About a dozen pregnant women check their own blood pressures and weights and record the results as they arrive at Apple Tree Maternity in Nelson for a group session.
They greet each other, chat with childbirth educator Anna Colin, and settle on chairs and couches in a big circle. Some of them know each other, some have a male partner with them, one has a toddler, and a visiting former member of the group brings her three-month-old, a handsome young man who immediately upon arrival becomes the centre of attention .
The subject this evening is the stages of labour. In small groups and one large one, they talk about what they expect will happen in labour, and Colin discusses, clarifies, and teaches.
Homey and professional
Like the atmosphere of the maternity centre itself, Colin’s approach is both homey and professional. The group discussion is relaxed and focussed.
Before the class, and part way into it, individual women leave the group and go into an office with midwife Ilene Bell for their “belly check.” This is part of the personal care they have all been getting at Apple Tree since early in their pregnancy.
Bell, one of the founders of Apple Tree, has been delivering babies in the Kootenays and advocating for midwifery here since the early 1980s.
“We check on how she is doing in general,” Bell says. “We ask if there are any concerns she has about herself or the baby, we check the growth of the baby, listen to the fetal heart, check on any testing or medications she might need. If there is a major concern we would schedule her a longer visit in the office in the next couple of days.”
Group support
Bell says sometimes if a woman has a concern that might be of general interest, the question is taken out to the group and answered there, creating a unique mix of individual and group learning.
“Naturally enough, it usually turns out that others have been wondering about the same thing,” says Bell.
Sometimes the concern might be about a decision the woman has to make about the pregnancy or birth, and discussions about that in the larger group can be powerful, says Bell.
“It is a decision made in community, rather than being left alone with it. We think that is really important.”
“It is super supportive,” says group member Ellen Beaudet, who is pregnant with her first child, pictured here with her partner Arthur Riediger. “It’s just full of information, with the check-ups through your pregnancy, the groups they offer, and the feeling of not being alone.” Bill Metcalfe photo
Seamless care
The person doing the individual consultations that night was a midwife, but on another day it might be one of Apple Tree’s two doctors. Also under the same roof are childbirth educators, doulas, breastfeeding experts, and counsellors.
“Having it integrated like this is comforting for the family when issues arise,” says Bell. “All of us know you, we can take care of you right here, and we have the information we need right here. It is seamless care.”
At Apple Tree, pregnant women may choose to receive prenatal and postpartum care in a one-on-one and/or group setting. In the first 20 weeks of pregnancy all women will attend individual visits with a care provider (midwife and/or doctor) and then they can also choose to come to the group sessions as well.
They also have access to other support programs including breastfeeding support. They remain in care for six weeks after the birth, including a home visit from their doctor or midwife after the birth of the baby.
"I like building this relationship with the people who will be there on your birthing day," says Justine Howells, who is pregnant with her first child. "I can ask any questions I want and everyone in the group is very comfortable and open about their own experience." Bill Metcalfe photo
First in Canada
Bell says this kind of integrated maternity care clinic is the first in rural Canada. And she says Apple Tree has progressed to the point where it provides care for two-thirds of the approximately 300 births in Nelson per year.
The relationship between doctors and midwives has not always worked well in rural areas even though midwives have been government- licenced and formally trained in Canada for 17 years. Bell says doctors and midwives tend to have different perspectives.
“For example, midwives have a background in offering choice of birthplace and we have been doing home births in this area for decades, whereas the physicians have not, it is not part of their training. It is only very recently that they have been allowed to attend home deliveries, so now they are allowed to but they have no training.
“So our doctors have been working with us to develop a level of comfort with that. We are training them.
“On the other hand, they have a wealth of expertise in areas that are peripheral but important, because women have issues sometimes that are not specifically obstetrical.”
A doctor’s perspective
Dr. Jeanette Boyd works at Apple Tree in addition to having her own family practice in Nelson. She says there is no hierarchy at the maternity centre.
“We (midwives and doctors) work collaboratively, we share care, we are peers. We all have the same philosophy of care. That is an unusual thing for a rural area. It may be a relevant question in other communities, but here it is the norm, and we are very fortunate for that. I have learned so much from working with the midwives, I am inspired by their dedication in terms of natural birth and support.
“What is different about this,” Boyd adds, “is the shared prenatal care, where we care for the same group of women in the same way.”
Travelle Ellis has attended the group before and after the birth of her son Yaheem. Bill Metcalfe photo
Collaboration is the key
Collaboration between doctors and midwives comes in many forms, says Bell.
“For example, people with thyroid issues must be monitored closely during pregnancy,” she said. “Midwives don’t prescribe for thyroid issues but doctors do, but being able to do it within the group is better for the woman because she can have everything in one place.”
And she says that in cases of premature births, where the woman has already been in the group, having a doctor’s advice and care while she is still in the group is very helpful. And when they come to the group with their babies, as has happened several times, “it is marvellous for the other participants — inspiring, exciting, educational — lots of appreciation and support from the group.”
Much of Bell’s approach to her work is about community building: communities of parents and families, communities of care providers. But for her, and for Dr. Boyd as well, it is also about sustainable health care.
Sustainable health care
“Team based care is where we need to go in terms of sustainable health care in rural communities,” says Boyd. “The old fashioned concept of the well-rounded family physician who would be available 24/7 is not possible given the complexities of our health care system. Our capacity and knowledge base has expanded so much in the past 20 or 30 years that it is not physically possible to do that. So I feel I am able to give that individualized attention because I am working in a collaborative team.”
She says the women in Apple Tree’s care recognize the benefits of it.
“They love the communication and the robust team working for them,” she says.
Open House
Apple Tree Maternity is having an open house on Friday, September 25, at 4:30.
It’s for past and present families, the centre’s professional colleagues, and the public, to celebrate Apple Tree’s first year.