Birthing practices in Canada have been shaped by periods of distinct though overlapping emphasis. During the first third of the century, the chief preoccupation was the high maternal mortality associated with childbirth.
Birthing practices in Canada have been shaped by periods of distinct though overlapping emphasis. During the first third of the century, the chief preoccupation was the high maternal mortality associated with childbirth. Towards midcentury the emphasis shifted to the relief of childbirth pain, while during the last third of the century prominence has been given to the well-being of the fetus and newborn.
The appallingly high maternal mortality rate during the first 3 decades (one mother dying for every 173 to 210 pregnancies) was unchanged from that of the previous century, and concerned and frightened pregnant women and their doctors alike. Mortality peaked in 1930, when 1441 mothers lost their lives in childbirth, a rate of 58 maternal deaths per 10 000 births. The maternal mortality began to drop precipitously during the 1930s, thanks to major medical advances such as blood transfusions for hemorrhage, safer anesthetics and antibiotics to combat infections, and is now more than 100 times lower. The current maternal death rate is about 0.5 deaths per 10 000 births. Today, an obstetrician can go through a lifetime of practice without ever seeing a maternal death, and the fear of death from pregnancy and childbirth has largely disappeared from the consciousness of Canadian women.
As the fear of death waned towards the middle of the century, relief of the pain of childbirth became the major concern. Heavy sedation during labour, twilight sleep with narcotics and amnesics, and general anesthesia for delivery became the routine practice. Women gave birth and babies were born in a semistuporous condition. As the adverse effects of these dangerous practices were recognized, they were gradually eliminated and replaced by analgesic measures that allowed women to be awake and aware for childbirth, such as psychological preparation for childbirth and epidural analgesia and anesthesia. The desire for anesthesia, which was especially dangerous when administered in the home, hastened the shift of the place of birth from home to hospital.
The last third of the century saw a shift of concern from the mother to the baby. Perinatal mortality (stillbirths and deaths during the first week of life) dropped steadily, from 65 per 1000 births in 1921, through 28 per 1000 in 1961, to 6 per 1000 in 1996. Unlike the sharp and sudden drop in maternal mortality as a result of major medical advances, the improvement for the baby was gradual, and was largely due to improved nutrition and general living standards among Canadian mothers. Another major factor was the development of neonatology as a specialty and enhanced care for preterm and sick newborn babies.
These improved results were not without cost. Investigations, tests and procedures came to be used indiscriminately, and these, when not required, can do more harm than good. Almost every pregnant woman in Canada has at least one ultrasound examination, and for some women, even with normal pregnancies, the test may be repeated many times. Caesarean section rates have risen from less than 5% in 1960 to almost 20% in 1990 and are only now starting to level out or slightly decrease. Concerned consumers and providers of maternity care have begun to look to alternatives that may provide psychological satisfaction without the sacrifice of physical safety.
While a few Canadian women choose the alternative of home birth to achieve the birth experience they desire, over 99% of births in Canada take place in the 572 hospitals with maternity services. Many of these hospitals provide family-centered care practices, although the degree to which these practices have been implemented varies widely and continues to change. By the latest available data (a major 1993 survey published in 1995), 60% of Canadian women attend childbirth education classes, and almost a quarter (24%) of Canadian hospitals offer their own classes. About half (51%) provide mothers with written information about labour and birth care specific to their unit. Eight percent have an instructional program for siblings to attend birth.
Obstetrical facilities have improved. Traditional delivery rooms are being replaced by combined labour-birthing rooms in which women may labour and give birth without having to change rooms just before delivery. Such rooms are now available in 39% of Canadian hospitals.
As of 1993, almost all hospitals encourage the woman's partner to be involved in labour and vaginal birth (82% without restrictions, 15% with restrictions); 87% encourage an additional labour support person. Grandparents are encouraged to be with the woman in labour in 35% of hospitals, but for vaginal birth only 25%. Nine percent of hospitals encourage siblings to be present during labour, and 6% encourage them to be in the room for vaginal birth. Three-quarters (76%) encourage the presence of partners during caesarean birth with epidural anesthesia, and 16% encourage them even when a general anesthetic is used.
Only a minority of hospitals insist on routine procedures such as perineal shaving (16%), enemas or suppositories (11%) or intravenous infusions (14%) for all women. Almost two-thirds (65%) routinely use initial electronic fetal monitoring for 20 to 30 minutes, but only 3% have a policy of routine continuous electronic fetal monitoring. Ninety-four percent of hospitals allow women to walk about during labour, and almost three-quarters (72%) have a bath or shower available for women to control pain. Sixty-eight percent of hospitals use nitrous oxide for pain control; 94% provide narcotics for labour pain, and about 40% of women use them. More than half of the hospitals (55%) have epidural anesthesia available. Of these, 61% have it available 24 hours a day. About 25% of women giving birth in hospitals with epidural available use it.
Almost two-thirds of hospitals (63%) allow women to adopt their own choice of position for birth. The majority (62%) of women give birth in a semirecumbent position, while an estimated 37% still give birth in a lithotomy position with stirrups. An episiotomy is used for approximately two-thirds (63%) of women having their first baby and 42% of women for subsequent deliveries.
Mother-infant bonding is encouraged in Canadian hospitals, although over two-thirds (69%) of the hospitals still separate mothers and babies during the routine 1- to 4-hour observation period for healthy babies after birth. Two-thirds (65%) of hospitals allow rooming in of mother and baby for 19 to 24 hours, although in practice most babies room in for much shorter periods of time. Hospital stay after birth averages 3.2 days, but most hospitals allow mothers to choose earlier discharge. Three-quarters (74%) of the mothers are breastfeeding at the time of discharge from hospital.
While the vast majority of births in Canada are attended by physicians, interest in midwifery care is strong. The Society of Obstetricians and Gynaecologists of Canada has supported the introduction of midwifery. Midwifery legislation is under active consideration across the country. Midwives have been practising in BC under legislation since January 1998. Manitoba has passed legislation legalizing midwifery, and legislation is pending in Saskatchewan. Alberta and Saskatchewan have not provided public funding for midwifery care, so the actual availability of midwives in these provinces is limited. In Ontario midwifery is fully publicly funded. A direct entry, baccalaureate program in midwifery has been initiated, with campuses in McMaster University (Hamilton), Ryerson (Toronto), and Laurentian University (Sudbury) universities.
Canada has an active program of research into the effectiveness of maternity care practices, and this is rapidly being translated into evidence-based guidelines to help caregivers and birthing women achieve the safety and satisfying experience they desire and deserve.
Murray Enkin et al, A Guide to Effective Care in Pregnancy and Childbirth (1989, rev 1995); Cheryl Levitt and Louise Hanvey, Survey of Routine Maternity Care and Practices in Canadian Hospitals (1995).