An Education in Care

If you want to get the inside scoop on birthing practices in BC, stand outside a kindergarten classroom just before the end of the school day. You’ll find a group of young mothers, with babes in arms, waiting to pick up their 5 year olds. They’ve been through the system - probably a few times - and are only too happy to share their hard won stories. Ask about their first birth experience, and you may hear stories of disillusionment, loss of dignity, overcrowding, or lack of continuity. They’ll tell you they wish they’d been better informed, and had known enough to find great caregivers.

Then there will probably be one woman in the group who shares her second birth experience, and shyly admits to feeling joy. “What a difference my second birth was!” she’ll say. “It was like night and day!” You might hear her talk about empowerment and laughter. What was the difference from her first birth, you ask? “Oh, I changed caregivers...and I hired a doula.”

Sadly, the majority of us stumble onto our maternity caregiver. Perhaps our family doctor doesn’t provide obstetrical care any more and refers us to a local obstetrician. Perhaps a friend gives us the name of the doctor who performed her D&C last year. Since there is often an element of surprise involved in the discovery of our first pregnancy, very few of us have the luxury of time to research the variety of available care in our area.

We are also victims of American media, watching their TV shows and reading their books, and mistakenly believe that an obstetrician will provide us with the best care possible. The system in BC is quite different from that in the U.S. The obstetrician doesn’t necessarily provide the best care for our particular needs (this is quite separate from being a good caregiver) - and most assuredly does not provide the greatest continuity of care. Many of the obstetricians that I work with will be the first to admit that their skills are best utilized by those who truly need them, those at high risk, and not by the average normal healthy pregnant woman. “You don’t want to see me walk back into this room,” said one obstetrician to my client the other day, after consulting with the woman’s family doctor. “I’m the surgeon.” Happily, this woman’s labour ended smoothly, without further consultation from this wonderful obstetrician.

Here’s the explanation provided by the BC Women’s Family practice Maternity Service: “In BC, family physicians, registered midwives, and obstetricians are all licensed to provide maternity care. Women can see any of these three caregivers: however, obstetricians are specialists with extra training in surgical skills and management of complicated pregnancies. They typically see women with complex pregnancy issues. Most women see either a midwife or a family physician. While both midwives and family doctors provide excellent care for the expectant mother, choose the caregiver that makes you feel most comfortable.”

In terms of continuity of care, your own family physician, if skilled in the area of obstetrics, might perhaps be your choice. This person would have prior knowledge of you and your family, be able to care for you during your pregnancy, both obstetrically and medically, and provide postpartum, baby, and family care afterwards. However, this “small-town” approach is rapidly disappearing.

Many family doctors these days have withdrawn obstetrical services due to time constraints, increasing insurance costs, or lack of experience in this area. Increasingly, family doctors refer their pregnant patients to another caregiver. It is worth doing as much research as possible before accepting a referral for maternity care. Know your options, then make an informed choice about your maternity caregiver. This decision will determine the standard of care for your birth experience, perhaps one of the most important experiences in your life. So take your time.

Regulated in BC since 1998, midwives are experts in healthy pregnancy, normal birth, and well babies, and are respected members of the BC medical system. Midwives attend births both at home and at hospital, following strict protocols governing safety. Their services are covered under the BC Medical Services Plan. The Midwives Association of BC website includes listings of midwives in your area. The College of Midwives of BC website provides more in-depth information on the model of care, standards, and education.

For those women whose family physicians no longer provide obstetric services, BC Women’s Hospital, Royal Columbian Hospital, and Lions Gate Hospital all have family practice maternity services. The doctors at these clinics are general practitioners who specialize in obstetrics. These doctors work in rotation to provide prenatal and birth care. At St. Paul’s hospital, there are some more informal groups of family physicians who will accept referrals for care during a woman’s pregnancy.

If pregnancy complications arise, both the midwife and family physician consult with other medical personnel, but remain involved in your care. If either the midwife or family physician requires an obstetrician’s consultation, then they are often able to select the caregiver most compatible with your personality, and most competent to deal with your particular concern on that day. This part of their service is particularly critical these days, with hospitals being stretched to their limits.

So, what are the odds of having your own midwife or doctor attend your birth? Midwives generally work in teams, with perhaps two or three midwives working in rotation. At a home birth, there are always two midwives in attendance. Continuity of care is of great importance. Very few doctors take all their own calls. The majority of family practitioners work in call groups of up to six doctors, working shifts of 24 hours. Some attend their patients’ births during the week, and rotate call on weekends. Many of the groups have “Meet the Doctor” nights, where you can visit with all the doctors in the call group, and listen to them talk about their philosophy.

If your pregnancy is complicated, or becomes complex, you may be working with an obstetrician through your labour. Remember that all obstetricians work in large call groups (of 8-20+ OBs), and are on call for 12-48 hours at a time. During that time, each obstetrician is responsible for his or her own patients, plus the patients of the other physicians in the call group. Because of the surgical work load, and for teaching purposes, an obstetrician relies on an obstetric resident to provide care for the woman in labour. Either the resident (junior and/or senior) or the obstetrician (or all) will be present for all procedures, and at the birth. At these more complex births, the nurse’s role and the doula’s role are critical. Since the physician who you have seen in your prenatal visits is unlikely to be present for your birth (or busy in the OR), the nurse and doula are left to provide continuity of care, and to work closely together to complete a multitude of tasks. Highly technical births need that extra bit of human touch, and we must all work diligently to make you feel honoured and empowered during this more challenging experience.

In all cases, whether you work with a midwife, a family physician, or an obstetrician, I will work with your caregivers to provide continuity of care. I will act as “translator,” working to facilitate open communication between you and the medical staff. I will provide physical and emotional support for you and your family, and make sure that you are provided with all the information so that you can always make informed decisions. I do my best to help you feel empowered by the process, to feel safe.

And I hope that, when you are that mum standing outside the kindergarten classroom, you will share your birth story and be able to smile and say, “I’m so glad I had such great care...and my birth was great - it was challenging, but it was amazing!”

- Jacquie Munro - Vancouver Doula, Slow Birth, Slow Planet