Women in remote rural communities face a different set of challenges than their urban counterparts. More and more often, maternity care is only available in larger centres. With no practicing midwives in the valley, discontinued prenatal classes and a baby boom in the works, are local women getting appropriate care before and during childbirth? In this series, the Rocky Mountain Goat explores rural birthing: What is working? What needs to change? What are other similarly remote communities doing to address the challenges?
By Andru McCracken
According to numbers provided by Northern Health to the Goat, women in the Robson Valley have a high rate of cesarean sections. Northern Health reported there were 127 births to Robson Valley women recorded over the last five years. In all, 44 were cesarean sections and 83 were vaginal births. That’s a 35 per cent cesarean section rate. Women who had births in Hinton or Kamloops outside of Northern Health facilities had an even higher occurrence: of 57 women who gave birth in those facilities, 28 had cesarean sections, or about 45 per cent.
According to the World Health Organization cesarean sections should only be performed when medically necessary. Based on World Health Organization targets, the Robson Valley should have seen only 13-19 births by cesarean section instead of 28.
“Since 1985, the international healthcare community has considered the “ideal rate” for cesarean sections to be between 10% and 15%.”
For Nancy Taylor, a former maternal health educator the number of women having cesarean births is outrageous.
“It’s tragic because women internalize the responsibility for it,” said Taylor.
Taylor believes a lack of birth culture, lack of education and shared knowledge is the cause.
“There is nobody saying you can do it. You need confidence that your body knows how to give birth to this baby. Women have been giving birth without obstetric help for forever.”
“There is nothing else we do in our lives that we do that feels like that.”
Kazuko Hiroe, a former Valemount resident and a second year student in the Midwifery program at the University of British Columbia cites the World Health Organization report and wonders at what is happening in the Robson Valley.
While alarming, Hiroe said the numbers correspond to recent studies showing how distance matters when it comes to childbirth outcomes.
“When you live within one hour of a hospital there are lower rates of cesarean sections,” she said.
She explained that women who live within an hour tend to wait longer to go to the hospital than women who live far away.
“When people are in Valemount they have to consider a long and potentially treacherous drive from 2.5 to 3.5 hours. They have to get there pretty early,” she said. “When they get to Hinton and they are [dilated to] 2 cm and starting to have irregular or somewhat irregular contractions, the care provider is not going to turn them away. They don’t want to send them back to Valemount.”
Hiroe said that being in the hospital with access to numerous methods of intervention and pain relief confounds the birthing process and can lead to a spiral of interventions that lead to a cesarean.
“When you are in early, people are going to want to see some progress. If there is no progress, the options for further intervention increase significantly.”
She said some hospitals are currently experimenting with not admitting women until they are dilated to six centimetres. It’s a way of making sure that hospitals don’t unnecessarily intervene in an otherwise healthy birth.
Hiroe said she knows some women are choosing to have a planned cesarean section and understands why.
“…but as far as safety, it isn’t the safer option,” she said.
Hiroe said that research shows that for women who have had a ca esarean section, a vaginal delivery for their second child is safer than having another cesarean.
“Birth process, recovery rate, impacts to subsequent pregnancies, if it is your first baby, with your second baby you have increased risk of retained placenta attaching to the scar,” she said.
Kazuko said if a local midwife or doctor was able to keep up their maternity care training it could lead to more babies being born locally.
“There has to be a little bit more confidence in rural community births,” said Hiroe. “Rural communities that have maternity care providers have good outcomes.”
Hiroe explained how midwives and doctors are able to flag indicators of high risk.
Hiroe said a number of things can reduce the rate, like ensuring that hotels are paid for, more education about the implications of going in too early, as well as being able to have births in Valemount, McBride or Jasper.
“I understand why people are going early and not wanting to have contractions every 2 to 3 minutes while driving,” she said.
Hiroe said that another option is hiring a non-medical practitioner called a doula for support.
“There is so much evidence to support doulas it is amazing it is not more utilized,” said Hiroe.
Although the cost of hiring a doula, ranging from $300 to $1500 is not covered by the health system, it has been shown to have a dramatic influence on birth outcomes.
Michele Dallaire recently moved to the area and was first trained as a doula 20 years ago and recently left a practice in Plamondon, Alberta.
“Doula is a Greek word for a women who is experienced in childbirth; it’s really a woman’s helper,” said Dallaire.
She said a doula supports the woman and her partner emotionally and physically.
“In my role as a doula I help the expectant woman and her partner get the information they need to make informed decisions about the birth of their baby.”
“I visit them two or three times prior to the birth of the baby. We practice different comfort measures, and labour positions, we talk about what kind of experience they want. And again, I help them gather the information to make informed choices.”
Dallaire said that research shows that having a doula shortens labour and reduces the risk of any kind of intervention.
“And one important factor too, is that it really helps the woman and her partner have a better experience of their birth,” she said.
Dr. Ray Markham, Chief of Staff for the Robson Valley said Valemount and McBride do not currently do planned deliveries at the moment.
He said it may be possible to have local women access midwives through their virtual care initiative.
Markham also mused about restarting planned deliveries in McBride and Valemount, though said he hadn’t spoken to his colleagues about the possibility so far.
“Would there be an interest in restarting Valemount or McBride as a Level 1a community?” asked Markham. “There are communities that will do local delivery without cesarean backup.”