Midwifery Care Continues to Face Challenges

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Despite the gains the midwifery profession has made in Canada over the past 10 years, it still faces many challenges. Some provinces are struggling for funding and others for legitimacy. Many doctors and nurses now consider midwives colleagues and may recommend midwifery care to their patients or choose it for their own births. However, in some communities, individual health care professionals may feel hesitant or even hostile about midwifery, the women who practise it and their clients. Access to midwifery training is an issue for women who live outside major centres where education programs are based, or in provinces with no midwifery education programs at all. First Nations and Inuit midwives still face great challenges around training and regulation.

Advocates fight for funding on a yearly basis, even in provinces where midwifery has been established for years. Malpractice insurance remains one of the most difficult issues for midwives and for health care ministries; the premiums increase exponentially, at one time jumping by more than 400% in a single year.

The consumer movement so integral to the formation of professional midwifery remains strong in some parts of the country, while in others, having slept through the post-legislation years, it is waking up to the new issues of the day.

In some areas, midwives’ increasing comfort with medical technology is causing concern. For example, will allowing midwives to administer epidurals change the core values of midwifery or will it support choice and continuity of care? Will schools continue to graduate midwives who are comfortable with homebirth, the roots of midwifery, and who are committed to care that is truly woman-centred?

A poster we spotted in practices around Toronto aptly proclaims midwifery to be “the oldest and newest profession.” Rich in history and with a solid philosophical stance, Canadian midwifery is still defining itself, one mother at a time.

Midwifery in Canada:
75% of the world’s children are born into the hands of midwives. How does Canada compare?

  • In Ontario, the Canadian province with the most midwives, 4.5% of children are caught by midwives.

  • 5 provinces/territories have no midwifery legislation or funding, 2 provinces have legislated midwifery but have not provided funding, and Quebec does not sanction homebirth, making this safe and inexpensive option nearly impossible for women who want reliable care.

  • In legislated and unlegislated provinces, many women seek midwifery care but are turned away because of a shortage of midwives.

The result is a radically different picture of midwifery care depending on where you live in Canada and many barriers to accessing midwifery care.

Province Legislated Funded Fee for service Home/Hospital/ Birth Centre Education Program
Alberta Yes No Yes Home/Hospital/ Birth Centre No
British Columbia Yes Yes No Home/Hospital Yes
Manitoba Yes Yes No Home/Hospital No
Newfoundland and Labrador No No No Hospital (remote areas only) No
New Brunswick No No No Home No
Northwest Territories No No Yes Home No
Nova Scotia No No Yes Home No
Nunavut Partially (one pilot project in 2002) Partially No Birth Centre (only on Rankin Inlet) No
Ontario Yes Yes No Home/Hospital Yes
Prince Edward Island No No Yes Home No
Quebec Yes Yes No Birth Centre Yes
Saskatchewan Yes No Yes Home No
Yukon No No Yes Home No


Why we need accessible midwifery care across the country:

  • By the year 2020, there will not be enough doctors to deliver Canadian children.

  • Midwives provide a type of care that doctors cannot or do not.

    • Midwives can provide excellent prenatal care, operating on the principle of “informed choice,” which provides women with the information they need to make smart choices that work for themselves and their families.

    • Midwives provide excellent emotional support through longer appointments with their clients, offering on average, 20 to 30 minutes more time per appointment than medical professionals.

    • Midwives provide “continuity of care,” which means that mothers know that the people caring for them during their pregnancy will be the same people attending their births and making sure that they and their babies are off to a healthy start, including six weeks of postpartum care.

  • Midwives are respectful of women’s choices to have their babies their way. Midwives offer the highest standards of practice and are supportive no matter what the outcome of the birth.

  • Midwives are the only legislated professionals who routinely attend births outside hospitals.

  • Midwives are strong advocates of birth without unnecessary interventions (epidurals, continuous foetal monitoring, episiotomies), and are experts in helping women birth in health and happiness without requiring these interventions. While medical interventions do help women when used appropriately, they have become routine in many medically attended births, often at great cost to the woman and to the health system itself.

  • Midwives provide care to women from every walk of life and are well trained to serve women from diverse religious and cultural backgrounds.

  • Hundreds of women have told us that the care they received from midwives has allowed them to become strong and confident mothers that raise strong and confident children.

  • In some areas of the country, a shortage of doctors means women cannot get proper, well-woman care, such as tests to detect cervical cancer or birth control counselling or prescription drugs. Midwives are capable of providing these services to their clients on an extended basis.

  • In some communities, women require costly transfers to larger centres to give birth to their babies.

  • Midwives have great success in aiding mothers to breastfeed, which has been proven to have long-term health benefits for children. The common problem of dehydrated newborns being brought into hospital emergency wards for treatment is solved by frequent home visits and nursing support from a known and trusted caregiver.

  • Six weeks of regular check ups for mother and baby, often in the home, means that potential problems, such as postpartum depression, can be avoided or detected early by someone who not only knows the signs of depression, but knows the woman well enough to note changes in her personality and behaviour.


Barriers to Universal Canadian Midwifery Care:

1) Lack of government support (legislation)
In provinces without legislation, very few midwives practice because of the difficulty of practicing in a quasi-legal way, and because of the difficulty in earning a living. In unlegislated provinces, the few midwives practicing cannot order routine blood and urine tests, or serve women whose particular pregnancies, or personal beliefs, would make a hospital birth a better option.

2) Lack of government funding
In provinces without legislation, or those where midwifery is legislated but not funded, women must pay for their midwifery care themselves. Even with the common practice of accepting payment on a sliding scale geared to income, many women cannot afford the cost of a midwife, leaving those already marginalized by society (the poor, new immigrants, young mothers) without access to midwifery care.

3) Lack of midwives
In provinces where midwives are legislated and funded, midwives are highly sought after and many mothers who seek care cannot be accommodated.

4) Lack of training opportunities
In order to get more midwives, you need to train more midwives. Though Ontario, Quebec and British Columbia offer university training for midwives, the aspiring midwives in other provinces need the opportunity to train in the areas where they currently live and work. Entering the existing programs is not feasible for many potential midwives, and ultimately means fewer midwives entering those already midwife-hungry provinces where the profession is already established.

5) Lack of intra-professional understanding
In our own care, we have benefited from respectful relations between midwives and physicians. However, there are many cases – some well-documented – of midwives being treated as lesser professionals by doctors and nurses. When this happens, women’s care is compromised.

In some legislated areas, individual hospitals grant – and deny – privileges to individual midwives. Should a hospital decide not to make privileges available to a midwife, she can be left unable to take clients who choose to birth in hospital, leaving these women without care, or forcing them to accept medical care instead.

6) Inability to practice in a home setting.
Some medical professionals still refuse to acknowledge the safety of homebirth, and campaign against allowing midwives to catch babies at home, and stalling or altering the move towards legislating midwifery. This despite studies showing homebirth is a good option for many mothers and babies, including a recent study by the Canadian Medical Association.

What Still Needs to be Done?
Lobby the federal and provincial governments for:

  1. Legislated and funded midwifery care in every province and territory, making this a truly Canadian option, available to the diverse populations of Canada.

  2. Decentralized educational opportunities for potential midwives. This can be achieved through the creation of satellite schools and investing in on-line learning. Also, experienced midwives in areas other than those with existing university educational programs must be allowed to act as preceptors for future midwives. This means allowing students to apprentice and study away from their midwifery education programme.

  3. Professional recognition of midwifery within the health care system through greater education about the benefits of midwifery care and the way in which midwives practice in Canada today. This will lead to better working relationships and increased privileges for midwives within hospitals.

  4. Recognition of home birth as a safe and viable option for women in all provinces and territories, and permission for trained professionals to attend these women.

Miranda Hawkins and Sarah Knox are the authors of the recently published, The Midwifery Option: A Canadian Guide to the Birth Experience (Harper Collins, 2003). For more information, visit www.midwiferyoption.ca