Doctors and intensive care units for sick babies

It’s hard to read this story without your heart going out to these women with high-risk pregnancies who, at one of the most stressful times in their lives, learn there are no intensive care beds for their babies. In just the past year, more than a hundred Canadian women and babies have had to be transported out of the country and away from their families to receive care.

As the Globe and Mail reports this week:

More than 100 Canadian women with high-risk pregnancies have been sent to United States hospitals over the past year – in what a doctors' group attributes to the lack of a national birthing plan. The problem has peaked, with British Columbia and Ontario each sending a record number of women to U.S. neonatal intensive care units (NICUs)... André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada, said the problem is due to bed closings that took place almost a decade ago, the absence of a national birthing initiative and too few staff. “Neonatologists are very stretched right now,” Dr. Lalonde said in a telephone interview from Ottawa. “We're so stretched, it's kind of dangerous.”...

Canada, once able to boast about its high rank in the world for low infant-mortality rate – sixth place in 1990 – saw its rank plummet to 25th place in 2005, according to figures published this year by the Organization for Economic Co-operation and Development. Specifically, Canada's infant mortality rate of 5.4 deaths per 1,000 live births is tied with Estonia's and more than double Sweden's rate of 2.4.

The inability for Canada to care for all of its sick and premature babies has caught the attention of renowned pediatrics professor Shoo Lee, who is studying the health outcomes of infants sent abroad, in addition to those who remain here, often under stretched staffing conditions. “If you have insufficient resources in the province, what does that mean for those kept in the system?” Dr. Lee, director of the Canadian Neonatal Network, said from Edmonton. “Are they being admitted to the NICU only when they are very sick? Are they being pushed out too early to make room for others?”

Philippe Chessex, division head of neonatology for B.C. Women's Hospital & Health Centre, said every effort is made to avoid out-of-province transfers. Even sick babies who aren't sent to the U.S. can still face several moves while at home. “We're transferring babies across the province, in all directions, to try to find an extra bed for the next potential birth or for any baby already born,” Dr. Chessex said in a telephone interview from Vancouver. “We now have babies who have been transferred up to six times after leaving here before reaching home.”

For parents, the devastating news that their baby is sick due to a malformation, illness or being born prematurely is compounded by the reality that there simply is not a bed available for their infant close to home....

The article goes on to profile the heartbreakingly stressful stories of several families of premature or sick babies, although thankfully, they all appear to have had happy endings. According to B.C. Health Minister George Abbot, simply adding NICU beds isn’t the answer because when they added beds in Victoria, they weren’t operational for a year because there was no neonatologist or skilled nursing staff to care for the babies. Before parents panic, press secretary to Health Minister George Smitherman stressed that these were still a fraction of deliveries and that the province will do everything to take care of mothers and babies, which is why they pay to send them out of the country.

Dr. Lalonde says the key is developing a national birthing plan, which SOGC estimates would cost $43.5 million through March, 20012. Its report, called A National Birthing Initiative for Canada, says that medical professionals “are telling us cracks in the system are reaching a breaking point and that the current situation is potentially dangerous and cannot be sustained.”

Blogger Patrick McIlheran, however, made an interesting observation. Canadian officials are saying the problem is the lack of a national birthing plan, but:

Spokane is located in a country which, best I understand, lacks a national birthing plan. Yet it managed to have a neonatal bed available. Great Falls, Mont., had space some months back when that mother in Calgary, a much larger, richer place, had to deliver quadruplets. Yet it, too, is in a country without a national birthing plan. In fact, it's in a country without a national health care plan, which Canada has, and yet the flow of patients is most decidedly from Canada to the United States, not vice versa. This might suggest that the problem isn't the lack of a national plan of one sort or another but, rather, its presence. But, hey, I'm not a doctor, so I'm sure I can't say.

While there are those who believe the healthcare system in the United States is so deplorable it should be totally tossed out and taken over by the government, undeniably, people from other countries come here for care, not the other way around. Similarly, while there’s a worldwide nursing shortage, Canadian nurse organizations are concerned about an especially critical shortage there. Our system is by no means perfect, but allowing the marketplace to respond to demands, rather than a government bureaucracy to act, appears to have offered some benefit for U.S. Americans.

Perhaps most troubling, is that this problem doesn’t seem impossible to have been foreseen, especially knowing that populations are growing and additional healthcare services would be needed to care for them. A 2002 article in the journal Pediatrics by doctors at the Dartmouth Medical School in Hanover, New Hampshire, for example, had found that the United States had greater neonatal intensive care resources per capita compared to Canada. Back in the late 1990s, there were already only about 6 pediatricians for every 1,000 live births in Canada compared to 14 in the United States. There was less than one intensive care unit (0.72) per 10,000 live births in Canada, with about half the intensive and intermediate care beds available there compared to the U.S. While overall neonatal mortality figures between countries are difficult to compare, looking at mortalities among specific weight babies defined as live births in 1997-1999 offered signs of concern: neonatal mortality among babies weighing 1000-2499 grams was 1.69% in Canada compared to 1.32% in the U.S., and 6% higher among larger babies weighing over 2500 grams.

SOGC issued a study last summer looking at maternity care in rural British Columbia and the closure of increasing numbers of rural maternity services. Its data suggested that “women and children are more likely to have perinatal morbidity if they live in rural and remote communities and deliver in a referral hospital.” As its consumer advisory said:

“Our findings point to a higher incidence of inductions, and preterm and cesarean section deliveries among these women,” says Dr. Shiraz Moola, an obstetrician with Kootenay Lake Hospital and one of the study’s principal investigators. “We also found that women in rural and remote communities whose obstetric care is outside their local health area are more apt to have babies with lower birthweights.”

The study has found that the reduction and removal of healthcare services – especially obstetric care – has had a negative impact on women in Canada’s rural communities. “We have a number of concerns with this issue,” says outgoing SOGC President Dr. Donald Davis. “To begin with, women forced to seek maternity care outside their local health area may face increased financial, emotional and psychological stress as a result – especially if they must travel long distances, are by themselves or are leaving young children back at home.”

It can also be a question of safety. Women who choose to delay travel until labour starts – for whatever reason – are placing themselves and their babies at greater risk if they deliver en route and encounter complications without the proper medical assistance. Faced with this possibility, more healthcare providers and their rural patients are now considering elective labour induction.

The situation underlines the real and growing need for safer and more accessible rural care and an increase in maternal service providers in these areas, but current statistics are not encouraging. With 30 percent of Canadians living in rural and remote communities and only three percent of Canada’s obstetricians practicing in those communities, the need for additional rural maternity care services is pronounced. Adding to this dilemma is the fact that many smaller hospitals are facing nursing shortages – further reducing the level of care available – and recruiting and retaining general practitioners who provide maternity care is becoming more difficult as older practitioners offering this service retire.

Amidst the discussion of medical home and the nationalized healthcare delivery system being envisioned for us, perhaps there's a lesson for us in this story.