Date:
Author:

Maternity services disappearing in rural Canada


The plan to eliminate obstetrical care at Banff’s Mountain Springs Hospital, and to replace it with enhanced vascular and plastic surgery services, was labelled a potential “quick win” in a 2012 community and rural health planning document.

Babies would no longer be delivered in Banff (population about 8,200) and instead obstetrical care would be “consolidated” at the Canmore General Hospital, located in the slightly larger town of Canmore (population 12,000), 22 kms east on the TransCanada highway.

With the departure of obstetrics, the Mountain Springs Hospital, located in the scenic town inside Banff National Park, would increase its capacity for joint repair and cosmetic plastic surgery for Canadians and foreign tourists.

Alberta Health Services and Covenant Health, “Canada’s largest Catholic Health Provider”, produced the planning document, but did not count on opposition from the Banff community. (Covenant operates the Mountain Springs Hospital, but not the Canmore General Hospital.)

The proposed change sparked a “Save the Banff Maternity Ward” movement early this year, protests were held in the community, and supporters of keeping birth in Banff even illustrated their concern with a humorous YouTube video.

But at the end of March 2013, the closure went ahead as planned and the maternity ward at Banff’s Mineral Spring Hospital was shuttered. The closure is the subject of an upcoming judicial review.

In some respects the Banff/Canmore story is unusual because services for local residents are being replaced by elective surgery, including privately paid non-medically necessary cosmetic procedures that are pitched, in part, towards nonresidents and non-Canadians. (Recognizing a business opportunity, local hotels provide discounts to plastic surgery clients.)

Maternity ward closures have wide-ranging effects

But the closure also fits into a larger trend. Across Canada, the number of hospital maternity wards in small towns has been steadily declining. The closures of these wards have wide ranging effects—on the safety of deliveries, the out-of-pocket expenses families must shoulder, the attractiveness of a community to young couples and the retention of physicians (such as general surgeons, anaesthetists and those interested in a broad range of practice) in smaller hospitals.

Maternity services in 20 British Columbia hospitals closed since 2000, according to research published in 2009 in the journal Health Policy.

In Ontario, five hospitals have ceased offering obstetrical services  since 2011, according to BORN Ontario. An earlier study (1999) revealed a similar trend in northern Ontario: of 55 general hospitals surveyed, the number not offering obstetrical services increased by 500% from 1981, states the study by Peter Hutten-Czapski.

And according to information published on the Public Health Agency of Canada website in 2009, 25.6% of women travelled to another city, town or community to give birth, and overall 2.5% of women travelled more than 100 kms to give birth.

No “robust evidence base” for closing rural & small town maternity wards

“There’s been a steady erosion” of locally available maternity services, says Stefan Grzybowski, the lead author of the Health Policy article and co-director of the centre for rural health research at the University of British Columbia.

But the article states that there’s no systematic approach to rural health service planning, and no “robust evidence base” for closing maternity wards.

And in an interview, Grzybowksi adds that maternity ward closures are often “the canary in the coal mine” that triggers the loss of other services—such as general surgery, anaesthesia, and emergency services— in smaller hospitals.  All those services are intricately connected, and so he also notes that the loss of any one of them can create a domino effect.

“Efficiencies of scale” is a mantra in health care planning these days, and nationwide there’s been a push to regionalize and centralize certain health care services, especially surgical procedures. The rationale is that more expertise, quality and safety are to be had with a higher volume of procedures such as trauma care and some cancer surgeries.

Evidence for a link between quality and volume in obstetrics is much more limited. There is some international evidence that suggests relatively low volume of deliveries at a hospital can be a safety concern.  However, there is also Canadian evidence that suggests that there is no relationship between a family physician’s delivery volume and adverse outcomes, although this research has not yet been replicated in rural settings. In any event, volume alone does not determine the safety of obstetrical services. Distance also matters.

Travelling to give birth increases the risk of “adverse perinatal outcomes”

Grzybowski and many who work in rural maternity care say that unlike trauma or cancer care, it is not “safer” to close local, functioning maternity wards so that woman have to travel to give birth.

Instead, women in labour who have to travel to access maternity care “have increased rates of adverse perinatal outcomes,” concludes “Distance Matters: A population based study examining access to maternity services for rural women,” another study co-authored by Grzybowski.

Depending on how far women live from maternity care services, they can experience either more unplanned out-of-hospital deliveries, or more inductions (when uterine contractions are artificially stimulated before labour beings on its own), the study found.

Importantly, it is the most “socioeconomically vulnerable” women and families who have the most difficulty mobilizing the resources to travel to a referral centre, the study notes.

Where you give birth, where you die: both have sacred meaning in people’s lives

Even when the distance from one’s home town to a centre with a maternity ward is not a great distance, the fact is that people are “philosophically tied to a sense of place,” says Sarah Newbery, a family physician in Marathon Ontario.

“Obstetrics and palliative care—where you birth and where you are allowed to die—are sacred in terms of their meaning in people’s lives.”

Newbery was one of six doctors who came to practice in Marathon in 1996. The group made their move to the town of less than 4,000 “contingent on the [hospital] board re-opening the obstetrical unit,” she says.

The maternity ward at the Wilson Memorial General Hospital had been closed for the previous two years because of a doctor shortage. The re-opening was noteworthy as it was the only maternity ward to re-open in many years. “We were a significant blip in the downhill slide,” Newbery observes.

Marathon is located on the north shore of Lake Superior between Sault Ste Marie and Thunder Bay. The closer of the two cities is Thunder Bay, a three to four hour drive away.

There’s no obstetrician in Marathon, so the hospital offers only low risk obstetrical services. Women are carefully assessed and those who aren’t deemed low risk—about 50% of pregnant women, for conditions including hypertension, diabetes, and opiate abuse—have no choice but to leave Marathon to deliver, usually at about 37 or 38 weeks, Newbery explains.

Families must shoulder the financial burden when they have to travel to larger centre to give birth

While northern Ontario residents are reimbursed for travel to get to medical care, only one night of accommodation is covered, which means women and their families face a considerable financial burden when they have to leave their home community to deliver, she notes.

Women who are deemed low risk go through a detailed informed consent process and about 90% of those who are eligible to stay decide to deliver in Marathon, she says. (The number of women delivering in Marathon has ranged from 19 to 40 per year over the past few years.)

A published study of pregnant women’s decision making in Marathon found that being close to home where it’s easy to have coaches and partners be present “are of prime importance in the decision.”

When obstetrical services are eliminated, it’s difficult to revive them

Newbery notes that she and her colleagues have also had to attend deliveries, deemed high risk, but where women were not able to leave Marathon because of bad weather or because the women went into labour early.

Researchers stress that once obstetrical services are closed, it’s very difficult to revive them.

Jane Fowke enjoys delivering her patients’ babies, but isn’t sure how long she’ll keep at it now that she can long longer attend her Banff patients in their home town and has to travel to Canmore, where she has hospital privileges.

“I’m happy being on call . . . but obviously, I’m not going to go up and down the road forever,” says the 56-year-old family physician who has been delivering more than 50 babies a year.

Total deliveries in Banff had exceeded 100 a year in 2010 and 2011, but last year the number dropped to 51, primarily because the other family physician who attended deliveries moved away.

Obstetrics a “core, essential service for a community”

No questions were ever raised about the safety of Fowke’s practice and obstetrical nurses at the hospital had maintained their qualifications.

Fowke says she was never consulted about the closure of obstetrical services in Banff.  While the AHS and Covenant Health refer to a community consultation being part of the planning, background documents of that meeting, attended by 11 people identified as “community members”, indicated that the consolidation of obstetrical services was not a prominent item being considered.

“Once I stop, there will be no one to do obstetrics,” in Banff, says Fowke, noting that this is a problem because not all babies arrive as planned and on schedule. “I think obstetrics are a core, essential service for a community hospital…and hospitals are more lively when there are births as well as deaths.”

Please join us on May 21st at 2pm (ET), 12pm (MT) for a live web chat with medical experts and Healthy Debate editors about whether it is time to reverse the trend of centralizing obstetrical services.

Should Canada reverse the trend of centralizing obstetrical services and begin reopening rural maternity wards?

Loading ... Loading ...

Leave a Comment

Enter the debate: reply to an existing comment
13 comments

  1. Karen Palmer

    Would the “real” Banff Mineral Springs Hospital website please stand up?

    Very different messages embedded in this “Banff Mineral Springs Hospital” website: http://www.banffmineralspringshospital.ca/ (pitched at medical tourists)

    as compared to this “Banff Mineral Springs Hospital” website site: http://banffmineralspringshospital.com/ (pitched at the Banff community)

    %featured%Seems pretty clear Banff hospital is swapping pregnant women and babies for more lucrative profit-generating patients. Is Banff hospital also planning to share those profits with the Canmore hospital?%featured%

    Banff hospital should remind itself of its vision, mission, and values, including “stewardship” for the community:
    http://banffmineralspringshospital.com/about-us/mission-vision-and-values/

  2. Madonna Gallo

    I experienced this issue firsthand with the birth of my third child in March. My family lives in a small community in Ontario’s near north (cottage country) and the closest maternity ward is about 2 hrs away. My other children were both born in hospital with an obstretcian. The experience was on the whole satisfactory. This time however we chose a planned home birth with the care and support of a midwife. Weather and distance factored prominently into our decision, along with my history of quick labours, healthy low-risk pregnancy and the reality of having two other young children. I’m not sure I initially would have chosen a home birth if other options such as a birthing centre or hospital care closer to home had been more accessible. However, in hindsight, my family and I were absolutely thrilled with our decision to have our baby at home. Our experience working with a team of midwives was truly empowering, client and family-centred, and cost-effective for the health system. I realize home births may not be the preferred option for everyone; however, %featured%I hope that we continue to challenge ourselves to find a range of creative solutions to keeping maternity care for women and families in rural communities as close to home as possible.%featured%

    • F. M.

      You made a huge gamble having a home-birth. Don’t congratulate yourself for making an extremely risky decision.

      All this “patient-centered” flowery talk sounds good and feels good, until the emergency happens and the baby needs to come out in 30 seconds or it dies. Or the mother bleeds profusely and needs to go to the OR immediately or she dies.

      Don’t confuse “patient-centered” care with charlatanism.

      • Karen

        Home-birth is not a gamble for a women without identified risk factors. She should congratulate herself on making an informed decision, as she explained in her post.

        What type of OR are you working in that is ready immediately. If a baby is going to die in 30 seconds without warning – it’s going to happen regardless of the birth location.

        Education is key.

  3. Lisa Prince

    Gee, I guess you only matter if you live in big city… and Banff getting rid of maternity, but increasing plastic surgery? Yeah, because that’s what every small centre needs – more plastic surgery. *shakes head*

  4. lewis

    Ontario and Canada have years of experience in centralizing authority and services (regional health authorities LHIN’s etc) and during that time Canada’s rank position for infant mortality dropped from being the 10th best in the OECD to being 27th, (1980 vs 2008). Over that same period our cost per capita went from 7th highest to 8th. Bluntly put we improved very slightly relative to our peers in costs and got much worse in terms infant mortality.

    Japan, which has more acute beds per capita and many smaller hospitals that are privately owned (usually by a physician or clinician), has both lower costs and lower infant mortality than we do.

  5. Ian R Macdonald

    The current situation is dangerous .Last Saturday a lady was turned away in pre- mature labour only to deliver when she returned several hours later in the same emergency deprtment .If she had been properly assessed she would have been sent to The Foothills Hospital when she first presented.Management claim the staff are trained when nothing could be futher from the truth. This case also as predicted shows a sad disinterest in assessing Obstetric patients properly.
    The people in Banff deserve better.
    Support Banff Maternity and the pending judicial review into a selfish decision !

  6. Renee

    Maybe midwifery services could help fill the void of no obstetricians for low risk women.

  7. F. M.

    Money talks. Obstetrics is not a money maker.

  8. Nicholas Leyland

    There are issues that the discussion does not take into consideration that may impact the continued provision of obstetrical services in rural centres. The new generation of physician providers are unlikely to provide the consistent 24/7/365 day coverage for such services in small numbers. A recent survey of final year obstetrical residents in Canada and the lack of Family Physicians choosing obstetrics as a component of their practice confirms this prospect. The smaller the centre the more difficult the recruitment and retention is for obstetrical coverage. Once the present generation of providers retires, it will be difficult if not impossible to attract new physicians willing to be on call 24/7 or other grueling rotas for coverage. Even midwives are tending to gravitate to larger centres for lifestyle reasons. The newer generation of providers would have to “OK” with the idea of availability for care at a moment’s notice, a daunting prospect that many with young families and a desire for a balanced lifestyle find unacceptable.
    Centralization actually provides aspects of safety that the article does not address. A larger group allows for appropriate in-hospital coverage for providers including anaesthetists and paediatricians to provide safe deliveries with resuscitation capability for mother and baby.
    As a member of an expert panel charged with the review the provision of such services to the Niagara Region recently, I had the opportunity to address the community concern regarding the keeping of a number of small maternity hospitals open or to consolidate at a single site. In the end, it was apparent that those senior providers who where happy to be available under such conditions as described above could not be replaced once they retired. Safe care could be provided most effectively at a consolidated site where care could be provided immediately by in-house obstetricians, family doctors, paediatricians and anaesthetics.
    Obviously with centralization something is lost but something is gained; we need to recognize in addition to access to truly safe maternity care, that a safe and healthy lifestyle for providers is something to which we should be aiming.

  9. Duff Sprague

    It saddens me that while the cost of educating a family physician is in the hundreds of thousands, we then make it impossible for them to use their education and training to practice to their full scope. Increasingly in rural communities where comprehensive care from family docs is needed most the blind devotion to centralization of services has had its most harmful impact .

    As the former Executive Director of the Prince Edward Family Health Team I know that it was both a source of great comfort and pride within our community that 5 of our 23 physicians practiced obstetrics. Sadly maternity services at Prince Edward County Memorial Hospital are threatened with removal along with beds and other services. The almost immediate impact of the elimination of these services is the departure of two great, young physicians – one who practiced obstetrics, the other the head of ER. The 23, soon to be, 21 physicians in that community serve as great role models to the Queen’s University Medical School residents and clerks doing their rotations in Prince Edward. They inspire many of tomorrow’s family physicians to practice rural family medicine and work to the full scope of their skills. However they need more then the will to do it, they need a place to do it.

    The impact of the reductions to the remaining 21 are the reduced opportunities to provide comprehensive care in and out of hospital to their patients.

  10. Jill Konkin

    New study from Norway disproved their hypothesis that centralizing maternity services would decrease maternal morbidity. http://bit.ly/1ggKfPi Need comparable studies in Canada before we decrease the number of rural maternity services any further. This should also lead to a more careful look at the opinion that centralizing any number of health services improves health outcomes.

  11. Andrea

    Where can I find the BORN report that indicated the closure of 5 additional obstetrical units?

Submit a comment