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Danielle Crittenden - Wall Street Journal - March 31, 1994 (Ms. Crittenden recently moved back to her native Toronto) ---------------------------------------------------------- Recently I spoke to a friend who had given birth to her second child a week after I did in November. My child's birth was covered by private insurance in New York; my friend gave birth here, under Canada's much-lauded, state-funded, universal health care plan. "Did you have an epidural?" she asked suspiciously, referring to the local anesthetic injected into the lower spine, a common painkiller for childbirth. "Of course," I said (neither of us romanticize the pain of "natural" labor). "It was wonderful. My husband and I played Scrabble in the birthing room right up until I had to push. I won," I added. A cold silence. "How did yours go?" I asked. "It was awful," she said bitterly. "When I got to the hospital, I asked for an epidural. The nurse said I had to wait - there were three people ahead of me. Soon, I was feeling sick with pain. The nurse told me to take a hot shower. I couldn't stand it anymore, and begged for the anesthetic. It still wasn't my turn. I was rocking back and forth in agony. Then the doctor arrived and said the baby was coming out and it was too late for anything. Afterward he apologized o me - he said I looked in terrible pain and it was horrible to watch." It seemed astonishing to me, listening to my friend's story, that in late 20th century North America a woman would have to give birth the old-fashioned way - in pain. It's true incidents like this do sometimes occur in the U.S., yet in Ontario - Canada's richest and most populous province - government control of medicine has made the exceptional the norm. My friend, who is an editor at a national magazine and married to a partner in a major law firm, give birth at St. Michael's, a bustling central Toronto hospital. The hospital's head of anesthesia confirms that from 4 P.M. to 8 A.M., as well as on weekends and holidays, there is only one anesthetist on duty for the entire hospital; for traffic-accident and burn victims, everyone. If he's busy, tough luck. St. Michael's isn't unique, either. I checked with other large hospitals in the city. Few had more than a single anesthetist on duty off-hours. At North York General, in the midst of Toronto's most affluent suburbs, 3,500 babies are born a year, 60% of them to women who request epidurals - and there is still only one anesthetist on duty off-hours. Outside of Toronto, the situation is even worse. Ontario's socialist government, desperately seeking to control its runaway health budget, has announced that epidurals will no longer be available to women in Thunder Bay, a community of 125,000 in the northwest of the province. Thunder Bay women needn't feel picked on. According to Richard Johnston, a spokesman for the Ontario Medical Association, the availability of epidurals is sporadic everywhere outside Toronto, because few small hospitals have the budget for anesthetists trained to give epidurals, especially during off-hours. Many women end up going to their general practitioners for delivery and doing it "naturally," whether they like it or not. Apologists for the Canadian health system blame greedy doctors for its chronic shortages and queues. But an Ontario doctor receives only US$100 to administer an epidural. His U.S. counterpart usually collects about US$1,000 (a figure that, unlike the Canadian, takes into account overhead and equipment). Epidurals are vanishing from Ontario, not because doctors are overpaid but because hospitals' fees per birth are capped at very low rates by a debt-burdened government. And, as many argue would happen under the Clinton health plan, it is illegal for either the doctor or the hospital to charge even willing patients more than the state-prescribed fee. The result? As Dr. Johnston says: "In the case of an anesthetist trained to give epidurals, it is not lucrative for him to offer his services all night. Why bother staying up, if you don't get paid extra for it?" Some American women have already gotten a whiff of the cruelties of Canadian medicine. In California, the Midwest, and Florida, according to Nancy Oriol, director of obstetric anesthesia at Beth Israel Hospital in Boston, some large HMOs refuse to pay for epidurals unless a patient has a medical condition thought to warrant it, such as a history of heart disease. And of course it is the intention of the Clinton health plan to drive ever large numbers of Americans into HMOs. My friend did have one choice that the users of HMOs do not - the freedom to choose her own doctor. But her choice was an empty one. For while she might pick an obstetrician, she had no way to be sure that he would in the end deliver her baby. Most Canadian obstetricians now work in groups, and a patient gets whichever of them happens to be on call at the time she goes into labor, or the intern on duty at the hospital (again, why bother to work late ...). Further, few Canadian doctors can afford to have ultrasound machines or other sophisticated machinery in their offices. Those tests have to be booked weeks in advance. My New York doctor, on the other hand, was there for me at any hour, even for a false labor at 2 A.M., because he is an old-style fee-for-service man. He also had an ultrasound in his examining room. In the end, my friend's baby was delivered by her family GP, because he promised to be present. Pregnant women, of course, are not the only Canadians suffering as provinces across the country seek to hold down health care costs. Americans are by now familiar with tales of Canadians queuing for heart bypasses and chemotherapy, or crossing the border for surgery. But what my friend's nasty experience reveals is that the system can no longer cope with an event as straightforward as birth. It is as if medical practice in Canada is reeling backward in time; in the case of birth, as much as a century. As part of this drive toward ever more primitive medicine, the Ontario government has set up three free-standing "birth centers," staffed by midwives. It is hoped that these centers, so much less costly to run than high-tech maternity wards, will attract "low-risk" pregnant women away from hospitals. Midwifery became a licensed profession in Ontario last year. These graduates of a three-year community college program will earn, on average, as much as $300 more per birth than obstetricians (who are paid $250 per delivery, and $18 per pre- and post-natal visit). The government has committed $8 million to the program. The ministry of health claims that its sudden munificence toward midwives is all the in the spirit of promoting "choice" for women. But given the difficulty women who do not want to suffer pain in childbirth face in exercising their right of choice, the gesture smacks of cynicism. It is health bureaucrats who are making the real choices. They have decided that epidurals are an "elective," even an extravagance, and that women who anticipate normal labors should have their babies without anesthesia, and better still, in someplace other than a costly hospital ward. You might expect that Ontario's anti-anesthetic policy would face charges of sexism. No one is suggesting, for instance, that men have hernia surgery without painkillers, under the knife of a "caring professional" who did not graduate from med school. When the American College of Obstetricians and Gynecologists last year found out that some U.S. insurers were refusing to pay for epidurals, they issued a report pointing out "there is no other circumstance where it is considered acceptable for a person to experience severe pain amenable to safe intervention while under a physician's care." But in Canada, the very feminist groups who ought to be outraged by the policy have, in fact, lobbied for it. These organizations have long complained about the male-dominated medical profession, its insistence on delivering babies in sterile hospital facilities, it enthusiasm for technology. One of the most important local advocacy groups is even proposing that five maternity wards in Toronto be shut down once the midwife program is up and running. A free-market health system, including one with HMOs, might not include insured epidurals; but it might create a relatively undistorted market in which people are to purchase this procedure themselves. A health system that is run by politicians is, however, subject to political pressure. This is especially true when a group's ideologic agenda coincides with the government's need to save money. In this instance, it actually puts women and their babies in the sort of danger and pain they have not known since their great-grandmother's day.