A Midwife Crisis: Maternity Care in Canada

In 1990 Canada was considered one of the safest places in the world to give birth. We ranked 6th in terms of infant mortality and 2nd in terms of maternal mortality. By 2006 we had slid to 21st for infant mortality and 11th for maternal mortality. The situation is particularly dire in remote or rural areas and things are about to get worse.

With 1/3 of Canada’s OB-GYN’s poised to retire in the next 5 years the situation is reaching critical mass. There is a narrow window of time to remedy the crisis, before birthing standards decline to unacceptable standards, and more families suffer the consequences. I won’t mince words – without quick and decisive action, the consequences will be the needless deaths of mothers and infants.

The solution, if we can actually convince politicians to sit up and take action, is to develop a model of collaborative maternal care, shared between OB-GYN’s, family physicians, nurses, and midwives, to care for women throughout all the stages of their pregnancies.

 The Society of Obstetricans and Gynaecologists in Canada (SOGC) has developed a National Birthing Intiative where front-line maternal care workers would work together “to implement  this collaborative initiative to ensure Canadian women and their babies receive appropriate care during pregnancy, delivery, and recovery.” (SOGC) For this strategy to be most effective it must be implemented before the mass retirement of Canada’s OB-GYN’s, but there are significant problems to be overcome in the meantime.

The practice of midwifery in Canada is regulated by provincial and territorial authorities.  Midwives can only legally practice their profession if they are registered with these authorities, but only seven provinces and territories have regulatory systems in place.  This means that midwifery is essentially illegal in the rest of Canada. Further compounding the problem is the fact that even where midwifery is legal, it isn’t always funded or covered by health care. A two-tier system of care has been established, where the standard of maternal care changes depending on your geographic location.  Midwives are only available to some women, in some parts of the country, and only some of those women can afford their services. 

The Canadian Midwifery Regulators Consortium has developed a chart  indicating the current status of midwifery in each province and territory:

Province/Territory

Implementation

Public funding

Alberta

Yes – 1998

No

British Columbia

Yes – 1998

Yes

Manitoba

Yes – 2000

Yes

New Brunswick

Legislation in process

 

Newfoundland & Labrador

No

No

North West Territories

Yes – 2005

Yes

Nova Scotia

In process

 

Nunavut

In process

 

Ontario

Yes – 1994

Yes

Prince Edward Island

No

No

Quebec

Yes – 1999

Yes

Saskatchewan

Yes – 2008

Yes

Yukon

No

No

Since early settlement in Canada until the beginning of the 2oth century birth was considered to be a home and community event. It has since become a medical event. How and why did such a drastic change occur?

 

A Brief History of Midwifery in Canada 

For centuries women presided over the business of birth. Until the 20th century Canadian women traditionally gave birth at home, surrounded  by female  relations and neighbours, and under the experienced care of a midwife. The midwife would care for the labouring mother, “catch” the baby, and provide essential post-natal care. It was not unusual for a midwife to stay at the home of the new mother for several days after birth, cooking, cleaning, and helping new mothers adjust to life with an infant.

 In the 1700’s forceps were invented, and infants could now be pulled from the womb without a midwife’s manual skills.  Women were taught that the use of forceps could shorten their labour and this discovery marked the beginning of   childbirth as a medical science. Subsequent scientific revelations, like the discovery of bacteria as a source of infection, growing knowledge of sanitation, and the effective use of anaesthesia to treat pain, helped to transform the practice of childbirth. Birth changed from being a natural occurrence within a community of women, to a clinical experience largely controlled by men.

 Technological changes and shifts in cultural perspectives lead to the practice of midwifery being marginalized by the medical profession. In the 1800’s both men and women generally believed in the intellectual superiority of men. It was believed that even if women were given the necessary training, they would never be able to use medical instruments properly. Physicians claimed that women had overly emotional characters that would interfere with the cool exercise of judgement necessary in surgical situations. Midwives had no formal organization or licensing, yet women who wanted to become licensed doctors were denied access to medical schools.

 By the turn of 20th century the medicalization of birth was complete. In 1900 midwifery was outlawed in Canada, although it persisted in very poor or remote areas. Midwifery was not reintroduced as a legal profession until the 1990’s.

 In the 1960’s attitudes once again began to change. There was a resurgence of interest in midwifery as women began to question the impersonal, sterile nature of their birthing experiences. More and more women began to ask for natural childbirth. Slowly, hospitals began to allow fathers to participate in births in the warmer environment of “birthing rooms.” Finally, in this new climate, the home birth movement re-emerged – a woman giving birth in her own bed, surrounded by her family, and assisted by a midwife.

The Current State of Affairs

 In 1990, despite lingering resistance from some physicians, midwifery once again became legal in some parts of Canada. Across Canada, the role of midwifery in the health care system is being considered and legislation is being revised. Funding for women choosing to see midwives is being considered, and midwifery training programs are slowly being initiated. Despite these changes midwives across the country are still struggling to be recognized as professionals integral to the health care system, and they often have to fight for hospital privileges.

Canada is facing looming shortages in professionals available to provide newborn and maternity care. As our OB-GYN’s retire, there are not enough doctors to replace then.  Many medical students are avoiding the field because of the long hours, relatively low pay, and the increasing risk of litigation if something goes wrong. Obstetricians are dramatically overworked, and simply don’t have the time to provide the one-one care that women need and deserve. Many of them have shifted their practices away from delivery to focus on other aspects of reproductive health, like fertility or family planning.  At the same time, fewer family physicians than ever are involved with delivering babies. Having midwives take greater responsibility for low risk pregnancies, in cooperation with other maternal care workers, is the only viable solution.

 The Benefits of Midwifery

Midwifery is a far more personal approach to childbirth. Midwives consult with clients from the very start of their pregnancies, placing mothers-to-be at the heart of the decision-making process. Visits with a midwife generally last at least 45 minutes, as opposed to the rushed 5 minute average that an OB-GYN can manage. Midwives care for their clients during the entire labour process, from the first pangs, to the first cry.  For the first ten days after birth midwives make home visits, helping mothers nurse and adjust to life with a newborn. According to the Canadian Institute for Health Information, women under the care of a midwife are:

  • Less likely to be hospitalized for prenatal care
  • Less likely to undergo caesarean sections
  • Less Likely to give birth prematurely
  • Less likely to have labour induced
  • Less likely to visit the emergency room for post-natal care

On top of these benefits, there are also financial incentives:

(These are the arguments most likely to persuade politicians to speed up regulations and funding)

  • Midwifery is generally less expensive physician care
  • The home visit policy keeps mothers and infants out of emergency rooms
  • Women under the care of midwives have much shorter hospital stays, freeing up resources and beds
  • Home births means no hospital stay or additional costs to the health care system
  • Training midwives is far less costly than training OB-GYN’s
  • OB-GYN’s would not have to cancel a full day of bookings to preside over a low risk pregnancy

Above all, the majority of women who have used midwives report extremely positive experiences. In a 2007 study conducted by Statistics Canada revealed that women whose primary caregiver at birth was a midwife rated their  \labour and birth experiences as “very positive” more often (71%) than those cared for by obstetrician/gynaecologists, family doctors or nurses and nurse practitioners (53%). So many women in Canada want midwives to supervise their pregnancies that supply has far outstripped demand. It is time that we started to pay attention.

In Conclusion

 We have only a small window of time to create a sustainable model of maternity care. All provinces and territories must regulate and fund midwifery services to guarantee that all Canadian women have access to safe pre and post natal care. To avert a real maternity care crisis, we need to increase the number of midwives practicing in this country.

Politicians (and some doctors) need to pull their heads out of the sand and recognize that midwives, as the deliverers of primary care in low risk pregnancies, can alleviate some of the current pressures on obstetricians, hospitals, physicians and nurses through taking on more cases, and developing collaborative relationships with other health care practitioners. This team approach is especially crucial in remote or rural areas where doctors are spread even more thinly than in cities.

In order for midwifery to become a legal, cost effective, and medically-sound practice uniformly across Canada, legal recognition, standardization of education, and funding is required.