MIDWIFERY IN CANADA: A NEW MIDWIFERY FOR THE NEW WORLD

by Lesley Page,
Head of the Department of Midwifery, Children's and Women's Health Centre of British Columbia and St Paul's Hospital; and Clinical Professor, Department of Family Practice, University of British Columbia

Canada was the last developed country to recognise the practice and profession of midwifery. However, it can take pride in the fact that although it was very late in developing what is considered in most countries an essential service for childbearing women it has been able to develop an ideal model of practice.

Canada's legislation is enacted separately in its different provinces. Of these, Ontario, British Columbia, Alberta, Manitoba and Quebec have begun to integrate regulated midwifery into their health care systems, and Saskatchewan and Nova Scotia have expressed an intention to do the same. In this article I will discuss the model of practice that has been developed in British Columbia (BC), and describe some of the cornerstones and progress with the development of the profession here. Also included will be some of the dilemmas of development and some of the lessons that can be learned from midwifery in Canada.

Background

Until recently it was not possible to practise as a midwife within the health care system in Canada, except in some very remote outposts. Obstetricians and family doctors provided maternity care, with assistance from nurses. In general, women still visit their doctor for prenatal care, and go to hospital for labour and birth, where a nurse attends them for labour. The woman's doctor manages the labour and is called for the birth. There are still a number of family doctors who provide intrapartum care, particularly in BC.

With some exceptions, recognition of midwifery has been completely lacking in Canada's history (Mason, 1988). However, there was a tradition of community and neighbourly midwifery. Women of the First Nations (indigenous women) attended their own population as well as the new settlers at birth (Couchie and Nabigon, 1997). This unregulated and unrecognised midwifery in Canada (which also existed in the USA), was almost eradicated by propaganda claiming, without evidence, that midwifery was unsafe. However, a small group of midwives have always continued to provide midwifery care, and attendance at home births to small numbers of women. These midwives were paid directly for their services by families. In general they could not practise within the hospital, although with a transfer in they would often accompany the woman as 'labour coach'. Many of these 'lay' midwives went to great lengths to educate and train themselves, and to gain overseas qualifications. In addition, a number of midwives registered in other countries have become part of the labour and delivery nursing staff, providing an essential and important service to childbearing women.

In 1994 Ontario became the first province to institute regulation of midwives, to fund midwifery services and to provide an undergraduate education programme. In 1995, the College of Midwives of British Columbia (CMBC) was established. Around the same time a home birth demonstration project was established. The results of this study are soon to be announced.

The midwifery established in Canada should be of interest to all. Because it has been set up without precedent, and does not rely on changing established systems, it has been possible to build the system that was wanted.

Present System

In British Columbia midwives provide a community-based service. They own their own practices, some operating out of their own homes, some from very attractive offices. Most have privileges to admit women under their care to hospital. The division of home/hospital birth is about 50/50.

Many of the present registered midwives were those who were lay midwives for many years. In order to be admitted to the register all midwives undertook a rigorous process of assessment. There are now about 66 midwives registered and practising in the whole of British Columbia. The Ministry of Health reimburses midwives for their services, and their caseload number is capped at 40 births per year. They are self-employed, and are not employees of the health service.

Midwives must provide continuity of care, and criteria for this are explicitly stated. Continuity of care is seen as the basis of the partnership between client and midwife, and as necessary for informed choice. A fundamental tenet of the philosophy of care is that a 'woman's caregivers respect and support her so that she may give birth safely and with power and dignity' (CMBC, 1997).

It may be difficult for those who can take for granted the right to practise, and the provision of midwifery services, to imagine some of the challenges of integrating a 'new' profession into the health care system. Although there has been considerable support for midwifery, from government, health care facilities, and other professions, there has also been misunderstanding and some resentment ( Kornelsen, 2000). Perhaps this is partly because, historically, midwifery has had no place in the mainstream culture of BC. Many people simply did not know what a midwife was, or thought midwifery was an old-fashioned profession with no place in the modern maternity service.

A few years ago it seemed to me that misconceptions of midwifery were commonplace. However, since my return to BC from the UK - three years after regulation - I have found a far greater understanding of and respect for midwifery. Conversations with women and families who have experienced midwifery care indicate that responses to such care are extremely positive. Midwives spend time in the prenatal period explaining what is happening and involving the woman in making decisions about her care; women appreciate having a midwife they know and trust, with whom they have formed a relationship, to be there for their labour and birth. The midwife provides follow-up care for three months after the birth. I hear midwives talk of the way they build up a relationship of trust with women and their families, and see the lengths they go to obtain good information, and to make decisions in partnership with women. Although it is a small profession it is making a big impact on those who experience the results of care.

The Future

The government of British Columbia has just agreed the establishment of a midwifery education programme to start in September 2001. This will be situated at the University of British Columbia. There is little doubt that the model of practice that has been established is close to ideal. The registration process is rigorous, and supports the established model. However, at the moment the small numbers of midwives means that the profession has little impact on the maternity services as a whole. There is much discussion about how the ideals of the model can be maintained while expanding the numbers. Sustainability of the profession - both in terms of adequate numbers for growth and renewal, and for the midwives involved in a demanding form of practice - is an important focus of the discussion.

Personally, my ideas about what constitutes midwifery and what is essential to effective midwifery were formed here in BC over 14 years ago. Now my return has sharpened my perspective and refreshed my confidence in midwifery. Here midwifery is autonomous, it works in positive relationships with women, and it is truly community based. All of these are essential to effective care. The challenge will be to maintain the ideals of midwifery while integrating into the health service, and expanding the profession.

Countries like the UK , with a long history of midwifery, have tried to institute reforms and modernise the service; some of the developments, like the One-to-One Midwifery project in London, strongly reflect Canadian midwifery. However, because the profession is mainly situated in acute care institutions, this development is very difficult. Midwifery, like birth, has become institutionalised. Although Britain has a strong midwifery service - still for over 70% of women the midwife is the most senior person at labour and birth - fragmented care, acute medicalisation, and confusion with nursing have taken their toll. The establishment of midwifery in Canada has provided a showcase that others, with a far longer tradition, may learn from.

References

College of Midwives of British Columbia. (1997) Registrant's Handbook. CMBC, Vancouver, Canada. Couchie C, Nabignon H. (1997)

A path towards reclaiming Nishnawbe birth culture: can the midwifery exemption clause for aboriginal midwives make a difference? The New Midwifery:Reflections on renaissance and regulation. Women's Press: Toronto, Canada. Kornelsen J. (2000)

Pushing for Change: Challenges of Integrating Midwifery into the Health Care System. BC Centre of Excellence for Women's Health: Vancouver, Canada. Mason J. (1988)

Midwifery in Canada. In: Kitzinger S, The Midwife Challenge. Pandora: London, UK.

Reprinted with permission, originally published by the International Confederation of Midwives in 'International Midwifery', volume 13, number 6, Nov/Dec 2000, pp6-7.