Nursing in Nunavut

June 2009   Comments

In this second part of a two-part series, writer Sue Cavanaugh takes a closer look at what Nunavut's mothers-to-be can expect when they're expecting, and how nursing professionals across

Canadian Nurse would like to thank the Nunavut Department of Health and Social Services for their generous support of this feature. 

Great expectations in prenatal care

Nunavut has the highest birth rate in the country. Although each of its health centres is equipped with an obstetrical birthing pack, women in labour, and even those who might be, are medevaced out of their community. The birth rate ensures that nurses have lots of contact with pregnant women. This is especially true for community health nurses; as the primary health care practitioners in most communities, they provide the majority of prenatal care.

Depending on where they live, mothers-to-be go either to their main regional centre or out of the territory altogether to give birth. The standards differ slightly from region to region, but women are generally expected to leave their communities at 36 weeks to move to a special residence or hotel near the birthing facility. And since predicting labour is not an exact science, this “boarding-in” phase can last for a month or more, during which time many women are separated from their families. It can be particularly hard for those who already have young children at home.

One of the two birthing centres in the territory is at Qikiqtani General Hospital in Iqaluit. For more than 35 years the hospital has provided labour and delivery services to women in the Baffin region. With more than 400 babies delivered there last year alone, it is a busy unit. A new facility, opened in 2007, includes four birthing rooms and a nursery, although mothers are encouraged to keep their babies in the rooms with them. At less than eight per cent, the hospital’s C-section rate is the lowest in the country, and if they are otherwise categorized as low risk, women who have previously had C-sections can choose to deliver via VBAC, with surgical backup available if necessary. Very few women in Baffin have to leave the territory to give birth; when they do it’s because they’re considered high risk — for example, if pre-term labour begins at less than 33 weeks’ gestation, or if they’re carrying twins or multiples.

Great expectations in prenatal care/Nursing in Nunavut Part II (Photo: Design Pics/Jupiterimages)

Births at Qikiqtani General generally involve fewer interventions than hospital births in the south. Inuit women often don’t even arrive at the hospital until their labour is well under way. One nurse explains the low-key nature of the experience: “Women aren’t strapped down to a machine; they’re walking around doing their own thing. We check the baby’s heart rate and vital signs, but otherwise it’s very hands off. When they’re ready to push, they let us know. It’s very calm, an amazing thing to watch.”

Rankin Inlet’s birthing centre is staffed by midwives. The local Inuit population lobbied to bring them to the region to give women the option of staying there to give birth. Midwifery is not a regulated profession in Nunavut, and the Kivalliq region is the only one with midwives at present. At one time, communities in the Northwest Territories had British-trained nurse-midwives working in their health centres, enabling women to stay home to give birth. However, changes in regulations and immigration laws saw those nurse-midwives disappear by the mid-1960s.

More than 600 deliveries, with not a single case of maternal or infant mortality, have occurred at the birthing centre in Rankin Inlet since it opened in 1992. A University of Manitoba audit in 2005 found that the centre had consistently provided safe maternity care. About 20 per cent of the 250 births per year in the region take place at the centre; the remaining 80 per cent of the women choose to go to Winnipeg or are sent there because they are at high risk for complications. The midwives and community health nurses encourage those at low risk to stay in the territory and give birth in Rankin Inlet, and although the numbers are still relatively low, they are growing each year.

Arviat, Kivalliq’s largest community, boasts the highest birth rate of any community in Canada, but women have to go to Rankin Inlet or Winnipeg to give birth. These flights represent a third of the cost of all medical travel in the region; even a low-risk delivery costs the health system $12,000. Norm Hatlevik, the Department of Health and Social Services executive director in Kivalliq, would like to see a birthing centre in Arviat modelled on the one in Rankin Inlet; families would not have to be separated and there would be huge savings to the health system.

Cambridge Bay, the regional centre in Kitikmeot, has no birthing centre, and pregnant women are sent to Yellowknife or Edmonton. The region is currently looking at the time frames set for leaving communities, with the idea that low-risk mothers could be assessed on a case-by-case basis instead of automatically being sent out at 36 weeks. Cambridge Bay has been identified as the next site for a birthing centre, with midwifery services targeted to begin later this year.

Great expectations in prenatal care/Nursing in Nunavut Part II (Photo: Department of Health & Social Services))

The government has passed a new Midwifery Profession Act (regulations are pending) and a maternal and newborn health-care strategy is currently being developed, but there are concerns that it may be difficult to recruit enough midwives, given the fairly small number of them in Canada. To date, 10 Inuit maternity care workers have graduated from the Maternity Care and Midwifery Education Program at Nunavut Arctic College; two graduates have gone on to become midwives. This unique program teaches traditional Inuit practices and western medicine.

The fetal fibronectin test is a tool used in many communities to reduce unnecessary early travel. Fetal fibronectin is a glycoprotein that resides in the lining between the placenta and the uterine wall. In a normal pregnancy the protein stays put between 25 and 35 weeks; it does not appear in vaginal secretions. If it does appear during this period, it is an indicator that labour might begin sometime in the next seven days.

The default management mode for suspected pre-term labour was to immediately medevac women at 32 weeks or less gestation who had any vague signs or symptoms of labour. Community health centres are not equipped to deal with premature babies, and the potential for severe morbidity and mortality meant that the threshold of when to call the medevac is very low.

An interprofessional pilot project that began in 2004 introduced fetal fibronectin test kits in four health centres and at the hospital in Iqaluit. The test consists of a simple vaginal swab that is placed in a processor; results take about 30 minutes and are an easy-to-read positive or negative. If the test is negative, the chance of a woman going on to deliver the baby in the next seven days is about 0.4 per cent. Dr. Sandy MacDonald, director of medical affairs at Qikiqtani General, headed up the project: “All other things being equal — no cervical dilatation, no painful regular contractions — a negative test is one more reassuring piece of evidence.” Nurses and other clinicians used the test to help them determine whether women were truly in pre-term labour.

After two years, the results showed that there had been no false negatives and uptake among clinicians was good. The project team reviewed charts and estimated that the tests had saved up to 20 unnecessary medevacs. Nurses reported feeling confident using it and felt it helped them to make good clinical decisions for their patients. Based on that response, the test kits were put into most health centres across the territory. The cost per test is $100, but well worth it when compared to the cost of a medevac flight. Between 2004 and 2007, more than 160 tests were performed across the territory, leading to savings estimated at several hundred thousand dollars per year.

MacDonald and his team at the hospital have since partnered with researchers from the University of British Columbia and the University of Ottawa in a new project. They are investigating the use of the test as a predictor of when women who are between 36 and 40 weeks’ gestation will go into labour — would the absence of the protein reliably predict the absence of labour over the next seven days. If so, the test could be used to help women stay home later in their pregnancies.

The research project will follow 20 women who are between 36 and 40 weeks and are in Iqaluit waiting to give birth. They are tested every other day, and tracked to see when the test result goes from negative to positive — and when their labour begins. The tests are purely for collecting data and are not being used as a management tool or in making decisions. If the results look promising, the researchers want to expand the project to multiple sites and follow at least 100 women to get a clearer data set. Preliminary results are expected to be released this summer.

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