There are only two birthing centres in Montreal Quebec
by ALEX ROSLIN
Special to The Gazette
TheMontreal
Saturday, September 29, 2007
The
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
For More Information
World Health Organization midwifery webpage
International Confederation of Midwives
American College of Nurse-Midwives
Canadian Association of Midwives
Regroupement Naissance-Renaissance (Quebec-based, French language)
Groupe Maman (Quebec-based, English & French)
La Leche League
Hypnobirthing.com: an alternative approach to pregnancy and birth
International Confederation of Midwives
American College of Nurse-Midwives
Canadian Association of Midwives
Regroupement Naissance-Renaissance (Quebec-based, French language)
Groupe Maman (Quebec-based, English & French)
La Leche League
Hypnobirthing.com: an alternative approach to pregnancy and birth
