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#79 Maternal Health Part 2: Pregnancy & Post-Partum

Jane Francis, registered dietician and PhD candidate in the Department of Nutritional Sciences at the University of Toronto

August 27, 2020

In part two of our maternal health series, we explore the journey through pregnancy, birth, and the post-natal period – including the planning involved, the decisions made, and any healthcare a person may receive along the way. We started out our conversation with Madeleine Springate-Combs, a midwife in Ontario, who told us about why someone may choose to receive care from a midwife and the philosophy of midwifery. We also spoke to midwife Lauren Wattam, who has worked with Médecins Sans Frontières (Doctors Without Borders) and practiced midwifery in missions to Ethiopia, Kenya, Sierra Leone, and Yemen. She told us about the important roles that midwives can play throughout pregnancy and childbirth around the world and the impacts of global health outreach. We also spoke to Dr. John Kingdom, the chair of the Department of Obstetrics & Gynaecology and professor of maternal-fetal medicine at the University of Toronto, and a clinician-scientist at Mount Sinai Hospital. He told us about some of the complications that can arise in pregnancy and the work he does to deal with them. Finally, we spoke to Jane Francis, a registered dietician and PhD candidate in the Department of Nutritional Sciences at the University of Toronto. Her work focuses on providing accessible breastfeeding support to mothers from marginalized populations.

Written by: Thamiya Vasanthakumar

Canadian Association of Midwives
Mount Sinai Ontario Fetal Centre
Medecins Sans Frontieres
Vulnerable mothers' experiences breastfeeding with an enhanced community lactation support program
Canada Prenatal Nutrition Program
Parkdale Queen West Community Health Center – Pregnancy and Parenting Programs
The danger of a single story by Chimamanda Ngozi Adichie
When Women Were Birds: Fifty-four Variations on Voice by Terry Tempest Williams

Melissa Galati [0:00] How did you decide what the birth of your child would look like,

Mom 1 [0:03] As someone born in the 80s, I was born in a hospital with a doctor, which is very normal for the time. But I had the unusual experience of having much younger siblings who were born at home with a midwife. And so I didn't really know that you did something else other than have a midwife when you're going to have a baby. And I didn't realize until my first midwifery appointments, that the fact that my mom has had it midwifery care in the 90s was actually surprising and really cool. And so for me, it wasn't really a question. If I wanted a midwife. The question was, which clinic I wanted to end up with. And we ended up taking the midwifery clinic that was the closest to our house, and it was the most positive health care experience I have had in my whole life.

Mom 2 [1:01] I think for me, I'm a pretty cautious person. And it had taken me two years to get pregnant. And I think for me, because just generally kind of the person that I am and the personality that I have, that I felt safer going to a hospital. So I, I didn't really consider alternatives. I didn't really consider having a midwife or anything like that, because my comfort level was really being in the hospital. And I think for me, I would still still have the babies in the hospital. And I think for each one of them, I felt like I was really well taken care of, and that the baby is really well taken care of. And I'm glad that I made the decision that I made.

Mom 3 [1:45] Yeah, so I saw a family doctor at Mount Sinai, they have a family medicine team there. And they offered prenatal classes to all of like the family medicine patients. So I attended that. And it was facilitated by a midwife and a family medicine resident. And so they offered information on like, pain management during labour. And yeah, it was really a great program. And that's sort of where I, I established my birth plan, excuse me, so to speak. And I also found using online resources really helpful. So there was like a website, I frequented a lot when I was pregnant, called www.babycenter.ca and you just create an account and you post anonymously, if you have any questions about labour, like anything that happens, you know, post-labor with your baby. And I found, it was really nice to get like unbiased opinions from ultimately like total strangers at times. And it can be sometimes more helpful, I think then asking like friends and family, because its own bias. So that helps a lot with establishing your birth plan for me as well, just going online and seeing what other people had to say.

Mom 4 [2:55] Well, first baby, of course, there was lots of planning and discussion. I, I also went to antenatal classes, which was a women's only group. And then the couple's group, it was very serious and intense. And everyone was very keen, they wanted to plan their births. And so we spent a lot of time discussing what was the ideal birth. And in those days, this is back in the early 90s, there was pressure to have a natural birth, whatever that meant to avoid drugs, if you could, and to breastfeed and all of these things. And so I guess, I had an idea in my mind, which is that I would like to minimize drugs if I could. So those were the hopes that I had, it would be going into hospital didn't have a problem with that for the first for the other for the second baby. I was okay about going into hospital, having had a, you know, a fairly positive experience first time. But everything I planned, sort of didn't quite go according to plan.

Mom 1 [4:01] I think that both their prenatal classes and our midwives really stress the idea that you can have a birth plan, but it's really best to think of it as a birth idea, as opposed to exactly what's going to happen because babies arrive, however they arrive and it's not necessarily anything like what you imagine. And so I mean, we plan a homebirth, I wanted our little one to be born at home in an environment, I guess that I felt that I could kind of control and plan for and prepare. I didn't like the idea of being in a hospital. But with our team of midwives, I felt really safe. I may felt like I was still in control.

Madeleine Springate-Combs [4:57] I feel like I am super was and am super lucky because going into pregnancy, I already knew so much about it. As a midwife, I love attending homebirths. And for low-risk women without complications, I think they're a great option. I think that women pay to have their babies wherever they're gonna be the most comfortable, where there's going to be the least amount of stress, and that will help a labour progress, there's less stress hormones, then there is more oxytocin, which is the hormone that causes contractions and labour. So if a woman has a home that is going to freak her out, then she should be in the hospital, that's great, she's gonna feel like the right, yes, she knows that's where she's gonna feel calm. And like, that's the right place for her, for me that was that was at home.

Mom 1 [5:48] But once we were home, we had really regular both phone checkings with our midwifery team, and also in person visits. And so for the first couple of weeks, we didn't have to go out to go to appointments. One of the midwives from our team would come to our house and weight the baby and check how I was healing, and talk us through anything that we were having questions about the nursing or weight gain or anything that came up. And so it was really, really supportive.

Melissa Galati [6:27] Welcome to Episode 79 of Raw Talk, you just heard from several mothers discussing how they made decisions about their birth. In fact, you might recognize them from our last episode number 78, which was part one of a two part series on maternal health. In our last episode, we explored the topic of fertility and the science behind getting pregnant. I'm Melissa, and in today's episode, we're exploring pregnancy birth and the first few days postpartum, you'll hear about the role of midwives and physicians about situations involving high-risk pregnancies, as well as a global health perspective on maternal health. We explore disparities in maternal health both within and beyond Canadian borders, as well as some solutions to address these disparities. Before we dive in, we wanted to share that we recently wrapped up our COVID-decoded series on YouTube, where we hosted experts to discuss how the pandemic has impacted various facets of Canadian life. If you miss the streams, you can still go back and watch the discussion on our YouTube channel linked here in the episode description. Finally, Raw Talk is proudly supported by the University of Toronto affinity partners, including MBNA and TD insurance. UofT alumni get preferred financial rates and rewards including a customized credit card and competitive insurance packages, all while supporting alumni and student initiatives at U of T. Visit affinity.utoronto.ca or click the link in our show notes to get access to exclusive deals. Okay, let's dive in.

Madeleine Springate-Combs [8:19] A lot of people don't know don't know what a midwife is. They are a primary health care provider, specifically for women and babies. So women for the length of their pregnancy, for the labour, the delivery and then they continue to be primary care provider for the mom and the baby for the first six weeks of the baby's life.

Melissa Galati [8:36] In Ontario, a women can elect to have either a midwife as their primary care provider or a physician such as an obstetrician-gynecologist or family doctor, followed by a pediatrician to look after the baby post-birth under OHIP, either are covered but not both.

Madeleine Springate-Combs [8:52] Okay, so other I guess differences between midwifery and a doctor, a midwife is an expert in, in normal pregnancy, normal situations, healthy pregnancy, normal deliveries, when things go outside of that the midwife consult with a physician or, you know, appropriate other caregiver. Basic example: a midwife doesn't do a c-section. So, and I think some of your questions will get to those later, but if a women need the c-section that is a temporary transfer of care to an obstetrician to perform the surgery. But then care of the baby and care of the mom would be transferred back to the midwife when it is appropriate. Other differences with midwifery and the medical model is like more kind of philosophical, but that also leads to differences in what it looks like.

Melissa Galati [9:43] Madelyn alluded to several specific philosophies that midwives have, we asked her what those philosophies were and how they guide midwives practices.

Madeleine Springate-Combs [9:50] So midwifery in Ontario is based on three main philosophies. So one of those is choice of birth place. And so midwives offer women a choice of a birthplace so you can have your baby in the hospital, you can have your baby at home, or if there is one, you can have your baby in a birth center. So the second philosophy is informed choice. The medical equivalent would be informed consent, which is great, but how I think about it is informed consent is saying: "This is a procedure that we're going to do, do you agree to it? Whereas informed choice is saying: These are your options, let's talk about it. What do you want to do?" Spend more open ended. And I get what that how that changes the practice of midwifery is that our appointments are a lot longer, a general visit with a midwife is 30 minutes to 45 minutes, which would be which is considerably longer than you would generally get with an obstetrician or a family doctor. That gives us a time to talk about what your options are in pregnancy, to talk about the different tests that are available, and really let women make their their choice. And we really respect that it's the family's decisions when it comes to the, you know, interventions that are offered in pregnancy. That said, we do offer all the same testing. Third philosophy is continuity of care. So generally, when a woman comes into care with a midwifery practice, they're kind of teamed with a small team of midwives. And those midwives get to know the woman so the woman will only see those that small team and it is extremely likely that one of those midwives that the woman knows, will be at her birth, not only at her birth, but at her whole, like active labour, birth and immediate postpartum. So essentially, what that looks like in the labour and delivery room is that the midwife is doing the role of the nurse and the doctor. And then in the postpartum, it's awesome that women have a person that they have had a relationship with, and they know and trust that actually does home visits. In the first few weeks postpartum.

Melissa Galati [11:57] Madeline talked us through what care from a midwife might look like. We wondered what other types of health care professionals a midwife might collaborate with and under what types of situations that might occur.

Madeleine Springate-Combs [12:07] So we'll collaborate with a variety of specialties, whoever is most appropriate. So like I mentioned, maybe we'll be working with or consulting with your family physician, if there's like a pre-existing condition, the care provider we're consulting with the most often is obstetricians. But then also pediatricians because we're also taking care of the baby for the first six weeks of their life. So if there's a complication, and then we be consulting with the pediatrician,

Melissa Galati [12:33] While expectant moms can elect to have midwife care for them and their baby instead of a physician Madeline mentioned that in cases of high risk pregnancies, a midwife would transfer care to an OBGYN. We spoke to Dr. John Kingdom, a physician at Mount Sinai Hospital here in Toronto specializing in placental complications and high-risk pregnancies. We first asked him about the work done at the Ontario Fetal Center and High-risk Pregnancy Clinic.

Dr. John Kingdom [12:57] There's two parts to high-risk pregnancy care. One is maternal complications of pregnancy. The other one is all the range of fetal diagnosis. So we cover all fetal anomalies and all that sort of common perinatal problems like ruptured membranes, bleeding, placenta previa, twins, short cervix, all that sort of stuff. Then we do all the inocula normally diagnosis and management. And then we have two separate things. One is preterm-birth prevention. The other one is placental complications, which are medical ones and surgical ones. And fetal includes fetal therapy, so you know, interventions before birth, to try and improve the outcomes for say, twins with twins-twin transfusion syndrome, or certain kinds of fetal abnormalities, including surgery for fetal spina bifida, but that program had to be stopped during covid. But all the other programs are running, running quite normal, you do have to be referred and you want to have at least a reasonable reason to come. So we have a filtering system, we have a triage system, we can get 50, 60 referrals a day, so we can't see 50, 60 people per day. And if we have to pick, pick who we're going to see so someone will get disappointed or do we can give advice, we can you know, write advice out back to the referring midwife or doctor. I mean, a lot of the elements of good care require collaboration with surgeons and oncologists and other people. So, you know, a lot of it's very interdisciplinary care.

Melissa Galati [14:20] As Dr. Kingdom alluded to earlier, complications arising during pregnancy don't just originate from the maternal side, but also the fetal side.

Dr. John Kingdom [14:28] So we we have specialty clinics at Sinai with the key people who are at the sick kids, so you know, we would work with sick kids and the really the three areas, those three areas in particular, to get the accurate diagnosis, look for associated abnormalities, and then talk about prognosis, and decide do you want to continue the pregnancy, plan the delivery and go to Sickkids or do you want a termination of pregnancy? That’s the general you know, pathway of how we manage patients with fetal abnormalities, you know, major fetal abnormalities. Of course, every pregancy is screen for major fetal abnormalities with the 19 to 20 week anatomy ultrasound, and their screen for common chromosome abnormalities using first semester screening and NIPT.

Melissa Galati [15:13] Given the large range of cases seen at the clinic, we asked Dr. Kingdom to describe the approach he uses to deal with some common conditions. Dr. Kingdom also spoke about their approach in cases where mothers face mental health problems and the potential side effect of any medications.

Dr. John Kingdom [15:28] So in terms of common conditions, I mean, an accurate screening and diagnosis and management of preeclampsia, which is nuancing hypertension in pregnancy and fetal growth restriction due to placental disease, we have better and better tools to do those things well, and their everyday common problems. The diagnosis and management of fetal abnormalities is a pretty efficient process now. Fetal therapy for a number of conditions as well established like, for example, prevention and treatment of research disease is well established. The accurate diagnosis and delivery and management of congenital heart disease is fairly well established. So we're getting better at screening and diagnosis of that. We also have a program in pregnancy for people who become pregnant with a prior ongoing significant mental health diagnosis, particularly in the major mood disorders. Of course, they could have a concurrent disorder, they could have an addiction associated with a major mood disorder. I mean, you can get neonatal withdrawal from SSRIs and SNRIs at a sort of staged 123. So stage one withdrawal is subtle, but would be recognized by, you know, a trained physician and or a nurse. And the parents wouldn't necessarily be aware, you know, so I mean, full blown withdrawal and seizures are really uncommon. So most people are recommended to remain on their mood stabilizer drugs, during pregnancies, the benefits of stability greatly outweigh any risks.

Melissa Galati [16:53] We were curious to hear about complicated cases, those where much is still unknown, how do they approach such cases?

Dr. John Kingdom [17:00] Okay, so with very complex cases, you registries is one way forward, and it can be done internationally. So UK, for example, has a registry for rare diseases. And they basically picked 10 a year, and they just sort of ordered them for a year and a country in a population of 50 million people. So, you know, for example, at our hospital, we will you know, we've had 10 cases in 20 years of disease x and we'll do a systematic review meta analysis of the cases and present that publish that. So it's our way forward. observational studies are the norm in many areas of prenatal diagnosis and treatment. But we have had, you know, successful international randomized control trials for rare conditions like say surgery for fetal spinal Bifida. The nastiest problem with the least understanding is for sure, spontaneous preterm labor, ruptured membranes and deliver been 70% of all Singleton births, ending up in NICU are the results of spontaneous preterm labor and or and or ruptured membranes with no other known pathway. No underlying pathogenic explanations. So, you know, we're in our in our infancy for some of those things. Okay. Yeah. And they're very common. Yeah.

Melissa Galati [18:13] So what are the main factors determining a woman's risk level when becoming pregnant,

Dr. John Kingdom [18:18] Your previous reproductive history, performance, your previous medical and surgical history, your family history, all of these things are relevant. But I mean, we're not going to see them when they're not pregnant unless they're referred. So it's very much a primary care issue. And many women was a more and more aware of potential risk by being pregnant. But it's amazing how many will, you know, get pregnant in quite treacherous circumstances without any previous pregnancy consultation, the best example of that is IVF in women that are very overweight, right? So there's a big push to try and get women to have IVF clinics to not do this. And so people have pre-pregnancy consultations to go over the implications of being pregnant when in a high BMI, BMI category, certainly BMI over 40. But there are many women attending our hospital with BMI over 50. In fact, 50 is a cutoff. Because we have so many high high BMI patients. So we don't see anybody for that reason unless their BMI as above 50. But I mean, people are getting pregnant from my private IVF clinics and carrying a lot of significant comorbidities without necessarily having had a pre-pregnancy consult. So what we do at Sinai is we have a direct link between the Sinai fertility and then Maternal Fetal Medicine, both pre-pregnancy for consultation then when they are pregnant, they seamlessly move from the RER division to one of our MFM members who specializes in pregnancy care for infertile patients, because they're much more likely to have potential complications, for example, as well.

Melissa Galati [19:48] As you might have gathered from the discussion so far on the type and magnitude of cases seen at Mount Sinai. It really is one of the top centers for maternal and fetal medicine here in North America. Dr. Kingdom explains that the complexity of care delivered, number of rare cases seen, and caliber research conducted at Mount Sinai have made it a world leader in pregnancy care. In fact, despite their already full caseload Dr. Kingdom mentions that the center often receives referrals from patients from other countries who sometimes seek refugee status to obtain specialized care here.

Dr. John Kingdom [20:20] It’s by far the biggest program of its kind anywhere in Canada, because there are 20 members of the MFM division including three geneticists. So of the seven and a half thousand deliveries a year here, 3000 will be clearly high risk. So we are the biggest volume hospital and the biggest volume highest pregnancy program by far, we will be in the top five in the world in terms of volume and specialization. Because we do, there's nothing there's nothing we don't do, right? We do all of fetal therapy, we do all the patients with cancer, organ transplantation, complex obstetric surgery. So in other hospitals in the GTA area would have MFM physicians, either working on their own or in smaller groups. So Sinai will always be that it will always be the number one in Canada because of the population in the GTA, and it's an it's in central Canada, opposite of the big Sickkids hospital so they get federal referrals. It's a federal MFM referral unit, basically. So people will come from all over Canada, particularly English speaking Canada, for treatment, you know, we have 10 Maternal Fetal Medicine fellows. And at any one time we've got we're turning a mix of Canadians plus a few from more of the world.

Melissa Galati [21:33] Another important and often challenging time is the postpartum period, Dr. Kingdom spoke to us about the support provided to women at this critical time and the work being done to address challenges here through the summit program.

Dr. John Kingdom [21:45] So we actually have a division of perinatal psychiatry, but when access to perinatal psychiatry isn't swift and easy. So in the COVID area, it coincided with Sinai becoming the major site of a US study called summit, which is around scaling up online mental health support for women. And that's proven to be remarkably successful, because of course, people that's the only default pathway to support people in the COVID era. I mean, one in four, one in five patients in high risk pregnancy management will either have or need mental health co-care.

Melissa Galati [22:20] The clinic has implemented telemedicine to address the problem of accessibility to maternal pregnancy care and a broader sense, not just postpartum services.

Dr. John Kingdom [22:29] Yeah, we're trying really hard to do that. We're, you know, to provide better outreach, and it isn't worth at all to travel, as opposed to getting a car and driving two hours north to Orillia and back, you know, so we do a bit of telemedicine, but what we do is we triage really very well, we try and do definitive consultations in one go. And then we do shared care, and we keep people for delivery that we need to and we try hard to devolve care back again as much as we can. Because those are important points mean some of the hardest scripts to do with our, you know, young First Nations women on reserves, five hours north of here, you know, that they're, so they're a tough group, when actually it doesn't, they have, paradoxically, they have no financial cost because everything is fully covered by their band. So the uninsured, non non-native status people in very Northern Ontario, they're the ones who struggle because they'll get a northern travel grant, but it will cover only a small fraction of the cost of coming. But people do come six, eight hours, there are ways of getting around coming in to some extent, often as a substitute for imaging the patient yourself and talking to them eye to eye and having a good counseling session. You know, so do do as much interdisciplinary care on the same day as you possibly can.

Melissa Galati [23:45] Given the need to make the most out of each visit, we ask Dr. Kingdom what the clinic strategy is to address this and the use of telemedicine to do so.

Show Host [23:53] Is there a battery of tests that you go through usually, just to make sure that some standard things are covered?

Dr. John Kingdom [23:59] Well, often those things are all, most of the standard early testing is initiated by the primary health care provider which we can then see online. So we've that's the reason we formed what's known as the Ontario Fetal Center at Sinai. We received some government funding for that. So we have nurses that coordinate all those things. So if somebody is going to come from five hours north, we'll review the triage and we know what the likely diagnosis we might set up appointments B and C. So A is with us and then B and C to follow and to try and get as much done for them to decide to one termination of pregnancy Yes or no? What do I see the right people to get the prognosis so that we're making a decision to carry on it's as well informed as possible. It's way better to see people that are possible, because imaging is so important in fetal medicine and the maternal medicine patients are going to be our patients anyway. So telemedicine really works best for people who are more remote for an opinion. So there's a segment of people where it works well. It doesn't work uniformly well. I'll be honest. So The key point is constantly triage and recalibrating that so we're, we're looking at the thin end of the ice cream cone. So there's only so much work we can do. So we try and concentrate on the patients with the greatest probability benefit.

Melissa Galati [25:15] After hearing about how complicated the cases scene at the clinic are we couldn't help but ask how collaborative the patients are when it comes to risk assessment and pregnancy management. So we asked Dr. Kingdom about his approach to patient counseling and his experience regarding the response.

Dr. John Kingdom [25:30] Um, somewhere in the middle, I mean, I think patients want doctors to give them an honest opinion, when there are there are circumstances where pregnancies a very treacherous to occur, for example, signs of congenital heart disease is one or you know, complex cancer that's really only metastatic. So our situations, you know, Surat, you know, cirrhotic liver disease, serious chronic lung disease, when there are situations we look someone in the eye and say you could get pregnant with a very, you know, limited chance of success, we could go one in three chance of dying, but the kind of person has a one three chance of dying, may see being pregnant as life affirming for them, and they really approach to that risk. But what they need is very compassionate, honest counseling, worsing is people who are, you know, desperate trying to be pregnant their late 40s, early 50s through donor egg IVF. But people are pregnant, much older and much more complicated situations than ever before, in ever increasing ever increasing numbers. And they're the things that that's that's where the wall of problems are. So all the stillbirths and hypertension and birth destruction all comes from that triad of diabetes, hypertension, advanced maternal age, IVF, that sort of mixture creates, you know, and metabolic syndrome creates all that general higher risk, which is why for example, today, despite modern technology, we still have a one in 200 to one and 300 stillbirth rate in the third trimester, despite the fact that the average pregnant woman has three or four ultrasounds. You know, so why is that? Well, the answer is that we still need to improve on our diagnostic on our screening precision for those conditions. And we need to be more more and more aggressive about late preterm delivery to prevent stillbirth. I mean, you know, pregnant for the first time to a baby over 40 is definitely a red flag, no question. But people don't want to believe they're getting older. So there's a difference between fitness and reproductive aging, reproductive age is a real phenomenon that people don't want to. They don't want to buy into it, you know.

Melissa Galati [27:36] Dr. Kingdom emphasizes that he understands it's hard to reconcile the potential risks of getting pregnant at older ages with the opportunity to have a baby. There are so many reasons for why someone might put off pregnancy including waiting for the right partner, pursuing education, lack of economic stability, or potentially vulnerable housing situations. It's obviously a sensitive topic and one that requires much open and judgment-free discussion. As he alluded to just now, even when someone is physically very healthy at an older age, they still have significantly higher risk for complications, something that can be very difficult to accept.

Show Host [28:12] So in all your I know you've done this for a really long time. Are there any specific stories that do you have this cases in your mind that it just stuck there and I don't know either a good one or a bad one.

Dr. John Kingdom [28:24] So I had a recently I recently had a Turkish refugee who'd had two pregnancies with abruptions, where she was put under general anaesthetic and had cesearens and woke up and both babies were dead. And so you know, it's hard to work out exactly what was going on. But I mean, that's pretty devastating to have: two pregnancies, two dead babies and two caesarean, and so they came to Canada. He's an engineer, and I took them on as patients. And she had a little low PLGF. I gave her a heparin as well as aspirin. We watched her carefully, I put her into the hotel component of the hospital because she lived a long way away. And we dug the baby out by caeserean at 36 weeks, and I've got a very nice photo of mom, dad and the baby. And that was amazing. And they gave me a Turkish coffee pot and two bags of Turkish coffee, a little present, but I treasure the card that they wrote me so you can win sometimes against the odds, you know, and that's what makes the job worthwhile. You know.

Melissa Galati [29:24] Dr. Kingdom alluded to maternal health care outside of Canada when he spoke about his last patient and potentially some of the disparities that exist across the world. We wanted to explore some of the reasons why this might be as well as what's being done to address such disparities.

Lauren Wadham [29:38] My name is Lauren, I'm a midwife, primarily based in Ontario, but I also work outside of Ontario in a variety of context.

Melissa Galati [29:50] Lauren has been a midwife since 2012. The context she's referring to outside of Ontario refer to her work in both rural communities in Canada's north as well as her Work with Médecins Sans Frontières or MSS or Doctors Without Borders, an organization many of you might be familiar with.

Lauren Wadham [30:07] It's an international medical organization, nonprofit that specializes in emergency medical care globally. And they are working on the principles of impartiality, neutrality, bearing witness to what they see, as well as like medical ethics and transparency.

Melissa Galati [30:31] Lauren knew about MSF from several of her acquaintances who had worked with the organization before. Since she had some background in tropical medicine and a desire to work with NGOs, she applied and was accepted to work with the organization as a midwife in 2015. Since then, she's been on five different missions in Ethiopia, Kenya, Yemen, Sierra Leone, and just recently returned from her second mission in Yemen, where she was providing rural maternal-newborn care in a conflict zone. I think when people think of Doctors Without Borders, they usually think of the doctors being the ones in the field or sometimes even nurses. I think nurses were involved in the original MSF when it was created. But midwives like when I heard that you were a midwife and were working with MSF. I didn't even realize that that was something that you could do or...

Lauren Wadham [31:19] Yeah, I just think our understanding globally of the role of midwives is not very clear in the Canadian context. Like, in Canada midwive, I think most people already know this are doing about like 15% of obstetrical care delivery. But globally, midwives are like 90% of the workforce when it comes to obstetrical care. So like, it's it's part of like the UN mandate to increase skilled birth attendance globally. And that's mainly out of midwives, because nurses and midwives (this being the year of the nurse and the midwife - 2020). An..

Melissa Galati [31:53] I didn't know that, that's cool!

Lauren Wadham [31:55] Yeah. So this is 2020 is the year of the nurse and the midwife.

Melissa Galati [31:59] I love that well, that's great.

Lauren Wadham [32:00] It's a very special year. Yeah, especially with COVID and everything that's happening and how nurses are so fundamental to what's like the progress. Yeah, it's amazing. So midwives globally are the first line workers for all the technical care, it's quite odd in our context for low risk women to be seeing high risk practitioners. So like globally, women are being seen by midwives, first line. So that being said, as an NGO, midwives going into these contexts to work with midwives makes more sense than a physician going in there to do that.

Melissa Galati [32:39] Lauren also mentions that while half the staff are field workers, the other half of hired staff work in logistics, administration and operations, which provides the backbone of care delivery. She also mentions that MSF aims to hire local.

Lauren Wadham [32:53] So this specific NGO, hires 90% local workers, and 10% are international coming in. Because it just, it just makes sense. And I could go into that for hours about why that makes sense. But yes, like, at its core, the objective is for it to be a community based health care system. So like, when we go in there, we are very, very focused on acceptance, because without acceptance from the community, our work is very ineffective. So anthropologists, health promoters, field coordinators, will be going to the local religious leaders, so local community has the even like the females that are kind of like the main caregivers, before there was like, a functioning structural system, right. So a big part of that is going there and meeting with them and getting their blessing essentially, and saying like, are we providing what you need? And how can we do that? So that's like the ultimate goal. It's, it's very imperfect, for sure. But that's essentially what I'm trying to do. So coming in there, and building a strong community group of like, hired individuals that also like collaborative individuals is like the goal.

Melissa Galati [34:14] Lauren, emphasize that well, MSF isn't perfect. They really do aim to foster community ties and acceptance in the locations they serve. The program can't work unless that trust is there. For context. She describes the situation in her most recent mission to Yemen, and how it differed from her previous mission there.

Lauren Wadham [34:33] It was really difficult because we felt like the patients, at one point were not coming to the hospital because of fear of getting COVID themselves at our facility, or because of misinformation that was being passed on about how COVID patients are being treated. And so we were finding that during especially the first I think April in the month of April, at the hospital I was working at which does about 1800 to 1000 deliveries a month, for the facility that we were, we had, which was very modest, we were probably having one of the lowest mortality rates I've ever seen in any of my contacts, like we were providing really high-quality care for what our context was, but then come COVID. And because patients weren't coming early enough, they were seeking care so late, or they were going to private clinics that didn't have the facilities that they needed, they would come to us very late. And we had some very poor outcomes and the highest mortality rate that we had seen for years, like my midwife that I was working with, we were just like shaking their head, not understanding why we were having so many women come and die, because of this, like perceived fear of the hospital that wasn't there before. And they had been working over the last five years, so hard to get accepted within the community. And for something like this pandemic, to really break all of that and just like have it all crumble down. So we thought, I think the hospital just before I left had really recovered in their like ability to help the population understand, and we were doing better health promotion. But like those three months, just a lot of harm to the population. Even in that short time, because of the perceived fear and inability to really promote what we're doing effectively.

Melissa Galati [36:35] It's clear that the covid 19 pandemic has changed the experience of pregnancy and birth, both here in Canada and around the world. But that women in different countries are clearly affected in different ways. We asked Lauren to speak to maternal health care similarities and differences globally, how are outcomes different across the world?

Lauren Wadham [36:54] So globally, I kind of think like all women fundamentally are seeking the same thing. They're seeking safety, dignity they're seeking a cultural appropriateness, traditional appropriateness. And at the most basic level, they're seeking not to be harmed in their health, whatever that means. Like, obviously, in the context I've worked in, that means like not dying, or not having a severe morbidity coming out of pregnancy related complications, which seems like very foreign to us, living in Canada. So like, just for numbers sake, just to kind of bring people's awareness. Like in the last couple of years, it's about like 800 women a day, globally are dying from preventable pregnancy related complications. So not just complications, but like preventable. And like, as a juxtaposition. In Canada, we on average, would have about eight out of 100,000 women a year, dying from those types of complications. Whereas when I worked in Sierra Leone, which has the highest maternal mortality rates, it's about 1300, per 100,000. So out of all of the 800 a day deaths that are preventable, 94 95% of those are happening in low or low to middle income countries. So when we're talking about global health, it's very basic, we kind of think of it in three main barriers. So one of the biggest barriers to women receiving good healthcare, life-saving health care, quality health care, is not even knowing about the service existing. And this can be because they're migrants, they're displaced, they don't have access to consistent electricity to be able to receive like a WhatsApp message. Or there's no good health promotion from the government or from an NGO in the region for them to be aware of what they can access. So like, that's the basic is like the knowledge of the service isn't even there. And then the second barrier is the ability to get to the service. So once she knows about the service, what is her ability to get to the service? What are those barriers, so that could be lack of finances, a cultural inability to move, like when I was in Yemen, women tend not to move without a male caretaker, or the middle of the night, there's not taxis running close to where she is. So she has to wait till the morning we had a few of those or they came in very late to care not because she didn't want to seek that care, but because she didn't have access to transportation until the morning, these types of things. And then the fourth is the quality service itself. So maybe she knows about the service, maybe she can get to the service. But then the actual facility is a rural health post that doesn't have a nurse it only has a nurse assistant or doesn't have laboratory services or doesn't have a blood bank. Or she can't access antenatal care because there's not a midwife there, like, the services themselves are not quality. So we kind of in developmental aid and things like this are kind of focusing on how do we get those three things to line up. And then even when we get all of those things to line up, which in itself feels like a big job, then how do we make that healthcare, a healthcare that's sensitive to the patient's specific story and journey? And how do we provide a healthcare system that takes into consideration the traditional medicine that she might value and think is part of that normal pregnancy? Like, how do we put those together? So that's like another level that I think we struggle with on a day to day basis within health care globally, especially when international people are coming into those contexts. So those are like a very basic level are the barriers, let alone all the other things that we deal with in Canada that we do know are real barriers, but then just to kind of get those basic ones out of the way is a struggle in itself in some of these contexts.

Melissa Galati [41:06] Lauren discussed some of the barriers to care for expectant moms in developing countries. MSF tries to address each of these barriers by hiring local, supporting transportation costs for patients, and engaging in health promotion, through radio, whatsapp and Facebook. So in addition to all the amazing work that you've done with MSF, you also work here in Canada as a midwife. And you mentioned that you provide some relief care in rural areas of Canada, such as Nunavut, we often think of disparities in maternal health as like, as you mentioned, many of the deaths related to maternal health happened in the developing world. But like in Canada, there are also disparities in care in rural and remote areas. So can you talk a little bit about your work in Nunavut and some of the inequities in access to care and how that exists there?

Lauren Wadham [41:59] Yeah, yeah. I'm glad you're touching upon this, because I think we really other countries that need help, and we don't realize how, how much our own system has to change. So my role in working in the north, has been for mostly like coverage and relief, because of a major problem of them not having enough staff to cover the health health clinics up there. Because ideally, I shouldn't be going there. Ideally, it should be local midwives, just in the same way that like, globally, ideally, I shouldn't have to go to these other countries, right.

Melissa Galati [42:40] Lauren explains that there's a lack of providers for the Inuit communities living in Nunavut. In fact, there are only three and you add midwives for the whole territory, with just a handful of non-Inuit midwives and the rest coming from southern Canada for relief work like herself. The Inuit are negatively impacted by several social determinants of health, a big one being social support.

Lauren Wadham [43:02] they really value a community approach to their birth and to their care. So because we don't have Inuit midwives, and we don't have a good structure for allowing birth within communities, a lot of women are flown outside of their community to have a delivery. Having said that, a lot of the midwives do go to Yellowknife. There's a hospital called Stanton Hospital in Yellowknife, which provides some of the most culturally appropriate and sensitive care that I've ever heard, I've been seen, and I'm very, very, very proud of what they do. But having said that, the ideal is for women to be able to choose to stay in their own communities for their pregnancy in their birth, or at least to have the option whether they want to stay or not. And I think of the biggest barriers to that is that we don't focus on training Inuit midwives, or health care providers in general, a lot of people I've worked with in the nurse or non-Inuit, at the higher levels at the physician level have been nursing level at the midwife level. And I think if we focused on that, that would really help with many of our disparities that we're seeing, because it's just traditionally language and culturally more appropriate. And on top of that, because of our history in Canada's, it's only really been a generation between the residential schools and a lot of the horrible things that our nation has done to the Inuit people. And I was even able to see that while I was there, and it's gonna take us a very long time to come out of that. And there's a lot of work to be done there. And healthcare is very much at the center in the core of that because, yeah, the disparities in the north are very huge, very huge. And I just feel so privileged that I get to be working up there, but I also feel like there's just more we could be doing, and I think we can do it. I don't think it's attainable I think it's completely attainable.

Melissa Galati [45:02] As Lauren reminds us, we sometimes don't recognize that disparities exist in our own backyard. It's important to build capacity within a community and with the beneficiaries to make sure resource or program can provide the maximum benefit. Our last guest is Jane Francis, a PhD student and registered dietitian in the department of Nutritional Sciences here at U of T. Her research focuses on increasing access to breastfeeding support for new mothers from marginalized backgrounds, a program called pin step, the Parkdale Infant Nutritional Security Targeted Evaluation Project.

Jane Frances [45:35] I'm currently doing my PhD in Nutritional Sciences here at U of T. And so the research program that I'm part of is called PINSTEP. And this is actually an academic and community partnership that we have with Parkdale Queen West Community Health Center in Toronto, in the Parkdale and Queen West neighborhood. And what this partnership is interested in exploring is whether we can integrate postnatal lactation support into a program we have in Canada called the Canada Prenatal Nutrition Program, or CPNP. And we're interested in this to increase access to postnatal lactation support for vulnerable women and hopefully help increase breastfeeding practices among vulnerable women.

Melissa Galati [46:26] Nice. And so so the focus of this episode is on the experiences and decisions that expectant or new moms might make. One of which is whether or not to breastfeed. So what are like sort of the Canadian guidelines around this? What would you want to tell expectant moms? What do you think they should know? So the actually, the global public health recommendations for infant feeding come from the World Health Organization or the WHO, and these infant feeding guidelines have been adopted by Health Canada, and it is recommended for women to breastfeed exclusively for the first six months of life. And so what that means is that for the first six months, babies only need to receive breastmilk. So no other foods or liquids, not even water are needed. And in Canada, we do recommend infants to get 400 International unit vitamin D supplement for babies who are breastfed. Just because in Canada, we are in a northern latitude, and it's actually recommended to protect your skin from the sun so that vitamin D supplement is needed. Jane emphasized the benefits of breastmilk for both the infant and mom. for infants. Breastmilk is the optimal source of nutrition, but also contains bioactive components, like antibodies, and human milk oligosaccharides, which help protect against infection and help with gastrointestinal development. For moms, breastfeeding has been shown to reduce their risk of breast and ovarian cancer, as well as diabetes. So there are a lot of reasons supporting breastfeeding. But what about moms who can't breastfeed because of lack of resources, knowledge, support or financial barriers?

Jane Frances [48:05] As I mentioned, I think we do a good job of delivering the message that women should breastfeed and that there are benefits to it. But I think oftentimes, the conversation kind of ends there. And there's no further discussion on how lactation works, or how the first few days postpartum, like what those will actually look like. In reality, you don't just deliver a baby and your milk starts flowing, right? There's challenges that will happen. And and we need to talk about those challenges before women deliver so they know what to expect. And then they also know where to access support. So I mean, what's really interesting is that in Canada, most women start breastfeeding. So we have really high breastfeeding initiation rates around 91%. So a lot of women start breastfeeding, and many women want to breastfeed, but half of women stop breastfeeding before six months, and only 30% in Canada are exclusively breastfeeding for six months. So we do a really good job of promoting breastfeeding so that women start, but I think we kind of have to focus a bit more on the actual postnatal period when women are actually doing the breastfeeding and them and their baby are learning it. So it's interesting you asked about, you know, women's to sit like it's an individual, whether it's a women's individual choice to breastfeed and whatnot. So one of my favorite quotes from the Lancet breastfeeding series from 2016 is breastfeeding is generally thought to be an individual's decision and the sole responsibility of a woman to succeed ignoring the role of society in its support and protection. So it's not just about the mom, it's about the whole family, and it's about society, and the way we look at infant feeding and the way that we support new moms.

Melissa Galati [50:05] Jane's PhD work focused on doing just that, supporting Toronto based moms from marginalized populations to breastfeed. She recently published a qualitative study in the Journal of Maternal and Child Nutrition assessing a new postnatal lactation support program run through the Parkdale Queen West Community Health Center, and their on site CPNP or Canadian Prenatal Nutrition Program. We asked her to walk us through some of her key findings.

Jane Frances [50:31] The CPNP is a federally funded program. So through the Public Health Agency of Canada, they provide funds for for community agencies to develop or expand maternal infant health interventions, and programming specifically for vulnerable women, or women who are living in challenging life circumstances. So as we talked about, this might mean women who are low income have low education, social isolation, single parents, etc. And so the actual goal of the CPNP is to improve healthy birth weight, so improve birth outcomes, but also to promote and support breastfeeding. And so there's a really great prenatal breastfeeding education component built into the CPNP. And so we want to build on this breastfeeding promotion and strong breastfeeding education component that they have to integrate postnatal lactation support, so that there's support available to women once they deliver their baby and when they might encounter challenges. And so with this paper with our community partners at Parkdale, Queen West Community Health Center, they had existing funding additional charitable funding to create a lactation support program for their CPNP participants. So we saw this as an opportunity to evaluate this existing model to see what's working well and what women think of of their experience with this program to better inform kind of our next steps of how we could bring this model of postnatal lactation support to other CPNP sites. And so with this study, it was a it was a qualitative study. So we spoke with almost 50 moms who attended this CPNP site and had access to the postnatal lactation support. And this postnatal lactation support includes in home visits with a lactation consultant. So a lactation consultant is an expert in lactation and lactation management. So they're the experts. And typically lactation consultant services or private lactation consultant services are available but it's it's not covered by OHIP. So it can be pretty expensive support to to access, sometimes up to $150 an hour, so it's not typically a service that vulnerable moms would even know about or be able to afford. And so this postnatal lactation support provides in-home lactation consultant services and double electric breast pumps to moms if they need it. And we wanted to hear about their experiences with breastfeeding and their experiences with the program, the lactation support program. And what we found and what they told us was that most women experienced a lot of breastfeeding challenges that they weren't expecting. And so through discussions with these women interviews and focus groups, we found that there were actually three distinct types of challenges. So physical challenges which might have included things such as low milk supply or difficulty with breastfeeding technique, like latching and positioning. Practical challenges included just kind of things that made it difficult to breastfeed with a new baby like not having enough money to access, lactation support, or just time constraints and time commitments, caring for other children and recovering from childbirth. And then emotional challenges are challenges with breastfeeding self efficacy, which is mother's confidence in her ability to breastfeed. So most women said they knew that they wanted to breastfeed and they started breastfeeding, but they just weren't prepared for these challenges. And what they also told us was that the lactation support was really highly valued by these women and helped to address kind of each of those elements of of breastfeeding difficulties. And there were there were kind of these three components that were especially essential according to the women that we spoke to, and that was the skilled support so the skilled provider who was the lactation consultant who provided care in the home and in a non-judgmental and caring manner. So, those were kind of the key findings.

Melissa Galati [55:10] Jane emphasized that the biggest impact of the program came from the ability of the moms to have lactation consultants come directly to their home, free of charge on a flexible schedule that worked for them, removing the necessity for them to travel, especially in the first few days after birth when they're still recovering from birth, or possibly even caring for other children. She mentioned that some of the moms who participated in the study were newcomers to Canada. And while many would have had support from family and friends had they been in their home countries, they often lacked that same support here in Canada, making navigating the postpartum period extra difficult. She says that we need to be mindful to create programs that are accessible to and can work for all mothers. Finally, like Lauren, who emphasized how MSF strives to integrate into existing frameworks to gain community acceptance. Jane also explains how the effectiveness of the postnatal lactation support program was increased by integrating it into existing CPNP sites that had gained community acceptance already,

Jane Frances [56:12] like another reason that we want to, you know, try and integrate postnatal lactation support into CPNP sites is because, you know, there's already this network of an established program that has a really strong social support component. And from our experiences, they're just talking to women, they they have a relationship with the, with the providers, they are providing these CPNP services, right. So they have a comfort level already with this program. And then by offering postnatal lactation services, it's not just someone random calling you to see how breastfeeding is going. It's coming from, you know, a trusted person, that you've built a relationship with prenatally, not necessarily the lactation consultants themselves, but just the providers at the CPNP the team members who are dealing with these women prenatally. So, yeah, I think I think trust and building that relationship is is a really key component, which is why we want to try and integrate these postnatal lactation services into an existing program where that social support and trust already exists.

Melissa Galati [57:30] Jane says that the next step is to quantitatively show that the program increases breastfeeding in the first six months postpartum. And then to scale up the program across other CPNP sites in Toronto, and eventually across Canada, with the goal of being able to provide the evidence to encourage increased funding allocation to support such programs.

Jane Frances [57:49] Since CPNP is a national program, we need data on whether it's effective at improving breastfeeding rates in different areas in different places across the country. So we're currently exploring opportunities to do this on the east coast of Canada. So in the Atlantic provinces, and basically, we will do similar work at building relationships with community partners, which is really key in all of this work. And our community partners are wonderful, because they're the ones who are actually providing these programs and services to women, right. So our relationship and having them involved in the research and understanding what they need as well, has just been so key. So we want to develop these relationships with potential community partners and CPNP sites out east to figure out how this model could be adapted to, to integrate into their sites, and hopefully, across the whole country eventually,

Melissa Galati [58:49] it's programs like these that are aiming to decrease disparities in maternal and infant health care, but getting moms the support they need when they need it. We asked one of our new moms what advice she might have for expectant mothers, or those who know someone expecting a baby.

Mom 1 [59:04] I think the most important thing is that you're gentle with yourself. If you're the birthing parents, or a member of a family that's waiting for a baby, especially now, especially now in the middle of a pandemic. Be Be gentle with yourself. Having a baby trying to have a baby is such a wonderful thing. But it's also hard and you will be tired, and that's okay. Be gentle with yourself and find community in a form that works for you. I guess if there's anyone listening that isn't about to have a baby but that knows somebody who is that a great kindness would be to offer to do something specific for them. Can I bring you a meal? Can I partner in a pandemic? But whatever it is, if it's someone in your bubble: Can I come over and sweep your floor and make you a cup of tea? Whatever it is that reminds that person that actually, you've just had a baby or you're about to when it's normal to need some help.

Melissa Galati [1:00:31] We would like to take this time to give a massive thank you to all our guests, Madeline springett - Coombs, Dr. John Kingdom, Lauren Wadham, and Jane Frances for their insight and expertise, as well as the mothers who shared their own lived experiences. Be sure to check out the resources and links in the show notes. If you're interested in learning more about the topics discussed in this episode. catch us in two weeks on September 9 for the launch of season five, where we're kicking off with a roundtable discussion on this year's COVID decoded YouTube series. This episode would not be possible without Alex, our audio engineer, Stefania, Frank, Kat and myself who developed the content for this episode hosted and conducted interviews. I was the executive producer. And until next season, keep it raw.