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Uncertainty and Postponement: Pandemic Impact on Fertility in Canada

Ana Fostik, PhD

June 30, 2020

 

In the first weeks after the public health measures and economic lockdowns began in response to the COVID-19 pandemic, the social life of millions of adults was suddenly halted and many started spending every day at home. This led some to wonder about whether, in about nine months, we would see a spike in births. Could there be a “Coronial” generation, a baby boom due to couples spending more time together?1

Although many couples have been spending more time together, they have also been experiencing a variety of challenges and difficult transitions never experienced by our current generations: the health care system was heavily impacted by the pandemic, children were suddenly out of daycare or school and in need of homeschooling, some adults needed to work from home while caring for young children in the household, and many others had difficulty with their family finances, as they found themselves unemployed, working fewer hours or making less income.

Indeed, millions of workers were left without employment or working fewer hours than normal as a result of the lockdowns, and the unemployment rate reached a historic high of 13.7% in May 2020, up from 5.6% only three months prior. About half of the self-employed saw a reduction in the number of hours worked, accompanied in most cases by a loss of income. As a result, more than 1 in 5 adults lived in a household reporting financial difficulty to meet basic obligations such as rent, mortgage and groceries that month.2

“In this context, I would be really surprised if family projects did not change,” says Benoît Laplante, a family demography professor at the Institut national de la recherche scientifique in Montreal. Indeed, evidence suggests it is very unlikely that fertility will increase nine months after the lockdowns started. On the contrary, past research shows that a reduction of the total fertility rate can be expected in the short term. Economic downturns and recessions, labour market uncertainty and, more broadly, general societal uncertainty and negative expectations about the future have all been associated with a postponement of childbearing plans, and thus with reductions in the number of births within a population.

Labour market uncertainty impacts childbearing plans

A recent meta-analysis on the impacts of unemployment and temporary employment on fertility in Europe showed that people who have experienced episodes of unemployment tend to delay planned births.3 As unemployment results in a loss of income and increased uncertainty about future job prospects, plans for starting or expanding the family are more likely to get halted until better financial times.

This was particularly true among heterosexual couples when the male partner became unemployed, and it had an impact not only on their decision to have their first child, but also among those with children who had planned on expanding the family. Data also showed that unemployment became increasingly more detrimental for childbearing between 1970 and 2015, as conditions in the labour market became more challenging and permanent jobs less common.

On the other hand, women in some countries leveraged their periods of unemployment as an opportunity to carry out their fertility plans and have their planned children in that moment, as time for childbearing and childrearing became more available and the opportunity costs diminished (in terms of the time spent in the labour market developing experience that allows advancing their professional careers). However, this was not true in the countries hardest hit by the 2008 Great Recession in Southern Europe (i.e. Italy and Spain), which were also those with the lowest fertility levels.

People with temporary jobs were also found to be less likely to have children during periods of economic uncertainty, particularly when having a second or third child, which the study suggests is the result of the increased financial impact of expanding the family. Men were more impacted by unemployment than by having a temporary job; especially in contexts where men are expected to be the main financial providers of the household, having a job, regardless of its characteristics, is better than having none in order to start or expand the family.

Great Recession associated with fertility decline in Europe

Economic crises can impact fertility intentions and actual childbearing, even when individuals are not personally affected by the loss of a job or income, as downturns translate to a reduction in GDP growth and an increase in unemployment. In times of uncertainty about the economic future and labour market stability, people might become risk averse and avoid any long-term commitments, of which having a child is the most irreversible one. Negative expectations about the future may lead many families to postpone childbearing plans until times of greater certainty.4

An interesting recent example of this can be found in Europe, where fertility rates had been increasing since the first years of the 2000s. During and after the Great Recession of 2008–2009, fertility rates stagnated and then decreased in most European regions, particularly those most affected by the recession.

A recent article on the impact of this recession on fertility in 28 European countries analyzed the effects of unemployment, long-term unemployment and GDP decline on fertility rates between 2000 and 2014. The study found that when unemployment increased, fertility rates decreased significantly. Moreover, the effect of unemployment was stronger during the period of the recession (between 2008 and 2014) than before its start, suggesting that the negative impact of unemployment on fertility behaviour may be magnified during times of recessions.5

Research suggests that “fundamental uncertainty” impacts childbearing plans

While the European economy recovered after the Great Recession, fertility did not bounce back in many European countries and, in fact, it continued to decline. This was especially true in some Nordic countries, where the effects of the Great Recession were mild and where fertility decline started later and continued past 2014, after the macro economic conditions had improved. This led some researchers to focus on the presence of “fundamental uncertainty” regarding the future and its impact on family aspirations. Their argument is that fundamental uncertainty regarding the future of the economy, but also of political systems at a global level, can have an impact on the narratives, perspectives and worldview of individuals, regardless of whether they have experienced a precarious job or unemployment themselves. As “narratives of uncertainty” become widespread, births are delayed, even if and when the economy recovers.6

A study of the effects of a financial crisis in Italy in 2011 to 2012 showed that, as individuals googled the technical term “spread” (an indicator used by economists to measure the lack of confidence in a financial system), births fell sharply nine months later. They estimated that births were reduced between 2.5% and 5% as a consequence of these “narratives of uncertainty.”7

Recent research shows the COVID-19 pandemic is affecting childbearing plans

A recent survey of adults aged 18 to 34 years old in several European countries (i.e. Italy, Spain, France, Germany and the U.K.) estimated the proportion of births that were planned for 2020 that are being delayed. Adults who had declared in early 2020 (i.e. before the coronavirus outbreak) that they were planning on conceiving or having a child by the end of the year were asked whether the pandemic had altered these plans in any way. The study found that individuals did indeed change their fertility plans in all studied countries, either by delaying or abandoning the plan for this year.

The impact varied across countries, but in Italy and Spain, nearly one-third of those who were planning a birth for 2020 abandoned the project for the year. Half or more of respondents in Germany, France, Spain and the U.K. declared that their plan to have a child still stood, but they were postponing it for later in the year.8

Planned births among mothers aged 40 and older may be significantly impacted

Experiences from past economic and sanitary crises (e.g. the 1918 flu pandemic) have shown that some of the births that are postponed in times up upheaval are caught up with later on.9 People sometimes wait until times are less uncertain before going forward with births that had previously been planned.

Laplante points out that the difference between delaying a birth and abandoning the project to have a child altogether may become especially blurry in the current circumstances. “What’s most likely is that people will delay or abandon (their reproductive plans) … and when you delay, after a while, you may end up abandoning … now, everyone is living in uncertainty, and when will we have a vaccine? In two years, maybe.” Laplante’s reasoning is that, if women in their 30s were planning to have two children, and then decide to wait until a vaccine becomes available to have their next birth, they might run out of time to have either their first or their second child before they reach a biological limit.

It is therefore possible that some of these birth plans might not be “recovered.” In many Western countries, women are increasingly waiting longer to have their first child, as many choose to develop their professional and educational paths beforehand. Even births at age 40 and older have increased in the past few decades, representing an increasing share of first births.10 In 2014, an estimated that 3.6% of all births in Canada were to mothers aged 40 years and over.11

For women aged 40 years and older, an important proportion of births is facilitated by assisted reproductive technology.12 Given that many of these procedures were interrupted for months on end in the midst of the pandemic, births at older ages might be more acutely impacted. In societies where a higher share of births are occurring among women in their 40s, some of the planned births that were already delayed might not ever happen: the biological clock might run out before both the labour market and health systems go back to previous standards.

Data from Quebec and Ontario show impact on fertility beyond economic recovery

The total fertility rate is a “snapshot” indicator, an estimate of how many children women would have on average, over their lifetime, if fertility conditions at the moment persisted during their entire reproductive life. That is why we can expect a reduction of fertility rates during a period of social and economic turbulence and/or uncertainty, followed by an uptake once the crisis is over: at least a portion of the births that were postponed are simply “caught up with” – so long as reproductive plans and ideals remain intact.

Laplante cautions that in Quebec and Ontario, fertility rates started falling in the 2008 Great Recession,13 and, as happened in European countries, continued falling once the economic downturn was over and unemployment rates were low. He is now investigating why the fertility decline did not reverse in these two Canadian provinces: are there more fundamental changes under way that are not just the product of temporary upheaval?

Only time will tell if the generations impacted by the COVID-19 crisis will have the same number of children they had been planning, but at a later time, or if their ideal number of children will change in these circumstances. If some adults decide to forego childbearing altogether as a response to the new challenges brought about by the pandemic and its associated economic crisis, younger generations might be more likely to not have children. It is currently too early to tell, but research on changes in fertility intentions before and after the pandemic will be of crucial importance to understand this aspect of family life.

Ana Fostik, PhD, Vanier Institute on secondment from Statistics Canada

 


Notes

  1. See, for example, “Is the COVID-19 Baby Boom a Myth? How Relationships Might Be Tested During the Pandemic,” CTV News (April 19, 2020). Link: .
  2. Statistics Canada, “Labour Force Survey, May 2020,” The Daily (June 5, 2020). Link: .
  3. Giammarco Alderotti et al. Employment Uncertainty and Fertility: A Network Meta-Analysis of European Research Findings. Econometrics Working Papers Archive 2019_06. Universita’ degli Studi di Firenze, Dipartimento di Statistica, Informatica, Applicazioni “G. Parenti” (2019).
  4. Tomáš Sobotka, Vegard Skirbekk and Dimiter Philipov. “Economic Recession and Fertility in the Developed World,” Population and Development Review 37(2), 267-306 (2011).
  5. Francesca Luppi, Bruno Arpino and Alessandro Rosina. The Impact of COVID-19 on Fertility Plans in Italy, Germany, France, Spain and UK (2020).
  6. Daniele Vignoli et al. Economic Uncertainty and Fertility in Europe: Narratives of the Future. Econometrics Working Papers Archive 2020_01, Universita’ degli Studi di Firenze, Dipartimento di Statistica, Informatica, Applicazioni “G. Parenti” (2020). Link:.
  7. Chiara L. Comolli and Daniele Vignoli. Spread-ing Uncertainty, Shrinking Birth Rates. Econometrics Working Papers Archive Universita’ degli Studi di Firenze, Dipartimento di Statistica, Informatica, Applicazioni “G. Parenti” (2019).
  8. Francesca Luppi, Bruno Arpino and Alessandro Rosina. The Impact of COVID-19 on Fertility Plans in Italy, Germany, France, Spain and UK (2020).
  9. Nina Boberg-Fazlić et al. Disease and Fertility: Evidence from the 1918 Influenza Pandemic in Sweden, Discussion Paper Series, IZA – Institute of Labor Economics (2017); Sebastian Klüsener and Mathias Lerch. Fertility and Economic Crisis: How Does Early Twentieth Century Compare to Early Twenty-first Century? Paper presented at the Population Association of America, Virtual (2020).
  10. Eva Beaujouan. “Latest‐Late Fertility? Decline and Resurgence of Late Parenthood Across the Low‐Fertility Countries,” Population and Development Review 0(0), 1-29 (2020). Link: https://bit.ly/2AjlOD6.
  11. Eva Beaujouan and Tomáš Sobotka. “Late Childbearing Continues to Increase in Developed Countries,” Population and Societies, no. 562 (January 2019).
  12. Eva Beaujouan. “Latest‐Late Fertility? Decline and Resurgence of Late Parenthood Across the Low‐Fertility Countries.”
  13. Melissa Moyser and Anne Milan. “Fertility Rates and Labour Force Participation Among Women in Quebec and Ontario,” Insights on Canadian Society, Statistics Canada catalogue no. 75-006-X. Link: .

 

Mother’s Day 2019: New Moms Older, More Likely to Be Employed Than in the Past

May 12, 2019 is Mother’s Day, a time to recognize and celebrate the millions of women in Canada who are raising (and co-raising) future generations, often while managing multiple roles at home, in their workplaces and in their communities. The complex relationship between women, work and family across the country has evolved significantly across generations, as new moms are older and more likely to be employed than in the past – trends that are reflected in data recently released from Statistics Canada.

According to recent Vital Statistics data, women across the country are increasingly waiting longer to have children – in fact, the fertility rates of women in their early 20s and late 30s flipped over the past 20 years. Many are instead focusing first on pursuing post-secondary education and career development – continuing a long-term trend observed over the past several decades.

  • In 2017, the fertility rate in Canada for women aged 20 to 24 stood at 36 live births per 1,000 women, down from 58 per 1,000 in 2000.1
  • In 2017, the fertility rate in Canada for women aged 35 to 39 was 56 live births per 1,000 women, nearly double the rate in 2000 (34 per 1,000).2
  • In 2016, the average age of first-time mothers was 29.2 years, up from 27.1 years in 2000.3

Most of these new moms are (and remain) in the paid labour force at the time of birth or adoption of their newborn, often utilizing community supports to facilitate work and family responsibilities.

  • In 2016, the employment rate of mothers whose youngest child was aged 0 to 2 was 71%, up from 66% in 2001. As in previous years, this rate was higher in Quebec in 2016 (80%).4
  • In 2017, 79% of recent mothers across Canada had insurable employment, 90% of whom received maternity and/or parental benefits.5
    • As in previous years, recent moms in Quebec were more likely to have insurable employment (97%) and to have received benefits than their counterparts in the rest of Canada (91%).
  • In 2016–17, women accounted for 85% of all parental benefits claims made, down from 89% in 2002.6, 7

Since December 2017, new and expectant parents have been provided with more flexibility regarding the timing and duration of the benefit period.

  • New and expectant parents are now able to choose an extended parental benefits option, which allows them to receive their EI parental benefits over a period of up to 18 months at a benefit rate of 33% of average weekly earnings. Compared with the standard parental benefits option, this extends the duration of the benefit period but decreases the benefit rate, which stand at 12 months and 55% of average weekly earnings, respectively.8
  • Expectant mothers are also now able to access benefits up to 12 weeks before their due date – four weeks earlier than the previous eight-week limit (no additional weeks are available).9
  • In 2017, among recent mothers who had worked as an employee within the previous two years, more than 1 in 5 took or planned to take more than 12 months away from work (21%).10

 


Published on May 8, 2019

Notes

1 Statistics Canada, Crude Birth Rate, Age-specific Fertility Rates and Total Fertility Rate (Live Births) (Table 13-10-0418-01), page last updated May 2, 2019. Link: .

2 Ibid.

3 Claudine Provencher et al., “Fertility: Overview, 2012 to 2016,” Report on the Demographic Situation in Canada, Statistics Canada catalogue no. 91-209-X (June 5, 2018). Link: .

4 Martha Friendly et al., “Early Childhood Education and Care in Canada 2016,” Child Care Research and Research Unit (CRRU) (April 2018). Link:.

5 Statistics Canada, “Employment Insurance Coverage Survey, 2017,” The Daily (November 15, 2018). Link:.

6 Employment and Social Development Canada, “New Five-Week Employment Insurance Parental Sharing Benefit One Month Away,” News Release (February 18, 2019). Link: .

7 Canada Employment Insurance Commission, Employment Insurance 2002 Monitoring and Assessment Report (March 31, 2003). Link: .

8 Learn more in “Webinar Content: Changes to EI Special Benefits,” Transition (January 24, 2018). Link: https://bit.ly/302utBQ.

9 Ibid.

10 Statistics Canada, “Employment Insurance Coverage Survey, 2017.”

Families in Canada Interactive Timeline

Today’s society and today’s families would have been difficult to imagine, let alone understand, a half-century ago. Data shows that families and family life in Canada have become increasingly diverse and complex across generations – a reality highlighted when one looks at broader trends over time.

But even as families evolve, their impact over the years has remained constant. This is due to the many functions and roles they perform for individuals and communities alike – families are, have been and will continue to be the cornerstone of our society, the engine of our economy and at the centre of our hearts.

Learn about the evolution of families in Canada over the past half-century with our Families in Canada Interactive Timeline – a online resource from the Vanier Institute that highlights trends on diverse topics such as motherhood and fatherhood, family relationships, living arrangements, children and seniors, work–life, health and well-being, family care and much more.

View the Families in Canada Interactive Timeline.*

 

Full topic list:

  • Motherhood
    o Maternal age
    o Fertility
    o Labour force participation
    o Education
    o Stay-at-home moms
  • Fatherhood
    o Family relationships
    o Employment
    o Care and unpaid work
    o Work–life
  • Demographics
    o Life expectancy
    o Seniors and elders
    o Children and youth
    o Immigrant families
  • Families and Households
    o Family structure
    o Family finances
    o Household size
    o Housing
  • Health and Well-Being
    o Babies and birth
    o Health
    o Life expectancy
    o Death and dying

View all source information for all statistics in Families in Canada Interactive Timeline.

 

* Note: The timeline is accessible only via desktop computer and does not work on smartphones.


Published February 8, 2018

In Context: Understanding Maternity Care in Canada

If it takes a village to raise a child, it certainly takes one to bring a child into this world. New and expectant mothers receive care from many people throughout the perinatal period, and the networks and relationships that support them can play a major role in ensuring the health and well-being of new mothers and their newborns.

Childbirth is a milestone, an exciting time when the family grows and a new generation begins. It’s also a period of significant child development – a time of great vulnerability but also of great opportunity to benefit from healthy nurturing.

The experience of pregnancy, childbirth and postnatal care continues to evolve through the generations. Rates of maternal mortality (women dying as a result of pregnancy and childbirth), maternal morbidity (women developing complications as a result of childbirth) and infant mortality all saw significant declines throughout the 20th century following medical advances and improvements in maternal care, nutrition and general living standards.

Maternal and Infant Mortality in Canada

Maternal mortality dropped from 508 deaths per 100,000 live births in 1931 to 7 per 100,000 in 2015.

Infant mortality rates fell from an average of 76 deaths per 1,000 live births in 1931–1935 to 4.9 per 1,000 in 2013.

In the 1800s to the mid-1900s, maternity care in Canada typically took place in the local community and birth occurred in the home, with families and midwives routinely providing care to new and expectant mothers. However, with the development of medicare throughout the 20th century, births and maternity care gradually moved into hospitals and medical clinics, with care being delivered primarily by medical professionals such as doctors and obstetricians – a trend sometimes referred to as the “medicalization of childbirth.”

By the early 1980s, the vast majority of births occurred in regional hospitals, where family physicians or obstetricians were present and assisted by obstetrical nurses. Partners and other family members became largely left out of the childbirth process, often relegated to waiting rooms. Following birth, babies were placed in nurseries, separated from their mothers – a situation that was sometimes traumatic for mothers and their newborns.

Hospitals eventually started allowing the rooming in of mother and baby to facilitate mother–infant attachment and support breastfeeding for the health and well-being of both. During the rooming-in period, nurses would provide new mothers with information for the recovery period, such as instruction about breastfeeding and postnatal care. Throughout this transition in postnatal care practices, the length of time women spent in hospital after having a baby decreased significantly, from an average of nearly five days in 1984–1985 to 1–2 days after vaginal delivery today.

Today, partners are more involved in the birthing process and the perinatal period generally than in the past. Most are present for births, taking on a greater role in these first moments of their children’s lives and in the child rearing in the years that follow. It is more common for couples today to conceptualize childbirth as a shared experience, and many people use language that reflects this trend (“We’re expecting,” etc.).

 

What is maternity care?

Maternity/perinatal care (hereafter referred to as maternity care) is an umbrella term encompassing a continuum of care provided to the mother and child before, during and after birth. This includes prenatal/antenatal care (care during pregnancy), intranatal care (care during labour and delivery) and postnatal/postpartum care (care for the mother and newborn following birth). Since both mothers and infants undergo major changes throughout the perinatal period, maternity care entails a diverse range of health monitoring and care.

Prenatal/antenatal care (hereafter referred to as prenatal care) monitors and supports the health and well-being of mothers and the developing fetus prior to birth. Fetal health is monitored through screening and diagnostics, such as ultrasounds and blood tests. Health providers also closely track the mother’s health during this period; expectant mothers are provided with information about pregnancy, fetal development, physical comfort, testing, planning for delivery and preparing for parenthood.

Most women (87%) say they were supported by a partner, family or friends throughout the prenatal period.

According to the 2009 Canadian Maternity Experiences Survey, most women (87%) say they were supported by a partner, family or friends throughout the prenatal period. This support, as well as the care provided by health practitioners, can be particularly important during this time when many (57%) women report most days as being stressful. During pregnancy, maternal stress can have an impact on the well-being of the baby, leading to premature birth and/or low birth weight.

Nearly all expectant mothers (95%) report that they started prenatal care in their first trimester. Certain groups were more likely than others to report that they did not start prenatal care in the first trimester, however, such as women aged 15–19 years, those with less than high school education or those who live in low-income households. One of the main reasons cited for not starting care early in the pregnancy was lack of access to a doctor or health care provider.

Intranatal/intrapartum care (hereafter referred to as intranatal care) refers to the care and assistance provided to mothers during labour and childbirth. This involves facilitating the delivery itself in a safe and hygienic manner as well as monitoring the health of mother and child throughout the delivery process. This care is most often provided in hospitals, with mothers receiving care from a variety of health practitioners including obstetricians/gynecologists (reported as the main health care provider during labour and birth by 70% of surveyed mothers), family doctors (15%), nurses or nurse practitioners (5%) or midwives (4%).

Whether provided by a spouse, partner, friend, family member, midwife or doula (or some combination thereof), emotional support during this time is important. Research shows that women who receive continuous social support are more likely to have a shorter labour (i.e. fewer hours) and a vaginal birth, are more likely to report feeling happy with their labour and birth experience and are less likely to use pain medication.

Research shows that women who receive continuous social support are more likely to have a shorter labour and a vaginal birth, and are more likely to report feeling happy with their labour and birth experience.

Postnatal/postpartum care (hereafter referred to as postnatal care) supports mothers and newborns following childbirth, and involves health monitoring and routine assessments to identify any deviation from expected recovery following birth, and to intervene, if necessary.

The postnatal period accounts for the first six weeks of a child’s life – a “critical phase” in which examinations and care from health practitioners play an important role in ensuring the well-being of the mother and child, according to the World Health Organization (WHO).

In their 2013 postnatal care guidelines, WHO outlines best practices including postnatal care in the first 24 hours to all mothers and babies (regardless of where the birth occurs), ensuring that healthy women and their newborns stay at a health facility at least 24 hours and are not discharged early, and have at least four postnatal checkups in the first 6 weeks following childbirth.

According to the Maternity Experiences Survey, more than 7 in 10 women (73%) rated their health as “excellent” or “very good” by 5 to 14 months postpartum. However, more than 4 in 10 women in Canada (43%) said they experienced a “great deal” of problems with at least one postpartum health issue during the first three months following childbirth, such as breast pain (16% of women), pain in the vaginal area or in the area of the caesarean incision (15%) and back pain (12%).

Postnatal support can be important in mitigating postpartum depression, which is reported by 10%–15% of mothers in developed countries. Research has shown that maternal stress during pregnancy, the availability of social support and a prior diagnosis of depression are all significantly associated with developing postpartum depression. Studies have also shown that emotional support from partners and other family members throughout the perinatal period can reduce the likelihood for postpartum depression and emotional distress for mothers and newborns.

Postnatal care services vary across regions and communities in Canada. These can include informational supports, home visits from a public health nurse or a lay home visitor, or telephone-based support from a public health nurse or midwife.

Privately delivered postnatal services have become more prevalent over the past several decades, with postpartum doulas advertising high-intensity supports such as newborn care, breast- and bottle-feeding support, child-minding services, meal preparation, household chores and more. However, these private services often involve out-of-pocket costs that can limit accessibility for some families.

 

Who provides maternity care?

In addition to the care and support provided by family members and friends, modern maternity care is delivered by a range of health practitioners including family physicians, obstetricians/gynecologists, nurses, nurse practitioners, midwives and birth doulas – all of whom make unique contributions in the continuum of care.

Family physicians provide care to most new mothers throughout the perinatal period and can be involved in all stages of maternity and infant care, though not all provide the full range of care. Fewer physicians across Canada are providing maternity care than in previous decades: the share of family physicians in Canada delivering babies declined from 20% in 1997 to 10.5% in 2010. Today, a growing number of care tasks and responsibilities are being delivered by other medical practitioners, such as obstetricians and midwives.

Most family physicians who report being involved in maternity and newborn care provide “shared care,” offering prenatal care to a certain point (often between 24 and 32 weeks), after which they transfer care to another provider (e.g. obstetricians, midwives or another family physician who delivers babies). Some attend deliveries, but rates vary widely between provinces and the availability of other health providers.

Obstetricians and gynecologists (OB/GYNs) are providing a growing amount of intranatal care in Canada – though not all do so, and rates vary across the provinces. With specialized knowledge and expertise in pregnancy, childbirth and female sexual and reproductive health care (including surgical training, such as caesarian sections), many also serve as consultants to other physicians and are involved in high-risk pregnancies.

Nurses constitute the largest group of maternity care providers in Canada. They can be involved throughout the entire perinatal period, providing a range of care services including childbirth education, pre-birth home care services to women in high-risk situations, assistance during childbirth and sometimes follow-up care to new mothers. Following childbirth, nurses often provide information to new mothers while preparing them for discharge, educating them about topics such as breastfeeding, bathing, jaundice, safe sleep, postpartum mental health, nutrition and more.

Nurse practitioners (NPs) are registered nurses who play a wide variety of roles in health care. They sometimes serve as primary care providers for low-risk pregnancies, performing a variety of tasks such as physical examinations, screening and diagnostic tests, and postnatal care. When providing or facilitating maternity care, NPs often work in interdisciplinary teams with other health professionals such as physicians and midwives. In hospital settings, they also work in labour and delivery units, postpartum units, neonatal intensive care units and outpatient clinics. Due to the breadth of their training and expertise, NPs play important roles in rural and remote communities, where many provide a full range of health care services.

Due to the breadth of their training and expertise, nurse practitioners play important roles in rural and remote communities, where many provide a full range of health care services.

Midwives provide primary care to expectant and new mothers throughout the entire perinatal period, and are playing a growing role in modern maternity care in Canada. They provide a range of care services, including ordering and receiving tests, accompanying women at home or in birthing centres, admitting women for hospital births, as well as assisting with breastfeeding, the early days of parenting and monitoring postpartum healing. Midwives work collaboratively, consulting with, or referring to, other medical professionals when appropriate.

The role of midwives has evolved over the past several decades, with a growing number assisting in all settings where care may be needed – at home, in the community and in hospitals, clinics or health units. There has been increasing emphasis on specialization and training, as midwives have become recognized by and incorporated into most (but not all) provincial/territorial health care systems across the country.

Doulas provide non-clinical/medical support, working with new mothers and their families as well as health care practitioners such as physicians, midwives and nurses. Doulas are not regulated; they focus largely on emotional and informational support, and they do not provide direct health care or deliver babies.

There are different types of doulas for different stages in the childbirth process. Antepartum doulas provide emotional, physical and informational support during the prenatal period. This can include informing new mothers and their families about support groups, techniques for enhancing physical comfort and helping with home care tasks such as errands and meal preparation. Birth doulas support new mothers and their partners during labour and delivery, including emotional and informational assistance and supporting physical comfort. Postpartum doulas support new mothers after the baby is born, providing information about topics such as infant feeding and soothing techniques, and sometimes helping with light housework and childcare.

Perinatologists provide care in the event of high-risk pregnancies (e.g. pregnancy in the context of chronic maternal health conditions, multiple births or genetic diagnoses). They are trained as OB/GYNs and then receive specialized education to facilitate complicated pregnancies. OB/GYNs refer patients to perinatologists when needed, but continue to work collaboratively to support maternal health.

 

Unique experiences: childbirth in rural and remote areas in Canada

Maternity care in rural and remote areas (including Canada’s northern regions) faces unique challenges due to distances from medical facilities and specialized equipment, less peer support for care providers, as well as a limited number of physicians available for on-call services, and fewer caesarean section and anaesthesia capabilities/services compared with urban centres.

Rural maternity care is most often provided by teams of family physicians, nurses and midwives – in fact, in some communities, they’re the only health practitioners providing maternity care. Rural family physicians are far more likely to provide obstetrical care than their urban counterparts, though over the past several decades, many rural communities have seen a reduction in the number of family physicians providing maternity care and closures of maternity wards.

Due to the limited availability of maternity care providers and services in rural and remote regions, many expectant mothers travel to urban centres to give birth. According to a 2013 report from the Canadian Institute for Health Information, more than two-thirds of rural women in Canada (67%) report that they gave birth in urban hospitals, 17% of whom travelled more than two hours to deliver their babies. Rates are far higher in the North: two-thirds of surveyed mothers in Nunavut and half of those in the Northwest Territories report that they gave birth away from their home community.

Two-thirds of surveyed mothers in Nunavut and half of those in the Northwest Territories report that they gave birth away from their home community.

This has an impact on the well-being of many Indigenous women living in northern regions, many of whom have had to fly to hospitals far from their homes, land, languages and communities to receive maternity care at tertiary or secondary care hospitals (see Indigenous Midwifery in Canada textbox). When surveyed, the majority of mothers reported that leaving home to have their babies was a stressful experience and that it had a negative impact on their families. In April 2016, the federal government announced that it would provide financial compensation to allow someone to travel with Indigenous women who need to leave their communities to give birth.

The number of community hospitals offering obstetrical care in northern regions has fallen since the 1980s. However, a number of birthing centres have opened to fill this care gap, such as in Puvirnituq (Nunavik), Rankin Inlet (Nunavut) and in Inukjuak (Quebec). These facilities have helped women with low-risk pregnancies remain in their communities; however, those with complications or requiring a caesarian birth often still have to travel to give birth.

 

Unique experiences: new and expectant mothers new to Canada

Canada is home to many immigrant families, which have represented a growing share of the total population. In 1961, 16% of people in Canada reported that they were born outside the country – a rate that increased to 21% by 2011.

Immigration has an impact on the maternity experiences, such as when women decide to have children. Research shows that immigrants have relatively fewer births in the two-year period before migration, which is often followed by a “rebound” in fertility afterward. According to researchers Goldstein and Goldstein, “Fertility preferences of movers may more closely resemble those of the destination country than those of the source country even before they arrive.”

Studies have explored a number of reasons why fertility can be affected by the immigration experience, including temporary separation of spouses during the migration process, a conscious decision to delay childbearing until access to supports such as child allowances is ensured and economic disruption during migration and in the early period (while parents are securing paid employment).

Recent immigrants are significantly more likely than their Canadian-born counterparts to live in multi-generational households (those with three or more generations living under one roof); 21% of immigrants aged 45 and older who arrived in Canada between 2006 and 2011 reported that they live in shared homes, compared with 3% of the Canadian-born population. As such, new and expectant mothers in multi-generational homes may benefit from having more family members nearby to provide care and support.

With regard to accessing maternity care services, research has shown that many immigrant women generally have the opportunity to receive the necessary maternity care services, but rates of satisfaction with maternity care vary greatly across Canada. Some report having faced barriers to accessing and utilizing maternity care services, including (but not limited to) a lack of information about or awareness of the services (sometimes the result of language barriers), insufficient support to access the services (i.e. navigation of the health care system) and discordant expectations between immigrant women and service providers. In some areas, doulas provide valuable emotional, informational and navigation support to immigrant women during the perinatal period.

Social support (e.g. from family, friends and community members) has been identified by immigrant parents as a key factor in accessing maternity care. This circle of support can play an important role in connecting new and expectant mothers from outside Canada with maternity care, and can work with health care and service providers to ensure these women receive “culturally congruent and culturally safe” maternity care.

 

Maternity care: supporting Canada’s growing families

Pregnancy and childbirth are major life events, not only for new mothers, but also for their families, friends and communities. While there have been many changes in family experiences over the generations regarding pregnancy, childbirth and the postnatal period, there have also been some constant threads: the value and importance of quality care, the diversity of experiences across Canada, and the joy and excitement that can accompany this memorable and life-changing milestone.

 


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This content was reviewed by Dr. Marilyn Trenholme Counsell, OC, MA, MD, retired family physician and former Lieutenant Governor (New Brunswick), former Minister of Family (N.B.) and Senator (N.B.).

All references and source information can be found in the PDF version of this article.

Published May 11, 2017

Timeline: Fifty Years of Women, Work and Family in Canada

While mothers in Canada have always played a central role in family life, there’s no question that the social, economic, cultural and environmental contexts that shape – and are shaped by – motherhood have evolved over time.

A growing share of mothers are managing paid work and family responsibilities compared with previous generations, and the dynamic relationships between women, work and family continue to evolve. To explore these relationships through a broader lens, we’ve created a 50-year timeline for Mother’s Day 2016 that explores some of the long-term trends over the past half century, including:

  • An increase in women’s participation in the paid labour force, which has grown from 40% in 1968 to 82% in 2014 for those aged 25 to 54
  • A growing share of “breadwinning” moms among single-earner couple families, which has steadily increased from 4% of earners in these families in 1976 to 21% in 2014
  • A significant drop in the low-income rate among single mothers, which has fallen from 54% in 1976 to 21% in 2008
  • A declining fertility rate, which stood at 3.94 women per children in 1959 during the peak of the baby boom, but has since dropped to 1.61 in 2011
  • A continually rising average age of first-time mothers, up from 24.3 years of age in 1974 to 28.5 in 2011
  • A greater amount of time mothers are spending with family, with women reporting 421 minutes (7 hours) per day with family in 2010, up from 403 minutes (6.7 hours) in 1986

This bilingual resource is a perpetual publication, and it will be updated periodically as new data emerges. Sign up for our monthly e-newsletter to find out about updates, as well as other news about publications, projects and initiatives from the Vanier Institute.

Enjoy our new timeline, and happy Mother’s Day to Canada’s 9.8 million moms!

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Modern Maternity Care in Canada

Cecilia Benoit

Georgina, a mother of Mi’kmaq heritage, is in the last stage of her pregnancy. Reluctantly, she is preparing to leave her home community of Port-aux-Basques, located on the southwestern tip of Newfoundland, to give birth in the only remaining maternity hospital in her health region, the Western Memorial Regional Hospital in Corner Brook, 220 kilometres away from her family and friends. Her chances of having a maternity doctor or midwife she knows attend her birth are slim to none, and there is a 30% chance that her baby will be delivered by Caesarean section.

Millennium Development Goal 5, to improve maternal health, is one of the United Nations Millennium Development Goals (MDGs). Of the eight MDGs, the least progress has been made toward the right of every woman to the best possible maternity care. Indigenous, poor and rural and remote women such as Georgina are especially compromised. While Canada made major strides throughout the 20th century to improve maternal health and build a universal maternity care system, many shortcomings remain, including but not limited to the medicalization of childbirth and inequitable access to maternity providers.

History of childbirth in Canada

Pregnancy and childbirth are significant life events in all cultures. In earlier times, midwives were the primary care providers. Care during pregnancy typically took place in the local community and birth occurred in the home.

Medicalization of maternity care in Canada, while significantly predating the development of the modern welfare state, became enshrined and solidified within the package of policies and regulations that accompanied the adoption of universal health care, known as “medicare,” which was implemented and formally adopted in 1972.

While Canada’s health care model is often referred to as a simple single payer health care system, funding and delivery of insured services are in fact much more complex. They involve federal and provincial/territorial governments, community services, private insurance companies and individuals.

Most physicians work in private practice, with their services paid from the provincial/territorial insurance plans. Funding for the insurance plans comes from the general revenues of the provinces/territories, with additional transfer payments from the federal government through the Canada Health and Social Transfer or, more recently, the Canada Health Transfer.

Under medicare, only physician-provided maternity care services were covered by the public health care system, which resulted in shifting the role of midwives (women) to medical doctors (mostly men). In the publicly funded health care system that was created, physicians also retained their right to remain private entrepreneurs, establishing their practices wherever they deemed appropriate.

The system created through medicare did not address the pre-existing disparity in the availability of physician services and solidified the hospital as the control centre of the maternity care system. Due to concerns about modesty and fear of contagion, it also excluded partners and other kin from participating in the age-old event of childbirth.

Modern childbirth in Canada

By the early 1980s, virtually all women across the country were delivering their babies in regional hospitals, attended by a maternity physician or obstetrician and assisted by obstetrical nurses. But these institutional changes left women lonely and new fathers sidelined. Research shows that women who have the support of a partner during labour require less pain relief and feel more positive about the birth. As research began to show the importance of healthy parent–child attachment, the health care system responded by allowing partners to be active participants in the birthing process. Partners today are present for the majority of births, taking on a greater role not only in these first moments of their children’s lives, but also with child rearing and household management in the years that follow.

Maternal deaths rose in Canada from 6 to 12 per 100,000 births between 1990 and 2013.

In 2013, UNICEF ranked Canada 22nd out of 29 high-income countries for infant mortality rates, with the rate substantially higher among Indigenous peoples.

Canada currently boasts the lowest maternal mortality rate in the American continent, reflecting improvements throughout the 20th century in women’s education, their nutrition, control of their fertility and universal coverage of physician services. Yet maternal deaths rose in Canada from 6 to 12 per 100,000 births between 1990 and 2013. By contrast, Japan and a number of European countries today have mortality rates half the Canadian rate or lower. Equally disconcerting, in 2013, UNICEF ranked Canada 22nd out of 29 high-income countries for infant mortality rates, with the rate substantially higher among Indigenous peoples.

In recent decades, the number of family doctors involved in maternity care delivery has significantly declined, as has the number of hospitals offering maternity care services. At the same time, the percentage of deliveries attended by obstetricians has increased substantially; for example, obstetricians currently attend 80% of hospital births in Ontario.

Caesarean section rates have also steadily increased, with the total national rate increasing from 17.6% in 1995 to 22.5% in 2001, and 27.3% in 2013 (see table below). The current rate of Caesarean section births ranges from a high of 32% in British Columbia and 31% in Newfoundland and Labrador to a low of 23.1% in Saskatchewan and 21.41% in Manitoba. According to the World Health Organization, Caesarean section rates below 10% indicate underuse of this life-saving procedure, while rates above 15% are deemed to show overuse. Overuse of Caesarean section has been linked to higher morbidity in mothers, including an increased risk for depression and post-traumatic stress, lower breastfeeding rates and a greater likelihood of future complications in pregnancy. Despite popular media images of maternal demand for Caesarean section, there is little evidence that the increase in the national rate in the last 20 years, and the even more surprising current cross-country variation, is based on mothers’ demand for a convenient pain-free birth – the so-called “too posh to push” argument.

 

Modern midwifery in Canada

Beginning with Ontario, British Columbia and Quebec in the 1990s, and spreading across most other regions since, midwives have received formal education and become regulated, and their services have been publicly funded. Yet the occupation still remains unregulated and unfunded in Newfoundland and Labrador, Yukon, Prince Edward Island and New Brunswick. Moreover, only 9% of births in Canada are currently attended by a midwife. While the percentage of midwife-attended births is higher in some regions (e.g., 19% in British Columbia), the demand outstrips the supply, with a substantial proportion of women in all parts of the country wanting access to a trained, publicly funded midwife but unable to find one.

Women with lower education, younger mothers, women without a partner and women living in rural and remote areas or socio-economically disadvantaged communities have the least access to publicly funded midwifery services. The Association of Ontario Midwives estimates that as many as 40% of women who want to see a midwife in Ontario are currently unable to find one, and women in other provinces are also experiencing frustration trying to find midwifery care. Following developments in Quebec and Manitoba, Ontario recently funded two free-standing, midwifery-led birth centres. Yet this option is not available for many non-Indigenous and Indigenous women, such as Georgina mentioned above, who instead experience loneliness, disconnection from their local maternity traditions and isolation from family; the overall result is “stressful births.”[ii]

Modern postpartum care in Canada

The length of time Canadian women spend in hospital following childbirth has decreased dramatically during the modern period, from a mean of five days in 1984–85 to just less than two days after vaginal delivery today. Hospital stays are costly; early hospital discharge for mothers and their newborns helps administrators control or reduce obstetrical care expenditures. For some women with strong support systems and access to publicly funded physician or midwifery services, early discharge from hospital is usually a welcomed occasion.

As in earlier times, family support can be crucial in the postpartum period. Fathers and/or partners across Canada, with the support of parental leave policies, are playing a much bigger role after childbirth than in previous generations – a shift in family roles that continues to this day. According to Statistics Canada, 31% of recent fathers across the country claimed or intended to take parental leave in 2013 – a significant increase from 3% in 2000. The rate is much higher in Quebec, particularly since the introduction of the Quebec Parental Insurance Plan (QPIP), which is the only plan in the country that specifically provides paternity leave. Since the introduction of QPIP in 2006, uptake has almost tripled, from 28% in 2005 to 83% in 2013.

But for women without these familial and formal options, the result can lead to negative health outcomes for themselves and their infants. Provincial and territorial health care systems cover a limited range of postnatal care services. At the federal level, this has traditionally been restricted to the provision of informational supports by the provinces and the publication of national guidelines for maternity and newborn care. In some regions, an optional home visit by either a public health nurse or a lay home visitor is still available, while in other regions, services following discharge from hospital have been reduced to a telephone call to a new mother from a public health nurse.

Privately delivered postnatal services have emerged to fill this care gap. There currently exist no published research studies on the for-profit postnatal services that currently exist in Canada. Postpartum doulas who advertise online often propose tangible, high-intensity supports such as newborn care, breast- and bottle-feeding support, child-minding services, meal preparation, household chores and so on. Unfortunately, relatively high out-of-pocket costs make these forms of support accessible only to those who are able to pay for them. Doulas who advertise online generally charge around $25 per hour, or anywhere from $100 to $1,000 for overnight or week-long package deals, respectively. Research studies in this emerging area of practice are needed to determine the scope of practice and outcomes for mothers and their families. There is currently no information available on user demographics, patterns of use or outcomes associated with these forms of commodified care, though such information would offer insight into the types and levels of unmet needs that exist.[iii]

The future of maternity care in Canada

As is clear from our history, midwives were the main maternity care providers in what is now Canada before the arrival of European settlers and up to the modern period. Midwives provided not only crucial technical care, but also social support to enhance the health and well-being of women and babies in homes and local communities. Modernization of maternity care involved the move from midwives and natural childbirth into the medicalization of childbirth, with obstetricians replacing family doctors as the maternity providers, and labour and delivery restricted to fewer and fewer hospitals. High Caesarean rates and the associated unnecessary morbidity for mothers is one outcome of this modern system of care. The return to midwifery and the integration of midwives into our health care system have thus far been insufficient, as midwives are too few in number, they are concentrated in urban centres and their services are not equally available in all provinces/territories.

As the country works toward achieving MDG 5, as families become more complex and partners become more involved in childbirth and child care, and as we have access to more research on how to increase positive health outcomes for mothers and newborns, the health care system will continue to evolve and adapt to ensure the availability and effectiveness of maternity care in our communities from coast to coast to coast.

 


Cecilia Benoit, PhD, is a Scientist at the Centre for Addictions Research of British Columbia, Professor in the Department of Sociology at the University of Victoria and former co-leader of the Women’s Health Research Network. She is also recipient of the 2016 Governor General’s Awards in Commemoration of the Persons Case.

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SOURCES

[i] Cecilia Benoit et al., “Medical Dominance and Neoliberalisation in Maternal Care Provision: The Evidence from Canada and Australia,” Social Science & Medicine, 71:3 (August 2010), accessed August 24, 2015. http://bit.ly/1Jv2r5j.

[ii] Cecilia Benoit et al., “Maternity Care as a Global Health Policy Issue,” The Palgrave International Handbook of Healthcare Policy and Governance, Ellen Kuhlmann, Robert H. Blank, Ivy Lynn Bourgeault and Claus Wendt (Eds.). Basingstoke: Palgrave, 2015. .

[iii] Cecilia Benoit et al., “Privatisation & Marketisation of Post-birth Care: The Hidden Cost for New Mothers,” International Journal for Equity in Health, 11:1 (October 2012).

 

Timeline: 50 Years of Families in Canada

Today’s society and today’s families would have been difficult to imagine, let alone understand, a half-century ago.

Families and family life have become increasingly diverse and complex, but families have always been the cornerstone of our society, the engine of our economy and at the centre of our hearts.

Learn about how families and family experiences in Canada have changed over the past 50 years with our new timeline!