Postpartum Care Models: Impact on Maternal Morbidity and Mortality

We need to have a serious conversation about postpartum care models in Canada. Statistics suggest that maternal morbidity and mortality rates are on the rise. Digging deeper into the numbers calls into question all sorts of gaps within our current care models, how we can better address patient needs through interdisciplinary, collaborative care, the benefit of looking at other models internationally - and how the data collection itself may be leading to misrepresentative statistics.

Dr. Stephanie Ferguson, obstetrician/gynecologist based out of Guelph, Ontario, joins Dr. Alicia Power on today's episode to wade through this complex yet crucial topic on which her current research and fellowship focus on, and where she has already published articles on the topic, linked below.

Resources:

• New moms navigate postpartum care maze | October 19, 2023 | Canadian Affairs | By Dr. Stephanie Ferguson
• P4P Podcast Episode: Hypertension in Pregnancy

Feedback:

Please take a moment to fill out this very short anonymous survey (>1 minute). We want to optimize Pregnancy for Professionals to suit your needs, so any feedback is very valuable and much appreciated!

Transcript

[00:00:50] Dr. Alicia Power: Welcome everybody. I am so excited about today's topic because this is something I am so passionate about, postpartum care.

[00:00:56] Through my other, through our other lens, our She Found Motherhood patient [00:01:00] focus lens, we've learned that postpartum care looks very different across the country. And in fact, across the world and here in BC, I think we, not to toot my own horn, but I think we do a pretty reasonable job of providing care to the postpartum person and the newborn, especially for those of us who are more of the primary care provider lens because we have that bit more of that can do both skill sets.

[00:01:23] But certainly even for our specialist colleagues, I know that they provide that care as well in BC, generally speaking. I'm excited to welcome Dr. Stephanie Ferguson, who is an obstetrician gynecologist based out of Guelph, Ontario, who actually contacted me a little bit ag o because she's writing an article on postpartum care, which is very exciting. And so wanted to chat about our process here in BC and specifically at the clinic Grow Health, where I work. Stephanie, why don't we get started and you can just tell us a little bit about yourself and what kind of prompted you to do this work that you've delved into.

[00:01:54] Dr. Stephanie Ferguson: Perfect. So as you said, I am an OB GYN, I practice in Guelph, [00:02:00] Ontario. I've been practicing for about eight years now. I am very passionate about obstetrics and postpartum care but also about media attention. Much of what you're doing is why I reached out and how we get messages to patients and provide centered care for patients. So as part of that, I've actually started a fellowship. So I'm doing a fellowship for the year, at the Dalla Lana School of Public Health at the University of Toronto and in that fellowship, we are paired with media partners and we pitch and then write articles on topics in our specialty. So for me, in particular I've been looking at the area of postpartum care and published an article earlier this year in Canadian Affairs, looking at the experiences of women with postpartum care across Canada some of the new programs that we're developing and how we can make a difference.

[00:02:44] Because like you said, our care really is not standardized across the country and it can be very different depending on the province and even locations within the province that patients live in.

[00:02:53] Dr. Alicia Power: Yeah. Awesome. And we will link that article in the show notes. So if anybody's interested in having a look at that, it's a great article, very informative. [00:03:00] So I highly recommend it. But so why don't we start a little bit talking about definitions, because we're going to talk about mortality and morbidity. So do you mind just giving us a brief definition for those who it can be a little bit muddy what we're talking about when we talk about maternal mortality and maternal morbidity when it comes to childbirth in that first year postpartum.

[00:03:19] Dr. Stephanie Ferguson: Correct. So maternal mortality we're looking at deaths and often it's broken down into direct mortality and indirect mortality. Things that occur within that first year postpartum. And that's a definition that's really changed. So when we look, and we'll talk a bit about kind of maternal mortality statistics, a lot of the statistics really up to the last couple of years have looked up to six weeks postpartum.

[00:03:41] So any death of a mother that occurred within pregnancy and then for the first six weeks postpartum. And the definition is now expanding to some places, the WHO will call it late maternal deaths or combined maternal deaths, so that we're looking not just at that period, but also at the later period from six weeks postpartum or 42 days is often the [00:04:00] definition they use up to one year postpartum.

[00:04:02] And that's a really important part to focus on. And then severe maternal morbidity is looking more at illness in pregnancy. So women that have complications or severe illness as a result of things that occur within the pregnancy, either from pre existing health conditions or conditions that arise during the pregnancy and those morbidities, those illness make them more susceptible to complications, to admission to the ICU and even to death. Looking at those two different definitions.

[00:04:28] Dr. Alicia Power: Awesome. Thank you. And as always, when we use the term woman, we mean any kind of pregnant person or postpartum person. As we're moving forward, we'll use the terms interchangeably. So why don't we get started? And I know you want to talk a little bit more about the data around maternal mortality and morbidity.

[00:04:44] So why don't you share a little bit about, and this is for our non Canadian folks, this is going to be mostly Canadian data, but I do know you have a little bit of stats from elsewhere. But we're going to be focusing on, we're going to be a little bit Canadian centric here. So apologies to anybody else, but certainly in your article, you do talk a little bit more. [00:05:00] So why don't you go ahead, talk a little bit more about maternal mortality and morbidity.

[00:05:04] Dr. Stephanie Ferguson: So yeah, so like you said, we'll focus on Canadian maternal mortality but I think the big takeaway, particularly about mortality, is we just actually don't have great statistics in Canada. So some of the algorithms we're coming up and decisions we're making and conclusions we're making is also based on data we have internationally, particularly from the US and the UK. And we'll talk a bit about their databases and what they've developed.

[00:05:25] When you read headlines, and when I was going into this article and pitching it to a group of non medical professionals a lot of the headlines came up saying maternal mortality is increasing. And people with, outside of obstetrics would say, What do you mean it's increasing? Why is this not more widely covered within the media? And headlines would say things like, maternal mortality even on the SOGC website looking at prevention of maternal mortality, they quote that since the 1990s, maternal mortality has increased from 5.1 to 11.9 per 100, 000 live births in Canada.

[00:05:55] And earlier this year Statistics Canada put out some new data as [00:06:00] well saying that the maternal mortality has increased from 3.1 per 100, 000 live births in 2000 to 8.1 in 100, 000 live births in 2020, which is really quite substantial when we say in the last 20 years, we have more than doubled the mortality of women. And so I went back and looked at that and said, this would have to be huge articles everywhere if this if it was this was the case, and really what it comes down to is looking at it number by number. So when you break down the Statistics Canada data, for example, in 2000, there were 11 reported maternal deaths, and in 2021 or 2020, there were 34.

[00:06:37] So that looks quite substantial between the two. But then in 2001, there were 26 maternal deaths. So you can pick the years you look at and make it look more substantial than it is. But what's really come out is that we have, we don't have a great way of analyzing maternal data across the country.

[00:06:55] So each province has different registries, and even up till 2019, [00:07:00] Alberta was the only province that actually reported deaths from that six week up to a year postpartum. When we look at the data the World Health Organization in 2010 did a report looking at maternal mortality around the world, and when they looked at Canadian data, and how we're looking at our data, they said that we're probably actually under reporting our maternal mortality by a factor of about 60 percent which is crazy, yeah, crazy, crazy bananas, yeah, yes where those numbers put us and so when we use that coefficient in total, from Statistics Canada, about 523 women died during childbirth between 2000 and 2020, with that W.H.O. coefficient, it's probably a number closer to 800. And over time the S.O.G.C. and other provincial bodies are now coming up with ways of how can we do a better job of looking at that data? Not just to give us numbers, but to look at why does that death happen? So in many provinces, it doesn't even say necessarily was the woman [00:08:00] pregnant on the death certificate. And particularly from six weeks to a year, it doesn't say was the woman pregnant within the last year, so we just don't have great numbers about maternal mortality.

[00:08:10] Dr. Alicia Power: And I think it's important to point out because some people are going to say 30 and 100, 000, that's not actually that many if you look at like cancer and smokers etc.

[00:08:19] But we're talking about relatively healthy individuals, young people who have their entire lives to live, and often have other, wee children at home, who have now been left without a parent, right? So these are they look like quote unquote lowish numbers if you're looking at other causes of death, but in this population, this is significant, right?

[00:08:40] Dr. Stephanie Ferguson: Absolutely. Yeah. So when you have a woman who comes in, to your labor and delivery and she's otherwise been healthy with an uncomplicated pregnancy, has young children at home and doesn't survive labor or goes home after she delivers and at six weeks passes away from complications, that has, has far reaching implications.

[00:08:57] And we also know from data around the world. Recent studies that came out [00:09:00] of the US that they estimate 60 to 80 percent of maternal deaths are preventable. When we're comparing to cancer deaths, sometimes we're looking at higher numbers because we don't have solutions. We don't have treatment. But if we're saying 80 percent of maternal deaths are preventable those are numbers that we should be doing something about.

[00:09:15] Dr. Alicia Power: Yeah. So we talked a little bit about mortality. What about morbidity? Let's talk a little bit about that because I suspect those numbers are even higher.

[00:09:22] Dr. Stephanie Ferguson: So that links in nicely in saying, 30 numbers doesn't sound like a lot. But when we're actually looking at maternal morbidity, studies estimate that for every maternal death, 50 to 100 women will experience severe morbidity. So those are the women that are getting sick or ending up in the ICU and are having long term complications.

[00:09:41] And so those numbers we do have much better statistics on and we are seeing trends of increasing maternal morbidity in Canada. One recent study that was released in the JOGC actually found between 2004 and 2015 a 9 percent increase in maternal morbidity. And we think on average, [00:10:00] between the rates going up from about 1.3 percent of patients to 1.6 percent of patients, which again might not seem like a lot of women, but when we're saying going from one to two in a hundred women are going to end up with severe complications related to pregnancy and we'll talk a little bit about why some of those occur and those that are preventable. Those are pretty substantial numbers.

[00:10:18] Dr. Alicia Power: Yeah, they are. Yeah, sure are. So why don't we talk a little bit about the reasons now? I know one of the reasons is hypertensive diseases in pregnancy. We did a podcast not too long ago, we'll link below, talking about that. And I know in our community, we have 30 percent of our population has at least one of the hypertensive disorders of pregnancy risk factors, which increases lifelong morbidity. But what are we talking about in that first year of life?

[00:10:43] Dr. Stephanie Ferguson: Yeah. So what we're looking at in terms of the numbers, so the number one cause that we still see are diseases of the circulatory system and they do divide that out between hypertensive disorders, so hypertensive disorders runs about number four in the list in terms of causes but diseases of the circulatory system, so things like [00:11:00] cardiomyopathies, irregularities, arrhythmias in the fetal heart, or in the maternal heart rate so heart related diseases are number one.

[00:11:06] Number two, they actually list as other indirect causes. And the most common of those is mental health issues. And we see that in statistics across the UK, across the United States as well. In the United States in particular, they list mental health and suicide as one of the number one causes for maternal death.

[00:11:23] Number three has remained quite steady as postpartum hemorrhage. Number four, like we talked about is high blood pressure and then less common, we think, see things like obstetrical embolisms. And then infection as well are the more common causes. And these are similar across developing and developed worlds. It's, those are, those are often the top causes of maternal death.

[00:11:43] Dr. Alicia Power: Yeah. And just thinking about what we're going to be talking about, that postpartum care piece and that preventability piece, right? If we have more robust postpartum care pieces, we can often catch some of those things, checking people's blood pressure, checking in on people's mental health. Et cetera, et cetera, those symptoms that come along with those those illnesses and [00:12:00] diseases more effectively if we're actually have a bit more of a robust postpartum care platform system, right? Okay. Is there anything else that you wanted to chat around those pieces?

[00:12:12] Dr. Stephanie Ferguson: So I think the other pieces is how do we record that data?

[00:12:15] How do we do a better job of collecting that? And what can we learn from other countries? So the U. S. and the U. K. have developed national systems. The U. K. is one of the the systems that we try to follow and learn from as well. So in the U. K. they have a system called Embrace U. K. And they look at both direct and internal and indirect maternal deaths and they've used that data to come up with programs they have outlines every year of what are the leading causes and what are some differences that, that they can make. And they have really noticed a substantial decrease in maternal mortality from that.

[00:12:49] Interestingly, within their data same thing they find cardiac disease is the number one condition. But what they also point out is inequalities within ethnicities. [00:13:00] Within maternal mortality, they say a two times higher rate within their Asian population and a four times higher rate within the black population. And then they've also looked based on socioeconomic status. So they say they've compared the least deprived nation or areas in the UK with the most deprived and they find the most deprived again have a two times higher rate of maternal mortality. So there are things we can learn from these other countries.

[00:13:22] The United States so the CDC published a study just earlier this year and it got a lot of publicity through an article in the New York Times. And they specifically looked at periods within the postpartum period that women had passed away. And they found that over 53 percent of deaths actually occurred between day seven and one year postpartum, so over half of the deaths and that's what we were talking about, were seen in that later postpartum period, which is really focusing, not just on pregnancy, but also the postpartum, the later postpartum period.

[00:13:54] Dr. Alicia Power: So how would you suggest that we track things better? Have you come up with any ideas, or are you [00:14:00] advocating for a better tracking system in the work that you're doing, or how can we as individual care providers make note of these things or bring them to attention if they, if we see them happening?

[00:14:09] Dr. Stephanie Ferguson: So the SOGC is working on that right now. So they they do have a collaborative program and they have a site on their website, Prevention for Maternal Mortality, starting with provinces that have already had registries like in Ontario, we have the born registry and looking at that data, having better reports from coroner's reports on exactly when was the woman pregnant, what were potential reasons that this occurred.

[00:14:29] So that is happening in the background, I think things as always within a political sphere can take longer to just get the people involved and the paperwork involved, but that's definitely already underway through the SOGC as well as through the Public Health Agency of Canada.

[00:14:43] Dr. Alicia Power: Awesome, awesome. And I think one of the things that you were looking at is how are patients actually feeling about their, we're going to segue into kind of the actual postpartum care, because that's what we really wanted to chat around today, but how are patients interpreting their postpartum care? What are their feelings around the different systems of postpartum care? I [00:15:00] think you looked a little bit about from the patient voice and then we'll talk a little bit about providers and interesting models that you've discovered in your journey.

[00:15:06] Dr. Stephanie Ferguson: Yeah, so a lot of it like you mentioned earlier really differs based on province.

[00:15:11] So statistics say about 56 percent of women across the country are cared for by an obstetrician, then 30 percent by their family or 38 percent by their family physician. Then the rest of that is often care that is done through midwifery or through public health nurses and that varies greatly across the country. So about 20 percent of patients in Ontario are covered, are cared for by midwives and 25 percent in B.C. So really the highest populations in Ontario and B.C. And then the Atlantic provinces, only 2 to 5 percent of women are, patients are, covered, cared for by midwives, 4 percent in Quebec and about 8 to 10 percent in the prairies.

[00:15:47] And so the care you receive. It varies greatly depending on who you're seeing and that's really what comes back and I think from a lot of patients that I have spoken with from patients I did spoke with both for the article and then in my personal practice, in [00:16:00] patients when they're seeing obstetricians or they may be seeing family care and maternity care in Ontario they will be seen with their baby at their first 24 to 48 hours. And then often they're not seen again until six weeks. And so there's a lot of time in that period where they're just not feeling cared for. And so the most common thing that came out is I had this really intensive care in, especially in the last four or five weeks, I'm seeing my doctor every week. I've done my birthing classes. I've done my pregnancy plan, my birthing plan. And then baby comes here and everyone kind of forgets about mom.

[00:16:33] And I think that's a sentiment that a lot of women share. I know when I was speaking with you very different in a BC model where a lot of patients are being seen by family physicians and midwives as their primary providers. Midwives in Ontario and our midwives at our hospital, they will usually see patients three or four times within the first week for home visits. Then they will do a home visit again at two weeks, and then they will see, be seen again at four and at six weeks often in the clinic. So they usually have about six visits [00:17:00] in that first six weeks. I think similar to the programs at your clinic as well.

[00:17:04] Dr. Alicia Power: Yeah. And I think it's interesting and I wonder why it is, I'm going to guess here, cause obstetricians, gynecologists are specialists in pregnancy care, high risk pregnancy care and low risk pregnancy care. But not in newborns, not in babies. So there's pediatricians who support or maybe the patient's family doctor who would support the newborn care when they're seeing an obstetrician. Is that correct?

[00:17:26] Dr. Stephanie Ferguson: Correct. Yeah.

[00:17:27] Dr. Alicia Power: Whereas in, in my model of care, we support both pregnant and newborn up until about eight weeks and then discharge them back to their family doctor. If they're lucky enough to have one or their nurse practitioner. And so we just see both of them at each visit. And so we book for both patients. We see both. Mostly we're doing it, to be honest for the weight gain for the newborn and then we tack on mom's visit, but there's all or the postpartum person's visit, but there's always things that come up and we discussed contraception and breastfeeding and all those types of sleep and relationships and all of those pieces of the puzzle. [00:18:00] Right?

[00:18:00] And I, the midwifery model would be the same. So I, yeah, so I guess that's probably a big reason around that difference in the care model is because obstetricians are a fantastic resource and hugely trained in pregnancy, especially in the higher risk, more complicated pregnancies and the postpartum as well, but not in that newborn care. And I think many of us see the dyad for more for the newborn and care for the pregnant or postpartum person at the same time, right?

[00:18:27] Dr. Stephanie Ferguson: Absolutely. And that's a lot of the feedback that I received from people that they wouldn't know who to go to. So they knew they would see their obstetrician for themselves. And then for baby, they would have to see either their family doctor or their pediatrician within the first 48 hours. And there are many fantastic family physicians who as part of the appointment would say, okay, how are you doing, mom? And we'll take the time. But many moms would say, by the time I got my baby there in that first 24 hours, I got in the car, got them there, got them undressed, when they ask me about me, I'm like, I'm fine. I just want to get out of here and get this baby home and feed it. And so it's and for some family physicians, it's also really tough [00:19:00] because they don't have, that's not an appointment specifically for moms. So when moms do have issues, it's difficult in those busy clinics to, to deal with two patients at the same time sometimes. So moms don't really know where. where to go and all of that. Public health has changed as well. Many provinces used to have a very strong public health system. Like 20 years ago, public health nurses would go into the home for everyone in that first week. They would spend an hour or two at home. And then it changed to, okay, we will give everyone a phone call and they'd have a phone call about issues to then we will just people that are high risk and then people who self refer. And that reaching out of care, which many other countries still offer or in different ways offer a lot of women aren't getting, you know.

[00:19:37] Dr. Alicia Power: I agree with you. So just before we move on, because I think next we're going to talk a little bit about these different care models that you've looked into. But before I just want to let people know that we really appreciate feedback and comments. So if you guys have any feedback, to our listeners, comments suggestions, questions that come up during this podcast, please feel free to email us [email protected]. Also please take a moment and go do a [00:20:00] review on whatever podcast platform you are listening on. And if you really like this, post it to your social media and let other people know that this is a great podcast. Moving on though, you did some investigations in different countries and in this country, and came up with some innovative, different, new ways of providing care. So curious to hear your thoughts and experience around some of that.

[00:20:22] Dr. Stephanie Ferguson: Yeah. Lots of different programs across the country that people are coming with. And a lot of it comes back to collaborative care. So one of the programs is the TIME program. And it stands for The Interprofessional Midwifery Maternal Fetal Medicine Expanded Program, which is run through the London Health Sciences Centre and just completed their first year. And it's a program that came up with a group of MFMs and midwives who provide care together for patients. In the initial arm of this, of the program, they selected patients often that were at the highest risk population and throughout the pregnancy, they would see both MFM and midwives would attend appointments as well.

[00:20:57] So they had that extra support and [00:21:00] input the expertise of the maternal fetal medicine, the high risk obstetrics when they needed it but also general pregnancy and what to expect and also things for babies that MFMs may not necessarily have in the time to go through. And then importantly, when they delivered they had six weeks of ongoing follow up with midwifery as well. And the midwives had that instant connection with the maternal fetal medicine specialist. So if something came up, if there was an issue, high blood pressure. They could get in touch very quickly with the MFMs, get them into clinic or get them to be seen and especially keep them out of the emergency department.

[00:21:29] And like you were saying, they also provide that baby care. So the mom and baby dyad, so they could go in, they would be helping with feeding and they actually found their results, were greatest in terms of benefits to the baby as well and decreasing readmissions for babies. So it's not often we think just about the mom in that picture, but it's so much both of them. And and having that collaborative care, they said they've had fantastic response from everyone, that the thing that everybody says at the end of care is that all moms should have access to this type of care. So a really innovative [00:22:00] program that they've come up with and they've done that through a special funding model in Ontario called the Expanded Midwifery Funding Model so that they're able to get this funding for it. The difficulty in Ontario is that midwives are paid per patient, so they have to see them for a certain number of visits, and then regardless of the delivery or the home care they're paid an allocated amount. So It's really difficult for them to just provide that postpartum care for women that often our obstetrical patients could really benefit from that they feel is missing.

[00:22:28] Looking at these different models where we can provide collaborative care between OBs and midwives which leads me to, we spoke about your program as well, that you had started with the health ministry funded nurses which you might be able to better describe than I can, but I think that the bringing nurses into your office that provide a longer appointment times, I think you said they see them for their initial intake at 8 to 10 weeks, and then again, 35 weeks, and then again in that first week postpartum. So they still have their primary maternity specialist, but someone else that's in there providing care as well.

[00:22:58] Dr. Alicia Power: Yeah, exactly. And the [00:23:00] way that we can do it is that they are funded by the health authority, right? Because I think a lot of the issues in providing good, comprehensive, interdisciplinary, collaborative care come down to funding. And our governments, our systems which decide upon funding, don't necessarily see the benefit of it where we on the ground really do. And so I think these innovative models, you have to be innovative with your funding or have access to certain funding pots like the time model has, right?

[00:23:30] Yeah. Yeah, but certainly our patients yeah, our nurses are incredible and they're trained public health and they're trained perinatal health, mental health and other all perinatal kind of health lactation consultants. And so they really have that skill set to support our pregnant patients and our postpartum patients as well through that. They also do contraception counseling. So if somebody's not sure what they want to do postpartum contraception, the nurse will go through all of the options. Where I have a 10 or 15 minute appointment, they can take an hour to go through all the options and answer the questions, which gives [00:24:00] the patient much better ability for that kind of informed consent and making the right choice for them.

[00:24:05] Dr. Stephanie Ferguson: And interestingly, I don't know if this is what you came across when you were creating the model, or talking with them. They have a very similar model in finland for their postpartum and their antenatal care. And so finland has one of the lowest rates of maternal mortality, their maternal mortality is about three per 100 000 and they provide community care clinics, that are clinics that involve a nurse specialized in maternity care and in there many of their midwives they train as both nurses and midwives, so they often have midwifery care and physicians in the clinic and so they do exactly the same. They have allocated appointments throughout the pregnancy and then in the postpartum period where they come in, it's a 60 to 90 minutes intensive periods that they're looking at things like mental health, postpartum, they'll talk about contraception care and they have that access to physicians that if they notice blood pressures are creeping up or their symptoms that they're not sure about that they can reach out.

[00:24:54] And that's why you said it's not just about saying we need to increase our midwives or we need to increase our obstetricians. [00:25:00] People have different expertise and it's really about how people work these things together. It's also, I think, about how society looks at postpartum care. In Finland, for generations now, they have these birthing boxes that you might have seen have popped up around Canada too. And for every person, it's a publicly funded program. They send them this large box every year. You register around 20 weeks. And they have multiple onesies in them, warmers, blankets, they used to have bottles and they provide this like getting on your feet, let's support you in early parenthood. And so a lot of it is about just having a different mentality about postpartum and caring for mums and that just because you've delivered the baby doesn't mean you are done.

[00:25:39] Dr. Alicia Power: We call it the fourth trimester for a reason, everybody.

[00:25:42] Dr. Stephanie Ferguson: Exactly. Yes. Yeah. So bringing attention to that. And so there's a lot of countries that I think have recognized the fourth trimester long before we have recognized the importance of it.

[00:25:50] Dr. Alicia Power: Yeah. And I think it's, it's such a huge shift. You've got this huge hormonal shift. You have a new human being that you have no idea what you're doing about and have to care for. There's huge shifts in relationships. Nobody's [00:26:00] sleeping. Like it's such a vulnerable time for people, for the postpartum person, for the postpartum person's partner, and for the newborn.

[00:26:08] And yet, it's so undervalued in terms of that kind of bringing care and supporting people through that. And there's just so much evidence coming around ACE scores, so Adverse Childhood Event scores, that a lot of it stems from that first year postpartum marital discord, relationship challenges, lack of sleep, parental mental health or lack thereof, right? And so if we can support this population more effectively, I think we would have huge impact long term, short term, but also long term on population health and wellbeing. But those studies are hard to do and they take a lot of time and they take a lot of funding. Yeah,

[00:26:43] Dr. Stephanie Ferguson: Yeah. And so that's where there's some other programs that have come up with looking at more of the vulnerable populations as well. So in, in Guelph our midwives have come up with a program called the CAMP program. And it's the Community Access Midwifery Program. So a small group of midwives have also used this [00:27:00] expanded funding model so that they provide care for marginalized populations. So racialized, newcomer, low income substance abuse are often the highest groups.

[00:27:09] And they have allocated funding that they can also see women just in the postpartum period. So if we recognize that they are at higher risk and then they can connect them with social supports, community supports to really get them on their feet. So even when they're done that six week period they have supports in the community to help them from there. And then we're setting them up, not just for mom's wellbeing, but for the baby's wellbeing as well.

[00:27:32] Dr. Alicia Power: We've got a great program here in Victoria anyways, the Nurse Family Partnership, I suspect it's across BC, but it's public health nurses who are linked up with more vulnerable parents to help support them in the first two years of their child's life.

[00:27:43] So all of those things, starting solids and potty training and sleep training, and all of those pieces of the puzzle, parental mental health are all supported by that, but it's a very limited program. And but when it's when your patient's needed, it is fantastic to have access to. But again, it's all about that individualized [00:28:00] support, right? Yeah, it's hard. I'm curious, Stephanie, with all of this work that you've done, have you, or are you planning to make any changes to your own practice?

[00:28:12] Dr. Stephanie Ferguson: Good question. One of the things that, that came out of this when I was looking through the guidelines is the American College of Obstetricians and Gynecologists did actually put out a new postpartum care guideline. And as part of that, they included a postpartum birth plan, essentially, or a components of a postpartum care plan. And like I mentioned earlier, I think, I have tons of women who come in here as my birth plan, this is exactly what I want to have happen in labor. And then baby comes out and more often than not, women say to me, I had no idea breastfeeding was going to be this hard. I had no idea was I was going to be this tired. I try not to even ask moms, how are babies sleeping now? I just say, how are you dealing with sleep deprivation? Because there was just this stigma about how your baby's sleeping and everyone will be like, I'm fine. But if you ask them about sleep deprivation, then it's like, things start flowing.

[00:28:58] They came up with this postpartum care [00:29:00] plan. And so I'm actually coming up with a document to hand out to patients that says, let's come up with a plan ahead of time, because once you're in the middle of it and you are exhausted and it's the middle of the night trying to figure out how do I get lactation support? Where do I get mental health counseling? Women just don't have time for that or they don't know where to reach out to.

[00:29:16] So on their plan, they include things like who's going to be your care team, deciding when your postpartum visits are going to be, who you're going to see ahead of time, coming up with a meal plan with dad, talking about who's going to be doing feeding. Do I want to pump? And if so, what equipment should I have ahead of time? What bottles do I want dad to do? Who's going to do the nighttime wakings? Sometimes having those conversations ahead of time when you're not in the thick of it are really important. They also have a section on mental health. So what are my resources in the community for mental health? And how do I reach out to those? And I think focusing on that during the pregnancy so that women recognize we still want to care about them after they've delivered is important.

[00:29:53] Dr. Alicia Power: Yeah, we've got a few of those questionnaires in our prenatal course, just because as parents we know what we had happened to us, right? [00:30:00] We learn from our experiences and people come from such different experiences. So I always give the example of my husband and I doing cooking and doing dishes, right? In my family, whoever cooked, the other person did the dishes and cleaned up. In his family, whoever cooked cleaned up because they had set days. And so when I cook, I expect him to clean up, but he doesn't. And when he cooks, I expect to clean up. But I don't, so I get the best world, basically. But it's just one of those interesting examples of you need to actually have those conversations around who's going to clean the, who's going to change the diapers, who's going to mow the lawn, who's going to get the groceries, who's going to do that, and how is that going to shift when the postpartum person is spending 12 hours of their day breastfeeding a baby. And what other resources, what are the supports do you need to really bring in to help support that? And who is useful in doing that? And who is not? And who, how can you coordinate that or get somebody else to coordinate it? Yeah, no, such important things that we really don't talk about enough in pregnancy.

[00:30:53] Dr. Stephanie Ferguson: Yeah. Yeah.

[00:30:54] Dr. Alicia Power: Yeah. Awesome. Are there any other kind of, interesting tidbits that you learned, [00:31:00] things that you'd like to share with this audience.

[00:31:02] Dr. Stephanie Ferguson: I, I think the other interesting piece coming into this is looking, like we talked about it, what other countries have done around the world. And as we talked about, sometimes it comes down to funding, and we're seeing areas in which private systems are now coming in to fill in the gaps in our public healthcare system.

[00:31:21] And I think postpartum care and maternity care is a great example of that. One really interesting area that's come up and I'm just working on an article for it right now, is the system that comes out of South Korea. So in South Korea, they have traditions called the Sanhujori which are ancient traditions around moms and after childbirth, really caring for the mothers.

[00:31:40] So they in the first three to four weeks, it's expected that moms would stay at home even in the middle of summer, they wouldn't do anything that would make them cold. So they'd wear long sleeve shirts, you don't open windows, you don't lift anything heavy, they eat seaweed soup three or four times a day and then it was the maternal relatives that would care for the mom in that postpartum period. So really this cultural [00:32:00] acceptance of what we do for mom now, they believe impacts mom's health long term and baby's health as well. And then as things shifted, they came up with what's called the Sanhujoriwon, or basically the postnatal retreat. And so that's an area they now, 80 percent of women will attend these often for the first two weeks after they've delivered.

[00:32:18] And they go in, they have 24/7 nursery services, they will have, they have, they often call them kind of birth support or postpartum support. So going in to help with mental health with physiotherapy, massage, things to really get mom and dad off on the best start. And so that's been there, they now have 500 facilities. Some of them are privately funded. Some of them are publicly funded. And they really range anywhere from a thousand to two thousand dollars a night. You can have kind of the luxuries of support.

[00:32:47] And now we've started to see these pop up in North America. So the first one opened in New York City. There are a couple opening on the west coast in the U.S. and one is opening in Toronto. And they're highlighting the, they have a much different price [00:33:00] range. So most of them range from 900 to a thousand dollars a night, which are really inaccessible to the general population, but they're highlighting this gap in our postpartum care. And that women are saying, I want to be cared for. There's lots of women who say, I would absolutely love a resource like this that's going to help me get off on that start, feel confident as a mom when I go home. So we're seeing these areas start to pop up a bit more which is interesting.

[00:33:25] Dr. Alicia Power: I had a conversation with a friend of mine who's in Australia and she said with her first, she, there's these like sleep training hotels that you go to, I don't know, everybody's like desperate to get some help, so the probably like six to nine months, and you go and you stay for, I don't know, four or five nights, something like that.

[00:33:41] The first night you get a sleeping pill and your baby is just brought to you to feed if you're breastfeeding and then taken away. And the nurse is just, or the midwife, whoever runs it basically starts the sleep training process and then during the days are some educational pieces around kind of sleep training and how to do it and different options and what you prefer.

[00:33:58] And then over the next few nights, you're [00:34:00] you're now rooming in with your baby and you're doing the sleep training yourself so that when you go home, you've had a few nights of decent sleep and you have a pretty much sleep trained baby, which is so fascinating, right? Because it's such a challenging time for people that sleep training piece as well. And there's so much information out there. And am I going to do it the right way? Am I doing it the wrong way? The cried out method or the gentle method? What do I choose? And just having extra support around that and the education piece from a trusted resource can be incredibly powerful and somebody doing it for you. Yeah, it's also very lovely.

[00:34:32] Dr. Stephanie Ferguson: Yeah. And these hotels, there's the luxury end of them. And that's lovely for those who can afford them. We also as a healthcare community have the ability to provide this sort of care. So we have nurses, we have midwives, we've got OBs and family doctors, mental health counselors, we can do all of that. We need to figure out how to do that, where we can work together and provide that in the community for women in a way that is accessible that that is something that all women can reach out to. So I think there's programs that are starting to do that on different [00:35:00] levels, but hopefully we can continue to all work together to figure out how to make it, it work for everyone.

[00:35:05] Dr. Alicia Power: Awesome. Thank you for joining today. We talked a little bit about maternal mortality and that it's going up. And also maternal morbidity and that we can actually make some changes to help decrease both of those numbers. We talked about what patients are thinking and feeling about postpartum care and how varied that is across the country and even in provinces and communities and some of the struggles around that.

[00:35:28] And then we chatted about some different programs that you've found, which are really interesting and some great opportunities to learn and grow as communities. And a reminder to anybody, the best way to advocate is to write letters to your MLA. Write letters to the government because they make all the financial decisions and as we talked about a lot of the way that we as health care providers provide care is based on funding that we can access or can't access and that is also very different across the province, provinces as well and so if you feel like your [00:36:00] care is substandard, not adequate, wasn't what you hoped for, don't blame the care provider necessarily. It's usually a systemic thing and that we are all struggling to do the very best we can with limited resources. Advocate for better funding models for the care of women and children, basically. And how do we support that? Yeah, moving forward. So exciting. Thank you for talking. Thank you for coming and joining and having this conversation. It was lovely and it's inspired me. I've got some ideas percolating now. Yeah.

[00:36:28] Dr. Stephanie Ferguson: We will chat more about them then.

[00:36:30] Dr. Alicia Power: Awesome.

[00:36:31] Dr. Stephanie Ferguson: That sounds good.