Tag Archives: pregnancy

Philippe Barrette is a psychotherapist, workplace facilitator and former Assistant Clinical Professor at McMaster University, Department of Psychiatry.

David Streiner is Professor Emeritus in the Department of Psychiatry and Behavioural Neurosciences, and the Department of Clinical Epidemiology and Biostatistics at McMaster University; and Professor of Psychiatry at the University of Toronto.



Halfway through, Roma, the 2018 award-winning film set in the early 1970’s, the audience is suddenly confronted with witnessing a stillbirth. The scene elicited audible gasps from some viewers in a screening we attended, when the perfectly formed, dead baby was removed from its mother’s womb.

In the film, Cleo, the nanny and domestic worker for a middle-class family living in Mexico is rushed to hospital following an emotionally draining 9 months. Cleo’s boyfriend abandoned her shortly after learning of her pregnancy, and the family have endured marital tensions and a separation.

After an initial examination the assisting physician at the birth says, “I can’t hear a heartbeat," ...continue reading

Dr. Diane Kelsall, deputy editor, interviews Dr. Jason Stull, veterinarian and Assistant Professor at Ohio State University. Dr. Stull has co-authored a review article published in CMAJ. The authors say that health care providers should counsel patients regarding safe pet ownership, particularly those who are pregnant or who have altered immunity, and families with exotic pets and very young children. Stull and colleagues’ review of pet-associated infections provides practitioners with the tools to do this. ...continue reading

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pic3Alison Bruni is a resident in Family Medicine at the University of Toronto


“We’re so relieved that our child will be healthy.”

A pair of expectant parents voiced this sentiment in their family physician’s office after receiving normal amniocentesis results. Of course, this is a natural response to testing; all parents want their child to be healthy. However, there is grave misunderstanding inherent here: our prenatal screening and diagnostic tests are not infallible, and parental expectations for a “perfect” child, even given normal results, are unrealistic. As health care providers, we play a vital role in clarifying these misunderstandings. Providing comprehensive and balanced information about prenatal testing not only benefits our patients, but also our society at large, including the people who live with the conditions we test for. ...continue reading

Dr. Moneeza Walji, editorial fellow, interviews Dr. Angel Petropanagos, postdoctoral fellow at Dalhousie University in Halifax. Some women who anticipate fertility decline due to the natural aging process may now choose to freeze their eggs to preserve their future fertility. Dr. Petropanagos discusses the benefits, risks, ethical concerns and societal implications of this practice to provide family physicians with the tools to offer balanced information to clients who seek it. Dr. Petropanagos has co-authored an analysis article with Alana Cattapan MA, Françoise Baylis PhD, Arthur Leader MD, published in CMAJ.

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Brennan photoMadeline Brennan is GP Research Registrar at the Department of General Practice and Primary Care and Centre of Public Health, Queen's University, Belfast

Margaret Cupples is a general practitioner and professor at the Department of General Practice and Primary Care, Centre of Public Health and UKCRC Centre of Excellence for Public Health, Queen's University Belfast, UK.

Editor’s note: This post is based on a presentation to the Association of University Departments of General Practice in Ireland, at Queen’s University, Belfast.

As a GP research registrar embarking on developing my first research project, I didn’t think I was going to change the world, but I hoped that I could, perhaps, influence a few. Obesity is a major global problem and maternal obesity is rising in addition to that of the general population. My aim was to change the health behaviour of the expectant mother. ...continue reading


sarahCSarah Currie is a medical copy editor on CMAJ


Rhonda and Gerry Wile’s journey to creating their family is documented on their personal blog and in Leslie Morgan Steiner’s new book, The Baby Chase.

Rhonda and Gerry met and married in their late 20s. Like many women, Rhonda had dreamed of a future in which she would be a mother. Unfortunately, Rhonda discovered that she had an uncommon medical condition that resulted in infertility: although she had two vaginas and two uteruses, and could easily become pregnant, the small size of each uterus meant that all of her pregnancies would result in miscarriage. The Wiles could be included in the 16% of Canadian heterosexual couples affected by infertility.

Infertility is increasing in Canada, as it is elsewhere, and it can be a heartbreaking, isolating and depressing diagnosis. More and more couples who want to start their families are forced to make some very difficult choices as to how far they are willing to go to create a baby. For the Wiles, those choices took them thousands of kilometres from home.

Couples like the Wiles have four options for dealing with infertility: remaining child-free, seeking fertility treatment, pursuing adoption, and surrogacy. According to Morgan Steiner, about 50% of couples will choose to remain child-free and not seek other options. The remainder who choose to continue on the path to parenthood must navigate some very murky waters. ...continue reading

Domhnall MacAuleyDomhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK

Recognising achievement is important. A Fellowship ceremony at a Royal College marks the beginning of a career in a chosen specialty but it also bookends a difficult period of intense study, commitment, and sacrifice. It was a privilege to witness this milestone as a new wave of young doctors shared their pride and pleasure with friends and families. They are the future of medicine.

The academic procession of almost exclusively older men, predominantly grey haired and in elaborate academic robes, added gravitas to the occasion. But, I also wondered to myself what they might think of the changes in a profession undergoing a radical transformation.

Young doctors think differently. They expect a professional life with a work life balance. Work is not the only thing - an approach endorsed by working time directives and official guidance on duty and responsibility. Young doctors do not buy into the historical model of a male dominated competitive and career focused process of education and training. Expecting people to fit into an old style training programme is no longer realistic. The long and arduous rotas of previous generations are no longer acceptable and this means fewer hours.

Many senior doctors feel there is now insufficient exposure to patients- and they may have a point. If we simply reduce the hours without revising the educational model, this is unavoidable. It is simply impossible to squeeze traditional teaching into the time available so there will, inevitably, be less patient exposure, less experiential learning and, almost inevitably, inadequately trained doctors. We need to think differently. Education must adapt. We can no longer think of training towards an endpoint, but looking at training itself as a long term process.

The gender balance in medicine has also changed. Pregnancy is a reality. Yet, I am not sure that our medical leadership has fully accepted the principles of equality that must allow young women to integrate career and family, not to mention fathers. There is no equality without paternity leave. It is not sufficient to support the rhetoric of healthy pregnancy, shared family responsibilities and professional equality if we do not see it put into practice. Rather than see pregnancy as an inconvenience in medical training or an awkward gap where service needs are compromised, we need to accept it as the norm. It is unfair and unrealistic to expect half the profession to sublimate nature and delay pregnancy simply to fit with an archaic training model. We need to change the way we think and we need to change what we do

To create a caring empathetic and nurturing profession, we need to care, nurture and appreciate the needs and expectations of our colleagues. We need to be creative, and redesign, not just careers and curricula, but our mind set.

Uncomfortable as it may be, it is important that the profession has a radical rethink. True leadership means fostering change. It’s not just the attitudes of young doctors. Medicine has also changed; it is more technical, more ‘high intensity’, constantly monitored and increasingly less tolerant of uncertainty. On-call is difficult, work is tough, doctors’ quarters are long gone as are the comforts of the doctors’ mess. It’s the day job, except that it is at night.

Let’s recognise that doctors’ life aspirations have changed, the gender balance has changed, and the job has changed. We, the older members of the profession, need to change too.

Erin_photoErin Russell is an Assistant Editor working on CMAJ and CMAJ Open

Alcohol is an addictive substance, a cancer risk factor, and a teratogen – yet you can buy a glass of wine at the welcome reception of the Canadian Public Health Association conference. I’m not saying that this is wrong; just interesting.

I attended three sessions related to alcohol at last week’s Canadian Public Health Association conference Public Health 2014. The first was hosted by Ann Dowsett Johnston, author of Drink: The intimate relationship between women and alcohol. Along with a series of articles in the Toronto Star, the book is a product of Ann's Atkinson Fellowship in Public Policy. While the book deals with issues specific to women (i.e., higher risk of depression and anxiety than men, propensity to self-medicate with alcohol), the talk was relatively gender-neutral. The main question, left unanswered, in a room full of public health researchers and practitioners was, "How do we really feel about alcohol?"

In this session, and others that followed, our society was described as 'alcogenic' or simply a 'drinking culture'. A drinking culture because the majority of us (78%) drink. As for society’s alcogenicity, Ann’s book cites social events revolving around drinking, as an example. The alcohol industry no doubt contributes to this culture with its promotion of alcohol as a necessary ingredient for a fun and sexy lifestyle. This drinking culture prevails, despite knowledge of the harms associated with alcohol consumption (i.e., risk of addiction, increased risk of cancer and other chronic diseases, risk of FASD when consumed during pregnancy). Our perception of risk is personal, not evidence-based; even worse, it’s based on outcomes that we can most easily bring to mind. So an individual who’s never personally been affected by alcoholism, but has recently seen a television program that referred to ‘wine therapy’, may (erroneously) assume that alcohol is therapeutic and relatively low-risk. Armed with this understanding of how humans perceive risk, it’s important that public health messaging be visual, relatable, and story-based. Dowsett Johnston has done this with her book; drawing on her personal experiences as a child of two alcoholic parents and her own battles with alcohol dependency in her 50s. Her account illustrates that no one is ever truly free from the risk of alcohol dependency; even those who may have had a relatively healthy relationship with the substance in the past.

On the second day of #CPHA2014, a comparison of provincial alcohol policies was presented. This evaluation of ten policy dimensions across ten provinces produced a final ranking where Ontario, British Columbia and Nova Scotia received the highest scores and Quebec, PEI and Newfoundland and Labrador received the lowest scores. One conference delegate who had lived in both Quebec and British Columbia was quick to point out that this sort of standardized evaluation fails to take into account cultural difference between provinces. In his admittedly-anecdotal observation, despite their relatively lax liquor laws, Quebecers seem to have a healthier attitude towards alcohol than do British Columbians. Presenters agreed that there is no “one-size fits all” policy, and that the existing culture surrounding alcohol should be factored in when making policy decisions.
In a panel on risky drinking by women of child-bearing age, representatives from the Canadian Fetal Alcohol Spectrum Disorder Network, the BC Centre for Excellence for Women’s Health and the Canadian Centre on Substance Abuse described the challenges associated with FASD and the prevention initiatives underway in Canada. One major challenge is that women spend up to 30 years of their lives “of child-bearing age” and may not self-identify as “potentially pregnant”. While most women will stop drinking when they become aware of a pregnancy, high baseline levels of alcohol intake in this population prior to knowledge of conception may be a substantial contributor to the burden of FASD.
Individuals with health problems resulting from alcohol use deserve our understanding and compassion; not our judgment. It is hypocritical to attach stigma to such conditions, while permitting alcohol to play such a major role in our lives. Public values, along with evidence, can affect political change. We have the evidence and tools required to support alcohol reduction policies - Canada’s low-risk drinking guidelines were cited in each of the three presentations I attended – so public values must be to blame for our failure to affect political change. Which brings us back to the question, “How do we really feel about alcohol?”

DMacA_3Domhnall MacAuley is a CMAJ associate editor and a professor of primary care in Northern Ireland, UK

Teenage pregnancy rates have fallen in England and Wales according to recent reports. Teenage pregnancy was one of the great failures of society- scandal, horror, tragic headlines often accompanied by photographs of bulging girls in school uniforms. From a public health and societal perspective, the trend downwards is to be welcomed. Pregnancy changes the lives of every parent and teenage pregnancy creates particular difficulties.

For many teenagers coming to the surgery, periods were a distant memory and the bump palpable, so urine testing was unnecessary. Mothers stormed out of the consulting rooms at hearing the news, fathers wouldn’t speak to their daughters, schools scandalized and neighbors whispering. And, on a few occasions, there were completely concealed pregnancies. But, a new baby seems to melt even the hardest heart, sisters rallied around, and the new young grandmother took charge. On one occasion, after a delivery during the week, the new mum was at the disco on a Saturday night. Some of these pregnant schoolgirls are now old enough that their children are successful young adults and the past a forgotten memory. Although I wouldn’t wish the trauma of an unplanned pregnancy on any young women, it never appeared to me to be the awful tragedy painted by the self-righteous guardians of society’s morals.

The forgotten mums are the middle class, successful career women in their late twenties or thirties. Their expectations have been fed by a decade of shiny magazines full of happy smiling infants and glamorous super mums. The reality for them is very different. Suddenly they are faced with this 24 hour unpredictable creature with no off button and no instructions, an expectation of perfection, and complete lack of control. No one really explained about the end of sleep-ins, coffee with friends, or even time to answer the phone. Endless feeding and nappy changing. When you have been in complete charge of your life, this can be devastating. Often living away from their mothers and sisters, and their partners at work all day, the loneliness and isolation can be overwhelming. A little bundle of unlimited commitment, crying for no reason and with endless needs is not a bundle of joy.

Thankfully, it usually works out in the end. Memory is benignly selective and the human race continues. Children are wonderful but it’s not always perfect. For anyone.