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.