Desperately Seeking Midwife

WHY AREN'T THERE ENOUGH IN CANADA?

by Alex Roslin

TODAY'S PARENT

Spring 2009

Moiya Callahan’s first prenatal visit to the hospital didn’t go quite as she had imagined. A nurse and intern came into the room for a quick checkup, then the obstetrician dropped by “for literally a minute,” she says. “She came in, asked if I had any questions and left.” There was no time to build a relationship with the person who would bring her little one into this world. That’s not how she had thought it would happen.

Callahan, a music composer in Montreal, turned to the Internet, and that’s where she heard about midwives and their natural approach to pregnancy and childbirth. Still a little unclear on what that meant, she made an appointment. The experience was another eye-opener as she learned about midwives’ philosophy of birth as a healthy normal process that usually doesn’t require a doctor or even a hospital setting. “Your whole world changes. It’s a different perspective on pregnancy. I had never thought like that before.”

Opting for midwifery care

Callahan is part of a fast-growing trend of Canadian parents who are opting for midwifery care, as research shows they offer a safe, low-intervention alternative for the 80 to 90 percent of births that are considered low risk. But in much of Canada, parents are lucky to get in the door. While 24 percent of Quebec parents say they’d like to have their baby in a birthing centre or at home with a midwife, only 1.6 percent actually do. Two-thirds of moms who call for a spot with a midwife are turned away because of a lack of places. That’s largely because the province has just 90 practitioners, instead of the 500 that midwives estimate are needed to meet the demand.

That same story is being repeated across Canada. One of the last industrialized countries to officially recognize and regulate midwifery (beginning with Ontario in 1994), Canada is suddenly seeing a scramble to keep up with the exploding demand for midwives.

In Ontario, the province that leads the way in terms of the proportion of women giving birth with midwives (eight percent), demand is fast outstripping supply. A 2005 Ontario government study found that only 57 percent of women who wanted a midwife’s services in 2003/04 actually got to see one, compared to 80 percent in 1999/2000. According to a 2006 study, some 16,000 women seek a midwife each year, and 6,000 can’t get a spot. Last year, the Ontario government announced a $2.3 million plan to increase by 50 percent the number of enrolments for the four-year midwifery undergraduate program. The aim is to have an additional 1,200 women give birth with a midwife each year. But that will still mean 4,800 women will be out of luck.

While midwifery struggled for recognition as recently as the 1990s, health officials and doctors are quickly coming around, largely for the most pragmatic reason: Midwives can save the cash-strapped health system oodles of money because their natural delivery method costs about 30 percent less than the conventional hospital approach.

Officials also say midwives have a critical role to play in helping Canada’s health care system cope with a yawning lack of maternity care providers, a situation that’s reached crisis proportions and is poised to get a whole lot worse as boomer-aged doctors start to retire.

But despite this, midwifery still faces major obstacles in Canada. Don’t expect anything soon like New Zealand’s quick progress since it officially recognized midwifery in 1990; there, 78 percent of women today give birth with a midwife. In Canada, by contrast, midwives say that while many doctors and nurses support their profession, expansion is still happening at a glacial pace due to resistance from some in the medical community and inertia in the health care bureaucracy. Progress is also slow because of the same delays in turning out new graduates that the medical profession faces: a mishmash of differing approaches in each province and territory, and always tight health budgets.

The maternity case crisis

Callers to Corinne Leclercq’s medical clinic in Victoriaville, Que., got a stark awakening last summer about the crisis hitting the field of obstetrics and gynaecology. A phone message said the clinic had no spaces open for gynaecological exams for the following four months due to a shortage of doctors that would persist for nearly a year.

Gynaecologists’ offices have been inundated by a mini baby boom. Leclercq says a lack of maternity care doctors in the province has meant 20 unfilled hospital positions for OB/GYNs. “It will just get worse,” she says, noting that 30 to 40 percent of OB/GYNs in the province are aged 50 and up and will soon retire. In Ontario, the number of family doctors and obstetricians attending births has already dropped from 3,100 in 1984 to less than 1,300 in 2004. Across Canada, 36 percent of obstetricians and gynaecologists expect to retire within five years, according to a report from the Society of Obstetricians and Gynaecologists of Canada (SOGC). (Leclercq sits on the society’s board.)

These shortages are a key reason that Canada slipped from sixth to 21st place in national infant mortality rates between 1990 and 2002, and from second place to 11th for rates of maternal complications during labour, says the SOGC report.

“Midwives can help in part with this lack of professionals,” Leclercq said.

But Leclercq’s support comes with an important caveat: She thinks midwives should all work in hospitals and not deliver babies in homes or Quebec’s unique network of midwife-run birthing centres. “The risk is certainly higher at home or in birthing centres,” she said.

It’s a controversial argument that midwives vehemently reject, saying they’ve got not only a proven safety record, but also much lower rates of medical interventions than doctors.

In Wolfville, NS, midwife Louise McDonald is also turning clients away. She is one of just six midwives serving the entire province, where, like her counterparts in the other Atlantic provinces, the Yukon and Nunavut, midwives are not yet regulated by provincial law. This means their services aren’t covered by provincial health plans, and parents must pay $1,200 to $2,400 (McDonald uses a sliding scale depending on family income) for a full course of care at her clinic. It also means she has no malpractice insurance, rights to prescribe medications or hospital privileges, and risks being charged with practising medicine without a licence.

McDonald says midwifery in Atlantic Canada has progressed slowly because of squeezed health budgets — meaning no money for start-up costs for a midwifery program — and an erosion of awareness that most births can happen safely, without any need for medical interventions. “A lot of that is because of the lack of midwives. We can educate women on normal births. We are the specialists in normal births.”

Nova Scotia is now developing regulations to govern midwives and hopes to license and fund them by early 2009. New Brunswick has said it will also license and fund midwives this year. Maria Kuttner, former director of primary health care at the Nova Scotia Department of Health, says the use of midwives for normal birth will free up doctors to deal with cases involving complications. “It’s going to alleviate some of the wait times,” she says.

Kuttner agrees with McDonald that lack of awareness about midwifery in the medical community has contributed to the province’s slowness to license midwives. “They may not appreciate that midwives do more than deliver babies. They take care of families from the beginning of pregnancy,” she says.

The midwifery experience

In Alberta, where the province does regulate midwives, but their service isn’t included in the health plan, Heather Cook was willing to lay down the $3,000 fee to have her second baby in a natural, low-stress setting.

Cook, a Calgary writer, speaks in glowing terms about her experience. “I loved, loved, loved my midwife. I talk about her all the time. The care was so wonderful. I said afterward, ‘I want to do that again!’”

That’s not quite what she was saying after her previous baby was born. Prenatal appointments with her doctor had lasted less than 10 minutes. During labour, nurses did frequent manual checks on her progress that she says were quite uncomfortable. Nurses also advised her to start pushing before she was ready, which left her prematurely exhausted; then “the doctor popped in for the last 15 minutes,” she said.

With her midwife, by contrast, prenatal appointments lasted an hour or more; her midwife visited her at home before and after the birth; and during labour the two midwives who attended were reassuring and unobtrusive, checking her progress manually as little as possible. Cook said their confidence in her helped her trust her body and have a more comfortable labour.

She believes the contrast between the two experiences — both lasting the same nine hours — was the main reason for the large difference in her recovery time. “After my first child, it felt like I had been kicked in the crotch for an hour or two and I stayed in bed for 24 hours,” says Cook. “With my second birth, there was way less swelling and pain, and I was able to walk out of the hospital four hours after having my daughter.”

Leclercq acknowledges that OB/GYNs can’t give pregnant women the same attention as midwives because of vast differences in client loads. She has 200 to 225 maternity care clients per year, while midwives’ professional standards limit their patient load to 40. Leclercq also agrees that rates of medical interventions like C-sections are too high in hospitals, a trend she attributes in part to doctors not wanting to take chances due to the threat of lawsuits: “There are doctors who do too many C-sections.”

On the horizon

Back in Quebec, a radical expansion of midwifery is reportedly in the works at the provincial health ministry.

In June 2008, Minister of Health Philippe Couillard announced the creation, by 2014, of 13 new stand-alone birthing centres where midwives will be based, and a goal to have midwives delivering 10 percent of the province’s 80,000 annual births by 2018. That would mean a need for 2,000 midwives — more than 20 times the current number. Quebec midwives welcome the news. But like their counterparts across the country, they also worry that a fast expansion of midwifery in Canada will come with strings attached, like integration into the hospital system and having doctors train midwives. These are changes that midwives say would imperil their vision of birth as being, in most cases, a healthy normal event best left free of the risk-based approach of the medical model.

Also, despite the province’s support, midwives say that previous expansion plans have stalled due to resistance from a foot-dragging health bureaucracy, which wants control over the birthing centres, as well as from doctors fearing that midwives will take away their jobs. Case in point: In the Laurentians north of Montreal, advocates first proposed a regional birthing centre in 1992; the OK finally came two years ago, 15 years later — and only after the local mayor, who is married to a midwife, agreed to kick in city funds to build it. “The resistance coming from the medical community slowed the birthing centre for years,” said Céline Lemay, president of the Quebec Midwives Association.

For Moiya Callahan in Montreal, any expansion comes a little too late. Activists have lobbied for a birthing centre to serve the eastern and central part of the city, where she lives, for 10 years without much progress, and as she doesn’t have a vehicle, she had to rent cars or take the subway and bus to make her prenatal appointments at the West Island’s Maison de naissance Lac Saint-Louis — a 60 kilometre round trip. Still, the long treks didn’t stop her from having all three of her kids there. “I couldn’t imagine doing it any other way.”

Midwifery basics

Midwifery varies a little in each province and territory, but there are some common basics. Midwives believe moms with low-risk pregnancies can deliver with minimal medical intervention.

“Physicians and nurses are trained to look for illness in the body, whereas midwives tend to look at pregnancy and childbirth as a healthy process,” says Gisela Becker, a practitioner in Fort Smith, NT, who has a master’s degree in midwifery and is vice-president of the Canadian Association of Midwives.

A midwife will usually follow her client through pregnancy, labour, birth and for six weeks postpartum. “When women have one-on-one care, research shows there are better outcomes,” Becker says.

While she takes pains to point out that many doctors and nurses also provide excellent maternity care, Becker says that because midwives offer continuity of care by a single provider and spend more time with clients, they often have more chance to build trust, ease fears about birth and help women go into labour with more self-confidence. “Ninety percent of what we do is preventive care, and if we do that well, hardly any interventions will occur,” she explains.

Prenatal visits usually take place in a clinic or birthing centre and often last an hour or more, while births may happen in hospital or at home. In Quebec, clients deliver in a midwife-led birthing centre.

Looking for a midwife? Most of the provinces and territories have an association of midwives that can give you a referral. A starting place to learn more is the website of the Canadian Association of Midwives: canadianmidwives.org.

Midwifery safe, inexpensive

The research is clear: Midwife-assisted births are safe, lead to fewer medical interventions, such as Caesarean section and episiotomy, and cost less than births with a doctor.

A 2004 study by Quebec midwife Sinclair Harris, of 8,429 midwife-assisted births in birthing centres, found a perinatal mortality rate of 4.7 per 1,000 births from 1995 to 2002, compared to a Quebec average of 6.7 for low-risk deliveries in 1998.

A 2005 study led by Kenneth Johnson, an epidemiologist with the Public Health Agency of Canada, found dramatically lower rates of medical interventions among 5,418 midwife-assisted home births in Canada and the US, as compared to the same type of low-risk births in hospital. Interventions were less frequent for:

• episiotomy (2.1% vs. 33%)
• Caesarean section (3.7% vs. 19%)
• electronic fetal monitoring (9.6% vs. 84.3%)
• vacuum extraction (0.6% vs. 5.5%)

A 1997 study of midwifery for the Quebec government found midwife-assisted clients in the province had fewer premature babies than low-risk-pregnancy moms followed by doctors (2.9% vs. 5.7%) and a lower hospitalization rate during pregnancy (3.3% vs. 10.3%). The study also found midwife-assisted birth in hospital costs less than conventional birth in hospital ($2,062 vs. $3,016).

A 2002 Quebec government report found that 98% of midwife-assisted clients breastfed at birth compared to a provincial average of 72%.

Oceans Awash in Plastic

Ever wonder what happened to that plastic wrapper or water bottle you accidentally dropped on the sidewalk the other day?

Alex Roslin

The Montreal Gazette

Saturday, November 15, 2008

If you think it wound up in a garbage dump or recycling depot, think again. A lot of the plastic debris that litters Montreal streets is flushed into the city's sewers and straight into the St. Lawrence River.

It then floats off into the Atlantic, where circular ocean currents slowly bring it to the centre of the North Atlantic.

Scientists are growing alarmed about massive floating garbage patches that are believed to be building up in the calm centres of the gyres in the middle of nearly all of the world's oceans.

The best-known patch, dubbed the Great Pacific Ocean Garbage Patch, consists of an estimated 100 million tonnes of plastic debris that has accumulated in the North Pacific gyre. Environmentalists call it the Pacific Trash Vortex.

It is believed to be at least half the size of Quebec and possibly up to 10 times its size, depending on how it is measured. And it seems to be growing. Plastic from the vortex is increasingly washing up on Hawaiian atolls and being found in the guts of seabirds and fish.

An estimated 100,000 marine mammals die each year from eating or being entangled in debris - mostly plastic - in the North Pacific alone. Hence the vortex's other nickname: the Plastic Killing Fields.

Plastic in the sea doesn't biodegrade like other garbage. Instead, it slowly breaks up into tinier and tinier pieces that float on the ocean surface or sink to the sea bottom and can take years to finally reach the ocean gyres.

The vortexes are increasingly seen as environmental disaster zones. Plastic contains many toxic chemicals; it also soaks up other dangerous substances already present in the ocean, like carcinogenic PCBs and DDT.

While the oceans may seem far away, Montrealers are directly contributing to the plastic vortexes, say environmentalists like Hélène Godmaire.

Godmaire is the Montreal director of Great Lakes United, a Canadian-U.S. environmental group. The group will issue a report in coming weeks on how antiquated sewage systems in Montreal and other cities in Quebec are discharging massive volumes of raw sewage into the St. Lawrence.

The sewers lack filters and grates to prevent plastic and other street litter from being swept into the river, Godmaire said.

Indeed, 80 per cent of the plastic in the ocean gyres is believed to come from the land, while the remainder is litter from cargo ships, cruise boats and other sea vessels.

"Next time there's a rainstorm, just look at what's in the gutter," said Elaine MacDonald, a Toronto scientist with the environmental group Ecojustice Canada.

"The sewers are directly connected to our rivers and lakes." In a 2005 survey, Ecojustice gave Montreal's sewage system a failing "F" grade - the second lowest grade in the country after Victoria.

The group faulted Montreal for having an antiquated system of sewers. Two-thirds of the island has sewers that combine storm water and sewage in the same pipes.

In normal conditions, the city's sewage-treatment plant filters out plastic and other debris in the rainwater.

But when there is a heavy downpour, the pipes often back up, and raw sewage and debris are discharged directly into the St. Lawrence, said Duong Dao Dang, an engineer at the plant.

Ironically, the situation isn't much better in more recently developed areas of the island where storm and sewer pipes are separate - mostly in the West Island. Here, storm water flows directly into the river, with little filtering of debris.

Grates over gutters catch larger litter, but smaller pieces of floating garbage often wash into the St. Lawrence, Godmaire said.

Montreal city spokesman Philippe Sabourin confirmed culverts that discharge rainwater into the river don't have gratings or filters. "That could create a blockage," he said.

sss Richard Thompson is one of the few scientists studying plastic in the oceans. The marine biologist at England's University of Plymouth first noticed the problem in the early 1990s while working on his PhD at a lab on the Isle of Man, between Scotland and Ireland.

He helped organize a beach cleanup day and was stunned by the amount of garbage - mostly plastic - that had washed up on the island's shores. He borrowed the lab's pickup truck to carry away the debris, expecting he'd have a single load.

"We made six or seven trips and still hadn't touched a fraction of the quantity on the beach. It brought home for me the enormity of it," he said.

"Look at a street after a fair or busy shopping day. You don't have to walk long to see people dropping litter. It doesn't have to be dropped into the sea to wind up there." In a landmark study in 2004, Thompson looked at old samples of plankton collected in the North Atlantic starting in the 1960s. He found microscopic pieces of plastic in the water that had been scooped up with the plankton.

What's more, the amounts of plastic had exploded. The latest water samples had about four times more plastic than the earliest samples from the 1960s. That coincided with a 25-fold increase in plastic production worldwide between 1960 and 2000.

Even more alarming, the water samples were from an area of the Atlantic north of Britain that isn't even in the gyre. No one has ever studied the amount of plastic in the Atlantic gyre itself.

Thompson's studies reported other alarming research: Ninety-eight per cent of dead seabirds studied in northern Europe have plastic in their stomachs.

More than 260 animal species are known to eat or get entangled in plastic - turtles, fish, marine mammals, even small creatures like mussels, barnacles and beach flees.

Ten per cent of all plastic debris eventually winds up in the sea.

Ocean currents and winds are slowly bringing all that debris to the centre of five major ocean gyres in the North and South Atlantic, North and South Pacific and the Indian Oceans, said Marieta Francis, executive director of the Algalita Marine Research Foundation, based in Long Beach, Calif.

But despite the ever-growing plastic blobs in the oceans, the Pacific gyre is the only one that has been studied.

That research started when the Algalita foundation's founder, an avid boater named Charles Moore, chanced upon the Pacific Garbage Patch during a 1997 yacht race.

"There were shampoo caps and soap bottles and plastic bags and fishing floats as far as I could see," he told the U.S. News & World Report.

"Here I was in the middle of the ocean, and there was nowhere I could go to avoid the plastic." The vortex was in the North Pacific gyre, where a high-pressure zone forces debris into a central area that has low currents and winds.

Sailors used to fear getting stuck in gyres because the paltry wind could leave ships stranded without headway for weeks on end.

Moore returned with a scientific vessel to study the vortex and netted everything from a cathode-ray tube to a truck tire, a mass of fishing net and a chemical drum.

One of his most outlandish finds: a 16-kilometre-long slick of Taco Bell plastic baggies. He estimated there were 6 million.

Moore found up to 970,000 pieces of plastic per square kilometre in some areas of the vortex.

That was triple the density found in an earlier landmark study in the western Pacific by the U.S. National Oceanic and Atmospheric Administration.

That study, done in 1988, was the first to document large amounts of plastic in the Pacific. One area 1,000 kilometres east of Japan had 315,000 pieces of plastic per square kilometre.

The density in Moore's gyre is much higher. "You can go for days and days and see plastic everywhere," said Francis.

Moore estimated in 2002 that the volume of plastic in the gyre had tripled in the previous 10 years.

While much of the debris is large and conspicuous, most of it has disintegrated after years of washing around in the ocean.

The plastic pieces are usually five millimetres across or less and must be scooped up in nets finer than a window screen.

"It's not quite what people think. It's like a soup," Francis said.

In the Atlantic, the only research on plastic garbage is more than 30 years old. A survey in the northeastern Atlantic in the early 1970s found 160,000 pieces of plastic per square kilometre in some areas.

Back in Canada, the growing plastic vortexes still seem far from the official radar. At the Department of Fisheries and Oceans, oceanographer Denis Gilbert is one of Canada's leading experts on the St. Lawrence and Atlantic environments.

Gilbert said no one in his office is studying plastic debris entering the St. Lawrence River. As for plastic accumulating in the Atlantic gyre, he had never even heard of it. "We have no one working on that," he said.

Thompson, for his part, hopes to cobble together funds for a scientific sea voyage to the heart of the North Atlantic gyre to confirm for the first time that a plastic trash vortex is indeed gathering there, just as in the Pacific. He also wants to study the impacts on the environment.

"I'd be very keen to go. This stuff is here for generations to come. We haven't really begun to comprehend the impacts."

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Our Toxic Trash Winds Up in the Sea

Plastic accounts for an estimated 70 per cent of all the human garbage in the world's water bodies. Here are some more plastic facts:

8% of the world's oil production is used to make plastic.

40% of plastic is used for packaging material.

500 billion to one trillion plastic bags are used worldwide every year.

5% of plastic is recycled in the U.S.;

20% in the European Union.

10% of all plastic debris is thought to wind up in the sea.

80% of plastic in the Great Pacific Ocean Garbage Patch comes from the land.

1.7 million pieces of plastic were found per square kilometre of shoreline in a 2005 worldwide survey.

100 million tonnes of plastic is in the Pacific Ocean Garbage Patch, estimates the Algalita Marine Research Foundation.

OCEAN SCOURGE: "STOP IT ON LAND"

Marieta Francis says there is a simple solution to the growing soup of plastic trash in the world's oceans. "We need to stop it on land," says the California environmentalist.

Marine biologist Richard Thompson agrees. The first solution, he said, is not to litter the streets. "Any litter that is dropped has a high potential to get into waterways," he said.

Thompson's other solutions come from the three Rs: reduce, reuse and recycle:

Reducing plastic use. Thompson said two-fifths of plastic is used for packaging, which is typically discarded after a single use not long after a product is bought. Another big culprit: plastic bags. Some countries and cities have banned them outright, while others have slapped taxes on them.

Improving recycling. Just 5 per cent of plastic waste in the U.S. is recycled, according to the Environmental Protection Agency. The Canadian rate isn't known, but Toronto scientist Elaine MacDonald said it would be quite low, too. One reason: Each municipality has its own recycling program, while provincial guidelines are generally weak, she said.

Designing smarter. A lot of plastic products can't be easily recycled because they use different colours or types of plastic that can't be combined during recycling. "We should design products with a high potential for recycling," Thompson said. Japan is often seen as a model for this idea. Its goal is to achieve a "closed loop" economy in which all used products are recycled into new ones.

Developing biodegradable plastic. Scientists are experimenting with new biodegradable plastics that slowly break down when exposed to sunlight or water. Some of the products are made from corn or pea starch.

Canadian environmentalists Hélène Godmaire and MacDonald say Montreal and other older cities on the St. Lawrence Rivers and Great Lakes need to improve antiquated sewage systems that discharge a lot of plastic and other garbage into the water. They propose:

Filtering storm water. A lot of plastic gets into the sea through outdated city sewers that release debris directly into rivers and lakes. Solution: screens and grates to catch the litter. (Also important: cleaning the screens regularly.)

Upgrading sewage systems. During heavy rain, Montreal's sewage system often backs up, discharging untreated sewage and rainwater carrying plastic and other garbage into the St. Lawrence River.

Thompson said the public has a strong appetite for change.

"Already we are seeing consumers turning away from plastic bags. I think you'd find very quickly consumers would vote with their feet. The public is keen to do the right thing," he said.

WHERE OUR TRASH GATHERS

What are plastic garbage patches?

Scientists say they believe plastic trash blobs bigger than most countries are forming in the middle of the world's oceans. The debris is slowly brought there by circular ocean currents called gyres that sweep up debris and bring it to their centres. Think water funneling down the toilet.

The Great Pacific Ocean Garbage Patch is the only one that scientists have studied up-close. It's estimated to contain 100 million tonnes of garbage and its size is estimated at anywhere from 700,000 square kilometres (half the size of Quebec) to 15 million sq. km. (10 times Quebec's area) and at least 60 metres deep. Some scientists say it might actually be two trash vortexes - one between Hawaii and California, the other between Hawaii and Japan.

Where are they?

Plastic garbage patches are believed to be accumulating in five gyres - in the middle of the North and South Pacific, the North and South Atlantic and the Indian Ocean.

What's in them?

All sorts of litter has been found in the gyres - everything from a cargo spill of millions of plastic baggies to bottle caps, Styrofoam, syringes, water bottles, traffic cones, lighters, tires and toothbrushes, beach balls, plastic bags, shampoo bottles and plastic dinosaurs, checkers, highlighter pens, perfume bottles and fishing line.

Where does the trash come from?

One-fifth of the plastic in the oceans is thought to be litter from ships. The rest comes from land: Much of it is litter from city streets that is swept into sewers and gets discharged into rivers and lakes, eventually making its way into the sea. Some can also blow into the water from poorly secured trash bins or get taken there by seagulls having a snack at a garbage dump.

The trash can take years to bob its way to the ocean gyres, where it slowly breaks up into ever-smaller pieces until it resembles dust.

What does it look like?

Some of the plastic debris can be seen bobbing on or near the surface but much of it has broken down into tiny pieces after years of floating in the sea and is barley visible, so the garbage patch is often described as plastic "soup." Most pieces are less than five millimetres across. About a third of the debris floats on or near the surface - 60 metres down or more - while the rest sinks to the sea bottom.

What is the impact of the plastic garbage in our oceans?

Over 260 animal species are known to eat or get caught in the plastic debris. About 100,000 marine mammals are estimated to die from doing so in the North Pacific alone. On Midway Island in Hawaii, 400,000 albatrosses feed their chicks nearly five tonnes of plastic a year, John Klavitter, a biologist with the U.S. Fish and Wildlife Survey, has estimated. A European study found 98 per cent of dead seabirds had plastic in their stomachs.

Scientists fear toxic chemicals in the plastic may enter the animals' bodies. People may also ingest microscopic pieces of plastic when they eat fish.

Finding the Right Formula for Nursing

Just three per cent of Quebec mothers breastfeed exclusively until their babies are 6 months old, statistics show. A big part of the problem, says one mom, is the difficulty and cost of finding medical professionals who offer support.

Alex Roslin

The Montreal Gazette, Saturday, October 4, 2008

When Marie-Andrée Bossé had her first baby in 2005, she was all set to breastfeed. She knew breastmilk was the best food for her child.

But she soon started to feel pain and burning sensations during breastfeeding sessions. She consulted a long list of medical professionals—CLSC and hospital nurses and several private lactation consultants—but the problems only got worse.

Soon, there was intense pain in her breasts even when she wasn’t breastfeeding. She was advised to change how the baby latched onto her breast, but the changes helped only a little.

Adding to the pain, she learned she had contracted a host of breastfeeding-related illnesses with strange names she had never heard of before: candidiasis of the nipple, vasospasms and something called bleb—painful blisters around the nipples.

Still, Bossé, a sexology instructor at the University of Quebec in Montreal, insisted on breastfeeding. It was three months before the pain and ailments finally went away with the help of lactation consultants, who showed her how to improve her baby’s latch, and a sympathetic doctor who prescribed medications.

A big part of the problem, she said, was the difficulty in finding medical professionals specialized in breastfeeding issues and the cost of the help. She estimates her expenses for the consultations and drugs at $400 to $500.

“My problems required specialized expertise, and it’s very hard to find those services. That’s why most mothers stop breastfeeding when they encounter problems,” she said.

Breastfeeding experts say Bossé’s story is common and a key reason why, according to a 2006 study by the Quebec government’s statistics institute, just three percent of Quebec moms breastfeed their babies exclusively until they’re six months old. That’s the period of time recommended by Health Canada and the World Health Organization.

Seven years after Quebec adopted one of Canada’s most ambitious policies to promote breastfeeding, the province still has one of the lowest rates of sustained breastfeeding in the country.

For comparison, 19 percent of mothers Canada-wide breastfeed exclusively until six months; in Sweden, the rate is 70 percent.

Now, health officials are reviewing the province’s breastfeeding policy and trying to figure out the reasons for the glacial progress.

The problem, say breastfeeding experts, is that while most Quebec women start out breastfeeding their babies, health professionals are failing to provide proper support and advice when women encounter problems like a bad latch, soreness or poor milk supply.

That, coupled with abundant supplies of infant formula that companies give for free to most Quebec hospitals, makes it hard for women to keep breastfeeding when they encounter problems, said Howard Mitnick, a family doctor at the Jewish General Hospital’s Goldfarb Breast-Feeding Clinic.

“We live in a world where people don’t see breastfeeding and don’t know what it looks like. They have a baby and are suddenly expected to be experts, and people are not around to help them,” he said.

The stakes in the battle over the breast are huge. Research shows breastfed babies have fewer ear and respiratory infections, reduced allergies and diarrhea, a stronger immune system, higher IQ, less risk of diabetes later in life, better development of speech, jaw muscles and baby teeth, and better bonding with mom.

Mothers also benefit by losing weight quicker, experiencing faster contraction of the uterus and having lower risk of osteoporosis and ovarian and breast cancers.

In some cases, research shows breastfeeding is literally a life-and-death issue. A May 2004 U.S. study of 9,900 infants published in the journal Pediatrics found a 27-percent higher chance of death among kids who had never been breastfed compared to those who had, including a 19-percent greater risk of sudden infant death syndrome and 69 percent more chance of death by injury.

“Promoting breastfeeding has the potential to save or delay approximately 720 post-neonatal deaths in the United States each year,” the study said.

The poor situation in Quebec is especially ironic because it was the first Canadian province to officially mandate in 2001 that its hospitals and CLSCs get certified under an international pro-breastfeeding program called the Baby Friendly Initiative.

The initiative, created by the World Health Organization, sets out 10 measures for hospitals to adopt to encourage breastfeeding.

They include training for maternity-ward nurses and doctors, better education on breastfeeding techniques for moms and reduced reliance on formula.

The Quebec government set a target of having 20 hospitals and 40 CLSCs certified as Baby Friendly by 2007, as well as 75 percent of moms breastfeeding exclusively at birth—meaning no infant formula, water or other food—and 10 percent doing so at six months.

Quebec has fallen well short of those goals. Just 13 Quebec hospitals and CLSCs are now Baby Friendly, while only half of moms breastfeed exclusively at birth and just three percent do so at six months.

The failed targets don’t come as a big surprise to Mitnick. He said the province has devoted few funds to train medical staff on breastfeeding techniques, provide more breastfeeding education to parents, create more free lactation clinics or reduce reliance of formula in hospitals.

“The more money the health system puts into breastfeeding, the more money it saves through reduced hospital re-admissions, infections and malnutrition,” he said.

***

Why do so many moms stop breastfeeding early on? A study of Quebec moms in August found the main reasons for giving up are latching problems, pain and poor milk supply.

Most of these problems can be resolved with some expert help, said Louisa Ciofani, a lactation consultant at Royal Victoria Hospital.

Just three percent of moms actually can’t produce enough milk to breastfeed their babies exclusively, usually due to damage to the breast from cancer, burns or surgery, Ciofani said. But even these women can still usually breastfeed to some extent. Less than one percent of women can’t breastfeed at all, she said.

Long ago, it used to be that new moms got help for breastfeeding problems from their mothers, aunts and grandmothers. But after infant formula companies started touting their product as being as good as breastmilk in the 1950s—a belief that numerous studies have since discredited—several generations of women lost that knowledge.

Today, most women must rely on doctors and nurses for help. But few of those professionals have taken the 20-hour training course on breastfeeding that the WHO recommends for maternity-ward staff, Mitnick said.

“People (in hospitals) don’t have the skill set,” he said.

Without help from experts, many breastfeeding moms end up giving up, said Carole Dobrich, a lactation consultant at Mitnick’s clinic and president of the Quebec Association of Lactation Consultants.

“Mothers who are well-supported can get through it, but you have to have that support,” she said.

Tammy Sawyer, a registered massage therapist in Montreal, said she encountered unhelpful hospital staff when she gave birth to her daughter Sophie in August. Her daughter was born with a cleft lip and palate, and medical staff told her to avoid breastfeeding because they believed her baby wouldn’t be able to suck well.

“They said my baby was pretty much going to starve if I breastfed,” Sawyer said.

She said hospital staff advised her use to a pump to manually extract breastmilk, but didn’t show her how to use one.

She later discovered Mitnick’s clinic, where she learned how to breastfeed her baby successfully. She said Sophie is now growing nicely.

Dobrich said hospital staff are often too overworked to teach moms breastfeeding techniques. The result: infant formula is often seen as a quick-fix to feeding problems, she said.

“The quick answer is, ‘Let’s give mom formula because we don’t have time to teach her,’” she said.

Provincial government statistics show half of moms who breastfeed while in hospital are not doing so exclusively and are being given formula to supplement their babies.

The problem is early use of formula can disrupt the establishment of breastfeeding and, later, make it harder for moms to stick with it when they encounter problems or one too many sleepless night, Dobrich said.

The high rate of formula supplementation in hospitals runs counter to WHO guidelines on breastfeeding. The WHO says formula should be used only in cases of dire medical necessity, such as when babies or their mothers are severely ill or the baby has birth weight under 1.5 kilos.

Dobrich said the WHO guidelines are routinely flouted. Mitnick said Quebec hospitals also accept free formula from companies in violation of the WHO guidelines, which call on hospitals to pay at least 80 percent of the market price.

What’s wrong with hospitals accepting free formula? If it’s free, staff hand it out too readily, Mitnick said. “The more formula that’s around, the more it’s going to leak into the maternity rooms.”

And the province’s support for breastfeeding may soon actually diminish, said Isabelle Cloutier, president of the Nourri-Source Federation, a group of volunteers who help moms with breastfeeding problems. She said proposed government cuts to prenatal education classes will make it even harder for mothers to get breastfeeding information.

“We need the will and the cash to change practices,” she said.

Oct. 1 to 7 is breastfeeding week in North America and will be marked with a world-wide "breastfeeding challenge" on Saturday, Oct. 11, when organizers are trying to get the most women possible to come together to breastfeed at one time. In Montreal, last year's winning city with the most moms participating, there are 10 locations this year, including the Palais des Congrès, where the breast-in starts at 11 a.m. For more information and registration, visit Babyfriendly.ca.

For more info on breastfeeding:

Quebec government's statistics institute 2006 report on breastfeeding

Ask Lenore: website of Montreal lactation consultant Lenore Goldfarb

Quebec Nourri-Source Federation's website

Toronto lactation consultant Dr. Jack Newman's website

The Clones On Our Plates

Is food from cloned animals safe to eat? The debate continues, but some of the meat and milk is already making its way into the marketplace in the U.S. - and possibly Canada.

by Alex Roslin

The Montreal Gazette

Saturday, September 06, 2008

Clones. To some, the word evokes Frankenfood or Star Wars Stormtroopers. To veterinarian Donald Coover, it conjures a miraculous world of super-cows with high milk and meat yields and horses as fast as Secretariat, the legendary Triple Crown-winning thoroughbred.

Coover is helping to lead the clone revolution out of tiny Galesburg, Kansas, a village of 150 with one convenience store and two churches, surrounded by fields of wheat and cattle ranches.

This is the home base of Coover's company SEK Genetics and its thriving business of selling semen from elite cows to farmers. He says he has also sold enough semen from cloned cows to inseminate tens of thousands of farm animals, and he says "dozens at least, hundreds probably" of other cloning businesses in the U.S. are doing the same thing.

Despite a request by the U.S. Department of Agriculture that farmers respect a voluntary moratorium on selling food from clones to consumers, Coover says he has sold dozens of clones and their offspring to farmers for use in food production since 2001.

"It's not illegal, and it's not unethical," he said. "Instead of having just another damn horse, you have Secretariat every time. That is why it's enormously useful." Cloning is a way to create a perfect genetic copy of an adult animal. Its cell material is transferred to an egg that is grown into an embryo and implanted in a surrogate mother.

Advocates like Coover say the process can help farmers duplicate top livestock and improve meat and milk yields.

"It's frustrating to me that we've been able to develop this incredible technology, and people are bitching and moaning about it," he said.

Food from clones is still banned in Canada, but Health Canada is now considering whether to lift the ban.

Surveys show widespread public unease about the technology. In a 2003 survey for the Canadian government, only 24 per cent of Canadians and 32 per cent of Americans supported the use of cloned animals for food.

The most common concern was "long-term risk to human health," cited by 37 per cent of Canadians.

After a seven-year scientific review, the U.S. Food and Drug Administration last January okayed meat and milk from cloned cows, pigs and goats and their offspring as being safe to eat.

The selling of clone food to consumers is still on hold while the U.S. Department of Agriculture works out a plan to assuage the concerns of consumers in the U.S. and abroad. In the interim, it has asked cloners and livestock farmers to continue to respect its voluntary moratorium.

"The food in every respect is indistinguishable from food from any other animal," FDA official Stephen Sundlof told reporters last January.

But the scientific debate about clone food still appears far from over. In fact, Sundlof's statement seems to be contradicted by a 2006 background paper on cloning prepared by the Canadian Food Inspection Agency that was obtained through an access-to-information request.

The CFIA paper and the FDA's own 968-page scientific review published last January depict cloning as an unpredictable technology fraught with problems that almost always leads to outright failure or disfigured animals that aren't safe to eat.

Even in cases where clones and their offspring look healthy, they appear to suffer from genetic abnormalities and research is sparse on whether their food is safe, the documents say.

"There is not enough data to indicate there will be no problem," said Pascale Chavatte-Palmer, one of the world's leading cloning researchers, whose studies are cited over 50 times in the FDA report.

"I think we should know more. We feel there is a rush to accept those clones," she said in an interview.

In Europe, food from clones isn't being sold because of formal and informal moratoriums in various countries. But this week, the European Parliament voted 622-to-32 to urge the European Union's executive branch to ban food from clones, citing concerns about food safety, consumer confidence and animal suffering.

The move followed a report from the European Food Safety Authority in July that said, while there is "no clear evidence" food from cloned cows and pigs is unsafe, more study is needed because of the lack of data.

***

Chavatte-Palmer is no anti-biotech Luddite. She's dined on what she calls "very good" cloned Kobe beef, which she thinks was most likely safe to eat. Yet, she paints a picture of a technology that's about as precise as a steamroller.

Out of 1,000 attempts, a clone embryo is successfully developed and implanted into a surrogate mother only about 100 times, said Chavatte-Palmer, who is a research leader at the French government's Institut Nationale de la Recherche Agronomique, the leading agricultural-research institute in Europe.

Of those 100 embryo transfers, just five fetuses are typically born alive, she said.

The rest mostly miscarry due to genetic or physical defects or abnormal placentas. Their most common abnormality is called large offspring syndrome, which results in fetuses 20- to 85-per-cent larger than average.

The animals that survive to birth also often have large offspring syndrome - which occurs in up to half of clone births - or other severe problems like a deformed head, contracted tendons, extreme diarrhea, diabetes, respiratory failure, heart disease and kidney problems. Many die shortly after birth.

A Japanese study cited in the FDA's review painted an unsettling picture of several clone calves that had died. "The neck was bent backwards, the hind legs were stretched tightly or the second joints were bent toward the opposite direction from the normal position," it said.

"Calf No. 12 was disemboweled at parturition and the face of calf 16 was warped."

Some of the calves had been born with "an 'adult' appearance" and displayed "many wrinkles in the skin, thick bone structure and rough hairs resembling those of adult males."

Indeed, Dolly the sheep, the first mammal cloned from an adult cell in 1996, lived for only six years, half the average lifespan for her breed, and developed obesity, lung cancer and premature arthritis.

Even the few clones that appear to be healthy really aren't, said Chavatte-Palmer, who is one of a small handful of scientists worldwide to have studied the long-term health of clones.

"Cloned animals, although apparently normal, are however significantly different from (conventionally raised animals) maintained in the same conditions," she wrote in a paper in the journal Animal last year.

The CFIA came to a similar conclusion in its paper. "There is an inadequate amount of information on any species to determine long-term physiological effects (of cloning)," it said.

"Early research suggests that these animals have subtle gene expression abnormalities."

The CFIA said cloning "could have long-term effects that compromise animal health and survival."

***

So is food from clones safe to eat? The FDA's review concluded that meat and milk from deformed clones, which die early in life or need to be euthanized, is unsafe.

But in a little-noticed passage deep in its report, the agency okayed this food for entry into the human food chain if it is treated in a meat-rendering plant.

Rendering plants process dead animals from zoos and shelters, old meat from grocery stores and butcher-shop trimmings by chopping them up, then cooking them at high temperatures.

Rendering leads to several products that enter the human food chain directly and indirectly, including lard, tallow, protein for livestock feed and crop fertilizer.

The FDA report cites no research on whether or not rendered food from abnormal clones is safe.

"There is not a single study of that," said Jaydee Hanson, a policy analyst at the Washington, D.C.-based Centre for Food Safety.

Hanson said it can't be assumed the rendering process makes all animal products safe to eat. "They don't let animals with mad cow disease enter the food supply through rendering," he said. "They have a belief this is safe. Belief is wonderful for a religious organization."

As for healthy-looking clones, the FDA says their food is identical to that from other animals. "These products are not different than food from traditionally bred animals," Bruce Knight, a senior U.S. Department of Agriculture official, told reporters last January.

But the CFIA paper and the FDA's own review raise questions about this conclusion as well.

"The use of (cloning) may have an effect on gene expression in the resulting animals and thus alter food characteristics, such as biochemical composition, which may be a food safety concern," the CFIA paper says.

"Stress-related developmental problems in young clones may also present an indirect food safety concern. This may lead to increased usage of antimicrobials for the treatment of such disease-prone clones and could also have an effect on the shedding of antimicrobial-resistant bacteria."

The FDA's review acknowledges no large-scale studies of the meat and milk of clones have been done. It relies on 10 small-scale studies involving an average of just five clones each.

Five of the 10 studies found statistically significant differences between food from clones and conventionally bred animals.

Chavatte-Palmer did one of those five studies. She found cow clones reached puberty an average of 62 days later than normal animals, which she said "probably will affect the quality (of their meat) ... The full maturation of muscle is delayed in clones."

As well, she found milk from cow clones had different levels of some fatty acids and enzymes than milk from conventional animals. She concluded more research is needed on whether the differences could cause food allergies.

For pork, the FDA cited only two studies involving seven clones in total, both done by biotech company ViaGen. They found the clones grew 30-per-cent slower than normal animals and had less meat. Two of the clones had so many health problems their data wasn't even included in the final results. The FDA questioned the study because of the small number of clones.

No studies have been done at all on food from goats, the third clone species that the FDA okayed.

***

For all the talk about clones, the fact is we're actually unlikely to ever see a clone T-bone at the butcher shop. That's because clones are up to 10 times more expensive to produce than conventional animals - $10,000 to $16,000 for a cow and $6,000 for a pig.

The main source of clone-derived food is likely to be naturally bred offspring of clones. The FDA says clone offspring have fewer health problems than clones and are identical to normal animals.

But the CFIA background paper says there is "limited" data on food from clone offspring and cited two major U.S. reviews of the issue that expressed concern about the "inconclusive evidence" about the safety of their food.

The FDA's report cited no studies on meat or milk from the offspring of cows or goats and only two studies on pork from the offspring of pig clones. The clone offspring were mostly the same as conventional animals, but like the clones had several differences: Of 58 nutrients tested, clone offspring meat had significantly less of seven nutrients, while more of two others. It was also somewhat fattier, more acidic and shrunk more during cooking - indications of poorer quality.

There is also little longer-term research about the health of offspring as they age.

The FDA review says the offspring seem to be healthier than their clone parents because their genetic errors are "reset."

But one of the scientists the FDA cites in its review says he disagrees with the agency's conclusion.

Dean Betts, an associate professor of biomedical sciences at the University of Guelph, is one of the few scientists to have looked into the health of clone offspring.

Betts found the offspring of goat and sheep clones have genetic abnormalities - significantly shorter telomeres, which are the chromosome endings that are believed to control aging and susceptibility to cancer.

Shorter telomere lengths could explain why many clones seem to age faster than normal animals. Dolly the sheep was also found to have shorter telomeres.

"We don't know what it means or if it has health impacts," Betts said. "I would say not enough study has been done ... There could be some impacts on the species itself over generations."

In France, Chavatte-Palmer had hopes of getting some definitive answers to the questions about the health and food of clones and their offspring. But her cloning work has ground virtually to a halt. Funding has dried up, she says, because cloning is a sensitive issue for grant-funding agencies.

"We have piles of data that we haven't had time and money to get help to analyze," she said. "It's very difficult to get funding in this area of research. It's frustrating, very frustrating."

SIDEBAR

Are we already dining on clones?

No labels on clone food in U.S., FDA says

Canadians may have been consuming food from clones for years without knowing it, despite a Health Canada ban.

That’s one of the surprising revelations from documents on cloning from the Canadian Food Inspection Agency obtained under the access-to-information legislation.

About 800 cloned dairy cattle produced through an early version of cloning called embryonic-cell nuclear transfer and from embryo splitting have been registered in Canada since the 1980s, said a CFIA background paper on cloning written in 2006.

The CFIA paper said food from these clones can be sold to Canadian consumers. “There is generally no restriction on the marketing of products, by-products or the progeny of animal clones that are produced using the embryo-splitting technique in Canada or elsewhere,” it said.

The CFIA paper didn’t say whether milk from the cloned cows was indeed sold to consumers. An agency spokesperson didn’t respond to a request for comment.

Health Canada, however, says no food from clones, including embryonic-cell nuclear-transfer clones, can be sold in the country. “It shouldn’t be on the market,” said Paul Duchesne, a department spokesman.

Embryonic-cell nuclear-transfer was used in the 1980s and early 1990s but was replaced in the mid-1990s by an improved technique called somatic-cell nuclear-transfer cloning, which replicates an adult animal, instead of an embryo.

Donald Coover, a Kansas veterinarian who says he has sold clones and their semen to farmers in the U.S. for years, said hundreds of embryonic-cell nuclear-transfer clones were produced in the U.S. and that their meat and milk quietly entered the U.S. food supply without any official safety review.

He said it’s very likely the same thing happened in Canada. “Nobody at the time made a big deal about it.”

And now that the U.S. Food and Drug Administration has okayed clone food for human consumption, the CFIA again seems to have no plan for keeping it out of the country, according to an internal email sent by a manager at the agency.

“CFIA has no specific regulatory controls for animal clones,” said the email, dated Feb. 14, a month after the FDA’s decision last January. “There are no special tracking provisions.”

The issue of tracking food from clones is complicated by the fact that the FDA has decided not to label the food, and there’s no way to test if a particular animal is a clone.

“All we’ve had are some preliminary discussions on… the feasibility of detection,” said a CFIA official, who spoke off the record because she is not authorized to talk with journalists. “Nothing has been put in place, and no policies have been created around that.”

SIDEBAR

Quebec farmers shrug off cloning—it’s too costly

Quebec farmers don’t seem to be rushing to embrace cloning. The Union des Producteurs Agricoles, representing 44,000 Quebec farmers, says it has no position on whether to embrace food from clones.

“We haven’t discussed it very much,” said spokesman Patrice Juneau. “It’s not a very important issue for us.”

The 3,800-member Fédération des producteurs de porcs du Québec, also has no position, said spokeswoman Nathalie Hansen.

“The steps required to produce a live (clone) animal are almost a nightmare for farm applications,” said Roger Sauvé, a cow veterinarian in St. Louis de Gonzague, 45 kilometres southwest of Montreal, who specializes in reproductive services for farmers.

“It’s very, very expensive to produce cloned animals right now. Farmers are not ready to pay that kind of money. Practically, it doesn’t make sense.”

Sauvé said existing reproductive technologies are more efficient and cheaper and also offer the advantage of improving a herd’s genetics if two top animals are bred together, while clones can only be as good as their progenitors.

For more information:

- The FDA's Jan. 2008 risk assessment of food from clones and their offspring

- European Parliament reports on cloning

- The Center for Food Safety’s report on food from clones