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Nelson Dream Team Show

We have an extra special episode for you this week.  I travel to Nelson, BC for an up-close look at a place that's figured out a way to deliver top notch maternal care in a small community on the extreme West Arm of Kootenay Lake in the Southern Interior of British Columbia.

Nelson-560.jpgJoin us on Saturday, October 1 at 11:30 am (noon NT) and again on Monday, October 3 at 11:30 am (3:30 pm NT) on CBC Radio One.  Or click the link below to listen now, or download the podcast: 

Nelson was once famous for a gold rush in the mid to late 1800s.  Today, it's the home of some health care gold.  In this small city of just under 10,000 people, roughly 350 babies are born each year.  What's extraordinary is who delivers those babies.  One third are delivered by midwives, one third by family doctors, and one third by two obstetricians.

If that doesn't sound unusual, consider this.  In Ontario, where I practice emergency medicine, obstetricians deliver roughly 80% of all babies.  Until the past few years, midwives have been largely shut out of maternal care in many parts of Canada.  That is a quirky Canadian fact that none of us should be proud of. 

Since the dawn of recorded history, midwives have cared for women from pregnancy to nursing.   A 2011 report by the World Health Organization said midwives attend seven of every ten births in the UK and an astonishing 9 out of ten in the Netherlands.  The report also concluded that maternal and fetal mortality in the developing world can be reduced substantially if more midwives are recruited and trained to work there.

Here in Canada, they've just barely gotten their toes in the water.  And yet, for reasons that aren't entirely clear, they've gained a substantial foothold in Nelson. 

The other thing that's extraordinary about maternal care in Nelson is the remarkable degree of cooperation between midwives, family doctors and the obstetricians.   It's the kind of cooperation that carries some important lessons on how to restructure health care and perhaps how to protect Canada's stressed health care system.

My interest in this story goes back to a previous episode from three years ago on the state of obstetrical care.  Near the end of the show, I interviewed Ilene Bell, one of Nelson's veteran midwives, about the practice she and her fellow midwives share.

During the interview, Bell said something that has stuck in my mind ever since.  "In our community, our obstetrician doesn't do primary care," she told me three years ago.  Primary care is tech-talk for uncomplicated deliveries.  That comment made my ears perk up.  Where I come from, obstetricians scarf up every delivery they can get their hands on - easy and difficult.  The reason is largely financial.  In a fee for service model of health care, 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. 

"We have a consultant obstetrician and he comes in whenever the family doctor or the midwife feels that something's happening in that labor that is outside of normal," Bell said in 2008.  "An obstetrician is trained to do complicated deliveries."

Bell's words stayedwith me ever since because they make so much sense.  As a resident at the Hospital for Sick Children in Toronto, I can remember a veteran pediatrician lamenting that he did a residency in pediatrics to see and treat children with extraordinary illnesses.  And yet, he complained to me that he spent most of his days doing well-baby checks.

But talk is cheap.  I traveled to Nelson to see if the obstetricians, midwives and family doctors actually divvied up the labour (as it were) as advertised. 

And they do.  At Kootenay Lake Hospital, midwives, family doctors and two obstetricians practice together under one roof.  The watchword is cooperation.  The midwives and family doctors deliver primary obstetrical care.  That means they do most of the prenatal care of pregnant women and do all of the uncomplicated deliveries.  Unlike most other places in Canada, the two obstetricians who work there do not practice primary obstetrics.   They don't have a caseload of women with uncomplicated pregnancies.  Instead, the obstetricians practice by referral only.  That means their job is to consult with and advise the midwives and family doctors on women with high-risk pregnancies and when the delivery is likely to be beyond their scope of practice. 

Don't get me wrong.  At Mount Sinai Hospital, where I work, family doctors do uncomplicated deliveries and consult with the obstetricians all the time.  But unlike Nelson, there's no expectation that family doctors - let alone midwives - will take care of most if not all women with uncomplicated pregnancies.

To make the system work in Nelson, you need extraordinary professionals.   Obstetrician and gynaecologist Dr. Shiraz 'Raz' Moola and midwife Ilene Bell fit the description.

Raz Moola is an amazing professional and an amazing human being.  I first met up with him when he did his residency at Mount Sinai Hospital, where I work in the ER.  I asked him where he first became comfortable working with midwives.

"It happened in Africa," Dr. Moola told WCBA.  "During my residency I got to go to a rural Zimbabwean hospital.  The vast  majority of problems were dealt with by nurses and nurse midwives.  And in fact, it was a nurse midwife - Big Boy was his name - who taught me how to do a caesarean section by myself."

"It was clear to me that you don't need a physician to do everything."

Raz Moola trusts midwives like Ilene Bell because she works alongside him at the hospital.  But before BC midwives could take that step, they had to have their own College of Midwives and get licensed, something that didn't happen until January 1998.   Until then, midwifery in BC was unregulated.  Those who practiced back then -- Ilene Bell included -- were known as underground midwives. 

Today, Bell exudes confidence - her voice is a soothing as it is poised.  She remembers that getting her licence was only part of the battle.  She says it took some time to gain the trust of nurses and doctors used to working within the system.

"No one wanted to back us up or be in a consulting relationship," Bell told WCBA.  "it was really difficult when we needed that kind of help, and it was difficult for our patients.  We also didn't have the trust of the nurses, and so it was really difficult working in that context where they were watching us."

"I mean, now I understand better how they felt," she adds.  "They didn't have any reason to trust us.  They didn't have experience with us, and in fact they were afraid that they were gonna be involved in bad situation where there might be a bad outcome and they would be legally liable in that situation.  They didn't want to be there."

"I do understand that now.  But it was stressful."

Today, there's an amazing level of comfort between the various professionals who work at Kootenay Lake Hospital.  But that doesn't mean the midwives and the obstetricians agree on everything. 
Midwives like Bell see childbirth as normal.  They want as few medical interventions like fetal monitors as possible.  OBs like Moola see childbirth as something that can go terribly wrong in a hurry. 

In this week's episode, we also meet Tanya Williams, a 29-year old paramedic in labour.   Her first child, four year old Ryder, was delivered by caesarian section at the hospital in nearby Trail, BC because he was a breech birth.  Tanya is hoping for a vaginal delivery this time.  Tanya is what doctors call a 'VBAC' - which stands for 'vaginal birth after caesarean section'.  It's considered risky to some because there's a small chance the womb might rip apart during labour.  Some OBs almost never do it - especially in a place like Nelson where there's little back up if things go wrong in a hurry.
"For most women, a vaginal birth after caesarean section will end in a successful vaginal delivery," says Moola.  "However, there is a small risk - statistically speaking, that's about zero point seven percent risk of catastrophe happening during labour and the scar opening up.  Unfortunately or fortunately, I have had the experience of putting my hand on someone's belly and feeling their child outside their uterus as the woman was going into shock."

What's different about Moola is that he's far more willing than most OBs I know to give women in labor what they want and back up the midwives - knowing he's the one who may have to save the day. 

"Trust is important in obstetrics - trust between a mother and her health care provider, and certainly trust between the health care providers," says Moola.  "Ilene is a very skilled midwife.  The nurses are here and are available."

One thing Moola and Bell do disagree about is how much medical technology to bring to bear in a situation like VBAC.  Bell doesn't want high tech like fetal monitors unless absolutely necessary.  Moola sees childbirth as something that can go terribly wrong in a hurry.  He prefers the tech.

"Well, it's really up to the woman," says Bell.  "I think we agree on that.  "It's not just Raz's recommendation.  It comes from a broader set of recommendations.  It's our obligation to put that to our clients and we're behind it.  We're certainly aware that there's a risk there.  We're not ignoring that."

"The nature of obstetrics and gynecology is dealing with uncertainty," says Moola.  "Continuous fetal monitoring does not guarantee a healthy outcome for mum and for baby.  It certainly may make the physician feel better.  In this instance, it may be useful identifying early warning signs.  But I don't sleep any better or any less knowing that someone has continuous fetal monitoring."

Bell practices midwifery knowing she has Moola for back up.  Moola practices obstetrics knowing that it may fall to him to save the day.  What keeps him awake is the knowledge that things can go horribly wrong in an instant.

"I've been doing this for close to a decade and I've had my share of bad outcomes," says Moola.  "We talk about the silent graveyard that we water with our tears.  In quiet moments, the faces of patients and circumstances come back to you and they come back to you very vividly."

"As any surgeon out there will know, the greatest high you get from a successful outcome or successful delivery will not match how low you feel when things don't turn out right."

Ilene Bell and Raz Moola - midwife and obstetrician - are two halves of the same coin.  They expect birth to be normal but are ready for the worst.  The reason why they work so well together is because for them, it's not 'either-or' but both.  That provides the greatest benefit to women in labour.  And, it teaches a profound lesson for all of us who work inside the sliding doors.