Part 1 of a three-part series
Like many expectant mothers living in rural B.C., Amy Dash has left the comforts of her home during her pregnancy and has camped out in a larger centre with more medical resources.
Dash, who lives in Burns Lake, has been staying with family in Prince George for weeks as she waits to deliver her child.
Although she has relatives to stay with during her time in Prince George, the situation remains far from ideal. Her husband Kris Garneau is back in Burns Lake working, separating the couple during such an important time for any new parents.
"We can talk three times a day, but it's not the same as being at home and being able to sit on the couch and watch TV together or go to the movies," she said. "You can Skype and Facetime all you want, but it's not the same."
While Dash's pregnancy has been considered higher risk, other mothers from smaller centres in northern B.C. often have to travel to give birth because the lack of surgical care in their home community.
The majority of babies born in B.C. don't require surgical intervention, but in cases where emergency Caesarean sections are required, having a capable surgeon close by is needed. Since no one knows when an emergency situation will arise, having surgical care is a crucial backup plan during any delivery.
Prince George-based surgeon Dr. Nadine Caron said the lack of c-section capability in some rural communities is the "canary in the coal mine" for the larger crisis in rural surgical care that exists in B.C. and elsewhere in Canada.
As rural operating facilities become more scarce across the country, it's expectant mothers who are among the first impacted by the longer travel time to centralized surgical centres.
"Sometimes you're talking the urgency of minutes to hours to provide a Caesarean section or the capacity to have one. In many, many rural communities in Canada that simply is not possible," Caron said. "The implications of that are essentially that a women sometimes is flown out of her home community where she waits from days to weeks to deliver so that she has capacity nearby for c-sections, if that's necessary."
It hasn't always been this way.
In the past many small communities had maternity care much closer to home. Whether it was a general practitioner that was trained in some basic surgery or a specialist living in a rural community, for many years it was possible to provide full-service births in many small towns.
Dr. Stu Iglesias remembers firsthand working in Bella Bella in the 1980s when the coastal community had a fully functioning operating facility. His children were born there, but now that service is no longer available.
"We've been trying for 20 years to keep rural maternity care going in B.C., to some extent in spite of enormously committed people and some very good work and research that shows wonderfully good outcomes, they still keep closing," Iglesias said.
Iglesias is an advocate for a program called enhanced surgical skills (ESS) for family physicians. It gives family doctors an extra year of training where they learn a basic set of surgical skills ranging from hernias and appendectomies to c-sections. Through his work with the Rural Co-ordination Centre of B.C., Iglesias has touted the benefits of the ESS program for helping to maintain maternal care in smaller places.
The ESS doctors work with family physicians trained in anesthesiology as well as operating room nurses and other specialized staff to keep rural operating rooms running. While their c-section training allows them to keep maternity care close to home, Iglesias said it's the other services they can provide that makes the rural operating rooms viable by providing enough work for all involved.
Some rural centres have tried to continue to have maternal care even when surgical backup is a ways away, but Iglesias said it's difficult to maintain. All high-risk pregnancies need to be transferred to larger centres and many expectant mothers chose to go to a place with an operating room in case something comes up. Other cases are referred to the larger centre during labour if a vaginal delivery proves too complicated.
According to Iglesias, that leaves only about 25 to 30 per cent of births, not a large enough load to keep many programs running.
"The rural programs that try to deliver babies without local c-section capability do a heroic job of trying to keep it alive, but it seems that after a bit of time these programs die without that support," he said. "It's at least in part related to how stressful it is for doctors and nurses to deliver babies without the backup of c-section."
Dr. Brian Galliford, the medical lead for the perinatal program at Northern Health, said there are many benefits to having maternal care close to home and ESS physicians are one important part of the solution along with partnerships with midwives and other specialists.
But he said the necessary changes will take time as the capacity needs to be built up. For instance, one ESS doctor generally isn't enough to meet the demand of the on-call nature of emergcency c-sections.
"One such person often isn't sufficient for a small community,"Galliford said. "They can't be there 365 days a year, so often there are locums that are sought after but they are few and far between as well."
As it stands, many mothers like Dash need to travel a long way to deliver their babies. That can mean navigating the treacherous northern highways in the middle of winter and having to find accommodation that's not always cheap.
"I think it's a lot easier if you have family to stay with because there is no cost involved," she said. "Families that are low-income, I'm not sure what options they have - I think they just risk staying home and taking the ambulance ride or driving in the week of [the due date]."
The lack of surgical care or other obstetrics means many mothers from Burns Lake and Mackenzie need to come to Prince George to deliver. In other parts of the north, like in Fort Nelson, it's the same story - mothers and their families trekking hours to a larger centre and bunking down for days or weeks at a time.
Whether it's having a doctor with ESS certification nearby or another solution, Dash said it would be important for her and her partner to be able to have their children delivered closer to home.
"Just having my baby born in a community where my husband and I have lived for eight years," she said. "We've bought our second home now and we plan to live there and maybe retire there. Having our children born in the community that they're going to grow up in is ideal."
