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When we consider the challenges of obstetric anesthesia, most of us focus on the risks to a (relatively) young, (relatively) healthy mother and her fetus, on the often emergency nature of the care we provide, and on the unexpected need for our services. In this issue of the Journal, we present our readers with yet another challenge that we often fail to consider—what happens if no anesthesia providers are available to cope with these challenges? In 1999, Donen et al. drew attention to the potential crisis of Canada not having a sufficient number of anesthesiologists to meet its demands. In 1996, they conducted a survey of 2,206 specialist anesthesiologists and 487 general practitioner anesthesiologists (GPAs) who were identified as providing anesthetic services. Within the Canadian health care framework, GPAs provide a vital and important service to smaller, more rural communities and to a number of medium-sized communities. However, according to a 1999 report, there was a decrease in the number of GPAs from the 523 identified in a 1986 survey. Any further decline in the number of anesthetic practitioners could mean a loss of anesthetic services to those communities, including the provision of obstetrical anesthetic services. And yet, as identified by the Society for Obstetricians and Gynaecologists of Canada (SOGC) and others, pregnant women expect delivery in their local communities, and they also expect to have the safe obstetrical care that is available in larger hospitals. In this issue of the Journal, Dr. Angle et al. point out that small obstetric units/hospitals are closing in Ontario, possibly due to lack of anesthetic services. This problem is not limited to one province; it is widespread across Canada and across other parts of the world. In Canada, the majority of anesthetic care in small hospitals is provided by GPAs who face problems relating to burn-out (constantly ‘‘on-call’’), lack of access to continuing professional development (CPD) opportunities, an inability to ‘‘get away’’ from their practice due to a shortage of locums, and a decrease in the number of physicians wanting to work in rural areas. Not only will these issues lead to a further closure of small obstetrical units, but they will also lead to a reluctance by new family physicians to practice in remote areas. And yet, geographic (and meterological) realities suggest that all women should have emergency maternity services readily available at a reasonable distance. In Canada, weather frequently impedes access from smaller, more remote communities to larger facilities. The question then is—how do we provide and maintain emergency obstetric facilities? Anesthetic services are essential to any obstetrical unit, as even births predicted to be normal can suddenly present an urgent need for operative delivery. At least 26% of parturients require anesthesia services for delivery (based on the 2005–2006 average Cesarean delivery rate in Canada). However the percentage is much higher if other aspects of anesthetic practice are included, for example, anesthetic consultation, labour analgesia, and maternal/ neonatal resuscitation services. Failure to have a skilled anesthesia practitioner could mean that the ability to provide emergency obstetrical care is limited, if not impossible, even if there is a physician who can perform a Cesarean delivery. J. Douglas, MD R. Preston, MD Department of Anesthesia, British Columbia’s Women’s Hospital and Health Centre, University of British Columbia, Vancouver, BC V6H 3N1, Canada

Provision of obstetric anesthesia: throwing down the gauntlet!