An illustration of a couple on a couch, with a bearded man looking down at credit cards in his right hand, and a pregnant woman lying next to him.(Illustration: Myriam Wares)

Why More Canadian Women Are Giving Birth At Home—Without Maternity Care

When medical care is too far and difficult to reach, some rural Canadians are turning to unassisted home births for lack of a better option.

In the wee hours of March 27, 2018, Nena Martens thought she might be in labour. She had given birth four times before and knew she probably didn’t have much time. So she called her mother, who was asleep, to come look after the kids. She called her husband, who was halfway through a night shift as a logger, and told him to meet her at the hospital. Then she got into her car and drove herself, contractions and all, the hour from her rural home in Altona, in northeastern British Columbia, to the town of Fort St. John, the nearest place that had a hospital.

By the time she got there, however, her labour had stalled. The medical staff checked her out and chided her for coming in early. The couple got a few hours’ sleep in a nearby hotel, checked back with the hospital in the morning, then were sent home.

“I was really upset at myself,” Martens recalls. Her husband’s lost work, her mother’s lost sleep, the money squandered on a hotel—and still no baby.

Two nights later, when the contractions started again, she sat quietly in her living room. Her husband had gone to sleep early that night, feeling sick, and she had put the kids to bed herself. But the signs of labour were now undeniable. At about midnight, she made a call to the hospital, but they were so busy they accidentally hung up. Thirty minutes later, she called again, but because her water hadn’t broken, her contractions were still seven minutes apart and she was able to talk calmly on the phone, the nurse advised her to give it more time.

Martens wasn’t so sure. At 12:40 a.m., she called her mother to come over. At 12:45, she woke her husband and told him to warm up the car. At 12:50, when he came back in for her, she told him they weren’t going to make it.

“I wasn’t afraid,” she says. “I knew I would be happier at home. I knew I wouldn’t feel like I was putting anybody out.”

She draped herself over the kitchen table for a few minutes and then she found her way onto her hands and knees. Her husband calmly brought towels. She lay down. With a couple of pushes, the baby was born. Minutes later, her mother arrived.

“It was all serene, quiet. There was no beeping, there was no doctor calling orders to nurses. My husband did everything quietly. And then my oldest son came out of his bedroom and he could see the glow in the kitchen. And he came in with these huge eyes. And he said, ‘A baby!’”

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According to Statistics Canada, as many as 5,000 rural women give birth without medical assistance every year. We know the reasons vary. Some, like Martens, don’t make it to the hospital. Others are more deliberate. “Freebirthers,” for instance, believe that birth is a natural process that needs no medical intervention at all. Others have had traumatic or demeaning experiences in hospitals and are looking for a kinder, more respectful way to bring a new life into the world. Many who don’t want the hyper-medicalized hospital experience would still prefer skilled assistance, but they find there are no midwives in their area. Still others simply can’t afford the time or money to get to faraway care.

“I’m actually philosophically very supportive of people who are informed of the risks and choose to have an unassisted home birth,” says Jude Kornelsen, a health services researcher at the University of British Columbia in Vancouver, who focuses on rural health care. But she also knows that while most presumed low-risk births go just fine, never needing any special intervention, about 15 percent do run into trouble, according to her research. The mother could hemorrhage, for instance, or the baby could have trouble breathing.

Martens and her husband, as it happens, did end up going to the hospital the night their baby was born—to get help delivering the placenta.

Another woman I spoke to in the Fort St. John, B.C., area, Elly Hamilton, had her first two kids in the hospital, but decided to go it alone for the third and fourth. The hospital had changed the way it managed pregnancies—a specific doctor no longer followed the pregnancy from start to finish, but rather patients were seen by whichever doctor was working that day—so care felt impersonal.

Hamilton’s third child was born in the bathtub, her fourth in a large rubber horse trough that she and her husband had sanitized, lined and brought into their living room. Hamilton describes her last unattended home birth, in 2020, as “the most divine thing I’ve ever experienced in my life.” Still, when the bleeding wouldn’t stop, they called an ambulance.

But many rural birthers live a precarious distance from skilled care. In some locations, an ambulance isn’t an option. Some are several hours away by road. Some are separated by water and rely on ferries. Others live in fly-in-only communities. In all these scenarios, fog or snow or ice can delay a trip by hours, sometimes days. And what all practitioners know is that low-risk births can become high-risk births very suddenly and unexpectedly.

It’s because of this uncertainty that some midwives in Canada do not typically attend home births if they’re more than 30 minutes away from a hospital. So, where there are no hospitals, there are no midwives, either. That leaves birthers in remote regions with pretty stark options. What they are advised, in fact, is to head out of their community a few weeks before the due date to the place they want to deliver and sit tight until the baby comes.

That may be fine if you have relatives who can put you up, but for most folks, it’s a major challenge. It means paying for weeks of accommodations. It means taking extra time off work. It means being separated from your community and family members—your mother or your spouse or your older children—during one of the most important events of your life.

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That was the situation Winter Kaczmarek faced a few years back, even though she lives in Red Lake, a gold mining town in northwestern Ontario that has an 18-bed non-surgical hospital. She had her first baby there, although it meant no epidural and a medevac out if something went wrong. “I wanted to be able to have my mom [there],” says Kaczmarek. “But she owns a business and she would not be able to just leave and come with me out of town.”

Her second baby, born in 2013, was breech, however, so she opted to go to Winnipeg, a six-hour drive away. A few weeks before her due date, she drove there for a consult with the obstetrician, and he told her she should probably stay in town until labour started. Alternatively, he said, he could do a C-section the next day.

She had wanted to try to deliver vaginally again, but now she had a difficult calculation to make. Vaginal birth meant sitting in a Winnipeg hotel, waiting for the baby to turn. Kaczmarek would either be alone there for weeks, with no means of transport (she doesn’t drive), or her husband would have to stay with her and lose work. Someone would have to look after their daughter, too, who was about to start kindergarten.

Pull quote: “Many rural birthers live a precarious distance from skilled care. And low-risk births can become high-risk birthers very suddenly and unexpectedly.“

“Who has money to sit in Winnipeg for two to four weeks?” she says. Ontario offers travel grants for medical trips like this, but it wouldn’t come close to covering all the costs.

In the end, it came down to money, says Kaczmarek: “I had a C-section to save costs.”

When Kaczmarek was getting ready to deliver a third time, in 2018, she wanted to do what’s known as a VBAC—vaginal birth after C-section. The recovery from her C-section had been worse than she’d expected, and the long drive home with an incision, a blood clot risk and a newborn had been miserable. But because of the risk of a uterine rupture, the Red Lake hospital told her that she could not deliver there. By this time, Dryden, Ont., a community two and a half hours away, had a general practitioner who had special training in delivery, so Kaczmarek decided to give birth there.

That decision wasn’t cheap, though. She stayed at the Best Western, which was about $130 a night. Her husband, a miner, took time off work to be with her. Because her doctor was not technically a specialist, Kaczmarek was not eligible for a travel grant.

It was winter, and slippery outside, so she spent her time walking the halls of the hotel or dipping her feet in the hot tub. Seven days into their stay, worried about money, she started packing up to leave. “I was starting to get stressed out about the cost,” she says. A few hours later, however, her water broke, and not long after that, the baby was born, beautifully, in the Dryden hospital.

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The cost of getting out-of-community care is a major concern for many rural Canadians, says Kornelsen. Depending on how far you travel, how long you’re away and where you stay, expenses can run into the thousands of dollars.

In the course of her research, Kornelsen has come across many stories from rural birthers facing no choice but to have an unassisted birth. One woman had pre-eclampsia, a dangerous pregnancy condition that involves high blood pressure. She had to leave her rural B.C. community at 35 weeks and travel four hours to get to specialist care, and then there were complications after the birth. She and her partner lost their home as a result.

Many of Canada’s rural birthers are Indigenous. In a 2009 study focused on maternity services in Vancouver Island by the Centre for Rural Health Research, one woman told of taking a loan from her employer to pay for her birth travel and then having to forego maternity leave so she could work to pay it back. Another, five days after hemorrhaging and getting four blood transfusions, took the bus and ferry home—a 10-hour trip—rather than flying, in order to save money. Some Indigenous mothers-to-be fundraise with bake sales, flea markets and bingo to afford to get to the nearest hospital to give birth.

An illustration of a baby being birthed into a body of water, surrounded by hands of loved ones (Illustration: Myriam Wares)

Kornelsen is especially concerned, though, by people who want maternity care but can’t afford to get to it. One single 23-year-old, for instance, had her fourth child without medical assistance. When Kornelsen asked the woman why she’d decided to do that, the woman replied that it hadn’t been a decision—she’d simply had no choice. She would have had to drive three hours to deliver, but she had three other young children at home and couldn’t find anyone to look after them. She didn’t have money. So she gave birth unassisted, with a few friends by her side.

Going elsewhere to give birth is not just financially challenging, but emotionally challenging, too. Health care workers sometimes do inductions just so the patient doesn’t have to wait as long, according to a study of birthing in Vancouver Island’s north. That research also found that many Indigenous women who leave the community to wait out the birth return early because of loneliness. “I got called into the hospital in the middle of one night when I was working acute care,” one health care worker told the researchers. “We had a mom who was First Nations who had been sent down [to] Island to have her baby, but she’d hitchhiked back home [to]. . . . She delivered 11 minutes after arriving at Port McNeill hospital. . . . That happens very frequently.”

There is also plenty of evidence that making birthers travel long distances leads to worse outcomes. According to research on maternity services in rural B.C., if you have to travel more than one hour, your chance of a roadside delivery goes way up. More than two hours away, and you have a higher risk of your baby ending up in intensive care. If you have to travel more than four hours from your home community to where you give birth, there is a more than three times greater chance your baby will die.

Faced with all the financial, emotional and physical burdens of leaving, many people decide to just stay put. Says Kornelsen: “All of a sudden, it doesn’t seem so crazy.”

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About a fifth of all Canadians live in rural settings, and many of the birthers among them aren’t getting the maternity services they deserve. Over the past 20 years, says Kornelsen, many rural birthing services across the country have closed. That’s partly by design—several provinces have adopted a centralization mantra—but also due to staffing challenges. Red Lake’s hospital, for instance, told me they haven’t been able to provide birthing services since August 2022, because they can’t get enough doctors.

Kornelsen and her colleagues have developed a “rural birth index” to calculate the need for maternity services in specific catchment areas. She has proposed using three criteria: number of pregnancies and births, distance from an emergency C-section and social vulnerability of the population. Some regions, like Haida Gwaii, B.C., may not have many births, but are hours from an operating room.

No one is arguing for high-tech surgical suites in every tiny outpost. But there are innovations that would help at least some rural communities—like more family doctors with the surgical skills to do C-sections. In a 2019 consensus statement, the Society of Obstetricians and Gynaecologists of Canada came out in favour of this. “Their outcomes are great. They’re very safe,” says Kornelsen, who has just finished an analysis in B.C.

Family doctors with these “enhanced surgical and obstetrical skills” are already being deployed in Western and Northern Canada, says Kornelsen. “They’re the solution for the small communities who don’t have enough deliveries to support a local obstetrician.” Where there is local access to C-sections, she says, about 80 percent of the community can birth locally, either with doctors or with midwives. Where there is not, only about 30 percent can, and only with doctors.

The other part of the solution, she says, will be midwives. “They’re very comfortable in a low-resource environment,” Kornelsen says. “They know how to detect problems before they get too big.”

Kelly Graff, a midwife based in Kenora, Ont., and one of few midwives in northwestern Ontario, agrees. About one-fifth of the births she attends are out of hospital; her practice prioritizes them. When home is too far away, she invites clients to give birth in an Airbnb or in the midwifery clinic.

Rarely, her patients have said they’re having a home birth whether she’s there to help or not. Most of the time, her patients “realize that there’s a lot of value in having this person who knows what they’re doing, who brings anti-bleeding drugs, who brings all the resuscitation equipment,” she says.

Hamilton, the woman who’d rigged a horse trough for her delivery, had originally been excited by the news of new midwives in Dawson Creek, B.C., an hour from where she lives. But she was dismayed to learn that the Fort St. John hospital would not allow the midwives to work there, which meant they couldn’t assist her in delivering at home. She saw the midwives for prenatal care for her third pregnancy—“I kind of liked having one little toe in the system still,” she says—but since she insisted on a home birth, and they couldn’t be there, they cut ties around 38 weeks. (Hamilton is now a freebirth advocate and consultant.)

Graff does not support unassisted home birth—she thinks it’s too risky. “I understand why someone may be led to think that might be a good option,” she says. “But I don’t think it’s a safe option.”

For Kornelsen, birthers in rural parts of the country must remain a priority for health care practitioners. “We need a rational approach to planning where maternity services are going to be,” she says. It’s time to provide birthing care where birthers need it.