Obstetrics nurse Denise Sauvè finishes paperwork while cradling a newborn. (Glenn Lowson / For The Globe and Mail



A ward worth saving



More than 40 hospitals across the country have closed their obstetrics units in the last decade, most in rural and small-town Canada. As Kelly Grant reports, while tight budgets make maternity wards easy targets, rural communities are fighting to keep theirs open



When the midwife broke Annie Vogt’s water, she saw immediately that something was wrong.

The 24-year-old’s amniotic fluid was thick with meconium, the early stool that an infant usually passes after – not before – he or she is born.

Thank-you cards with pictures of happy parents and babies are mounted in the obstetrics ward at Leamington District Memorial Hospital. (Glenn Lowson / For The Globe and Mail)

Fearing the baby would inhale meconium in the womb and struggle to breathe at birth, Ms. Vogt’s midwife recommended she abandon her plan for a home birth and race to Leamington District Memorial Hospital, home of the nearest obstetrics ward. An ambulance whisked Ms. Vogt and her husband, Henry, 27, to Leamington in 10 minutes. About half an hour later, baby Avery emerged, frighteningly silent.

“They had to take her away right away and they suctioned a bunch of the meconium out. She didn’t cry until it was out,” Ms. Vogt said. “After it was all out she cried and she was healthy.”

Ms. Vogt can recall the scare now with equanimity. The Low-German Mennonite mother is bouncing her beautiful one-month-old girl on her lap, surrounded by her three older children and her husband in the family’s home in Wheatley, a small community just outside Leamington in the southernmost reaches of Ontario.

Still, she shudders to think what might have happened if the Leamington obstetrics unit had not been there.

The hospital’s board voted last fall to close the maternity ward to save money, but a fierce backlash from residents of the town of about 30,000 – a place best known as the tomato capital of Canada, though Heinz pulled up stakes in 2014 – led the region’s Local Health Integration Network to set up an expert panel to give the proposed closure a second look. That panel submitted a first draft this week, but the LHIN is keeping the recommendations confidential for now.

If the closure goes ahead, Leamington District Memorial will become at least the 43rd hospital across the country to lose its obstetrics ward in the last decade, most in rural and small-town Canada.

Some parts of the country have seen significantly more maternity wards shut down than others in the past 10 years, according to a survey The Globe and Mail conducted of provincial health ministries. In Alberta, for example, 14 have closed. At least 10 have closed in Ontario, six in British Columbia and five in Manitoba. Quebec, meanwhile, said it has not shut a single maternity ward in the last decade.

In some cases, these shuttered birthing units struggled to attract and keep specially trained doctors and nurses, a perpetual problem for rural medicine in all disciplines; in other instances, the units delivered so few babies that officials argued patient safety could be at risk and that care should be consolidated in a larger hospital. And in virtually every case, the maternity wards faced serious budgetary challenges that forced the hands of hospital boards or regional health authorities.

Delivering babies is expensive, especially for hospitals that don’t deliver many of them. Administrators can’t schedule births back to back like elective surgeries. They can either pay obstetrical nurses to sit there on days the ward is empty, or call them in on overtime when labouring women turn up, neither of which is cheap.

For cash-starved hospitals, maternity wards are low-hanging fruit.

Sandra Dick wants to have her baby in the Leamington District Memorial Hospital's obstetrics unit for the personal care given to mothers and babies. (Glenn Lowson / For The Globe and Mail)

TRAVEL TIME

Ward closures 14Alberta 10*Ontario 6British Columbia 5**Manitoba 3Saskatchewan 2New Brunswick 1Nova Scotia 1***Newfoundland 0Quebec 0Prince Edward Island *This figure is likely an underestimate. The province’s Better Outcomes Registry and Network, known as BORN, could only provide information as far back as 2012. BORN said that, in the last three years, seven Ontario hospitals have stopped delivering babies. Another agency, the Southwestern Ontario Maternal, Newborn, Child and Youth Network, flagged three more maternity wards shut down in the last decade, as well as several that closed before 2005. **Obstetrical services at one hospital have been suspended since 2012 because of staff vacancies and lack of access to C-sections. Not officially closed. ***Obstetrical services at one hospital have been suspended since 2006, because of staffing vacancies, but not officially closed.

The trouble with this gradual erosion of birthing services, say rural-maternal health experts, is that research shows it is actually safer for expectant mothers and their newborns to deliver at nearby hospitals – even those that don’t get much practice delivering babies and are not equipped to perform C-sections – than for labouring women to travel significant distances to give birth.

To cite one example, researchers at the Centre for Rural Health Research at the University of British Columbia found newborns in that province spent more days on average in the level three neonatal intensive care unit, which cares for the sickest babies, if their mothers had to travel more than an hour to give birth. The figures were even higher for expectant mothers who lived between two and four hours from the nearest obstetrical unit. (Women who live more than four hours from a maternity ward generally leave their communities three or four weeks before their due dates, creating a host of financial and emotional complications.)

Stefan Grzybowski, the co-director of the Centre for Rural Health Research and a co-author of the 2011 study, said he and his colleagues found a much higher rate of unplanned births at the side of the road or at clinics en route to out-of-town hospitals for women who had to travel an hour or more to deliver.

“It was a six or seven times higher rate than for women who lived within an hour of services,” he said. “So quite a dramatic increase in unplanned, out-of-hospital deliveries, which are by any stretch of the imagination a dangerous situation.”

George Carson, a member of the board of the Society of Obstetricians and Gynecologists of Canada and the director of maternal-fetal medicine for the Regina Qu’Appelle Health Region in Saskatchewan, said health officials across Canada need to work harder to keep small obstetrical wards open by making them part of perinatal networks with regular training provided by large referral hospitals.

“But you’ve got to be reasonable about it,” he conceded.

Rebecca Ismail, director of maternal/newborn and education at Leamington District Memorial Hospital takes part in a morning meeting, on March 17, 2015. (Glenn Lowson / For The Globe and Mail)

A 'SACRED MOMENT'

Some now-shuttered, tiny maternity wards that were delivering an average of one baby a month were relics of a bygone era, an age in which community hospitals tried to be all things to all patients.

Closing such units can make sense, as it did in the case of St. Peter’s Hospital in Melville, Sask., which stopped delivering babies in 2009. In 2008-2009, only five babies were born on the unit. The year before, it was 13. Women in the city of 4,500 already had access to a larger maternity ward in Yorkton, a 20-to-30-minute drive away.

“The people in Melville who want to go shopping go into Yorkton,” Dr. Carson said. “Why wouldn’t you go into Yorkton to have your baby?”

In the case of Leamington, the nearest birthing unit, at Windsor Regional Hospital, is neither close enough to make the proposed Leamington closure a no-brainer, nor far enough to render it a clear safety risk. Locals say it takes between 45 minutes and an hour to drive from the greenhouse-dotted farmers’ fields of Leamington to Windsor, a border city of about 215,000 with one of the highest unemployment rates in the country.

The Leamington District Memorial Hospital OB provides prenatal care to upwards of 60,000 residents in Leamington and the surrounding area and handled close to 400 births in the last fiscal year, March, 2014 to March, 2015.

The manufacturing-sector collapse that pummelled Windsor has not spared Leamington, which last summer bid farewell to the H.J. Heinz Co., and about 700 good-paying jobs.

“We just lost Heinz,” said Sandra Dick, a 31-year-old who is preparing to have her second baby at the Leamington hospital in April. “So our town’s been kicked.”

Ms. Dick is part of a group of mostly women campaigning to save the town’s obstetrical unit. On a recent Monday night, they gathered in a room above Setterington’s Gifts & Books of Faith, a shop in a historic house just off Leamington’s main street, to talk about their efforts.

“There are two sacred moments in your life,” said Andrea Cassidy, a midwife and one of the leaders of the campaign. “It’s when you give birth and when you die. You have to protect the right to make choices about where that happens.”

Over the course of the evening, nearly a dozen women streamed in to share the stories of their Leamington deliveries – how intimate the small ward felt, how easy it was for family to visit them there, how much it meant to give birth in the place they had been born.

“I had visitors every day,” said Lisa Warkentin, 32, who, because of bleeding and complications late in her pregnancy, had to check into the Leamington maternity ward a month before her daughter was due. Her husband slept in her hospital room, something that would have been more difficult if he had to commute to a hospital in Windsor. He was there when their healthy baby girl, Lily, arrived three weeks early.

“The night I ended up delivering was the night that he wanted to go home, but I begged him to stay,” Ms. Warkentin said. “Mother’s intuition maybe.”

As Tina Elias, 24, spoke about having both her children at the Leamington hospital – describing it as “so comfortable and accommodating” – her younger sister, Susana Hamm, 18, was in the obstetrics ward, in labour.

Ms. Hamm, a young Low-German Mennonite, was herself born at Leamington hospital, along with four of her five siblings. The next morning, Ms. Elias and her children, five-year-old Ava and two-year-old Carter, were there to meet baby Peyton, mere hours after her birth.

“I don’t think [the unit] should close,” Ms. Hamm said, cradling her newborn. “I think it’s very important for people who are having a fast labour. I know in the pain I was in, I wouldn’t have wanted to sit in a car for 45 minutes to an hour to get to a hospital.”

John Neufeld gives his newborn baby girl Peyton a close inspection while mom and partner Susana Hamm craddles her. (Glenn Lowson / For The Globe and Mail)

LOCAL PARIAHS

The outcry in Leamington over the ward’s potential closure led the Local Health Integration Network and Health Minister Eric Hoskins to put it on hold and strike an expert panel led by a former hospital president and made up of outside perinatal experts and some locals, including the town’s chief administrative officer.

The network’s board is expected to make an interim decision at a public meeting on May 5. The LHIN will then allow 30 days for written comment before taking another vote. Dr. Hoskins will have the final say, but will rely heavily on the LHIN’s advice.

“The whole process is to do what is best for Leamington and area … in a way that’s financially sustainable,” said Martin Girash, chair of the LHIN’s board. “Because if it’s not financially sustainable, it can’t last anyway.”

Like all Ontario hospitals, Leamington District Memorial is grappling with the Liberal government’s decision to essentially freeze hospital budgets for the past three years. This approach has left hospital boards and LHINs to make often unpopular cuts at the local level, while insulating the government from the blowback.

“The decision to close OB was for one reason and one reason only and that was because of money,” said Jim Gaffan, chair of the Leamington hospital’s board. “Why would I or any of the other 12 board members want to make a decision to close OB and become, basically, a pariah in our community? My friends and my family think I’m a terrible person for doing this.”

But the numbers, provided by a consulting company that reviewed the hospital’s operations and plotted a course for its overall future, seemed to leave the board little choice: In 2012-2013, the $1.4-million birthing unit was “losing” nearly $740,000 a year under the province’s Byzantine, volume-driven funding formula.

The reason? Many local expectant mothers were already choosing Windsor over Leamington for their deliveries. Only 50 per cent of Leamington births and 28 per cent of births from Kingsville, the town immediately west of Leamington and therefore closer to Windsor, took place at the Leamington hospital in 2012-2013.

Ms. Cassidy, the midwife, and her allies dispute those figures, saying they unfairly include the high-risk pregnancies that are already directed to Windsor. They also say the report, by consulting firm Hay Group, does not take into account important local nuances, such as the needs of the area’s Low-German-speaking Mennonite women, who often have large families and, as a result, lickety-split labours.

“Half of the deliveries we have here are Mennonite,” said Frederick Sabga, the hospital’s chief of obstetrics. “They come in and deliver within half an hour, maybe 10 minutes. There’s no way these people, this community, is going to be rushing to Windsor and making a safe delivery in Windsor.”

June 2014 saw the closure of the Heinz Co. factory in Leamington. Now the town faces the closure of the Leamington District Memorial Hospital's obstetrics unit, which has been slated to close at the end of June 2015. (Glenn Lowson / For The Globe and Mail)

SMALL-TOWN MYTH

Clearly though, some women who could give birth in Leamington are choosing the big-city hospital instead. Dr. Sabga and his colleagues say part of the reason is the myth that their small-town unit does not offer epidurals.

It does, 24 hours a day.

The maternity ward has been hustling to correct that misapprehension, an effort that has begun to bear fruit: The hospital delivered 300 babies in 2013-2014 and 373 in the fiscal year that ended March 31. That is up from 269 in 2012-2013, the year on which the Hay Group based its recommendations.

But the bump in births might not be enough to save the unit. Under the current funding formula, the Leamington maternity ward would need to deliver at least 600 babies a year to break even.

Dr. Hoskins said in an interview that he is hoping the expert panel will find a creative solution to Leamington’s plight, perhaps by looking more closely at a proposal for a collaborative team of obstetricians, midwives, family doctors, nurses and doulas that Ms. Cassidy has already submitted to the ministry.

“I’m very interested in the outcome of this, in the Leamington example,” the minister said. “It may actually provide a solution that the community has confidence in and it may be an innovative one.”

Dr. Girash, the chair of the LHIN, said Wednesday that he too is hopeful a “third option” of some sort can be found, one that might allow birthing services to remain in Leamington, regardless of the fate of the obstetrics unit in its current form.

If Leamington can set a creative example, other small and mid-size hospitals elsewhere in Canada might be able to follow suit. As it is, more maternity wards could be at risk of financially driven closure. In Ontario alone, 26 hospitals delivered fewer than 300 babies in 2013-2014.

“A lot of the collapse of rural maternity services has coincided with systems of efficiency, if you like,” said Dr. Grzybowski, the UBC expert. “We’ve lost a bit of the richness that existed out there in terms of understanding the importance of services to a rural community and the people who live there. Birthing services are really a key part of that.”