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A Teamwork Approach to Maternity Care in Nelson, BC

All pregnant women deserve to have access to compassionate, evidence-based maternity care which inherently supports the normalcy of labor and birth—and remains poised to effectively handle the occasional circumstance when birth strays from normal.  They deserve to be cared for by well-trained midwives, family physicians or obstetricians–depending on their particular situation and which type of care is most warranted–who work together seamlessly as a congruent maternity care team.  They deserve to be cared for by maternity care professionals who trust each others’ skills and resist the urge to question each others’ motives.  Expectant families deserve to remain center stage throughout their pregnancies, labors and births—avoiding being lost in the cacophony of politics that so often suffocates the system and obscures the practice of pure, evidence-based care.

Last weekend, Dr. Brian Goldman introduced his CBC Radio audience to this very scenario, during his show, White Coat, Black Art.  During the show “Dr. Brian,” who is both an emergency department physician in Toronto, and a medical journalist, takes listeners to Nelson, B.C., Canada, where he follows obstetrician Shiraz “Raz” Moola and registered midwife Ilene Bell who both work at Kootenay Lake Hospital.

Only minutes into the radio show, it becomes clear: expectant families delivering at Kootenay Lake Hospital are the beneficiaries of a truly integrated maternity care team where family physicians and midwives handle the majority of deliveries, leaving the complicated scenarios to obstetricians.  This is despite Canada’s fee for service medical system in which, “an obstetrician uses the fees he or she earns from doing easy deliveries to offset or subsidize the more time-consuming and more stressful deliveries that require additional skill and experience.”

During the course of the radio show, scenarios in which obstetricians are called in for deliveries are described.   Despite what sometimes feels like a disbelief in the humanity of obstetricians that some normal birth advocates imply, this radio show does an excellent job of pictorializing  the “why” behind the impetus to medicalize labor and birth.  During the interview, Dr. Moola describes a scenario in which he could palpate a fetus inside it’s mothers abdominal cavity—but outside the womb—following a cesarean scar rupture during an attempted VBAC.  Carrying around past experiences like this can prompt a level of caution—even if not evidence-based caution—as the human side of a physician hopes to avoid dealing with such a circumstance in the future.  And yet, the maternity care providers interviewed in Dr. Goldman’s story don’t seem to allow those past experiences—as few or frequent as they may be—to prompt a technocratic approach to their maternity care services.

“Our training is to promote the normal,”  says Ilene Bell.  “We want to normalize.”

In fact, the radio show audibly follows the progress of a VBAC candidate through parts of her labor and successful delivery, attended by  Bell.

“At one level, we all think we can do it the best,” says Dr. Moola.  But he goes on to describe how the “best” (maternity care provider) is most often a midwife or family physician, and only sometimes an obstetrician.

I highly recommend listening to the whole radio show, and forwarding the link onto your colleagues.  After listening, please come back here and answer the following questions:

 

  1.  What elements of the maternity care partnership described in this show does my local birth community already harbor?
  2. What elements of the maternity care partnership described in this show can my local birth community/hospital learn from?
  3. What are three steps I can take in my community to encourage this type of partnership approach to maternity care?

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Evidence Based Medicine, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) , , , , , , , , ,

  1. avatar
    Hillary
    October 6th, 2011 at 22:28 | #1

    I haven’t had the chance to listen, but wanted to say that your opening paragraph is powerful and deserves to be said again and again.

  2. October 7th, 2011 at 10:12 | #2

    @Hillary
    Thanks, Hillary!

  3. avatar
    Tami Michele, DO, OB/GYN
    October 10th, 2011 at 20:14 | #3

    It was so refreshing to hear how the team in Nelson, B.C. is providing collaborative, safe maternity care that is focused on the best interest of the patient. The relationship between the doctor and midwife is based on trust. He can trust that she has the skills to recognize when birth deviates from normal and that she will involve him for guidance or intervention as needed. She can trust him that interventions will not be used unless medically indicated if a transfer of care becomes necessary. The example given in this broadcast is consistent with the Mother-Friendly Care Initiative (see http://www.motherfriendly.org/MFCI). The consumer must be aware of the type of collaborative practice an obstetrician has when comparing statistics, however. The doctor who supports midwives doing low-risk births and truly takes only the high-risk patients, those who need medical intervention, or delivery by cesarean section, will have higher rates in comparison to other doctors who care for low-risk women. This makes the transparency in health care statistics inaccurate when choosing an obstetrician based on statistics alone. Allowing women to birth in hospitals using the midwifery model of care, seamless transfer of care from home with respectful medical intervention when needed, access to supportive VBAC care, and risk stratifying the patient to the appropriate health care provider are steps which can be taken to improve the maternity services in our communities.

    Dr. Tami Michele, OB/GYN, FACOOG
    CIMS Leadship Team Board Member

  4. October 11th, 2011 at 09:42 | #4

    “The doctor who supports midwives doing low-risk births and truly takes only the high-risk patients, those who need medical intervention, or delivery by cesarean section, will have higher rates in comparison to other doctors who care for low-risk women.”

    I couldn’t agree more, Dr. Michele. Thank you for pointing this out. In a truly collaborative maternity care model, we should expect the OB side of the team to have much higher intervention rates than the FP and midwife sides of the team. This ensures that the team members are operating on the grounds which they are trained for: high-risk or high-complication births vs. normal/low risk births.

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