Canada is recognized as part of the developed world where quality of life standards are high, but this reputation is slowly (or quickly, depending on your experience) sinking into decline. This is true of social determinants of health like education, housing, food insecurity, and especially health care, particularly for women, women of colour, and low-income individuals.
On any given day, news articles document the declining state of health care, plagued by longer than average emergency room wait times and a primary care provider shortage. Wait lists and hallway health care are becoming the new norm nationwide.
Chronic underfunding and understaffing, exacerbated by the COVID pandemic, have left an already shaky system in ruins. The entire health care system is at a breaking point, and it is having negative implications on health outcomes and the delivery of care, particularly for birthing women and their children.
Perinatal care as an indicator of decline
While Canada’s health care system is provincially mandated, its national performance on the global stage is dwindling. At one time, Canada was recognized around the world for the quality of its health care system, but today, the reality is that it is being outperformed by many other developed nations in many areas, including its ranking as a good place to give birth.
To be a good place to give birth, many things are considered: the number of care providers, the availability of hospital beds, and the number of hospitals per population, but also maternal and infant mortality rates, the average length of hospital stay, costs associated with birth, post-natal follow-up, and maternity benefits.
In one study that considered these various metrics, Canada ranked 35th while the U.S. ranked 36th, with many European countries outperforming both. Non-European countries that outranked Canada and the U.S. include Japan, South Korea, Mexico, Australia, New Zealand, Iceland, and Israel.
A good indication of a decline is the country’s count of maternal deaths. Unfortunately, no one is sure of how many maternal deaths take place during or after birth, with reports by the World Health Organization (WHO), UNICEF, and the Society of Obstetricians and Gynaecologists of Canada (SOGC) estimating that these totals are upwards of 60 percent higher than what is published by StatsCan.
While these figures are still lower than many countries, for a developed nation it indicates a system in dysfunction. As a wealthy nation, Canada does not even rank in the top 10 of countries when it comes to maternal mortality rates. Similarly, Canada’s infant mortality rate is something to be considered. Canada was once in the top 10 out of more than 20 OECD countries just a few decades ago, but in 2021 it plunged to 30th out of 38 nations.
Both maternal and infant mortality are public health indicators that are directly linked to the overall health of a country. As a country that prides itself on diversity and inclusion, our leaders should be concerned as health outcomes for people of colour, Indigenous peoples, immigrants, and low-income Canadians are even worse. Black women are three times more likely to die from a pregnancy-related complication than Caucasian women and are also more likely to be mistreated by their care providers. Similarly, Indigenous infant mortality in Canada was more than double the non-Indigenous mortality rate.
Improved access, standards, and performance of health care alone would not suffice to advance these rankings. The government must also focus on improving access to housing, education, food security, and expanded mental health supports, the social safety nets that support the overall health and wellness of a community. Health care is just a microcosm of a greater problem with the system.
A loss of trust
Increasingly so, women are losing trust in the Canadian health care system, as health care practitioners often fail to take their pain and their concerns seriously. Instead, birthing people turn to the care of midwives, the support and advocacy of doulas, and the calming environments offered by home births and birthing centers.
Unfortunately, not everyone has the resources or access to these alternatives and have no choice but to endure the conveyor belt health care system that has emerged in Canada where hospital birthing wards have become a sort of production line where women and babies are systematically processed through.
One in three births will be traumatic, some of which could be avoided. Certainly, birth can be traumatizing, but it doesn’t have to be. Treating birth as a medical event rather than a natural biological process in only one way to approach birth. While emergency situations will always be fraught with tension and uncertainty, most births go ahead without issue. The introduction of unnecessary or elective medical interventions (that often lead to secondary interventions) can be one of the causes of said trauma and appear to be more for the convenience of the birthing wards than they are for the birthing person.
Trauma at the hands of a care provider most commonly occurs when care providers place hospital policy above patient rights to coerce them into unnecessary or elective tests, procedures, or exams using threats or fear of death or harm to themselves or their baby. Being forced or coerced into doing something one does not want creates the same dynamic experienced in abusive relationships, except the abuser is now supposed to be a care provider whom a patient trusts.
A study by Harvard Medical School showed that those who experience sexual assault were more likely to have complications during birth due to traumatic stress response. What is worse, health care practitioners are usually unaware of and take no effort to know a patient’s compete history, particularly any history of sexual assault. Asking about this has become recommended practice by the American College of Obstetricians and Gynecologists since 2011, but it has not been adopted as it should and even if they did ask, there are limited resources to support the woman through this process in any case.
Traumatic births put women at a higher risk of postpartum depression or other issues related to post-traumatic stress disorder. While one in seven women are reported to experience post-partum depression, it must also be noted that these figures are also likely underreported given the number of women who suffer silently, most often because they have nowhere to turn. Why would they seek out the support of a care provider with no basis of trust?
If health care practitioners were to take a trauma-informed care approach, which is endorsed by bodies like the American College of Obstetricians and Gynecologists, outcomes could be immediately improved. By recognizing that their patients have experienced trauma and acknowledging the signs and symptoms of trauma as they manifest themselves, care practitioners could then integrate that knowledge into their practice to avoid re-traumatizing the patient.
Improvement is possible
Universal screening for trauma (both present and past) would elevate the level of care birthing people receive during their transition through matrescence. It does not take much to offer gentle care, be informative and respectful, and keep a birthing person apprised of the process and what can be expected along the way, offering support and empowering them to make the best decisions for themselves.
There is a belief that in the underfunded and overworked health care system there is no time for this level of inquiry, but to the contrary, it is necessary to overcome some of the dysfunction being experienced.
Likewise, better recruitment is needed. Right now, one of the biggest issues facing the health care system in Canada is a physician shortage, and recruitment, retention, and development efforts aren’t having an impact. The Ontario College of Family Physicians notes that 15 percent of the population—greater than two million people—are without access to a family doctor, a situation that continues to worsen.
An investigation conducted by The Globe and Mail identified that Canada is losing foreign-trained physicians to other countries where the barrier to entry is lower when it comes to licensing and recruitment. These barriers are why there are foreign-trained physicians and nurses who are working jobs outside of the health care field. Census records estimate that there are upwards of 13,000 foreign-trained physicians living in Ontario alone that are not working in their field. Likewise, fewer medical graduates are choosing to practice in Canada.
Improvement is desperately needed, and luckily it is possible. Securing more care providers is a key component of the effective delivery of health care in the country, but more needs to be done to hold this system accountable to ensure the delivery of a standard of care that the country can be proud of.
When a ship is sinking, women and children are saved first. If this is how we treat new mothers and the babies they birth, the newest caretakers and members of our society, how are the elderly or those with mental health and addictions issues treated? The time to do better is now and it is high time the government takes notice of the dysfunction that has become the norm in health care today.
