Centres of Controversy: Hospitals Vs. Midwives

There are only two birthing centres in Montreal, which must turn away many eager parents. Midwives say resistance from the medical community is hindering their practice from growing in Quebec.

Special to The Gazette
The Montreal Gazette
Saturday, September 29, 2007

There’s a fine line between relaxed and sleepy, and Renelde Napoli strikes it perfectly. She is in her seventh month of pregnancy and a little tired out, but still in good spirits as she juggles caring for first-born Olivia, 4, and preparing to exhibit her jewellery at an upcoming art show.
She hopes to have her baby at the CLSC Lac St. Louis Birthing Centre in Pointe Claire with the help of midwives. While many expecting parents opt for hospitals because they feel safer there, Napoli feels the opposite.
“The birthing centre feels like a more comfortable and safer environment. It feels more like home—not threatening, with machines everywhere.”
Napoli has experienced both settings. She had planned to give birth to Olivia in the Pointe Claire birthing centre, but her first baby arrived just days too early—36 weeks into her pregnancy.
The cutoff for births there at the time was 36 weeks, five days. (It has since been reduced to 34 weeks.) So Olivia was born at the LaSalle General Hospital with the assistance of Napoli’s midwife.
Napoli said the hospital’s staff were “really nice,” but that she far prefers the extra care and natural philosophy of a midwife. So when it came time for baby No. 2, she immediately signed up again at Pointe Claire despite the fact she doesn’t have a car and needs to borrow or rent wheels to make the 30-minute trip from her Plateau home.
“The birthing centre seems so much more natural,” Napoli said. “I love that they take time to talk to you. Each appointment is an hour, and if it’s longer, it’s no big deal.”
Napoli is part of a growing movement of Quebec parents seeking an alternative to the hospital birthing experience.
Waiting lists at Montreal’s two birthing centres (the second is in Côte des Neiges) are long, with only 30 per cent of expecting parents able to get a spot. Parents who don’t sign up within a few weeks of becoming pregnant probably won’t get a spot.
A 2005 poll for Quebec’s Health Ministry found 15 per cent of Quebec women would like to give birth at a birthing centre, while another nine per cent would like to do so at home with the help of a midwife.
Yet only about 1.5 per cent of the province’s 80,000 annual births are currently assisted by midwives. The reason: Quebec has only 90 midwives working at eight birthing centres, well short of the 500 practitioners and 40 birthing centres that midwives say are needed to meet the demand.
Advocates say birthing centres are more natural for the 80- to 90 per cent of pregnancies that are low-risk and don’t require medical intervention, and that they can ease the burden on Quebec’s overworked obstetricians, who typically have a caseload of 200 to 300 births per year, compared with 80 for each team of two midwives.
Yet plans to expand the number of birthing centres in the province have stalled. A new birthing centre scheduled to open next year in the Laurentians got off the ground only after 14 years of campaigning by community groups and funding from the city of Blainville to construct the building.
In Montreal, midwives and community groups have campaigned for 10 years to create a birthing centre in the Plateau. With the Health Ministry refusing to finance a third birthing centre on the island, the local health board that includes the Plateau said it is hiring four midwives this fall to work out of the Ste. Justine Hospital.
Activists are negotiating with a private foundation to finance the construction of a building in the Plateau that they hope the Health Ministry would rent for use as a birthing centre.
Such a centre nearby would have come in handy for Moiya Callahan, a Mile End resident expecting her third baby in April. Like Napoli, she must rent a vehicle to attend prenatal appointments with her midwife at the Pointe Claire birthing centre, where she had her first two kids. Because of the distance, she is considering a home birth the third time around.
When Callahan learned she was pregnant with her first son, she went to a hospital for her first prenatal checkup, but said quickly got turned off. “I saw the doctor for about three minutes. It was not a very nurturing environment.”
She learned about midwives on the Internet and was won over by their philosophy of natural childbirth and self-empowerment. “You can spend an hour with them at appointments. Then, you really have that trust. Having that trust in them makes you trust yourself more.”

So why the delay in creating new birthing centres? A big part of the reason, midwives say, is resistance from the medical community in a country that was one of the last in the industrial world in which authorities started to legalize midwifery.
Quebec let some midwives practice in a pilot project starting in 1995, but midwifery was legalized only in 1999, while midwife-assisted home births were allowed just in 2005. Midwifery remains illegal in Newfoundland and Labrador, New Brunswick, Prince Edward Island and Yukon and the Northwest Territories.
Indeed, if gynecologist Corinne Leclerc has her way, parents like Napoli and Callahan won’t be able to give birth outside hospitals. Leclerc heads a committee on midwifery issues at the Quebec Association of Obstetricians and Gynecologists.
“We are firmly against birthing centres and homebirths because of the security of the newborn and mother. We would like to work with (midwives), but in hospitals,” she said.
As an example of what can go wrong, Leclerc cited the case of a stillborn baby in a Montreal home birth attended by two midwives in Nov. 2006.
Quebec coroner Paul Dionne issued a report in August saying the death was preventable. He recommended the Quebec Order of Midwives, the professional body that regulates midwifery, change a number of its practices.
Midwives called the death tragic, but several said the coroner’s report was biased against midwives and has fostered misconceptions about the safety of their work.
“I thought the coroner was biased, not having done his homework,” said Gisela Becker, vice-president of the Canadian Association of Midwives.
“Many places in Canada and the world have demonstrated that home births are safe. When a death happens in a hospital, you hardly ever hear about the details.”
Sinclair Harris did a wide-ranging examination of Quebec birthing centre data as part of a study she presented at an international midwifery conference in 2004. Harris is a clinical instructor of midwife students who has worked for 14 years as a midwife in Quebec and Britain and 20 years as an obstetrical nurse in the high-risk-delivery room at the Royal Victoria Hospital.
Harris compared data on all 8,400 midwife-assisted births in Quebec between 1995 and 2002 and publicly available figures on 76,000 hospital births.
The number of perinatal deaths (those in which the fetus dies in the latter months of pregnancy, is stillborn or dies in the first weeks of birth) was 57-per-cent higher in hospital births, according to the data.
Harris cautioned the lower rate of interventions in birthing centres is partly because they accept only mothers with low-risk pregnancies. But, she said, the figures show midwifery is safe.
Harris criticized Dionne’s report, saying it suggests a lack of knowledge about midwifery protocol. “His recommendations are reasonable, but most are already in place,” she said.
For example, Dionne recommended that midwives get regular skills retraining and create guidelines to measure a labour’s progress and what to do in emergencies. Harris said retraining is already done and the guidelines already exist.
Another recommendation in the report falls into “grey zone,” she said—that midwives should transfer the mother to a hospital if they spot the presence of baby stool, known as meconium, in the amniotic fluid. In the case of the stillborn baby, Dionne said the fetus died as a result of swallowing meconium. The attending midwives later told police investigating the incident they had noticed some light meconium when they ruptured the mother’s water during labour on the night of Nov. 21, 2006.
Harris said the presence of meconium doesn’t necessarily mean the fetus is in danger and is not in itself a reason for a hospital transfer if the fetus is showing no other signs of distress.
Leclerc, the gynecologist, agreed meconium isn’t by itself normally considered a reason for a hospital transfer.
“Probably if the baby wasn’t suffering, the doctor would have said (to the midwives) it’s okay to continue what they’re doing,” she said.
Indeed, the Quebec Midwives Act requires only that midwives do a phone consultation with a doctor if “thick or unusual” meconium is noticed.
In the case of the stillborn baby, his heartbeat remained healthy for more than four hours after the discovery of meconium, slowing only during the final stages of pushing. The coroner’s report said the baby probably died about 15 minutes before it was born at 8:21 a.m.
Harris also criticized Dionne for failing to include a key fact in the two-page summary of his report published on the coroner’s website. The complete 10-page report, which the coroner’s office provided by email, notes an indirect cause of the fetus’ death was that it had a severely underdeveloped brain, which had a gestational age of only 23 to 25 weeks.
“The baby would have been completely incompetent neurologically and would probably have died within a few weeks (of birth),” Dionne told The Gazette this week.
But he said that doesn’t change his opinion that the midwives made mistakes. For example, he said, they should have called 911 immediately when pushing seemed to have stalled.
He also stood by his recommendation that a mother should be immediately transferred to a hospital if any meconium is detected. When told Leclerc’s differing opinion, he said: “I don’t give a damn. There should be an automatic transfer, period.”
As for the midwives’ criticism that he was biased and that his recommendations are already part of midwifery protocol, he said: “It’s not my business to answer them. Yes, I did some recommendations (for practices) I knew they were already doing. But it’s on paper, and their members didn’t do it. They were lax.”
The mother of the stillborn baby refused to comment: “We’re trying to turn the page.”
The Quebec health ministry, for its part, doesn’t plan to change rules governing midwives, and is leaving any reforms up to the Quebec Order of Midwives, which is studying Dionne’s report.
Back in the Plateau, Napoli said the death was “absolutely awful,” but that she believes midwifery has been unfairly maligned in the outcry over the case. “What about all the babies who die in the hospital? Doctors make mistakes, too.”

Midwifery Facts

Midwife-assisted births that involve a Caesarean: 6.2%
Hospital births that involve a Caeserean: 18.5%
Midwife-assisted births that involve an episiotomy (a cut to widen vagina to help baby emerge): 1.9%
Hospital births that involve an episiotomy: 30%
Perinatal deaths per 1,000 among midwife-assisted births: 4.7
Perinatal deaths per 1,000 among hospital births: 7.4
Fetal deaths per 1,000 among midwife-assisted births: 4.2
Fetal deaths per 1,000 among hospital births: 4.3
Cost of a midwife-assisted birth in 1997: $2,062
Cost of a hospital birth: $3,016
Percent of midwifery clients requiring hospitalization during pregnancy: 3.3
Percent among hospital clients: 10.3
Percent of midwifery clients who breastfeed at birth: 98
Quebec average for breastfeeding at birth: 72 percent
Sources: Public Health Agency of Canada, Evaluation Study of Quebec Birthing Centre Pilot Projects, Institut de la statistique du Québec, Quebec College of Physicians, Quebec Order of Midwives, Quebec Association of Midwives

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