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Last week, Angélique Lauzier, 40 weeks pregnant, went to her local hospital with contractions. But the obstetrical unit at La Malbaie hospital was closed due to a shortage of nurses, so the mom-to-be was told to head to Quebec City, 150 kilometres away.

Her partner drove frantically down Route 138 in the middle of the night but, 15 minutes from the provincial capital, he pulled over and Ms. Lauzier gave birth in the car.

The story is a graphic illustration of the growing challenges of giving birth in Canada, especially outside of large urban centres.

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In this vast, sparsely populated country, providing prompt, accessible health care to all is a challenge at the best of times. But pregnancy and childbirth have social, cultural and familial aspects that are just as important as the medical care.

Over the past two decades, rural hospitals have been steadily closing or reducing services, notably obstetrics and emergency care. Small town emergency rooms closing overnight and on weekends, and rural hospitals being unable to perform surgeries such as cesarean sections is not unusual any more.

Consolidation is designed to save money and improve the quality of care by centralizing expertise, but it places a growing burden on patients and their families – having to travel hundreds of kilometres for routine care, for example.

Access woes are also driven by the ever-worsening shortage of nurses – especially those in demanding specialties such as obstetrics. Recruitment and retention of health workers is doubly difficult in rural and remote areas.

Not to mention that the provinces and territories have failed to invest seriously in measures that would lessen the burden of some of these challenges, measures such as hiring more midwives and providing better medical transport.

After the news stories about Ms. Lauzier’s roadside birth, Quebec’s Health Minister, Danielle McCann, said that in the future, patients who need urgent obstetrical care will be transported by ambulance, not left to their own devices.

In much of rural and remote Canada, however, unexpected births are not the biggest issue, but the fact that women are shipped off to big cities weeks before their due date.

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There are about 380,000 births a year in Canada, and about 98 per cent of them occur in hospitals, one of the highest rates in the world.

Two-thirds of rural women give birth in urban hospitals, and almost one in five have to travel more than two hours.

Hospital Births in Canada: A Focus on Women Living in Rural and Remote Areas

When you’re pregnant, you want to be in comfortable, familiar surroundings, with the support of family and friends.

But many, many mothers-to-be – especially those from fly-in communities (almost all of them Indigenous) – have to move before their due date, and often they do so alone. Last year, federal rules changed to include a support person accompanying an expectant mother, but there can also be child-care issues back home, and often language barriers and emotional isolation.

The isolation and travel demands have consequences, not all of them bad.

Rural women are more likely to have their babies delivered by a family physician, 45 per cent versus 20 per cent in urban areas, a reminder childbirth doesn’t have to be overseen by specialists. Midwives are grossly underused across rural Canada – they are a much better investment than more plane rides for expectant moms.

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When a cesarean section is done – and the biggest concern about births in rural and remote areas is that an emergency c-section will be needed – it’s done by an obstetrician-gynecologist 98 per cent of the time for urban women, and 76 per cent of the time for rural women. This means general practitioners are doing a fair number of cesareans, which is not a bad thing, as long as they have appropriate surgical training.

Rural women are three times more likely to have preterm births than urban women (9.7 per cent versus 3.1 per cent). This reflects that poverty and conditions such as diabetes are more common in rural areas. But it also suggests that physicians and nurses in smaller communities are really good at doing triage, singling out those who are at high risk and need to head to larger centres.

It is also concerning that rural mothers are 40 per cent more likely to suffer serious complications in childbirth, though it’s important to note that the rates are quite low, 2.4 per cent rural versus 1.7 per cent urban.

Canada’s geography will always be a challenge but, clearly, more can be done to get maternity care closer to home for everyone.

Editor’s note: (April 16, 2019) An earlier version of this article references morbidity instead of mortality. This version has been corrected.
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