 Danielle Crittenden - Wall Street Journal - March 31, 1994
(Ms. Crittenden recently  moved back to her native  Toronto)
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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.
