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White Coat Black Art·Blog

Let midwives & GPs attend low risk births

For low risk births, family doctors are every bit as safe as obstetricians. Midwives should be part of the conversation.
Dr. Brian Goldman · CBC ·
These days, obstetricians attend nearly 70 percent of all low-risk births in Canada.  And that number is growing, as they squeeze family doctors out of the delivery room. But a study just published in the Canadian Medical Association Journal  says OBGYNs should not be the only option. And not just family doctors either.

Researchers from Memorial University in St. John's looked at the results from nearly 800,000 low risk births between 2006 and 2009 at 390 hospitals across Canada (except for Quebec). Seventy percent were attended by obstetricians and just over 25 percent by family doctors. There was no difference between OBGYNs and family doctors in the risk of the baby dying around the time of birth. There was also no difference in the risk of the mother becoming seriously ill or dying. In other words, when it comes to low risk deliveries, family doctors have as good a record of safety as obstetricians.

I'm not saying there's no role for obstetricians. The higher the risk, the more preferable and safer it is to call in an obstetrician. That includes women with pre-existing medical conditions such as epilepsy, high blood pressure, heart disease, or diabetes. One or more of these merits a referral to an obstetrician during the pregnancy to assume full care or to provide advice to the family doctor or midwife. If the previous pregnancy had complications or if potential problems are detected during pregnancy, an OBGYN may be called in to take over. An obstetrician may be called in as an emergency when complications occur during labour or birth.

This study and others proves what should be intuitively obvious. Obstetricians provide safe and effective care in low risk births. But there are several downsides. First, OBGYNs cost much more than family doctors. And obstetricians see birth as potentially risky event. They are trained to use technology to minimize risk. As a result, low risk births attended by an OBGYN are more likely to have interventions like rupturing the membranes, using medications to induce labour, episiotomies, epidurals and Caesarean sections. All of those cost the system a lot of money and carry their own risks - without necessarily increasing the odds of a safe outcome.

So why do fewer family doctors attend births these days? For a variety of reasons, the percentage of family doctors attending births has gone way down from close to 70 percent decades ago to close to just 11 percent today. Family docs say they get little recognition from colleagues for doing obstetrics and not enough money to compensate them for the disruption that attending births causes to their other patients and to their personal lives. Demographic factors are also at work. The average age of family doctors has gone up. In general, as they age, family doctors tend to give up attending births. Newly graduated family doctors are also less likely to do obstetrics because they're afraid of making mistakes and getting sued.

Across Canada, there are programs that are trying to entice family doctors back into attending births. Maternity Care for BC supports additional training for graduating family practice residents interested in doing low-risk obstetrics.

What's odd to me is that the study's authors missed the most obvious fix to the dearth of health professionals attending low risk births: Recruit and hire many more midwives. In countries such as Sweden and the Netherlands, midwives (not obstetricians) attend the vast majority of low-risk births. The key to making that work in Canada is to integrate midwives into the system so that they work seamlessly with obstetricians and with GPs.

It's supremely ironic to me that researchers from St. John's did this otherwise valuable study while ignoring midwives.  As we discussed last season on WCBA, until Newfoundland joined confederation back in 1949, midwives attended a large percentage of low-risk births.

We won't reverse the trend without a lot of public and political support.  To me, having many more midwives in the system is a no-brainer.

Dr. Brian Goldman is host of White Coat, Black Art, which returns September 12 with a brand new season - at two new timeslots:  Saturdays at 1:05 pm (1:35 pm Island Time), and Sundays at 6:30 pm (7:30 pm in Atlantic Canada and 8:00 pm Island Time) on CBC Radio One.