In the end, it was the 3am phone
calls that did it. Dr Jennifer Pettigrew had always planned
to attend births as part of her family practice and during
her residency in rural northern Ontario, she deliberately
signed up for rounds that would expose her to lots of
deliveries. Later on, she moved to Brampton and joined
a family practice obstetrics group, where she was on call
one night a month.
Then she moved to Toronto. "Originally,
I moved here with the intention of doing deliveries
again," she explains. "But I decided I would take the
summer to get settled into my office, and then at the
beginning of the fall I got engaged and decided to give
myself some time to get the wedding planning going.
By the time spring rolled around and I had time to stop
and think about it, I decided that I really liked not
being on call."
Such talk would be heretical in
the rural practices where she cut her teeth, she says.
But it's the truth. "There's something nice about going
home at the end of the day, and knowing you're going
to be home � or at the gym, or at a class, or somewhere
you want to be � and that you're going to sleep through
the night. And working in the big city, I have that
luxury."
GIVING
A WIDE BIRTH
According to a Canadian Institute for Health Information
(CIHI) report titled Giving Birth in Canada: Providers
of Maternity and Infant Care, Dr Pettigrew isn't alone.
Ever fewer family doctors are attending births: in 1989,
31% of family doctors were billed for obstetrical services;
by 1999 that number had dropped to under 19%. Ob/Gyns
picked up most of the slack, performing 61% of all vaginal
births and 95% of all c-sections in 2000 � up from 56%
and 93% respectively four years earlier.
For FPs, lifestyle is one of the
primary reasons cited for not attending births. "I haven't
figured out how to get these babies to schedule an appointment
for their arrival," jokes Dr Irene Kolabinski, one of
four family physicians who perform deliveries in Prince
Edward County, Ontario.
ADEQUATE
SKILL SETS?
It's not just a question of getting a good night's sleep,
though. According to the CIHI report, many new FPs fear
they lack sufficient know-how to deliver babies. Dr
Kolabinski says she's observed this trend. "As some
of the newer graduates are coming out of training, their
comfort level is such that they may not have the confidence
to go out and start delivering babies," she says, "especially
if they're going to areas where they may not have the
backup they're used to."
Part of the problem also lies in
a reluctance to deal with adverse outcomes. "Unfortunately,
in obstetrics, there's always the potential for an adverse
outcome" she says, "no matter how skilled and well-intentioned
everybody is. I think that's disconcerting for some
people." Dr Pettigrew agrees. "When stuff goes wrong,
it's very emotionally charged."
IT'S
A ... LAWYER
All this talk of adverse events naturally raises the
spectre of litigation. The CIHI study also states that
medico-legal issues are the other concern that keeps
family doctors away from the delivery room. But how
likely is a lawsuit in Canada? "If you're a family physician
who does deliveries, your fees to the Canadian Medical
Protective Association are more than four times higher
than a family physician who doesn't," says Dr Pettigrew.
So what are doctors doing instead?
Shared care appears to be the most popular solution.
The study reveals that "many family physicians in Canada
provide care up to 32 weeks of pregnancy, and then transfer
care to other family physicians, obstetricians or midwives."
For moderate-risk pregnancies, 74% of family doctors
either consult an obstetrician or transfer a patient
outright.
TAKING
STORK
Given all the obstacles, why would any FP choose to
deliver babies? Some of the reasons are strictly practical.
In a rural setting, options may be limited. "Somebody's
got to do it," says Dr Kolabinski. "I live in a small
town, and there aren't very many people around who are
still doing deliveries, but the service still needs
to be provided."
But there are personal reasons,
too. "It's still fun doing it," she adds. "It's kind
of nice to see that little person arrive on the scene.
When you hear them squall and you know they're fine,
and everybody else is fine, it's all worth it."
Despite the pay-off in her personal
life, Dr Pettigrew does miss delivering babies. "To
say that birth is a miracle sounds so trite," she says,
"but it really is. When there are so many potential
things that could go wrong, it's remarkable how often
things go right. And it's neat to be with a family,
coach them through their pregnancy, be there when the
baby is delivered, see them in your office a couple
of days later � it's lovely continuity, which is one
of the nice things about family medicine."
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