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.

 


Download this article in PDF format.

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

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