First Hands
Source: First Hands on http://www.canada.com
Reverence. A single word to describe the moment of birth. And for Nicole Séguin, it's the reason she became a midwife. "To be the first hands to touch a baby... is such an honour."
For Sean Devine, that moment of birth seemed as if it would never come for his wife Alexa. On the cold evening of Nov. 16, he waited by Alexa's bedside while the midwives quietly talked. He was worried about what they were saying, but could hear little of their conversation. His attention was on his exhausted wife. Shadows had deepened under her tired blue eyes; sweat-soaked strands of hair had wrestled loose from her long ponytail and now hung limp over her cheekbones. Many hours of labour and the baby still hadn't arrived.
The midwives' muted discussion was the only sound in the small upstairs bedroom otherwise devoid of sensory stimuli: no soothing music, no scented incense, no candles. The only lighting came from a single nightlight. The room was spartan, the way Alexa wanted it. Even low-level conversation seemed to aggravate the pain, so the midwives didn't talk for long.
Soon, Registered Midwife Lisa Sutherland looked over at the couple. Her face broke into a smile and she gave them the thumbs up. Before long, the baby would be born. Alexa's face relaxed with relief, and Sean felt the same. He realized then that the gravity he had noticed on the faces of the midwives wasn't worry at all. "It was just them being thorough," he says.
Both actors, the Devines met in Montreal in 2001. They soon married and moved to New York. They now call Vancouver home, and when Alexa found out she was pregnant, she talked to friends, researched her maternity-care options, decided on midwifery, and began interviewing midwives. Alexa, 33, and Sean, 38, decided on Bloom Community Midwives in Vancouver's West End. Alexa felt an immediate affinity for the trio of midwives who became her maternity care providers. Séguin, one of the Devines' midwives, was tending to another client when Alexa went into labour.
The midwives work as a group so that one of them is always on call. The Devines became comfortable with all three midwives, and when Alexa went into labour, Sutherland was the one on call. (A midwifery student and another midwife joined Sutherland. A doula was also present.)
Early in her pregnancy, Alexa had decided to deliver at home, having come to see home birth as a sensible choice for her low-risk pregnancy. Sean was a "late convert" to the home birth notion, and got resistance from some friends and colleagues. "They thought it was completely irresponsible to have a baby at home," he said. "It's not yet in the mainstream." However, he added, it's becoming accepted in Canada as a safe and common practice, as it is in many parts of the world. "In Holland, a full 80 to 90 per cent of births are home births," he noted.
Home birth in Canada is not without controversy. For many obstetricians it runs against the grain. "It's contrary to our training. It just makes most of us nervous," said Dr. Geoffrey Cundiff, head of obstetrics and gynecology at St. Paul's Hospital. In recent years, however, he has begun to soften his stance. "There are a fair number of studies to show that it's a safe alternative. I've somewhat changed my opinion." Still, the home birth question is "probably the most controversial thing between OBs and midwives."
In Metro Vancouver, the vast majority of midwifery births take place at a hospital. Yet, many pregnant women hesitate to use a midwife because of misconceptions that they must deliver their baby at home and be committed to delivering naturally to be accepted by a midwife. These are common myths, said Registered Midwife Lehe Elarar, who works out of Pomegranate Community Midwives on East Hastings.
Myths and misinformation regarding midwifery are still in place 10 years after it became a legal registered profession in B.C., partly because midwifery information is not readily available, said Elarar. "It seems you're either in the know or you're not," she said. "Access to information is somehow challenged."
For Alexa, it partly did come down to who she knew. In a downtown café 10 days prior to her labour, a very pregnant Alexa--petite with long, dark hair and brilliant, large blue eyes--glowed.
Over a steaming cup of herbal tea, she enthused about midwifery and the options it offered. "The quality of care," she said, ticking off one of her fingers as she itemized the benefits midwifery. This item pertained to her midwifery appointments. "It's amazing that I can spend half an hour to 45 minutes of someone's time and ask any questions I want." The midwives are trained to offer the full range of maternity care, she said, from doing examinations to ordering blood tests and ultrasounds. She ticked off another finger. "They're on call 24/7 throughout my pregnancy. The on-call aspect is crucial. I can call about anything. They really stress that." A sip of tea, another finger: "Postpartum care. They'll visit me in my home every two days for a week." All told, midwives offer six weeks of postpartum care. And the service is entirely covered by B.C.'s Medical Services Plan, she said. Many of her friends had used midwives, and so Alexa had started her quest for a maternity care provider with access to fairly up-to-date information.
For other Vancouver women, easy access to information is not always the case.
Belatedly and 11 weeks after the birth of her little girl Remy, new mother Margot Baloro discovered two important facts regarding midwifery care in B.C. She didn't know midwifery care is covered by MSP. The second fact, however, was more relevant to her current situation: the extensive postpartum care. In the first weeks postpartum, she had access to the B.C. Nurse Line and the B.C. Hot Line, and even though the nurses were helpful, she found their answers to her concerns "not really enough for me." Given that she was satisfied with her maternity care from her obstetrician, Baloro doesn't know if she would have used a midwife, but she would like to have been able to make an informed choice. She especially would have liked to have known about the long prenatal and postpartum visits.
The time to inform pregnant women, she said, is at the beginning. "When you first find out you're pregnant, it would be great if the government sent out a comprehensive package of what's available, what's covered."
This is a suggestion seconded by Andrea Eckersley, new mother of little boy Amory. Like Alexa, Eckersley is a client of Bloom Community Midwives. However, her decision to use a midwife took some time, and she would have preferred better access to the information that she and her husband eventually managed to find on their own. Besides a lack of information, they also had their own misconceptions about midwifery. Eckersley wanted to have her baby in the hospital, but was under the impression she couldn't if she used a midwife.
As it turned out, she delivered at St. Paul's Hospital with Séguin as her midwife. Managing pain was another important factor when choosing to go with a midwife. She wanted to try to have a natural birth, but wasn't sure if she could manage it. Again, she discovered she was in luck with midwifery care.
"The midwives have a series of steps to deal with pain," she said. "They would never deny me pain relief if I wanted it. Some things they can administer, or they could call for an anesthesiologist. They were happy to support whatever decision I made."
For hospital births, pain relief options are the same whether a midwife or a doctor attends an expectant mother. If a woman wants an epidural, she'll get one. For home births, pain management falls into the "natural" category, which includes breathing and massage.
Another myth is the absence of collaborating between midwives, doctors and OBs--and that "doctors and midwives don't get along," Elarar said. "Certainly that exists, but not to the degree that people think it does. We have amazingly integrated collaboration."
This opinion is shared by Cundiff and Dr. Jan Christilaw of B.C. Women's Hospital. They strongly support midwifery in B.C. Cundiff, also a professor at the department of obstetrics and gynecology at University of B.C., first learned maternity care at the hands of midwives. He trained at Parkland Memorial Hospital in Dallas. "It's probably the biggest maternity centre in the U.S." There, he learned to do vaginal deliveries from midwives and in the process came to appreciate the profession. The model of maternity care in the U.S. has changed, however.
"OBs, for various reasons, have become the primary caregivers for all pregnancies. That's not the case here. In Vancouver, there is a more logical role for obstetrics," said Cundiff. That logical role has an obstetrician handling high-risk pregnancies and deliveries, while a family physician or midwife handles low-risk maternity care.
"At St. Paul's I'd like to have a bigger presence of midwifery." He has found that the midwives are "a strongly opinionated group. They have to be strong. They're very careful about providing quality care." He sees roles for family physicians, midwives and obstetricians to work together.
"I'm a big fan of the team-based approach to care," added Cundiff. "At St. Paul's I've been a champion of creating a collaborative-care model."
Christilaw, vice-president of maternity at B.C. Women's Hospital, agrees. "[Midwifery] is very well regulated and promotes a non-interventionist approach to normal vaginal birth, which is very important." She said that midwives are well trained to deal with normal, low-risk pregnancies. In fact, in many countries, midwives are the first person to go to for low-risk maternity care, which leaves the experts available for high-risk pregnancies.
This is a model of practice that Cundiff and Christilaw support and want to promote. "Less than 10 per cent of births [at B.C. Women's] are attended by midwives," said Christilaw, who is also the senior medical advisor of Provincial Women's Health Programs. "I'd like to see that increase. [Midwifery] regulation is very safe. The training's very safe."
As an obstetrician, she has always worked with midwives. Christilaw sits on the advisory board of the department of midwifery at UBC. "Right now they have 10 students per year. We'd like to see that double in the next couple of years. We've been meeting with the government to see how we can expand the school."
Ontario-trained Séguin, who works with many locally trained midwives, describes the UBC midwifery school program as akin to boot camp. "It's a very rigorous, strong program," she said.
UBC offers the only midwifery training program in British Columbia, and is one of six programs certified in Canada (three of these programs are in Ontario). At some point in the future, UBC is planning advanced entry into midwifery for qualified people such as nurses, and offers a pilot project that certifies midwives trained outside of Canada.
There are currently 106 practising registered midwives in B.C. The bulk of these work in Metro Vancouver or on Vancouver Island.
The commitment a midwifery student makes to the four-year bachelor degree program is not taken lightly. After the first year of the program students oscillate between month-long to two-week-long intensives and balancing clinical placements with a full academic load. The sacrifices midwifery students have to make include limitations on holding down paying jobs, being on-call for much of the later years of the program, and leaving family and friends (or taking them with them) to go to remote locations of the province for practical training.
The bulk of UBC midwifery training is spent with registered midwives doing practical training called preceptorships, and in the last term of year four the student does a clerkship where she carries the full responsibility of the midwife. The midwifery student trains not only with midwives, but also with obstetricians, pediatricians and family physicians. As well, she has the chance to work with high-risk women and do international placements. By the time she receives her Bachelor of Midwifery (BMW), at a minimum she will have attended 60 deliveries and acted as the primary midwife for 40 deliveries. Most graduates hold up to double these numbers.
Midwives' gross incomes can very considerably depending on their client load. The figures can range anywhere from $50,000 to $90,000 per year. But these are their gross incomes. The amounts are significantly reduced after taxes, liability insurance, clinical overhead and equipment, and professional dues are paid.
Midwifery can also take a toll on home life, noted Séguin and Elarar, who are both mothers. They are two of many midwifery migrants who trained elsewhere and have set up practice in B.C. Balancing the needs of their own families with the enormous workload of a busy midwifery practice is challenging. Elarar said that after an all-night birth, she can't just go home and go to bed. She has two small children to take care of. Séguin began her midwifery studies at Ryerson University in 1995 and graduated in 2003, taking time out along the way to give birth to her own two children.
But for all the struggles to be a midwife, and the often difficult balancing act of midwifery and family life, there remains a fundamental reason why they are midwives: the honour of being the first hands to touch a baby.
In the wee hours of Nov. 17, 2008, after "undergoing hell," Alexa Devine's labour was finally over. The delightful result--little Charlie Devine. Minutes later Sean held his wriggling nine pound, four ounce baby. In the preceding hours, the midwives were constantly checking the baby in utero. "They were all over me, all of the time. After every contraction they'd check his heartbeat," Alexa said in a phone interview three days postpartum, and light years from the easy conversation in the downtown café. "They went to great lengths to ensure I had the birth I wanted to have."
Whether it's a family physician, obstetrician or midwife, the goal for all maternity care providers is identical, Séguin said: healthy baby, healthy mom. "We're all after the same thing. Safely bringing life into the world."