Monday, March 31, 2008


Change. Is it always good?

In the next month or so, obstetricians at BC Women's will be changing their provision of care at the hospital. Rather than having three call-groups providing an in-hospital rotating OB consulting service (24 hour call, with each physician or midwife being able to choose one of the three available OBs, if a consultation is warranted, depending on the case at hand), there will be two obstetricians on hand (one primary and one secondary) at all times, each working 12-hour shifts, drawn from the combined pool of 20+ obstetricians that used to make up the three smaller OB groups at BC Women's Hospital.

When I heard about the change, I asked if caregivers would have a choice of obstetrician if they required a consult during labour. "No," said the head nurse, with a quizzical look. So, you'll just get who is available, not who might be the best "fit" (clinically and emotionally) for the client on that day. Even if an OB has been consulted during the pregnancy, if a family practitioner or midwife needs OB assistance in labour, they will be not be able to choose between the 2 OB's in hospital, but will only be able to consult the one who is designated for consultations. And remember, there will be one less OB in the hospital at any time. Hmmm...

I know that other hospitals have been using this one-OB-fits-all approach for years (e.g. St. Pauls - but they have a small pool of OBs, and a low-tech high-touch philosophy that seems to work well from the patient's perspective, and their nurses are given quite a lot of autonomy). At first glance, this change at BC Women's might appear to signal a departure from patient-centred care. But, apparently, improving patient safety was the primary motivating factor. So, it may be a good thing in the long run - the 12-hour shifts might result in more energetic OBs providing more focused patient care. But, the shorter work day (and the inability to chose the OB) could result a loss in continuity of care for the labouring woman. Could the positive working relationship between a family physician and a small OB call group be lost in this reorganization, causing further internal conflict? Who knows.

Will notice of this change be given to each woman prior to her decision regarding her primary caregiver for pregnancy, so she can make an informed decision about prenatal care? Now, this is a tricky question. Pre-conception information regarding "the caregiver decision" is already lacking in B.C., with many women making their decisions based on non-B.C. books or the internet. For example, many newly pregnant women don't know that B.C. midwives are covered by BC Medical (practicing in both home and hospital), or that the BC Women's "Birth Docs" are there for women whose family doctors don't provide obstetric care, or that, in B.C. (unlike the U.S.), obstetricians are not intended to be the primary caregivers of "low risk" women, but are consulted after a referral by a family doctor or midwife, if the pregnancy becomes "high risk".

As a doula, part of my role is to inform clients about their choices, their rights and responsibilities, and to help them to retain their autonomy. I'm also there to quietly remind them that birth is a normal life process. I do my best to provide my client with comprehensive information in a balanced and thoughtful manner, working in concert with their caregivers (many of whom I've known for 20 years). I certainly don't have all the answers to the questions that I've posed in this post, but a general wariness of change (I'm a Taurus, through and through) made me sit down to write this. Despite my feeling of unease, I'm going to have to sit on the fence with this one, and wait to see how it all works out.

To the obstetricians, it might look good on paper. But we'll just have to see how it works in reality....for the labouring women.

(Update June 11/08: The new system has been in effect for a while, and, while the obstetricians are well-rested and seem to have a new lease on life, I have witnessed some dangerous gaps in continuity of care when an OB is the primary caregiver of my client.)

(Update March 2009: Obstetricians are still voicing their concern about the 12-hour shift. Yes, they are well-rested and able to perform better in the OR, but some women have fallen through the cracks due to a lack of continuity of care. Some women may have three of four different OBs looking after them in labour, each with a different approach. No solution so far...)

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