (soon to be expanded to home and a few hospitals) N.B. No No Yes Home No N.S. No No Yes Home No P.E.I. No No Yes Home No N.L. No No No Hospital No (remote areas only) Y.T. No No Yes Home No N.W.T. Yes Yes Yes Home No (act to be (2004) (before 2004) proclaimed in 2004) Nun. Partially Partially No Birth centreNo (one pilot project in Rankin Inlet)

Source: Adapted from Hawkins M, Knox S. (2003). The Midwifery Option: A Canadian Guide to the Birth Experience. Toronto: HarperCollins Publishers

Between 1993 and 2002, the number of Canada’s Midwives in 2001 regulated midwives practising in Canada grew from 96 to 413, a 330% increase. Some • In 2001, there were over 370 midwives of this increase reflects regulatory changes, in Canada. such as registration requirements, rather than • Three quarters (over 75%) were female. actual growth in the number of midwives. Nevertheless, with the increase in the actual • As of 2001, 54% of Ontario’s midwives number of midwives and in the number of were over the age of 40 (other provinces provinces who train and regulate them, more do not routinely collect this information on expecting mothers are choosing these health their midwives). care professionals to deliver their babies.

11 12 Giving Birth in Canada: Providers of Maternity and Infant Care 13 FIGURE Source: midwives in2000tookplacehospital,upfrom61%1994. ofHealthandLong-TermMinistry Careestimatesthat72%ofdeliveriesattendedby Programrather thanthehome.For fromtheOntario example,theOntarioMidwifery data fromOntarioshowthatmidwivesareincreasinglylikelytoprovidecareinhospital, and 2000–2001.(Similardataarenotavailableforallyearsotherjurisdictions).Other provinces. Asseenbelow, Ontario sawnearlyaseven-foldincreasebetween1994–1995 attendedbymidwivesisincreasinginseveral The numberofpubliclyfundedhospitalbirths AttendedbyMidwivesinCanada Hospital Births also significantly moresatisfiedwiththe caretheyreceived. perineal tearsweresimilar inbothgroups.Women cared forbymidwiveswere to havetheirlabourinduced andtohaveanepisiotomy. Complicationratesand doctors, and by either women caredfor In theUnitedKingdom,researchers lookedattheexperienceof1,299pregnant family physicians,andobstetriciansprovidevaries. of researchersinCanadaandelsewherehavestudiedhowthecaremidwives, babies, theireducation,perspectives,andpracticepatternsmaydiffer. Anumber While severaldifferenttypesofhealthprofessionalsaretrainedtohelpdeliver Providers andRatesofInterventions the practicepatternsofobstetriciansandfamilyphysicians. thesia, andhadlowercaesareansectionrates.There was littledifferencebetween were lesslikelytousecontinuouselectronicfetalmonitoring andepiduralanaes- physicians, obstetricians,andcertifiednurse-midwives, certifiednurse-midwives who comparedpatternsofobstetriccareprovided to low-riskpatientsbyfamily Similar resultshavebeenfoundinothercountries.According toAmericanresearchers assisted ventilationatfiveminutesoflife. However, thebabiesbornintohandsofmidwivesweremorelikelytoneed prenatally, toundergoacaesareansection,andgivebirthpreterm babies. care. Women caredforbymidwiveswerealsolesslikelytobehospitalized undertaken lessoftenwhenmidwiveswereprimarilyresponsibleforawoman’s tests suchasultrasound,geneticamniocentesis,andglucosescreeningwere were usedlessoftenwhenwomencaredforbymidwives. medical careinthemid-1990sfoundthat,overall,obstetricaltechnologies compared 961pairsofpregnantwomenreceivingeithermidwiferycareor % of all Hospital Deliveries 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Discharge AbstractDatabase,CIHI 9419 9519 9619 9719 9819 9920 0020 2001–2002 2000–2001 1999–2000 1998–1999 1997–1998 1996–1997 1995–1996 1994–1995 family practitioners.Women caredforbymidwiveswerelesslikely midwives orbyacombination ofmidwives,hospital Ont. Man. Alta. 14 A Quebecstudythat B.C. 15 16 14 For example, Canada’s Anaesthesiologists Anaesthesiologists in 2001 In 2002, there were 2,406 anaesthesiologists in Canada, or 8 per 100,000 population. This Pregnancy and Delivery: Who Provides Care? • In 2001, there were 2,420 rate varies by jurisdiction. These specialists provide anaesthesiologists in Canada. pain relief during labour and delivery, anaesthesia • Of these, 24% were female, during caesarean sections, and neonatal resuscitation, up from 22% in 1996. among other contributions to the birthing process. According to the Canadian Anesthesiologists’ Society, • The average age was 48 (0% 35% of women in labour annually have epidurals were under 30 years of age, requiring the services of an anaesthesiologist. In but 17% were 60 or older). some cases, family physicians may also be able to FF do this procedure.

The per capita rate of anaesthesiologists is lower in rural and remote areas; so are rates of caesarean sections and vaginal deliveries with epidural anaesthesia. For example, in urban teaching hospitals in eastern and southeastern Ontario, 63% of vaginal births had epidural anaesthesia. That compares with 11% in small community hospitals.17 In some cases where anaesthesiologists are not available, general practitioners provide some anaesthesiology services. In other cases, expecting women may receive care in hospitals outside the area. (See section on care in rural and remote north for more information.)

Nurses In 2002, more than 5% (12,167) of the total Canada’s Nurses in 2001 230,957 registered nurses employed in nursing in Canada identified their primary area • In 2001, there were 231,512 registered of responsibility as maternal/newborn care, nurses employed in nursing in Canada. about the same as in 1995. Nurses are • Of these, 95% were female, about the involved at every stage of maternity and same as in 1996. infant care—from providing childbirth education classes to offering pre-birth home • Most were between 30 and 59 years care services to women at high-risk and of age (9% were under 30, but 5% assisting during labour and delivery. After were 60 or older). the birth, public health nurses may also provide follow-up care (including lactation FF consulting) to new mothers and their babies.

Shared Care Many pregnant women start their care with one primary health care provider, then transfer to another health professional for the remainder of their pregnancy. For example, many family physicians in Canada provide care up to 32 weeks of pregnancy and then transfer care to other family physicians, obstetricians, or midwives. In some jurisdictions, nurse practitioners may do the same. It has been suggested that collaboration among providers of maternity care is a way to address some of the issues relating to access to care, especially in rural and remote areas.22 Shared care may also be a way to ensure that providers are making the most of their various skill sets.

Collaboration among providers is also often required for high-risk pregnancies. For example, midwives are typically required to refer high-risk deliveries to appropriate physicians. Likewise, family physicians may do the same. The National Family Physician

13 14 Giving Birth in Canada: Providers of Maternity and Infant Care autonomously. legislation thatallowsNPs topractise Territories/Nunavut) havepassed and Labrador, andtheNorthwest Brunswick, NovaScotia, Manitoba, Ontario, of Canada(Alberta,Saskatchewan, particular tasksmayvary, mostparts health caresettings. worked inexpandedrolesprimary Northwest Territories andNunavut in 2002,about60%ofnursesthe from theseprofessionals.For example, areas aremorelikelytoreceivecare but Canadiansinruralandremote NPs workinmostpartsofthecountry, the rolesofotherhealthcareproviders. complement ratherthansubstitutefor of nursesinprimaryhealthcaremay prenatal careto32weeks. nosis, birthoptionscounseling,and Ontario mayprovidepregnancydiag- psychosocially. family) asa nurses focusmoreonthepatient(and diagnosis andtreatmentofdiseases, cians’ educationtendstoemphasize ple, someassertthat,whereasphysi- and expertisetotheirroles.For exam- NPs maybringauniqueperspective scribing drugs. tests, diagnosingillnesses,andpre- only byphysicians,suchasordering certain servicesformerlyperformed education, includingtrainingtoprovide nurses whohavereceivedadditional renewal visions.NPs areregistered is partofmanyprimaryhealthcare useofnursepractitioners(NPs)Wider for NursePractitioners Expanding Roles egated byaphysician. scope ofnursingpracticemustbedel- tasks thatfalloutsideoftheirtraditional whole, bothphysicallyand 20 18 For example,NPs in In thisway, therole Quebec, New 19 Although the Newfoundland 21 Elsewhere, of professionals. existed betweenthetwogroups by collaborating, andthattension care towomeninparallelratherthan nurses andmidwivesgenerallyprovided found thatmaternalandnewborn British Columbiahealthcaresystem the introductionofmidwivesinto For example, asurveyconductedafter ing, anditmaytake timetoestablish. However, collaborationcanbechalleng- provide carebutconsultedanobstetrician. More (63%)saidthattheycontinuedto births indicatedtheytransferredcare. obste ferred who pro Workforce trician: 11%ofthosewhoattended their moderate-risk patientstoan their moderate-risk vide maternalcareiftheytrans- Survey asked family physicians 23 Other Professionals Involved in Supportive Maternity Care Prenatal Educators Prenatal education classes, which provide information about various aspects of pregnancy, birth, and early parenting, are often offered in hospitals with maternity services or in the community. Prenatal educators come from a variety of backgrounds, including nursing. No universal certification standards for prenatal educators currently exist in Canada, but a few organizations have established their own certification requirements. As well, some community colleges offer certificate-level, continuous study courses in prenatal education. Doulas Doulas provide non-medical Labour Support and Caesareans emotional support for expecting Labour support is a term that describes mothers and their families during the “presence of an empathic person birth and postpartum periods, but who offers advice, information, comfort do not perform clinical tasks. There measures, and other forms of tangible are two types of doulas: birth doulas assistance to a woman to help her cope and postpartum doulas. As of with the stress of labour and birth.”24 Many January 2004, there were about different practitioners are trained to offer 200 birth doulas in Canada certified support during childbirth, including nurses, by the Doulas of North America. midwives, and doulas. They provide support primarily during labour and birth. Postpartum Does having continuous support doulas provide support in the home during labour reduce the likelihood of a caesarean section? A systematic following delivery. A doula training review of 14 studies involving 5,000 course usually consists of a two or women from 10 countries compared three-day seminar where skills in continuous support from a professional relaxation, breathing, positioning, or non-professional caregiver (family pain control, massage, and other members and friends) and regular care comfort measures are developed. (some support, but not continuous). The authors concluded that uninterrupted Doulas are not regulated or certified labour support was beneficial: it was in Canada, although several organi- associated with significant reductions zations offer certification in the U.S. of caesarean section deliveries, opera- and in some European countries. tional vaginal delivery, and use of pain medication.25

Screening and Diagnostic Testing Some health professionals are involved in maternity care at specific points in a pregnancy, Did You Know? rather than on a continual basis. In 2003, the Canadian Task Force For example, most pregnant on Preventive Health Care stated that there was fair evidence supporting women undergo a set of routine the benefits of ultrasound screening screening and diagnostic tests, during the second trimester in peri- such as ultrasounds and blood odic health examinations in normal pregnancies. They reported that tests. If there are suspected ultrasound screening has been complications or if the pregnancy shown to contribute to increased is high-risk, more invasive and birth weights, early detection of twins, decreased rates of induction, more frequent tests may be and increased rates of abortion for undertaken. Radiologists, ultra- fetal abnormalities. Serial ultrasound sound and laboratory technicians, screening throughout normal pregnancies is not recommended. and other professionals perform these tests.

In some parts of Canada, particularly rural and northern areas, the limited availability of these professional and technical groups may affect the care available to expectant mothers. More information regarding imaging staff and services is available in Medical Imaging in Canada, a CIHI special report (available at www.cihi.ca).

Special Challenges for Care Providers In popular song, pregnancy and childbirth have been referred to as a “common little miracle.” When all goes according to plan, women have healthy pregnancies and babies are born without the need for exten- sive medical intervention. However, there are cases for which special types of care are needed in order to ensure the safety of both mother and infant.

Pregnancies are deemed high-risk if there is a higher-than-average chance of complications developing. For example, women with a history of medical conditions such as gestational diabetes, heart disease, or those carrying more than one child, may be considered high-risk. A normal pregnancy may also become high-risk when certain problems, such as signs of preterm labour, are identified. Typically, obstetricians tend to coordinate the care of high-risk women, and additional monitoring tests (e.g. ultrasounds) are often suggested.

High-Risk Pregnancies Many hospitals have specialized Did You Know? clinics for women experiencing About 10% of all pregnancies are consid- high-risk pregnancies, but these ered to be high-risk. High-risk pregnancies tend to be located in major urban are those where either the mother, the centres. This is also true for hospi- baby, or both have a higher-than-average tals with specialized intensive care chance of developing complications. The units to care for high-risk infants. In complications could be due to a health Ontario, for example, of the 16 in- problem that the mother had before she hospital neonatal intensive care became pregnant. Or they could have units, 10 are in major urban centres. developed during her pregnancy or during delivery. 7 20 Giving Birth in Canada: Providers of Maternity and Infant Care Childbirth inRuralandRemoteAreas in 1998. women needingcareandforproviders.Examplesinclude Childbirth inruralandremoteareasofCanadapresentsuniquechallengesforboth Puvirnituq, Nunavikin1986; inRankinInlet,Nunavut1993, to remainintheircommunities. For example, birthingcentres werecreatedin to hospital.However, someofthosewithlow-risk pregnanciesarefindingiteasier Women withcomplicationsorthoserequiringacaesareanbirth still oftentravel Today, birthratesinthefarnortharemuchhigherthanthoseurban Canada. had anegativeimpactontheirfamilies. home tohavetheirbabieswasstressful.Inaddition, 54% reportedthatleavinghome Labrador InuitHealthCommissionfoundthat84%of womenreportedthatleaving from home.Inthemid-1990s,aregionalhealthsurvey ofbirthingexperiences bythe This practicemeantthatspecializedcarewascloseat hand,butwomenwerefar done throughapprenticeship. to beaccreditediftheirtrainingwas legislation allowsAboriginalmidwives Aboriginal midwifery. on InManitoba, Columbia toestablishacommittee the CollegeofMidwivesBritish Aboriginal midwivesareworkingwith midwifery act.InBritishColumbia, not regulatedundertheprovincial practise intheirowncommuni In Ontario,Aboriginalmidwiveswho for changestothislegislation. Nunavik officialshavebeenlobbying model ofAboriginalmidwives. Rivières butnottheapprenticeship l’Université duQuébecàTrois- only thetrainingprogramat legislation currentlyrecognizes in training.Thisisbecausethe working inNunavik,butnotthose nizes Inuitmidwiveswhoarealready ties. Quebec’smidwiferylawrecog- apprentices intheirowncommuni- and Inukjuakstudymidwiferyas Quebec, InuitmidwivesinPuvirnituq learn throughapprenticeships.In communities, midwivescontinueto the generations.InsomeAboriginal and skillswerepassedalongthrough Traditionally, childbirthknowledge in Canada Aboriginal Midwifery 31 ties are 28 30 occurred innortherncommunities. plications. Onlyunplannedbirthsusually having multiplebirthsorhadothercom- their duedates,particularlyiftheywere care hospitalsaboutfourweeksbefore north oftenflewtotertiaryorsecondary Since the1960s,womenlivinginfar Birthing inCanada’sFar North travel tourbancentresgivebirth. those withhigh-riskpregnancies,must areas isthatmanywomen,especially of maternityservicesinruralandremote One resultofthemorelimitedavailability of ruralmaternitypracticeinclude Specific challengestothesustainability thesmallnumberofbirthsin • thelackofavailableanaesthesia • thelackofcaesareansectioncapability; • thelimitednumberofphysicians • theneedforproviderstohave • thelackofpeersupportforproviders • distancesfromfacilitiesandspecial- • rural areas. services; and services; available foron-call expanded or specialized skills. and coveragefortheirpractice; ized equipment; 30 26, 27 and inInukjuak 17 29 14 Where Family Physicians and Obstetricians Practise Most obstetricians providing maternal care live in Canada’s urban centres. Billing data

show that the distribution of these specialists was relatively stable between 1996 and 2001. Special Challenges for Care Providers FIGURE 90 80 70 60 50 40 30 20 10 % Ob/Gyn Billing for Maternal Care Maternal for Billing Ob/Gyn % 0 1996 1997 1998 1999 2000 2001 50 45 40 35 30 25 20 15 10

% GP/FP Billing for Maternal Care Maternal for Billing GP/FP % 5 0 1996 1997 1998 1999 2000 2001

>100,000 Population Between 10,000 and 99,999 Population Less Than 10,000 Population

Source: National Physician Database, CIHI

Birthing in Rural Canada While birth rates in the far north are among the highest in the country, fewer Answering Questions babies are being born across Canada’s for Mothers in Rural Areas rural areas than in the past. In some parts of the country, maternity services are also A recent study in Ontario and Alberta being reduced. In a survey of northern examined women’s experiences of Ontario community hospitals, 15 of 39 rural maternity care. The study found that women identified their family communities had no obstetrical services 32 physician as the primary source of in 1999, compared to only three in 1981. answers for parenting questions and The remaining hospitals offered a variety often did not look beyond the range of services, ranging from no local caesarean of maternity care options presented capability to obstetrician-provided cae- by their family physician. Where sareans. In some hospitals, family physi- family physicians were not as readily cians or general surgeons also performed available, women tended to consider caesareans. Researchers estimated that the a wider range of options.34 average time to the nearest community with caesarean capacity was 45 minutes.

21 22 Giving Birth in Canada: Providers of Maternity and Infant Care emergency caesareansectionsfrom1994to1999. A similarstudyofruralhospitalsinBritishColumbiaexamined theavailabilityof transfers areavailableandusedappropriately. are possiblewhereaccesstospecialistconsultationandtimely fact, theysuggestedthatgoodoutcomesinlow-volume settings on thenumberofbirthsperformedannuallybyphysicians.In that thecompetenceofamaternitycaresettingisnotdependent Rural Physicians ofCanadaaffirmedina the CollegeofFamily PhysiciansofCanada,andtheSociety The SocietyofObstetriciansandGynaecologistsCanada, the caseforphysiciansattendingbirths,providingthattheyhaveappropriatesupport. better patientoutcomes.Anexpert panel,however, recentlysuggestedthatthisisnot In manyotherareasofcare,researchshowsthathigh-volumecentrestendtohave and thosewith24-houravailability. in perinataldeathsbetweenhospitalswithlittle deliveries fromthelocalhospitalcatchmentarea,nosignificantdifferenceswerefound provided byspecialists.Whilehospitalswithmoreserviceshadahigherproportionof had 24-houravailabilityprovidedbyfamilyphysicians;and25 capacity toprovidecaesareansections;insixtheywereavailableonalimitedbasis;10 2002 jointstatement 35 or noavailabilityofcaesareansections 33 Of 60ruralhospitals,19hadno Care in the First Weeks of Life A generation or two ago, women often stayed in hospital for close to five days with an uncomplicated birth, and even longer if there were complications.36 Today, healthy mothers and their infants are typically discharged 24 to 48 hours after delivery. Some mothers may choose to return home even earlier—particularly if a midwife delivered the baby.

Most babies and their mothers who go home 24 to 48 hours after birth do not experience problems. But some babies have jaundice, dehydration, or other conditions and need to return to hospital. In fact, according to CIHI data, between 1994 and 2000, jaundice was the number one cause for hospitalization of infants up to 28 days old in Canada. Several studies have found a correlation between declining lengths of stay and increased readmission rates for jaundice and dehydration.37, 38, 39 To monitor these and other health concerns, women cared for by family physicians or obstetricians are often instructed to have their newborns seen by a family doctor (or paediatrician) 24 to 48 hours after leaving hospital, and midwives typically continue to provide care up to six weeks after birth. In addition, a variety of other professionals may become involved in care after birth. The following section highlights what we know about some of these health care providers.

15 Who Provides Health Care for Baby? Paediatricians According to Statistics Canada’s National Longitudinal Paediatricians are special- Survey of Children and Youth, a family physician was ists in caring for children.

FIGURE consulted at least once for health care for 70% of infants Most adults do not see a 0 to 11 months old in 2000–2001. A paediatrician or a specialist for all their rou- public health nurse was consulted for just under 50% tine care. However, some of the infants in the same time period. Canadian parents opt to have their infants and Family Physician children cared for exclu- Paediatrician sively by these specialists. Public Health Nurse Other Medical Doctor In 2002, there were Other Trained 2,197 paediatricians** Professional in Canada. As with other 01020304050607080 health care professionals, % of Respondents these doctors were distrib- uted unevenly across Source: National Longitudinal Survey of Children and Youth, Statistics Canada the country. Among the provinces, Manitoba had FF

** This number includes all paediatric subspecialties, including paediatric oncology, paediatric general surgery, and paediatric cardiology. 24 Giving Birth in Canada: Providers of Maternity and Infant Care specialists. ear infections(otitismediawitheffusion)to their decisiontoreferchildrenwithrecurring diatricians looked atthefactorsthatinfluenced example, asurvey offamilyphysiciansandpae- approach childhoodillnessesdifferently. have foundthatpaediatriciansandfamilydoctors and familyphysiciansprovide?Somestudies Is thereadifferenceinthecarepaediatricians est (fourper100,000population). and Saskatchewan andNewBrunswickthelow- the highestrate(nineper100,000population) much lowerthresholdsforreferringthandid support onlyfromNICUstaff. ing lessstressthanthose who received who receivedpeersupportreportedfeel- According totheresearchers,mothers had previouslyachildinNICU. tional supportoftrainedpeerswho providers; onegroupreceivedtheaddi- the usualsupportfromNICUhealthcare Two groupsofmothersboth received may helpmotherswithinfantsinNICUs. study suggeststhattrainedpeersupport can beverystressfulforparents.Arecent with alargeteamofhealthcareproviders Having aninfantinaNICUanddealing for infants. diagnose illnessandprescribemedications care fornewbornsallowingthemto ple, havereceivedadvancedtrainingto field. Neonatalnursepractitioners,forexam- often acquireadditionalskillstoworkinthis respiratory therapists,dietitians,andothers occupational therapists,pharmacists, professions. Nurses,physiotherapists, also becomeasubspecialtyinmanyother and prematurebabies.Neonatologyhas gists) speciallytrainedtocareforhigh-risk ing paediatricians(knownasneonatolo- large teamofhealthcareproviders,includ- unit (NICU).Theretheyreceivecarefroma be admittedtoaneonatalintensivecare Babies withserioushealthproblemsmay Health CareNeeds Care forInfantswithComplex 40 Overall, familyphysiciansreported 42 40, 41 For and babies,butmanydo. care nursesprovidetomothers responsibility. Notallcommunity health astheirprimaryareaof nursing, dialysiscare, orpublic isolated areas,hospicecare,parish identify nursingcareinoutposts/ The categoryincludesRNswho possibly includingcareinhomes. in asettingoutsideofinstitutions, registered nurses Canada. Communitycarenursesare there were12,302such community carenurses.In2002, larger groupofproviderscalled Public healthnursesarepartofa prior to2000–2001. a publichealthnurseintheyear 0 and11monthssawortalked to of womenwithchildrenbetween Children andYouth, justunderhalf National LongitudinalSurveyof According toStatisticsCanada’s HealthNurses Public did paediatricians. of preventiveantibioticusethan of hearingloss,andfewermonths months ofeffusion,lowerlevels fewer episodesofillness, tended toreferchildrenafter paediatricians. Family physicians • • • C i n

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Healthy Babies, Healthy Children Care in the First Weeks of Life Public health nurses and other professionals provide a broad range of services for families, before and after birth. In Quebec, for example, the Montreal Diet Dispensary program was begun in the 1960s to improve pregnancy outcomes in socially disadvantaged urban women. Now part of the Canada Prenatal Nutrition Program, the diet dispensary works with high-risk, low income women in the greater Montréal area. Starting with a home visit, education and counseling are key components of the program, which aims to improve diet and therefore facilitate a healthy pregnancy. As well, 94% of the program’s clients receive food supplements. An evaluation of the program found that it helped to reduce the number of low birth weight babies. It also sugested that the costs of the program were more than offset by savings in subsequent health care costs.44

Likewise in 1998, the Ontario Ministry of Health and Long-Term Care launched the Healthy Babies, Healthy Children initiative.43 This province-wide program is run by public health nurses who provide follow-up care to pregnant women identified as “at risk,” as well as to all new mothers. Typically, within 48 hours of discharge from hospital after the birth of a baby, a public health nurse calls or makes a home visit to provide support for infant care and breastfeeding, as well as to help with the transition to parenthood. This program can also provide ongoing home visits by a public health nurse or a supportive home visitor, and referrals to other agencies and services if necessary.

In 2002, Ontario researchers published the results of a two-year program evaluation of Healthy Babies, Healthy Children. Based on almost 10,000 participant interviews with families, public health nurses, and lay home visitors, their findings included:

• In 2001, 88% of mothers with new babies in Ontario agreed to be screened. More than 80% of families with new babies received a phone call from a public health nurse shortly after returning home from the hospital. • About 7% of all Ontario mothers with new babies could benefit from extra help and support. At the time of the evaluation they were receiving, on average, a 1.2-hour home visit every 18 days. • One-third of all formal referrals were to breastfeeding, nutrition, prenatal, and infant health services; 16% were to parenting programs and services; 15% to medical services, child therapy, and development programs; 12% to economic, social, and related family supports; and 25% to other services. • When researchers compared families who received Healthy Babies, Healthy Children home visiting with similar families who did not, they found that: · Children with home visits scored higher on most infant development measures. · Parents receiving home visits had a stronger sense of connection with community services and were more confident about their parenting skills. · Families receiving home visits made more use of community services and they had more contacts with public health nurses and other early years professionals.43

25 26 Giving Birth in Canada: Providers of Maternity and Infant Care Getting CareOverthePhone logged morethan2.5millioncallsin1998–1999. ability tohelpparents?Intotal,Quebec’sInfo-Santé What doweknowabouttheseservicesandtheir and other Ontario,Alberta,BritishColumbia New Brunswick, Telephone triageservicesarealsooperatingin telephonetriageservice. the firstprovince-wide beganin1995.Itlaterbecame Quebec’s Info-Santé information lines. Or theymaybereferredtoothercrisisorcommunity informationonhealth-relatedtopics. to pre-taped an emergencyroom.Insomecases,callerscanlisten see adoctororotherhealthcareprovider, orgoto help callersdecidewhethertocareforthemselves, nurses whoworkwithcomputer-assisted toolsto conditions. Theyaregenerallystaffedbytrained callers abouthowtohandlenon-urgentmedical answers tohealth-relatedquestionsandadvise available 24-hoursaday, Theysupply aweek. 7-days across thecountry. Theseservicesaregenerally to turn.Telephone triageservicesarespreading in manypartsofCanadatheynowhaveanewplace parents havequestionsabouttheirchildren’s health, When healthproblemsarenotemergencies,orwhen supply. Motherswithmore difficultproblemsmay ment withsubsequentmastitis, andinsufficientmilk including difficultyinestablishing feeding, engorge- for bothmotherandbaby. Butproblemscanoccur, Breastfeeding ofteninvolves ashortlearningcurve in 1998–1999. of duration:75%in1994–1995versusalmost82% More mothersalsoreportedbreastfeedingregardless By 1998–1999,thisfigurehadincreasedto63%. reported breastfeedingforthreemonthsormore. surveyed aspartofanationalinitiative,about59% mothers withchildrenlessthantwoyearsoldwere Survey ofChildrenandYouth, in1994–1995when 1990s. According totheNationalLongitudinal Rates ofbreastfeedingroseinCanadaduringthe Lactation Consultants project werechildren’s rashesandfevers. top 10reasonspeopleaccessedatelehealthpilot service. Likewise, innorthernOntario,twoofthe children—were themostfrequentusersof between 25and44—especiallythosewithyoung That’s 348callsforevery1,000residents.Women Canadian communities. 8 46 8 45 to as“The18-HourCourse.” Hospital and PromotioninaBaby-Friendly the provide thiseducation.Called hours ofclinicalskillstraining—to training course—includingthree developed anevidenced-based tion. TheWHOandUNICEFhave 18 hoursofbreastfeedingeduca- ing mothersshouldhaveatleast with pregnantand/orbreastfeed- staff whomaycomeintocontact for Canadarecommendsthatall The BreastfeedingCommittee hospitals hadthisstatus. In Canadaasof2003,onlytwo set bytheWHO/UNICEFinitiative. that theyhadmetthestandards designated Baby-Friendly, meaning pitals in134countrieshadbeen As of2003,morethan15,000hos- promote andsupportbreastfeed wards toadoptpracticesthat care facilities,andmaternity to encouragehospitals, Hospital Initiative.Itwas launched theBaby-Friendly Organization (WHO)andUNICEF In 1991theWorld Health life—is highlypromoted. least forthefirstsixmonthsof exclusively breastfeeding—at Nationally andinternationally, according tomanyexperts. Breastfeeding isgoodforbabies, Hospital Initiative The Baby-Friendly Breastfeeding Management program, itisoftenreferred designed health ing. seek support and help from associations Canada’s Lactation Consultants such as the La Leche League or specialized in 2002 lactation consultants. A lactation consult-

ant is a breastfeeding specialist trained in Care in the First Weeks of Life • In 2002, approximately 1,191 Canadian preventing, identifying, and addressing lactation consultants were certified and breastfeeding problems such as incorrect registered with the International Board technique, cracked nipples, and infection. of Certified Lactation Consultants. Lactation consultants may also provide • Lactation consultants come from a specialized breastfeeding counseling in variety of backgrounds. They could circumstances such as multiple births or be from any field of health care preterm babies. or possibly from other areas. While there is no certification program • They may gain breastfeeding expertise in Canada, the International Board of through special training, personal Certified Lactation Consultants (IBCLC) experience, volunteer counseling, paid does provide a certification examination employment, or academic means. for those worldwide wishing to become a • In 2002, 169 Canadians wrote the certified consultant. The IBCLC requires examination to receive certification that their members complete both univer- through the International Board of sity or college level course work in addition Certified Lactation Consultants. to clinical training, and members must also re-certify every five years. In Canada in 2002, 1,191 lactation consultants were certified and registered with this board.

Conclusion Many different health professionals provide care to women and infants before, during, and after birth, working in hospitals, clinics, laborato- ries, physicians’ offices, or in patients’ homes. Declining overall rates of births, together with increasing rates of births requiring more specialized care, have the potential to affect all providers of maternity and infant care—so may what they are required to do in their profession and what they choose to do. Fewer newly practising family physicians are choosing to include obstetrics in their practices, for a variety of reasons. As family physicians in many regions are attending fewer births in general and fewer higher-risk births in particular, women more often are choosing obstetricians and midwives to deliver their babies. In rural areas, community hospitals have cut maternity services, requiring mothers to make different care choices.

Some innovative responses, such as formal shared-care services and the growing number of community birthing centres, have emerged. More innovations may be on the horizon. The changing scope of practice, along with a general trend toward earlier retirement, have implications for decisions in health human resource management, including recruitment and retention, professional training and continuing education, payment methods (salaries or fee-for-service), and fee structures. We hope governments, professional associations, and health facility associations can make use of information such as that contained in this report to respond to these changing needs.

What We Know • The number of family physicians providing intrapartum and shared care. • The percentage of hospital births, vaginal and caesarean, which are attended by obstetricians, family physicians, or midwives. • The average number of births attended by family physicians and obstetricians in a year. • The number of registered nurses who identify maternity/newborn care as their primary area of responsibility in each province and territory. • The number of registered midwives in Canada, the provinces that have regulated the profession, and those funding their services. What We Don’t Know • What types of informal care—such as from friends, family, and community groups—do parents and infants receive? What mix of formal and informal care would work best for different families and communities? • How will declining birth rates, the increase in multiple births, and other demographic trends affect the demand for health care for mothers and babies? What is the best mix of obstetricians, family physicians, midwives, and other care providers to meet this need? What are the implications for training, costs, scopes of practice, and the delivery of health services? • What impact will the increasing number of midwives have on obstetrical care in Canada? How has this change, as well as changes in the scope of practice for other professionals, affected the care provided to mothers and babies, their health, their satisfaction, and the costs of their care? • How many allied health care providers provide care to mothers and their infants? What services do they provide? What is their effect on maternal and infant outcomes? What’s Happening • Negotiations are underway between certain CLSCs and hospitals in Quebec that would allow midwives to deliver babies in hospitals. Also, the Quebec government is expected to pass a regulation allowing midwives to perform home births. • The government of British Columbia has earmarked $2 million to encourage more physicians to continue delivering babies. Physicians with low obstetrical caseloads will receive a 50% bonus for up to 25 deliveries a year. • Researchers at McMaster University are collecting policy and position statement information on the rationalization of maternity care in Canada with a particular interest in rural maternity care. They expect findings to be available by the summer of 2004. • CIHI released updated health personnel data for years 1993 to 2002. As well, a special report on changing scopes of practice that includes information on how much time family physicians are devoting to obstetrical care will be released later in 2004. • In March 2004, Saskatoon’s Baby Friendly Initiative Partnership received the Health Quality Council Stellar Award. This recognizes the initiative’s benefits for several programs, such as a pharmacy hotline, designating breastfeeding-friendly work sites, and a welcome wagon to increase use of lactation consultants.

31 32 Giving Birth in Canada: Providers of Maternity and Infant Care Fast Facts Number ofPhysiciansbySpecialtyAcrossCanada,2002 Source: population estimatesandmaydifferslightly from previously published figures. Physician:Population ratiosare expressed asphysiciansper100,000population. Physicianper100,000ratesuseupdated 53 anaesthesiologists,and50paediatriciansin2002. records 448familyphysicians, 30obstetricians/gynaecologists, in theannualreport oftheNMBRegistrar. The NMBRegistrar practitioners inthisreport butare countedasspecialistphysicians specialists in2002.Thesephysiciansare countedasgeneral (NMB) grantedfullorprovisional licensesto132non-certified other publications.Forexample,theNewfoundlandMedicalBoard service planpaymentarrangements.Assuch,ratesmaydifferfrom a physicianissubjecttoprovincial licensure rulesandmedical reflect theservicesprovided, astherangeofservicesprovided by physician classificationinthismannerdoesnotnecessarily included inthe specialists),are specialists(orCanadiannon-certified certified physicians, includingnon-CFPCgeneralpractitioners,foreign- of Canadaand/ortheCollegedesmédecinsduQuébec. oftheRoyal CollegeofPhysiciansandSurinclude certificants the CollegeofFamilyPhysiciansCanada. Physicians designatedas credentialsbased onpostgraduatecertification achievedinCanada. For purposesofreporting, physician specialtyclassificationis College ofPhysiciansandSurgeons respectively. ofAlberta, not bepublished.Yukon datafor2000donotreflect andAlberta theannual updatefrom theGovernmentofYukon orthe cians whoare notlicensedtoprovide clinicalpracticeandhaverequested totheBusinessInformationGroup thattheirdata 31 ofthereference year. Thedataincludephysiciansinclinicalandnon-clinicalpracticeexcluderesidents andphysi- Note: u.1 3)0()0()0()10(35) 46(111) 52(175) 0(0) 59,412(189) 929(175) 3(7) 191(136) 1(3) 2,197(7) 1,943(206) 0(0) 32(6) 9(6) 1,185(157) 0(0) 1(3) 2,406 (8) 66(7) 29(4) 15,800(212) 31(6) 21,735(179) 2,077(181) 0(0) 7(5) 1,564(155) 559(7) 1,592(5) 2(5) 888(7) 1(3) 86(9) 102(9) 5,637(180) 50(7) 44(4) 10(35) 30,258(96) 20(4) 8,243(199) Canada 5(4) 30(72) 566(8) 227(7) Nun. 48(161) 924(8) N.W.T. 99(9) 51(5) 237(6) 585(110) 30(4) 62(6) Y.T. 119(85) N.L. 229(7) 399(5) 1,007(107) P.E.I. 700(93) 666(6) 351(8) 58(5) N.S. 7,917(106) 40(4) N.B. 10,242(85) Que. 133(4) 1,073(93) Ont. 187(5) 966(96) Man. 3,020(97) Sask. 4,541(109) Alta. B.C. Physician countsincludeallactivegeneralpractitioners,familypractitionersandspecialistphysiciansasofDecember Southam MedicalDatabase,CIHI hscasGneooit neteilgssPeitiin AllPhysicians Paediatricians Anaesthesiologists Gynaecologists Physicians aiyObstetricians/ Family f a m i l y

p r a c f a t i m c e i l y counts. Itisrecognized that

p r a c t i t F i o n F e r s S

include certificants of include certificants p e c i a l i s t All other

p h y s i c i geons a n s (Rate per100,000Population) Registered Nurses (RNs) Specializing Number of RNs in Maternal and Newborn Care Across (% of all RNs Employed in Nursing) Canada, 2002 B.C. 1,684 (6.0) Alta. 1,444 (6.2) Sask. 403 (4.9) Man. 693 (7.0) Ont. 4,352 (5.5) Que. 2,296 (3.9) N.B. 364 (4.9) N.S. 533 (6.3) P.E.I. 87 (6.7) N.L. 258 (4.7) Y.T. 17 (6.3) N.W.T. 29 (6.0) Nun. 7 (2.6) Canada 12,167 (5.3)

Note: CIHI data will differ from provincial/territorial data due to the CIHI data collection, processing, and reporting methodology. Source: Registered Nurses Database, CIHI Residency Programs

Obstetrics Paediatric Paediatric Maternal/ and General Emergency Paediatric Neonatology/ Fetal Family Gynaecology Paediatrics Surgery Medicine Radiology Perinatolgy Medicine Medicine University of X X X X X X X British Columbia University of Calgary X X X X X X University of Alberta X X X X X University X X X X of Saskatchewan University X X X X X X of Manitoba University of X X X X X X Western Ontario McMaster University X X X X X University of Toronto X X X X X X X X Queen's University X X X University of Ottawa X X X X X X X McGill University X X X X X X X Université de Montréal X X X X X X X X Université X X X de Sherbrooke Université Laval X X X X Dalhousie University X X X X X X Memorial University X X X of Newfoundland

Note: Family medicine data were compiled from university Web sites by CIHI. Source: Royal College of Physicians and Surgeons of Canada

For More Information 1Canadian Institute for Health Information. (2001). Hospital Morbidity Database, 2000–2001. Ottawa: CIHI.

2World Health Organization. (2000). Munich Declaration: Nurses and Midwives: A Force for Health, 2000. www.euro.who.int.

3British Columbia Centre of Excellence for Women’s Health. (2003). Solving the Maternity Care Crisis: Making Way for Midwifery’s Contribution. Policy Series. Vancouver: British Columbia Centre of Excellence for Women’s Health.

4Hawkins M, Knox S. (2003). The Midwifery Option: A Canadian Guide to the Birth Experience. Toronto: HarperCollins Publishers.

5Statistics Canada. (2000). National Longitudinal Survey of Children and Youth. Ottawa: Statistics Canada.

6Wen SW, Mery LS, Kramer M, Jimenez V, Trouton K, Herbert P, Chalmers B. (1999). Attitudes of Canadian women toward birthing centres and midwifery care for childbirth. Canadian Medical Association Journal, 161(6), 708–709.

7Blecher, MB. (2001). When Your Pregnancy’s at Risk. www.my.webmd.com/content/pages/3/3608_926.htm.

8 Health Canada. (2003). Canadian Perinatal Health Report 2003. Canadian Perinatal Surveillance System. Ottawa: Health Canada.

9 Reid T, Grava-Gubins I, Carrol JC. (2002). Janus project: Family physicians meeting the needs of tomorrow’s society. Canadian Family Physician, 48(7), 1225–1226.

10 Canadian Institute for Health Information. (2001). National Physician Database. Ottawa: CIHI.

11 Godwin M, Hodgetts G, Seguin R, MacDonald S. (2002). The Ontario family medicine residents cohort study: Factors affecting residents’ decisions to practice obstetrics. Canadian Medical Association Journal, 166(2), 179–184.

12 Blain D, Lalonde A, Milne JK. (2000). SOGC survey on practice patterns in obstetrics and gynaecology. In Society of Obstetricians and Gynaecologists of Canada: Strategic Plan 2000–2005. Ottawa: Society of Obstetricians and Gynaecologists of Canada.

13 Chan BTB, Willett J. (2004). Factors influencing participation in obstetrics by obstetrician-gynecologists. Obstetrics and Gynecology, 103, 493–498.

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38 Johnson D, Jin Y, Truman C. (2002). Early discharge of Alberta mothers post-delivery and the relationship to potentially preventable newborn readmissions. Canadian Journal of Public Health, 93(4), 276–280.

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37 38 Giving Birth in Canada: Providers of Maternity and Infant Care 40 46 45 44 43 42 41 Canadian FamilyPhysician children withotitismedia:Dofamilyphysiciansandpediatriciansagree? McIsaac WJ,CoytePCroxfordRHarjiSFeldman.(2000).Referralof 2001 Canadian InstituteforHealthInformation.(2001). statistique duQuébec,chapitre21. Enquête socialeetdesanté1998,2eédition,Québec,Institutla (2000). Dunnigan, L. of Canadians Canadian InstituteforHealthInformation.(2004). ministry_reports/healthy_babies_report/hbabies_report.html. Healthy ChildrenReportCad Ontario MinistryofHealthandLong-TermCare.(2003). Medical AssociationJournal mothers ofverypreterminfantsinaneonatalintensivecareunit. Preyde M,ArdalF.(2003).Effectivenessofaparent“buddy”programfor care physicianspecialty. Boulis AK,LongJ.(2002).Variationinthetreatmentofchildrenbyprimary 1210–1215. . Ottawa:CIHI. . Ottawa:CIHI. Recours au service téléphonique Info-Santé CLSC Recours auservicetéléphonique Info-Santé Archives ofPediatrics&AdolescentMedicine , 46,1785–1788. , 168(8),969–973. . w.health.gov.on.ca/english/public/pub/ Health Care inCanada Improving theHealth Healthy Babies, Canadian , 156(2), .