Delivering Midwifery: The Integration of Midwifery into the Canadian Health Care System

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By Ivy Lynn Bourgeault

There have been some dramatic changes to the face of Canadian women's health care in the past decade. Brought on by massive cuts from both federal and provincial governments, many of these changes reduced care. But along with changes that have many social commentators predicting the demise of Canadian health care as we know it, one recent health care initiative has been heralded as most progressive and long overdue. This is the integration of midwifery into the Canadian health care system.

In the 1970s, the practice of midwifery in Canada was neither legal nor officially recognized. In fact, Canada had the dubious distinction of being the only developed nation not to have any formal provisions for midwifery care.

Yet by the end of 1993, midwifery in one Canadian province, Ontario, became fully integrated into the government-funded health care system. Legislation integrating midwives in Alberta, British Columbia and Manitoba has recently been enacted (though the funding of midwifery services is still uncertain in Alberta), and is in progress in Quebec. Advisory committees in Saskatchewan, Newfoundland, and most recently in Nova Scotia have also recommended integration.

So, midwifery has evolved from an "underground" practice to a legitimate, self-regulating profession. Midwives are now publicly funded to practice as primary caregivers in both home and hospital, for several reasons.

First, the effective lobbying of midwifery leaders, their consumers and supporters worked. Second, the nursing and medical professions were preoccupied with other concerns. And third, a relatively sympathetic government viewed midwifery as a politically-correct cause and potentially cost- effective form of care.

Despite an initial adjustment period which saw a temporary decline in the number of practicing midwives, the formal integration and public funding of midwifery has resulted in a much larger proportion of women in Ontario having access to midwifery care.

Recent statistics reveal that the number of midwives have increased from a little more than 60 in 1994 to over 120 in 1998. The number of midwifery-attended births has increased proportionately from 1,800 births to 3,368 in that same period.

More than half of these births take place in hospital where midwives, unlike before, are now able to independently admit and discharge patients, helping give women continuity in their care as well as a choice of birthplace.

But integration has not only resulted in greater accessibility, it has also produced some subtle challenges to midwifery's egalitarian philosophy. For example, changes to the organization and regulation of midwives throughout the integration process have the potential to create a wider social distance between midwives and their clients.

Previously, the midwifery community could be described as an egalitarian social movement, today it has become a more bureaucratically organized profession.

Earlier, midwives were more or less being regulated by clients, now they must adhere to professional self-regulation. Midwives are now not only accountable to their clients, but also to professional standards of practice enforced by their College. This may not necessarily be bad for women or for midwives, but it may alter what is unique about midwifery care.

Many challenges to midwifery remain even in light of official integration. In my recent research, I have specifically examined the challenges of midwives' work and workload, midwives' integration into Ontario hospitals, and the devolution of government funding for midwifery services from one centralized government agency to several community transfer payment agencies.

Being on-call is particularly challenging for midwives, especially if they are also mothers of young children. With integration, many midwives have also found their workload increase dramatically, not only providing care to more clients but also doing paperwork as a result of having hospital privileges and government funding.

Hospital privileges not only mean more work, but hospital policies also place varying degrees of control over the way midwives provide care. The devolution of funding also has the potential to fragment midwifery practice, creating yet another layer of accountability to the community as well as to their client and their profession.

Studies will show how this works itself out.

There has been an almost parallel increase in the number of studies on midwifery, in which I as a researcher take part. To foster links between these researchers, I and others, including Cecilia Benoit, will be organizing Reconceiving Midwifery: The New Science of Midwifery in Canada, an open conference at the end of July.

Ivy Lynn Bourgeault, PhD, has done extensive research on midwifery.

For more information on the conference, Reconceiving Midwifery: The New Science of Midwifery in Canada,
contact Ivy at:

Department of Sociology & Faculty of Health Sciences
University of Western Ontario
London ON N6A 5C2 Canada
Tel: (519) 679-2111 ext. 5385
Fax: (519) 661-3200

Midwifery Resources

Midwifery in Canada, 1980-1997: A Brief History and Selective Annotated Bibliography of Publications in English By Lise L. Hackett
Available for $28.95 from:
School of Library and Information Studies
Dalhousie University
Halifax NS B3H 3J5 Canada

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