Maternity care in Canada: what can we deliver?

For 22 years I delivered babies as a family physician—22 years of wearing a pager 24 hours a day, 7 days a week. It was amazingly invigorating and inspiring, and at times onerous and overwhelming. September is the perfect time to talk about delivering babies—9 months after New Year’s, it is always a busy month in labour and delivery.

This is a National Physician Survey (NPS) year, and one of the trends tracked in the NPS is the role family physicians play in maternity care. In 1997, 20% of Canadian family physicians reported doing intrapartum care; in 2007, it was down to 11%.1 What will it be in 2010? These results are important to women; to all family physicians, including those who provide intrapartum care and those who do not but who are looking to refer their prenatal patients; to other maternity care providers; and to family medicine residency directors, department heads, and governments.

Many family physicians who deliver babies are becoming more focused, and some do maternity care exclusively. Models like this are popular in places like Calgary, Alta, and involve hard-call systems with large low-risk maternity care groups. This approach is often attractive to new graduates and family physicians who want to practise intrapartum care but also want some predictability and structure to their call schedules. These innovations have helped to demonstrate that delivering babies can be enjoyable and sustainable. Funding for maternity care has also been improving in many provinces, and this cannot be underestimated as a factor in supporting those who provide these services and the call structures needed to organize coverage.

Although the number of family physicians providing intrapartum care has declined, many of those who do deliveries are delivering more babies. There are still centres in Canada where family physicians continue to be involved in more than 50% of deliveries. This is good news for women. Family physicians manage low-risk pregnancies and deliveries with outcomes similar to and better than obstetricians. We do this well, and our patients appreciate the continuity family physicians provide.

I have delivered babies for my own patients and for those referred to me—first, second, and third babies. I have so enjoyed delivering babies and watching them grow. It is such a rewarding experience and a wonderful addition to practice. I have learned the role of physician as healer doing intrapartum care, when my very presence in a room resulted in less pain, better control, and a rediscovered awe in the moment. It is wonderfully rewarding to see a mom back with her next pregnancy and pick up where we left off after the last delivery. I have heard many women lament that their own family doctors are giving up obstetrics or that the family physicians who delivered them will not be delivering the next generation. It is a shame, as it is such an incredible privilege to share in these momentous events in families’ lives, and we do it well.

Courses such as the College’s ALSO (Advanced Life Support in Obstetrics) course have become integrated into most family medicine training programs. Residents are learning early how to manage obstetric emergencies and are developing more confidence in their maternity care skills. These courses strengthen an evidence-based team approach to maternity care. It is still a challenge to provide strong family medicine–centred obstetric experiences in residency, and in some departments there is a shortage of family physician faculty to model intrapartum care to learners. Maternity care delivery and training are considerable concerns for departments of family medicine across the country. Providing solid training and positive experiences are important strategies for addressing the maternity care crisis. We need more family physicians who do intrapartum obstetrics in faculty positions and more enhanced skills programs in maternity care. Ultimately, the goal is to attract more residents to this area of need to improve access, care, and outcomes for pregnant women.

We should also be exposing students early in their medical training to family medicine maternity care. Pregnant women I have followed have often been incredibly generous about involving learners in their care and delivery, and many have enjoyed sharing the experience with students. It was often an exciting and moving experience for the students as well—one that set the stage for future involvement in family medicine maternity care. In turn, students often left me reflecting on the gift of participating in this amazing event in women’s lives.

The College of Family Physicians of Canada has a dedicated group, the Maternity and Newborn Care Committee, working on addressing many of these issues. In the past year they have produced a paper1 with several recommendations for addressing the maternity crisis in Canada. The 2010 NPS is under way. Let’s hope we are making progress in addressing the crisis. We need to keep the family in family medicine. We need to deliver.

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